Thanks for publishing this! Do you mind defining what an ACT is?

(Disclosure, I used to work as a contractor for Living Goods).

There are different philosophies here of course, but from my perspectives hospital staff time required to set everything up (including training etc), and international staff time, should be treated as costs, while hospital workload improvements and improved hospital or patient costs should be treated as benefits. Among other things, that is because the benefits are somewhat speculative while the costs are more certain.

To John's point (which I agree with), these cost estimates just include the cost of purchasing and maintaining the equipment. But there are other costs! As John notes, at the very least there are people costs — the cost of your time, and hospital staff time — and probably if studied carefully we would discover that there are even still other costs.

Thanks Niek for your thoughts.

Regarding this:

On a personal note, while I understand and endorse the rigorous processes that donors and evaluators require, I sometimes feel frustrated by the lack of urgency.

I don't mean to speak for anyone but myself, but I sense that there has been an increase in skepticism in recent decades, as interventions that seemed promising and which "we know work" turn out not to have any measurable effect, or even to have negative effects, when carefully studied. My prior, at least, regarding any new intervention that I hear about is that any effect is probably illusory or minimal.

It's not that there is no urgency about the problems in the world — those are indeed urgent and demanding — but rather, our resources are so limited, and good interventions so hard to find, that we should probably dedicate only a small amount of our funding to more speculative projects, so that we can build evidence over time and not waste funding on projects that turn out not to work. As an example of what we want to avoid doing, look at what happened with microfinance.

Of course the situation would be different if we had already fully funded well-studied projects like bednets, deworming, Vitamin A, etc.; but sadly that's not the world we actually inhabit.

Do we have a sense of how large the commissions typically are as a percentage of the premium? Also curious what sort of auditing/verification you have in mind, if any.

If gene drives are a common naturally occurring phenomenon, are the defenses also common and naturally occurring? Might we expect that (for example) a mosquito infertility gene drive would in practice run up against such natural defenses?

Good points!

If your boss would have as little trust in you as the average parent has in their child, I think it would feel terrible

On the other hand, if you lied to your boss as frequently and blatantly as most kids lie to their parents, you should expect not to keep your job for long. In other words, the trust may be lower, but the consequences/expectations are also lower.

Might be worth clarifying which risks you are asking about, unless you intentionally want to keep it open/ambiguous.

The story of Jesus being anointed by a woman with a costly jar of perfume leads us to the question of how we should divide our resources between religious gestures (“praise”, if you like) and helping the poor. Is this story still relevant in the current age, and if so how should we think about this question today?