Mountains Beyond Mountains (Tracy Kidder) and the case against cost effectiveness

Mountains Beyond Mountains is a biography of Paul Farmer, an American doctor who founded a small clinic in Haiti and ended up saving hundreds of thousands of lives, possibly millions.  But that’s at the end.  The beginning is spent with him  doing obviously suboptimal things like spending $5000/year per patient treating AIDS patients in a country where people were constantly dying of malnutrition and diarrhea (average cost to treat: <$30), while baiting me by bragging about how cost ineffective it was.  I was very angry at him for a while, until it dawned on me that getting angry at a man for distributing lifesaving drugs probably said more negative things about me than it did about him.  Plus he did maybe avert a worldwide epidemic of untreatable tuberculosis, so perhaps I should stop yelling at the CD player and figure out what his thinking was.

Let’s take tuberculosis.  At some point in the story (it’s frustratingly vague on years), Farmer’s friend brings him to Peru, which had what was widely considered the world’s best TB containment system (called DOTS).  The WHO held it up as what the rest of the world should aspire to.  DOTS did many things right, like ensuring a continuous supply of antibiotics to patients and monitoring them to ensure compliance (intermittent treatment breeds resistance).    On the other hand, the prescribed response to someone failing to get better on drugs (indicating their infection was resistant to them) was “give them all the same, plus one more.”  This is exactly the right thing to do, if what you want is to make sure the bacteria evolve resistance to the new drug without losing its existing resistance.  The protocol specifically banned testing to see which drugs a particular patient’s infection was susceptible to, because that is expensive and potentially difficult in the 3rd world.

The WHO ignored the possibility of drug resistant TB because it was considered an evolutionary dead end.  Resistance had to evolve anew in each patient, and rendered the infection noncontagious.  I don’t know what evidence they based this on, but  at best it was a case of incorrectly valuing evidence over reason.  At worst, it indicates a giant sentient TB cell has infiltrated the WHO and is writing policy.

Hello fellow humans. I sure do hate death and suffering.
Hello fellow humans. I sure do hate death and suffering.

If your evidence says a contagious disease spontaneously becomes completely noncontagious at a convenient moment, your first thought should be “who do I fire?” because obviously something went wrong in the study design or implementation. If you check everything out and it genuinely is noncontagious, your next thought should be “wow, we really lucked out having all this extra time to prepare before it inevitably becomes contagious again.”  At no point should it be “sweet, cross that off the list”, because while you are not looking it will redevelop virulence and everyone will die.

Farmer’s response to the ban on treating multiple drug resistant TB was to steal >$100,000 worth of medicine and tests from an American hospital to treat a handful of patients.  When caught, a donor bailed him out.

Or take cancer.  A young child with weird symptoms shows up at his clinic.  He drops a few thousand dollars on tests to determine the child had a rare form of cancer.  60-70% survival rate in the US, no chance in Haiti.  He convinced an American hospital to donate the care, but when the child becomes too ill to travel commercially he spends $20,000+ on medical transport.

Both of these went against standard measures of cost effectiveness, as did Farmer’s pioneering work treating AIDS patients in the 3rd world.  But let’s look at his results:

  1. The WHO’s “yeah, it’s probably fine” approach to drug resistant TB worked as well as you would think.  Farmer proves it is contagious, is treatable, and drives down the price of treatment (to the point it is $/DALY competitive with standard health interventions). He goes on to change the international standard for TB treatment and lead the effort in several countries. Book gives no numbers but I estimate 142,000 lives and counting, plus avoiding an epidemic that could cost 2 million lives/year.*
  2. Kid’s cancer is inoperable, he dies in the US.  American hospital agrees to take a few more cases each year.

In retrospect his actions in the TB case seem pretty damn effective.  But he didn’t set out to change the world.  He stole those drugs for the exact reason he flew that boy to the US: someone was dying in front of him and it made him sad.  It’s possible you couldn’t correct his answer in the cancer case without also “correcting” his answer in the TB case. And while someone more math driven could have launched the world changing anti-MDR TB campaign, they didn’t.  Farmer did, and we need to respect that.

Lots of people in the philanthropic space, including Farmer and most EAs, say that it’s unreasonable to expect perfect altruism from everyone.  People need to spend money on themselves to keep themselves happy and productive, and constant bean counting about “do the morale effects of name brand toilet paper make up for the kids I won’t be able to deworm?” is counterproductive.   You put aside money for charity, and you put aside money for you to enjoy life, and you make your choices.  What if we view Farmer’s need to save the life in front of him as a morale booster that enables our preferred work (averting world wide incurable TB pandemic), rather than the work itself?  By that measure,  $150,000 on a single kid’s cancer and 7 hours doing a house call for one patient in Haiti is a steal.  Given that I pay my cats more (in food and vet care) than what 1/6 of the world survives on, I do not have a lot of room to judge Paul Farmer’s “saving children from cancer” hobby.

Farmer himself raises this point, in a way.  It turns out that effective altruism did not invent the phrase “that’s not cost effective.”  Lots of people with a lot of power (e.g. the WHO) have been saying it for a long time.  From Farmer’s perspective, it seems to be used a lot more to justify not spending money, rather than spending it on a different thing.  He also rejects the framing of the comparison: cancer treatment may save fewer lives per dollar than diarrhea treatment but it saves way more per dollar than a doctor’s beach house, so how come it only gets compared to the former?  Those are fair points.

It’s not clear he could have redirected the money even if he wanted to.  Most of the care for the cancer patient was donated in kind; there was no cash he could redirect to a better cause (although that’s not true for the cost of the medivac).  No one gave him $100,000 to spend on TB treatment, he stole drugs and got bailed out.  It’s not clear the donor would have been as moved to rescue him if he stole $100,000 worth of cheap antibiotics.

In essence, I’m postulating that Farmer operated under the following constraints.

  • Evaluating cost effectiveness is emotionally costly even in the face of very good information.
  • Low quality information on effectiveness
  • Financial discipline was emotionally costly
  • Some money was available for treatments of less relative effectiveness but could not be moved to the most effective thing.  But the money was not clearly labeled “the best thing” and “for warm fuzzies only”, he had to guess in the face of low information.

Under those things, evaluating cost effectiveness could easily be actively harmful.  Judging by the results, I think he did better following his heart.

Doing The Most Effective Thing is great, and I think the EA movement is pushing the status quo in the right direction. But what Farmer is doing is working and I don’t want to mess with it.  At the same time, his statement that “saying you shouldn’t treat one person for cancer because you could treat 10 people for dysentery is valuing one life over another.” (paraphrased) is dangerously close to Heifer International’s “we can’t check how our programs compare to others, that would be experimenting on them and that would be wrong.” (paraphrased), which is dangerously close to Play Pump’s “fuck it, this seems right.” (paraphrased) as they rip out functional water pumps and replace them with junk.  So while Farmer is a strong argument against Effective Altruism as “the last social movement we will ever need” (because some people do the most good when they don’t compare what they’re doing to the counter-factuals), he’s not an argument against EA’s existence.  Someone has to run the numbers and shame Play Pump until they stop attacking Africans’ access to water.

It doesn't even make sense as a toy. The fun part of carousels is the coasting, not the wind up
It doesn’t even make sense as a toy. The fun part of carousels is the coasting, not the wind up

And just like you couldn’t improve Farmer by forcing to him do accounting, you can’t necessarily improve a given EA by making them sadder at the tragedy immediately in front of them.  EA is full of people who didn’t care about philanthropy until it had math and charts attached, or who find doing The Best Thing motivating.  We’re doing good work too. I understand why people fear doing the math on human suffering will make them less human, but that isn’t my experience.  I cry more now at heroism and sacrifice than I ever did as a child.

Ironically the one thing I was still angry at Farmer for at the end of the book was his most effective choice: neglecting his children in favor of treating patients and global health politics.  I could forgive it if he felt called to an emergency after the children were born, but he had kids knowing he would choose his work over them.  For me, no amount of lives saved can redeem that choice.  Maybe that is what he feels about letting that Haitian child die of cancer.

*This paper (PDF) estimates 142,000 deaths averted 2006-2015 by the program Farmer pioneered, and the program is still scaling up.    I estimate a drug resistant TB epidemic would cost a minimum 2.3 million lives/year (math below), although how likely that is to occur is a matter of opinion.  That’s ignoring his clinical work in Haiti, the long term effects of his pioneering HIV treatment in the 3rd world,the long term effects of his pioneering community-based interventions that increased treatment effectiveness,  infrastructure building in multiple countries, and refugee care.  I would love to give you numbers for those but neither Paul Farmer nor PIH believe in numbers, so the WHO evaluation of the TB program was the best I could do.


Untreated TB has a mortality rate of ~70%l

TB rates have been dropping since ~2002, but that’s due to aggressive
treatment. New infection rate held steady at ~150 people/100,000
from 1990-2002, so let’s use that as our baseline. With 7.3 billion people, that’s 11 million cases/year. 11 million * .7 chance of death = 7.7 million deaths. Per year. 25% of those are patients with AIDS who arguably wouldn’t live very long anyway, so conservatively we have ~5.7 million deaths. If I’m really generous and assume complete worldwide distribution of the TB vaccine (efficacy: 60%), that’s down to 2.3 million deaths. Per year.

For comparison, malaria causes about 0.5 million deaths/year.

Thanks to Julia Wise for recommending the book, Jai Dhyani and Ben Hoffman for comments on earlier versions, and Beth Crane for grammar patrol.

Review: The Hot Seat (Dan Shapiro)

Let me begin by describing something The Hot Seat does not do.  A while ago I read Never Say Die, about how society talks about old age.  Sometimes I would want to argue with its factual statements (“old women have no access to sex”), but feel immediately aversive.  Eventually I realized that this was because Never Say Die spent a long time deriding anyone who believed anything good about old-old age as delusional or mean.  I didn’t want to be delusional or mean, so even in the privacy of my own head I resisted arguing.  This is a bad tactic for finding out the truth.   You don’t win arguments by deriding people who oppose you, you win them with facts.  And the facts are that old people in nursing homes get a lot of STDs.*

A lot of business books do this too.  “Other people will tell all a company needs is a website and a mascot, but we’re not like that.  We think you should have a product.”  It’s not quite argument from bravery– more like argument against stupidity.  It often follows statements like “we won’t sugarcoat this” and “fancy new economy idiots/stodgy old economy losers believe…”.  The effect is to discourage critical thought about what they are telling you.

The Hot Seat does not do this, at all.  It gives you information- both legal rules and the unspoken ones, from funding to people management.  I think it would be useful for someone planning on starting their own company, but that wasn’t my use case.  I want to be an early employee at a start up, and want to be able to tell good start ups from bad.  Hot Seat isn’t a complete book for that, but it is a very strong foundation that will make it easier to assess if I’m getting good advice from other books.  It is also extraordinarily readable, to the point I would read it for fun.**

*When I went to look up the numbers I saw that they counted everyone above age 65 or even 50.  The book’s main thesis is that people take happy statements about the (upper class) young old and inappropriately apply them to the old old (80+).  So the author may not have even been wrong, but I don’t like the way she proved her point.

**Other books I read for fun:

But I don’t read finance for fun, so this is novel.

Thoughts on So Good They Can’t Ignore You (Cal Newport)

Recently I read So Good They Can’t Ignore You.  I have well known trouble distinguishing “things the book said” from “thoughts I had while reading it”, so I’m just going to tell you what I thought and if you’re interested you can track down the book and see how original this was.

The book’s official tagline is “Why Skills Trump Passion in the Quest for Work” and it frames itself as anti-passion, but Newport eventually admits that’s a marketing hook.  Mostly his thesis is that passion alone will not make you happy, and skill can be used to extract concessions from your employer that make life more pleasant, so you should focus on skill.  Passion is a great driver for developing skills so that seems like a weak criticism of passion (he puts all the positive aspects of passion under “mission”), but he also suggests that it’s impossible to find something you’re really passionate about until you have a certain amount of skill, so still focus on that.  Given the essentially infinite number of skills available it seems like there’s room for your interests to have input earlier in the process.  I think what he’s really attacking is the idea that your job should be a source of entertainment.  That has given me severe clarity in what I’m looking for job-wise.

The epitome of the jobs-as-entertainment model is “Choose a job you love, and you will never have to work a day in your life”.  That is neither true nor desirable, unless you use a very specific definition of work.  Let’s take this blog.  No one is forcing me to write it.  For the first year I had something like five readers, most of whom I regularly talked to in person.  Obviously it was motivated entirely internally, which is another way of saying “powered by love.”  And yet, it was still work.  Even if you discount all the reading I did as “things I would have read for fun anyway”*, and the thought I put into it as “a thing I can’t stop my brain from doing”, I have to organize my thoughts and translate them to things other people can understand.  I had to configure the page layout so it was neither hideous nor generic.  I had to proofread and correct mistakes.  I had to retype entries from scratch after WordPress broke again.  I had to correct all the typos Beth pointed out to me after I published.  Nothing past writing the first draft could be considered entertaining the way playing Twenty is entertaining, and even the reading, thinking, and first drafts took considerable time and effort.  That sounds like work to me.  And yet obviously I was doing something I loved because there was no other reason to do it. **

Love doesn’t erase the fact that something is work.  It can motivate the work, it can cushion the annoyances of work, it can give you the incentive to continue when you would otherwise give up, but it can’t erase it.  And I kind of resent attempts to try.  I am a grown up human, I do not need swings or field trips to chocolate factories to trick me into swallowing a pill showing up.

How I feel about office scavenger hunts
The canine equivalent of the company picnic

What I do need is a good working environment, clarity around my goals, and the tools to achieve them.   Those are what let me accomplish things, which is the reward I want from work.  An occasional morale event when I we’re all producing really good work together can be really rewarding, but frequent events (like my job has) when I’m unhappy with my productivity feels like… like eating too much dessert when what I really need is a nutritious meal.  My taste buds notice the sugar but I don’t get any of the associated psychological rewards, and it turns into queasiness.  Speaking of which: office candy counts as entertainment but the nutritious-organic-local-cuddled meals at work are productivity aids.  Let’s not throw the baby out with the bathwater.

Like 80,000 hours, So Good They Can’t Ignore You has a large emphasis on building career capital.  This section isn’t perfect. A lot of the case studies are opportunistic (in the positive sense of the word), and serendipity is not repeatable.   I feel like it’s skipping a critical step without acknowledging it.  It’s also a little too “be a good worker bee until you’re called up to the the big leagues” for me; traditional corporate or academic paths work for a lot of people and the whole “the only thing holding you back is fear” narrative is stupid, but there’s a lot of other paths to success that get a lot less publicity.  But this was still useful.

I have some topics I find both interesting and skills that would be useful in an associated career.  But as you may have noticed, I have a lot of interests, many of which require expensive, brittle credentials to pursue.  It would suck to spend years in school only to get bored with the field. I highly suspect interests are a better predictor of what will be entertaining than what will be rewarding.  What SGTCIY suggests in this situation (actually all situations, but I think it applies to me more than most) is to build capital in things that will be useful in service to lots of interests/goals.  Like, say, programming, a skill and job I already have but really always skated through on raw intelligence and a willingness to do low status work.  Between this book and not getting a job I really wanted I’ve started make deliberate choices and investing.

It’s also really nice to read a career guide by someone with a career that is not writing career guides (Newport wrote the book in between finishing a computer science PhD and starting a professorship), and one with writing skills to boot.  I finished the book in two days because it was just that readable.

*I used to read things with the explicit goal of blogging about them; they were worth blogging about so rarely I stopped.

**I was planning on using the blog as a portfolio for job purposes, but one of the reasons blogging works as a signal of interest and skill is that it’s so costly and low-reward no one would do it unless they loved it.

IQ Tests and Poverty

Recently I read Poor Economics, which is excellent at doing what it promises: explaining the experimental data we have for what works and does not work in alleviating third world poverty, with some theorizing as to why.  If that sounds interesting to you, I heartily recommend it.  I don’t have much to add to most of it, but one thing that caught my eye was their section on education and IQ tests.

In Africa and India, adults believe that the return to education is S-shaped (meaning each additional unit of education is more valuable than the one before, at least up to a point).  This leads them to concentrate their efforts on the children that are already doing the best.  This happens at multiple levels- poor parents pick one child to receive an education and put the rest to work much earlier, teachers put more of their energy into their best students.  Due to a combination of confirmation bias and active maneuvering, the children of rich parents are much more likely to be picked as The Best, regardless of their actual ability.   Not only does this get them more education, but education is viewed as proof one is smart, so they’re double winners.  This leaves some very smart children of poor parents operating well below their potential.

One solution to this is IQ tests.  Infosys, an Indian IT contractor, managed to get excellent workers very cheaply by giving IQ tests to adults and hiring those who scored well, regardless of education.  The authors describe experiments in Africa giving IQ tests to young children so that teachers will invest more in the smart but poor children.  This was one of the original uses of the SATs in America- identifying children who were very bright but didn’t have the money or connections to go to Ivy League feeder high schools.

This is more or less the opposite of how critics view standardized testing the US.  They believe the tests are culturally biased such that a small sliver of Americans will always do better, and that basing resource distribution on those tests disenfranchises the poor and people outside the white suburban subculture.  What’s going on here?

One possible explanation is that one group or the other is wrong, but both sides actually have pretty good evidence.  The IQ tests are obviously being used for the benefit of very smart poor children in the 3rd world.  And even tests without language can’t get around the fact that being poor takes up brainspace, and so any test will systematically underestimate poor children. So let’s assume both groups are right at least some of the time.

Maybe it’s the difference in educational style that matters?  In the 3rd world, teachers are evaluated based on their best student.  In the US, No Child Left Behind codified the existing emphasis on getting everyone to a minimum bench mark.    Kids evaluated as having lower potential than they actually do may receive less education than they should, but they still get some, and in many districts gifted kids get the least resources of any point on the bell curve.

Or it could be because the tests are trying to do very different things.  The African and Indian tests are trying to pick out the extremely intelligent who would otherwise be overlooked.  The modern US tests are trying to evaluate every single student and track them accordingly.  When the SATs were invented they had a job much like the African tests; as more and more people go to college its job is increasingly to evaluate the middle of the curve.  It may be that these are fundamentally different problems.

This has to say something interesting about the meaning of intelligence or usefulness of education, but I’m not sure what.

Improving Commuting

As a follow up to yesterday, I just want to say that having a thing I look forward to that I can only do on the bus is working out brilliantly as a device for making commuting less miserable and it was totally worth buying the Kindle Fire to make it happen.  If you want to try for yourself, I recommend getting the 16gb, the 8gb could barely hold three HD episodes. I also recommend an anti-glare screen, because its glare is awful and the screen picks up fingerprints like woah.

The next recommendation is a little weirder.  I bike to the bus, which means I’m in biking clothes and have to maneuver my bike onto the cow catcher.  This makes waiting for the bus a little tricky- anything I have in my hands will have to be put away really quickly so I can rack my bike and get on, but I have no pockets.  And for reasons that may not be entirely rational, the time it takes to unsling my backpack and put a toy away makes me really stressed out.  But if I don’t use a toy the time at the bus stop is wasted, and that’s stressful too.  What I wanted was a way to make the whole of commuting feel either productive or like an indulgence.

So I made myself a shirt, out of two shirts and some fabric glue.

Two shirts enter, one shirt leaves
I believe my cat may have been getting high off the fabric glue.


  1. Place desired toy on shirt, cut patch around it.  Leave space for depth.
  2. Put fabric glue on single edge of patch and apply to surviving shirt.
  3. Lock cat in other room.
  4. Reapply patch to surviving shirt.  Once you have it aligned, apply glue to other two edges and apply (you leave the top open so it’s a pocket).  Remember to apply it less than completely flat, so the pocket will have depth.
  5. I don’t know if this is a property of the fabric glue, my shirt, or this project in general, but some of the glue filtered down such that the base shirt was glued to itself and the patch ran free.  If you catch this early enough you can separate and try again.

This shirt is not aesthetically pleasing and is weirdly stiff where I overapplied fabric glue, but it gets the job done.

Making Hannibal Make Sense

[explicit spoilers for episode 1 of Hannibal, implied spoilers for 2 and 3.  I haven’t seen past that  but I am making predictions about what will happen]

My need to make movies make sense is most obvious when it comes to animal behavior*, but that’s not its only manifestation.  Take police procedurals.  I made Bones tolerable by saying la la la science fiction.  I’m now watching Hannibal because it’s one of the best shows available on Amazon Prime Streaming, which is the only streaming service that allows offline viewing, which is important because I have a bus commute again.**

Hannibal… does not make a ton of sense.  The premise is that an ex homicide detective is a brilliant criminal profiler but unable to get into the FBI because he couldn’t pass the psych screening, so they just hire him as a “special agent” that does everything a normal agent does, including field work.  You would think that was Hannibal Lecter, but it is not.  Lecter is the psychiatrist the FBI hires to babysit the unstable profiler (who I can only imagine will one day regret copying Lecter’s answers off a psych test).  Lecter also accompanies the agent on field work, which I don’t think even regular FBI agent’s counselors are normally allowed to do.  The actual profiler (Will Graham) comes up with theories more or less out of thin air and they always turn out to be correct.  He insists the evidence makes it obvious.

On the face of it, this makes no sense.  But what if Hannibal is set in a just slightly alternate universe, where psychic powers exist but are considered shameful because they make people mentally unstable?  The FBI can’t officially hire them, and they in fact test for powers before hiring to make sure they don’t hire any psychics.  But if there just happens to be a profiler who makes totally evidence based leaps, enabling them to catch really gruesome serial killers they otherwise couldn’t, well surely you can hire them on a contract basis.***

Why doesn’t the psychic Graham notice Hannibal is murdering and eating people? I’m glad you asked.  Hiring a babysitter for a psychic is tricky business.  You wouldn’t want someone they could manipulate or even read, that would defeat the purpose.  So you hire someone who’s a null field to psychics, or at least your psychic.  As a bonus, this person can lie to them when need be.  Note that Graham says he hates going to psychiatrists- presumably every one he’s been to has been unreadable to him, and he hates that.

And that’s how I learned to enjoy Hannibal.

*Ask my brother about watching the King Kong with me.

**”So you’re coping with your motion sickness by watching a show about food and gore?” “Yes”

***The same way my team at Microsoft rehired the same contractor for our Apple version over and over again.

Review: Inside Out

First, it’s great, and totally reverses Pixar’s downward slide.  Second, they did an amazing job of making everything work as a character/story and a metaphor for how the brain works and an Aesop.  A good chunk of the time kids’ shows teach lessons I consider abhorrent (looking at you, My Little Friendship Means Never Having Boundaries) , and at the beginning it looked like they were setting up one of those, but in the end in became clear they considered it exactly as problematic as I did.

Also I need to see it at home so I can cry harder. That is all.