Country Director @ OneDay Health
1467 karmaJoined Oct 2018Working (6-15 years)Gulu, Ugandaonedayhealth.org



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


Dislaimer: Amazing post thanks @ClaireZabel  - I haven't thought about this nearly as hard as you, so this is at best a moderately thought through hot take

I feel like the attraction of the deep and rich philosophy that is effective altruism may be underrated.

Effective Altruism is a coherent philosophy that was built from the ground up (and continues to branch and grow), with a rich philosophical underpinning from a bunch of great thinkers growing out of utilitarian roots. This has attracted a relatively stable, committed and slow growing movement which has branched and expanded, while remaining true to the phililsophical tenets from whence it came. 

If we look at enduring movements which inspire people and create change, such as the civil rights movement, religions, political systems like capitalism and socialism, they have a rich and well thought out philisophical underpinnings - they don't stand without those. I'm not sure just floating X-risk and "We're all going to die" is going to galvanise support and get people on board. 

I think pushing X-risk will get a lot of people will nod their heads and say "yeah", and perhaps get instagram likes but very few of those initially enthusiatic people will passionately devote their lives to fighting against said risk. Unlike so many who are fighting x-risk like you say after arriving at that point through a rich journey exploring effective altruism (or similar). 

Preaching these clear ideas like "X-risk" or " without the philosophical "baggage" may seem like an easy evangelical route, but the house built on the sand can more easily collapse, and the seeds planted on hard ground don't usually flourish.

As a final comment I agree that "Longtermism" isn't a great cause to rally around, largely because it is only a branch of the deeper EA system and not really a standalone philosophy in and of itself. Without EA principles, does longtermism exist?

But why not test it though? Someone can try and start an anti existential-risk group without pulling people from the effective altruism crowd and we can see how it flies. I would love to be proved wrong (and could easily be). 

I strongly disagree that utilitarianism isn't a sound moral philosophy, and don't understand the black and white distinction between longtermism and us not all dying. I might be missing something there is surely at least some overlap betwen those two reasons for preventing AI risk.

But although I disagree I think you made your points pretty well :).

Out of interest, if you aren't an effective altruist, nor a longermist then what do you call yourself?

Thanks for this update this makes a lot of sense. The cost-effectiveness of a malaria vaccine could well rival and even exceed nets, especially if this RTS'S vaccines real-world effectiveness comes close to the incredible effectiveness shown in the initial trial.

My only query around vaccines is how neglected they really in terms of funding. GAVI, UNICEF and the WHOa s as mentioned are obviously huge players but also direct government aid and even the Gates foundation have helped to fund malaria vaccine trials and rollouts.

It surprises me a little that a high profile malaria vaccine like this wouldn't get all the funding it needed without GiveWell input, but I trust GiveWell have considered that well.

One other issue I have is that I think it is possible like Kenya, Ghana and Ugandan governments have enough capacity now to be able to deliver these vaccine programs with their own systems without 5 million dollars in help from an NGO like PATH. That's a LOT of money for logistic support. Having another NGO in between GAVI / vaccine producers and a government which is accustomed to rolling out vaccines seems inefficient. I'm not sure how much "technical assistance" they need. Here in Uganda vaccine rollouts no longer involve a huge amount of NGO input, with Polio and other vaccines often rolled out at fairly short notice without too much trouble. The bottlenecks that I see seem only to be paying extra allowances to those in the vaccine supply chain and those giving the vaccines. Obviously I might be missing something about the logistics specifically of difficulties in distributing the vaccine.

To put it more simply, if the government of Kenya was given just the vaccine and $500,000 (or less) would they have been able to do a similar job without help from PATH?

As another idea is that  perhaps a trial could have been done where PATH were put in charge of the rollout in one country (Ghana), and only the Government in another (e.g. Kenya) to assess just how much PATH really improved efficiency.

Nice work Givewell as usual!

Thanks Kyle, I like the idea of the IRS cost effectiveness thing but agree with Jason that practially it would never work. Even if it came in, it would be so loose as to be meaningless.

Thanks George and Jason all good points

One small other point I will add is that this already happens a LOT, through a couple of mechanisms which include (this is just what I've seen in Uganda)

  1. Supplementary funding for programs - for example AMF give money to local government health departments to help them distribute nets
  2. Results based funding for government health centers, for example paying the local government providers money for every delievery they do.
  3. Straight programme funding - people like World vision and Save the children sometimes deposit money in local government accounts for implementing / supervision of health programs

I would say this stuff is huge bikkies, but it is ongoing. Personally here in Northern UGanda I'm generally not a big fan of this approach (inefficiency, corruption, money just goes to supplement already largeish salaries) but the idea isn't bad. In other places it might work better.

That's a good point, like you say I suspect helping to treat wasting would be among UNICEF'S more cost effective interventions.

I wouldn't necessarily advise looking into it unless you can find that number in the OP published somewhere. GiveWell have indeed already done their analysis also which is likely better than you or I could manage. We don't have strong evidence (I dont' think) yet that it is an official UNICEF number

Nice one Jesper!

I completely agree there would be enormous value in making this kind of info public. The BINGOS (Big NGOs) know that too, but they also know that if they publically estimated cost effectiveness of their interventions, it might make for pretty sombre reading as ther cost effectiveness might be orders of magnitude less than many other orgs - and I'm not just talking the creme de-la creme Givewell ones. 

There's also the problem that they would probably expose that some of their most public "Marquee" interventions might be less effecitve than some of their lesser known interventions, even within the same BINGO. For example if they found out that the small amount of money they spent deworming to prevent river blindness was far more cost-effective than their more heart-throb malnutrition intervention they are advertising, how would they respond to that?

Unfortunately it is most likely In the BINGOs best interests NOT to do (or at least not to publish) cost-effectiveness analysis on their interventions. It is a rational decision on their part. All they might achieve is more scrutiny on how low-impact their interventions were and perhaps even get less funding as a result

That's why they don't publish these kinds of analysis, not because its that hard to do - they have the staffing and expertise. Small orgs like ours and Lafiya Nigeria have had a go even without specific expertise. I'm somewhat surprised UNICEF dipped their toe into publicly sharing any kind of cost-effectiveness here, which we possibly should be giving them some credit for. At least they kind of tried?

I realise it sounds like this is dripping in cynicism, but I genuinely think this explains to a large part why the BINGOs don't publish this kind of info and instead go full ostrich.


I agree with all the comments below, but just to add further clarity from my perspective, a doctor who has worked a little with malnutrition in Uganda.

  1. This claim will be wrong. Any reasonable cost estimate for malnutrition treatment will not achieve that degree of cost effectiveness, unless perhaps if they had a new technology or product outside of the current treatment paradigm. Its just as likely the individual got it wrong as they were told to say that by UNICEF.

 To explain (using basic hack estimates) why this is probably so wrong, here's some basic math. They will likely have underestimated the cost of treatment and overestimated the effect

  • I'm guessing they claim to treat one child with malnutrition for $1 a day. But this would barely cover the cost of the food, let alone the cost of medical staff and medications needed. Perhaps they only include the cost of UNICEF'S contribution to the food, not the cost of medical care, tests and medications which is borne by the public health system and/or the patients' family

    I'm going to pretty wildly estimate the real cost of treating malnutrition as $4-10 daily (I'm sure givewell and others have more accurate estimates).
  • I'm guessing they are assuming they and they alone save every child they treat, not accounting for at least 3 factors that some children treated will die, that some would have been treated to varying extents without UNICEF intervention and that  some would have survived without the treatment. I'm going to very generously assume that UNICEF's intervention saves the lives of between 1 and 5 and 1 and 20 of the kids that they support

    These factors alone could make an order of magnitude difference in their cost effectiveness estimate - which to be honest I doubt they have really done. More likely someone probably had basic flawed logic like

    "We contribute $1 worth of food for each kid in this program which must save that child's life"
  1. UNICEF in my personal experience here in Gulu, Northern Uganda is a classic "White Landcruiser" NGO and shows the classic signs being an inefficient charity, paying a lot of office workers huge salaries while claiming to "strengthen government programmes" in ways that can't really be measured and which I usually don't believe. I'm actually a big fan of activism and lobbying as a potentially cost-effective method but they don't do activism and lobbying, they just cosy alongside.

Thanks this is brilliantly articulated and also fun to read. The sad thing is that strong arguments can be made for the expected value of many forms of smart, even semi-revolutionary activist methods (and have been on this forum) but like you said they seem not keen to engage with our framework at all.

Perhaps they should have hired you to help them write more compelling book!

I have one observation about your use of the term "social justice" which surprised me a little. The way I used to use the word at least, I would consider effective altruism's approach to be an effective "social justice" approach, to rectify social injustices like kids dying from malaria and factory farming. But your use (and perhaps the generally accepted use now) is very different. Like here...

"We should fully expect maximizing welfare to generate complaints about “inequitable cause prioritization” (p. 82) from those who care more about social justice."

I would have thought of maximizing welfare to be one form of social justice, and they would certainly not be mutually exclusive, but apparently the term now has more sinister connotations. When I think of social justice, I think of MLK, Ghandi and Mandela, all pragmatic activists who were wildly successful at creating lasting change with a cost effectiveness and scale that should make effective altruists salivate. I find it sad that "social justice" these days seems to carry the baggage of something like a...


And "social justice warrior" seems to be even worse. Until 15 years ago I would have been proud to identify as a social justice warrior, ie someone who thoughtfully and effectively fights injustice against animals, malaria deaths as well as racial inequity, but I fear the politicisation and pigeonholing of the term may now be irreversible.

Mind you I've lived in Uganda for the last 10 years and so perhaps I'm just behind on a legitimate evolution of the English language!

Would be interested to hear your thoughts.

Fantastic was going to say the same thing! 

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