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NickLaing

Country Director @ OneDay Health
4692 karmaJoined Oct 2018Working (6-15 years)Gulu, Ugandaonedayhealth.org

Bio

Participation
1

I'm a doctor working towards the dream that every human will have access to high quality healthcare.  I'm a medic and director of OneDay Health, which has launched 35 simple but comprehensive nurse-led health centers in remote rural Ugandan Villages. A huge thanks to the EA Cambridge student community  in 2018 for helping me realise that I could do more good by focusing on providing healthcare in remote places.

How I can help others

Understanding the NGO industrial complex, and how aid really works (or doesn't) in Northern Uganda 
Global health knowledge
 

Comments
651

Thanks those are all great points nice one and I agree with almost all of that. Again love the focus on low skill workers

On supply and medical staff
"They argue that low incentives to work in rural areas are a much bigger problem than the total supply of physicians (and how that supply is affected by emigration)."

The funny thing is that a big part of that exact issue there may well be supply! If there were more than enough doctors to fill roles in cities, and they struggled to emigrate (doctors find this far easier than other professionals) then doctors would be pushed into working in rural places as that's where the jobs 

My example to back this up is that in Uganda there's a massive oversupply of nurses, and it means in search of jobs many open drug shops in the village and many are willing to work in rural areas. We have no problem at all recruiting at OneDay Health. Supply is a huge factor.

Wow thanks for the fascinating article. I'm amazed these kinds of disasters are tolerated without stronger action. The way the article paints it at least, companies might be getting away with cutting costs on net production and almost causing deaths through inadequate insecticide infusion. In this article the WHO "WHO sent a letter of concern to Germany-based Mainpol GmbH because some of its nets contained too much or too little insecticide." Is that really strong enough action? Surely you cut the supplier, investigate and maybe sue them if they haven't met a standard?

Tesla recalls tens of thousands of cars for a minor manufacturing defect that might cause a death or two, while the WHO just writes letters about defects that could be killing thousands?
 
Although it wasn't clear, there might also be a "DDT" effect here - where concern about the environmental effects of a chemical means they switch to an inferior one.

"The original coating contained PFAS, dubbed forever chemicals because they’re so slow to break down. While PFAS are still widely used to make shoes and backpacks water resistant and to produce firefighting foams, they’ve been linked to increased cancer risk, decreased fertility and developmental delays in children.Their use has been restricted in many countries and industries have been seeking alternatives."

 Are we willing to do some potential harm in order to do more good? Always a tricky question.

Sometimes I wish we had laughing emoji on the form for nice comments like this. But I get the downsides too :D.

Thanks David appreciate the article - I think its a good indication of how complex the question of immigration  is and how I don't think its a slamdunk in either direction.

My impression is though that the article is a pretty poorly researched and misleading piece - even though some of its arguments might still stand in many cases despite that.

First its weird that the article makes zero mention of the state of the Nigerian health system, nor how this mass emmigration might be affecting it. Is staffing getting better or worse? Are outcomes getting better or worse? How many nurses are actually needed in the system? Building your entire argument on "nurses trained" vs "nurses immigrating to England" seems quite short sighted and reductionst.

Second (probably most important), they only taken into account nurses leaving for England - a weird comparison decision. That 2300 nurses left for england that year is fairly irrelevant, what matters is the total number. Nurses leave for other european countries and the middle east too .The Nigerin government says 42,000 nurses left in the last 3 years, that's 14,000 a year, more than they are even training per year. 

https://africa.cgtn.com/nigeria-says-42000-nurses-left-the-country-in-3-years/

So their basic argument that enough new nurses are being trained is bogus

In addition, you must consider the increasing population. The population of Nigeria has grown by 5,000,000 people in that one year (2.5% increaser ). Nigeria has something like 180,000 nurses.  This means even just to maintain their already poor nursing ratios, they would need to train and put into the workforce an extra 3000 or so nurses each year just to maintain the status quo, without even improving nurse/population ratios.

Its also likely that many of the the best and brightest that are leaving Nigeria. They are more likely to pass English exams and be accepted (unless they cheat as ofen happens) and have the drive and gumption to try and move overseas. My guess would be its most likely that England is taking the better nurses to work in a health system that is 10x better while leaving the lower quality nurses in Nigeria, the health system which really needs the best nurse to lead and drive the system. The qualification itself is only a small part of the story, the difference in ability, skills and leadership potential between nurses is immense.

There are also other second order effects, If you've ever been in a country where many people are trying to emmigrate because many people are leaving, its hard to retain stability in your hospitals and health systems. People are distracted and staff turnover is high and morale can be low. This can really hurt productivity of those who remain.

I'm also more concerned about Doctors than nurses - but that's a whole nother story.

I probably wasted too much time hacking away at this poor article, but it annoyed me a little ;). I'm not anti immigration at all, but I am for medical staff in this kind of scenario and there are many, many factors to consider in the discussion.

That's great that you are focusing on low and mid-skill workers. Its a complicated question, but I think that moderate high skill workers leaving low and middle income for western jobs can be net-negative, especially in the healthcare field - for example the flood of West African doctors and nurses heading to Europe and the Middle east at the moment. I really like that some countries like Nigeria are bonding medical staff for 2+ years after they complete their training.

https://www.semafor.com/article/02/15/2024/nigerian-nurses-reject-rules-attacking-japa

Sometimes though there can be claims of "overproduction" of positions such as nurses like in Kenya, but when public hospitals are grossly understaffed then why is the governement spending money on training nurses rather than actually putting the resources directly into their medical system?

https://ntvkenya.co.ke/news/we-are-overproducing-graduates-health-ps-defends-govt-plan-to-export-nurses/

I agree that's possible, but I'm not sure I've seen his rhetoric put that view forward in a clear way.

Thanks Yanni, I think a lot of people have been concerned about this kind of thing.

I would be surprised if 80,000 hours isn't already tracking this or something like it - perhaps try reaching out to them directly, you might get a better response that way

Thanks Gewind for the insights

I haven't got this far in terms of estimating the costs of doing it at a bigger scale - after this trial I was probably a little less enthusiastic about the idea than before I started to be honest so I probably won't go ahead and do that right now anyway.

 I don't think I'm a person with the minimum required medical knowledge at all though, it would be harder for others but doable.

The adverse effects you speak of is certainly a real risk but I don't think one of the biggest factors. I think the approach would be to only accept poor subsistance farmers from rural areas who were super unlikely to be able to afford treatment counterfactually - my instinct would be to just exclude anyone who lived in any kind of city or even township. I think helping individuals like this could only remain cost-effective if people were identified by our agents, not people "applying" or coming to ask for help or anything like that.

Thanks so much for the encouragment, really do appreciate it.

Great point I hadn't thought about risk neutrality vs non-neutrality here and that there might be a pool of people even within EA who would rather pay a "premium" for higher confidence. Outside EA my experience has been that perhaps even the majority of people would probably prefer to pay for higher confidence.

Thanks Ulrik, this is a really interesting question about a list of interventions and you might be right there is scope for more work here. I would imagine @CE (charity entrepreneurship) have thought about this before, and might have a list of specific medical interventions that could be cost-effective.

I might start by splitting these into "life saving" interventions, where most of the benefit comes from one potential life "saved" - situations like malnutrition, cancer treatment and heart operations "life improving"  interventions where most of the benefit comes from things like fistular surgery, sight-saving medication and surgery and fixing retracted testicles.

The problem is though where do you stop considering something a single "intervention"? Treatment for malaria, pneumonia and sickle cell could be cost effective but is already a standard part of almost any health systems, and its more about making sure people get the treatment quickly and cheaply or for free.

I also like your idea of "networks of people we can trust" to support individuals as well, which could have the advantage of building EA community and resisting value drift as well. Keep in mind though these kinds of people might also be busy with other work. I personally love to be contacted with questions about this kind of thing so am always happy to give my poorly-to-moderately-informed opinion on medical stuff.

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