Podcasts about rct

In the past few decades, we have witnessed the rise and consolidation of “evidence-based medicine” among health professionals. This refers to a systematic approach to medicine in which doctors and other health care professionals use the best available scientific evidence from clinical research to help make decisions about the care of individual patients. But the COVID-19 pandemic has managed to transform what constitutes reliable medical evidence into a topic of public concern and debate. These debates have taken place within and beyond the medical establishment, such as in news reports and social media posts. And suddenly everyone began offering an opinion on the efficacy of measures such as quarantines, lock downs, school closures, and mandatory face masks. How then should we understand “evidence”? Does evidence mean the same thing in different contexts and constituencies? In their new book, Rethinking Evidence in the Time of Pandemics: Scientific Vs Narrative Rationality, and Medical Knowledge Practices, Eivind Engebretsen and Mona Baker argue that we ought to adopt a more nuanced and socially responsive approach to medical expertise that incorporates scientific and lay processes of making sense of the world and how we decide to act in it. Using the narrative framework, they offer a model of analysis that sheds greater light on why different people arrive at different decisions based on the same sources of evidence and why we must acknowledge their reasons for doing so as rooted in different types of rationality rather than dismissing them as irrational. Eivind Engebretsen is a Professor at the Faculty of Medicine, University of Oslo, where he is also the Executive Chairman of the Centre for Sustainable Healthcare Education.Mona Baker is Director of the Baker Centre for Translation and Intercultural Studies at Shanghai International Studies University. She is also affiliated with the Centre for Sustainable Healthcare Education at the University of Oslo. Host:Professor Dan Banik, University of Oslo, Twitter: @danbanik  @GlobalDevPodApple Google Spotify YouTubehttps://in-pursuit-of-development.simplecast.com/

Durant son enfance Lourdaise, c'est après s'être essayé à d'autres sports que Soané attaque le rugby, au sein du mythique Football Club Lourdais. À l'adolescence, il s'y met sérieusement puis rejoint les Reichel de la Section Paloise. Dès la fin de sa première saison, il fait son baptême du feu chez les Pros face à Montauban, dans la cuvette de Sapiac ! Pas forcément dans les petits papiers des entraineurs Béarnais, Soané signe en 2004 chez le rival Tarbais, où il passera 1 saison, avant de filer sur la Rade et d'intégrer l'ambitieux projet Toulonnais ! Il fait sa place au milieu de stars mondiales et y reste 4 belles années. Passé par la suite par Mont de Marsan, Lourdes ou Béziers, Soané à toujours su se remettre en question, menant une carrière longue de plus de 2 décennies ! Aujourd'hui installé dans le Var, Soané y a joué quelques années avant de se lancer dans une aventure à peine croyable : il officie à plus de 40 ans dans le championnat Allemand, à Offenbach ! Par ailleurs employé dans une société dans le secteur des carburants, il se régale dans cette vie tout à fait singulière. Aussi gentil et discret à la ville qu'il n'était rude sur le terrain, Soané est vraiment un chouette gars, et on a passé un super moment ! Bonne écoute ! -----------------------------

Is duloxetine a viable option for youth with MDD? In this episode, we discuss the need for additional medication options in youth with depression as well as an RCT of duloxetine to assess its efficacy and a label extension trial to evaluate its long-term safety. Faculty: David Rosenberg, M.D. Host: Richard Seeber, M.D. Learn more about our membership here Earn 0.5 CMEs: CAP Smart Takes Vol. 04 Efficacy and Safety of Duloxetine in Children and Adolescents With MDD in Japan

The global development domain currently faces huge challenges. Apart from trying to stimulate economic growth and ensuring a fair distribution of the benefits of that growth, national governments and their international partners must also tackle complex conflicts, provide humanitarian assistance, and not least address the harmful impacts of climate disruption. What then should the role of external actors be? How can good intentions be best mobilized into effective actions on the ground?Håvard Mokleiv Nygård is a Deputy Director-General of the Norwegian Agency for Development Cooperation, Norad, where he directs the Department of Knowledge. Until a few years ago, he was Research Director at the Peace Research Institute Oslo (PRIO), where his research focused on armed conflict and political violence, peace building, and patterns of democratic development. Twitter: @havardmnResources:Joint statement by donors on locally led development (December 2022)Norwegian aid statistics (Norad.no)Key highlights Introduction - 00:49Foreign aid vs. development cooperation - 04:52Locally led development - 13:10The aid effectiveness debate - 24:15What works in global development and how to measure success - 43:49Bridging the gap between research and policy and the future of aid - 52:45Host:Professor Dan Banik, University of Oslo, Twitter: @danbanik  @GlobalDevPodApple Google Spotify YouTubehttps://in-pursuit-of-development.simplecast.com/

The cage match you've all been waiting for! iGel vs King LT in cardiac arrest. Which is associated with higher survival? Airways-2 was an RCT of iGel vs ETI in OHCA and found no difference. PART was an RCT of King LT vs ETI in OHCA and found a slight difference favoring King LT. How about in those patients just getting a SGA... how does the iGel compare to King LT? Dr. Jarvis interviews the amazing young researcher and medical student Tanner Smida about his new paper using the ESO dataset to answer just this question. Citation: 1. Smida T, Menegazzi J, Crowe R, Scheidler J, Salcido D, Bardes J. A Retrospective Nationwide Comparison of the iGel and King Laryngeal Tube Supraglottic Airways for Out-of-Hospital Cardiac Arrest Resuscitation. Prehospital Emergency Care. Published online January 18, 2023:1-13.See omnystudio.com/listener for privacy information.

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Remote Health Centers In Uganda - a cost effective intervention?, published by NickLaing on February 27, 2023 on The Effective Altruism Forum. TLDR: Operating basic health centers in remote rural Ugandan communities looks more cost-effective than top GiveWell interventions on early stage analysis - with huge uncertainty. I'm Nick, a medical doctor who is co-founder and director of OneDay Health (ODH). We operate 38 nurse-led health centers in healthcare “black holes,” remote rural areas more than 5 km from government health facilities. About 5 million Ugandans live in these healthcare black holes and only have bad options when they get sick. ODH health centers provide high-quality primary healthcare to these communities at the lowest possible cost. We train our talented nurses to use protocol based guidelines and equip them with over 50 medications to diagnose and treat 30 common medical conditions. In our 5 years of operation, we have so far treated over 150,000 patients – including over 70,000 for malaria. Since we started up 5 years ago, we've raised about $290,000 of which we've spent around $220,000 to date. This year we hope to launch another 10-15 OneDay Health centers in Uganda and we're looking to expand to other countries which is super exciting! If you're interested in how we select health center sites or more details about our general ops, check our website or send me a message I'd love to share more! Challenges in Assessing Cost-Effectiveness of OneDay Health Unfortunately, obtaining high-quality effectiveness data requires data from an RCT or a cohort study that would cost 5-10 times our current annual budget. So we've estimated our impact by estimating the DALYs our health centers avert through treating four common diseases and providing family planning. I originally evaluated this as part of my masters dissertation in 2019 and have updated it to more recent numbers. As we're assessing our own organisation, the chance of bias here is high. Summary of Cost-Effectiveness Model To estimate the impact of our health centers, we estimated the DALYs averted through treating individual patients for 4 conditions: malaria, pneumonia, diarrhoea, and STIs. We started with Ugandan specific data on DALYs lost to each condition. We then adjusted that data to account for the risk of false diagnosis and treatment failure (in which case the treatment would have no effect). We then added impact from family planning. Estimating impact per patient isn't a new approach. PSI used a similar method to evaluate their impact (with an awesome online calculator), but has now moved to other methods. Inputs for our approach Headline findings For each condition, we multiplied the DALYs averted per treatment by the average number of patients treated with that condition in one health center in one month. When we added this together that each ODH health center averted 13.70 DALYs per month, predominantly through treatment of malaria in all ages, and pneumonia in children under 5.ODH health centers are inexpensive to open and operate. Each health center currently needs only $137.50 per month in donor subsidies to operate. The remaining $262.50 in expenses are covered by small payments from patients. Many of these patients would have counterfactually received treatment, but would have incurred significantly greater expense to do so (mainly for travel). In addition, about 40% of patient expenses were for treating conditions not included in the cost-effectiveness analysis. We estimate that In one month, each health center averts 13.70 DALYs and costs $137.50 in donor subsidies. This is roughly equivalent to saving a life for $850, or more conservatively for $1766 including patient expenses. However, there is huge uncertainty in our analysis. The Analysis Measuring Impact by Estimating DALYs...

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Why I don't agree with HLI's estimate of household spillovers from therapy, published by JamesSnowden on February 24, 2023 on The Effective Altruism Forum. Summary In its cost-effectiveness estimate of StrongMinds, Happier Lives Institute (HLI) estimates that most of the benefits accrue not to the women who receive therapy, but to household members. According to HLI's estimates, each household member benefits from the intervention ~50% as much as the person receiving therapy. Because there are ~5 non-recipient household members per treated person, this estimate increases the cost-effectiveness estimate by ~250%. i.e. ~70-80% of the benefits of therapy accrue to household members, rather than the program participant. I don't think the existing evidence justifies HLI's estimate of 50% household spillovers. My main disagreements are: Two of the three RCTs HLI relies on to estimate spillovers are on interventions specifically intended to benefit household members (unlike StrongMinds' program, which targets women and adolescents living with depression). Those RCTs only measure the wellbeing of a subset of household members most likely to benefit from the intervention. The results of the third RCT are inconsistent with HLI's estimate. I'd guess the spillover benefit to other household members is more likely to be in the 5-25% range (though this is speculative). That reduces the estimated cost-effectiveness of StrongMinds from 9x to 3-6x cash transfers, which would be below GiveWell's funding bar of 10x. Caveat in footnote. I think I also disagree with other parts of HLI's analysis (including how worried to be about reporting bias; the costs of StrongMinds' program; and the point on a life satisfaction scale that's morally equivalent to death). I'd guess, though I'm not certain, that more careful consideration of each of these would reduce StrongMinds' cost-effectiveness estimate further relative to other opportunities. But I'm going to focus on spillovers in this post because I think it makes the most difference to the bottom line, represents the clearest issue to me, and has received relatively little attention in other critiques. For context: I wrote the first version of Founders Pledge's mental health report in 2017 and gave feedback on an early draft of HLI's report on household spillovers. I've spent 5-10 hours digging into the question of household spillovers from therapy specifically. I work at Open Philanthropy but wrote this post in a personal capacity. I'm reasonably confident the main critiques in this post are right, but much less confident in what the true magnitude of household spillovers is. I admire the work StrongMinds is doing and I'm grateful to HLI for their expansive literature reviews and analysis on this question. Thank you to Joel McGuire, Akhil Bansal, Isabel Arjmand, Alex Cohen, Sjir Hoeijmakers, Josh Rosenberg, and Matt Lerner for their insightful comments. They don't necessarily endorse the conclusions of this post. 0. How HLI estimates the household spillover rate of therapy HLI estimates household spillovers of therapy on the basis of the three RCTs on therapy which collected data on the subjective wellbeing of some of the household members of program participants: Mutamba et al. (2018), Swartz et al. (2008), Kemp et al. (2009). Combining those RCTs in a meta-analysis, HLI estimates household spillover rates of 53% (see the forest plot below; 53% comes from dividing the average household member effect (0.35) by the average recipient effect (0.66)). HLI assumes StrongMinds' intervention will have a similar effect on household members. But, I don't think these three RCTs can be used to generate a reliable estimate for the spillovers of StrongMinds' program for three reasons. 1. Two of the three RCTs HLI relies on to estimate spillovers are on in...

In this “Breathe Easy Critical Perspective” podcast, Dr. Dominique Pepper interviews Dr. Nina Andersen-Ranberg. They discuss her recent RCT published in the NEJM investigating haloperidol for delirium in ICU patients. Dr. Andersen-Ranberg is a physician undergoing her PhD training in Anesthesiology in Zealand University Hospital, Køge Denmark.

Amber Barnato is an expert in simulation studies.  A health services researcher and palliative care physician, Amber lauds the ability of simulation studies to isolate one variable in a study.  For example, we spend the first half talking about a RCT simulation study of clinician verbal and non-verbal communication with a seriously ill patient with cancer. In one room the physician under study interacts with a white patient-actor, and in another room interacts with a Black patient-actor.  They found no differences in verbal communication, but clear differences in non-verbal rapport building communication: physicians stood farther away, crossed their arms, didn't touch the Black patient as frequently.  Amber tells the moving story of how these findings led a clinical colleague, her chief, to question and change his behavior. Of note, we talked about implicit bias in depth in this podcast with Kimberely Courseen.  As we've written about on GeriPal when we were a blog (a decade ago!) these simulation studies can be used to study language, such as patient or surrogate choices when we use the terms “allow natural death” vs “do-not-resuscitate.”  This change in framing is a nudge, more evidence that the choices we make to use one phrase or another, or the order in which we present options, are all nudges that influence patient choice - listen to our podcast on the ethics of nudging with Jenny Blumenthal-Barby and Scott Halpern for more.     Additional links to simulation studies: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201411-495OC https://journals.lww.com/ccmjournal/Abstract/2011/07000/A_randomized_trial_of_the_effect_of_patient_race.9.aspx https://www.liebertpub.com/doi/full/10.1089/jpm.2015.0089 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687021/ https://journals.sagepub.com/doi/pdf/10.1177/0272989X14522099 Theoretical underpinnings: https://home.csulb.edu/~cwallis/382/readings/482/nisbett%20saying%20more.pdf

The Filtrate:Joel TopfSwapnil HiremathNayan AroraSophia AmbrusoWith Special Guest:Amit Garg @AmitXGarg, Nephrologist at Western University, London, and lead PI of the MYTEMP trial. Editor:Joel TopfShow Notes:MyTEMP in pubmed: Personalised cooler dialysate for patients receiving maintenance haemodialysis (MyTEMP): a pragmatic, cluster-randomised trialMyTEMP Summary on NephJC It's really cold in OntarioThe NephTrials blog summary on Pragmatic TrialsThe pragmatic TiME trial on longer time on dialysis (ahem, sabotaged by site investigators like Joel who cut dialysate time) Dember et al in JASNPoor quality of trial data preceding MyTEMP, a systematic review from Mustafa et al in JASN The 2007 European Best Practice Guideline (EBPG) from 2007, recommending “Cool dialysate temperature dialysis (35–36°C) or isothermic treatments by blood temperature controlled feedback should be prescribed in patients with frequent episodes of IDH (Evidence level I).” in NDT47% of centres from a DOPPS study of 273 centers routinely use of lower dialysate temperature, Dasgupta et al in JASNHow do you convert from C to F? Almanac.com (35.5 C is 96.9 F; 37 C is 98.6 F)More on the rationale and design of MyTEMP: Al-Jaishi et al in CJKHDHow big is 4.3 million (the number of hemodialysis treatments in MyTEMP)? Very big indeed.NephJC discussion of another cluster RCT and granular data only on a subset SSASS Participants in dialysis clinical trials are not representative of the real world dialysis cohorts, Smyth et al in JAMA Int MedPeritoneal dialysis numbers in Ontario are high, Blake et al in PDI, though with ~ 60% CVC rates, Blake et al in Kidney360Dialysate Magnesium #DreamRCT from Swap, NephTrials discussion of DialMagStatistical analysis plan of MyTEMP, Dixon et al in CJKHDTubular SecretionsSwap: Watch Everything, Everywhere All At Once on PrimeNayan: Read The Midnight Ride from Ben Mezrich (brother of Josh Mezrich from the NephJC Summer Book Club 2021)Sophia: Making nephrology education fun at the UC DenverAmit: The wrestling team at Western U from 1990-91Joel: House of the Dragon on HBO Max

Remember AIRWAYS-2, the British RCT comparing iGel to ETI in adults with cardiac arrest? Have you wondered if those results would hold up in a different prehospital population? Wonder no more. Dr. Jarvis reviews the SAVE Trial, another RCT of adult, non-traumatic cardiac arrest comparing iGel to ETI in Taiwan. Citation: 1. Lee AF, Chien YC, Lee BC, et al. Effect of Placement of a Supraglottic Airway Device vs Endotracheal Intubation on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest in Taipei, Taiwan: A Cluster Randomized Clinical Trial. JAMA Netw Open. 2022;5(2):e2148871. doi:10.1001/jamanetworkopen.2021.48871See omnystudio.com/listener for privacy information.

This week we are reviewing the CBP crew's recent RCT on forward head posture changes in a chiropractic care group vs a standard exercise group. Important to note is not only significantly greater change at 6 week mark, but the 3 month follow-up will astound you. Please subscribe/rate/review - and share this with a friend!

Episode SummaryIn this livecast episode, we welcome back Dr. Zain Chagla, Dr. Stefan Baral, and Dr. Sumon Chakrabarti to address some of the issues we've seen throughout the pandemic, new variants and what to expect with future variants, discussing what we've done well over the past few years, misinformation, the effect of social media and the messaging on Twitter, the role media plays and the influence of experts on policy, public health agencies, booster shots to combat new variants and who actually needs them, where we are at with public trust, and much more!SHOW SPONSORBETTERHELPBetterHelp is the largest online counselling platform worldwide. They change the way people get help with facing life's challenges by providing convenient, discreet and affordable access to a licensed therapist. BetterHelp makes professional counselling available anytime, anywhere, through a computer, tablet or smartphone.Sign up today: http://betterhelp.com/solvinghealthcare and use Discount code “solvinghealthcare"Thanks for reading Solving Healthcare with Dr. Kwadwo Kyeremanteng! Subscribe for free to receive new posts and support my work.Thank you for reading Solving Healthcare with Dr. Kwadwo Kyeremanteng. This post is public so feel free to share it.Transcript:KK: Welcome to ‘Solving Healthcare' I'm Kwadwo Kyeremanteng. I'm an ICU and palliative care physicianhere in Ottawa and the founder of ‘Resource Optimization Network' we are on a mission to transformhealthcare in Canada. I'm going to talk with physicians, nurses, administrators, patients and theirfamilies because inefficiencies, overwork and overcrowding affects us all. I believe it's time for a betterhealth care system that's more cost effective, dignified, and just for everyone involved.KK: All right, folks, listen. This is the first live cast that we have done in a very long time, probably a year.Regarding COVID, we're gonna call it a swan song, folks, because I think this is it. I'm gonna be bold andsay, this is it, my friends. I think what motivated us to get together today was, we want to learn, wewant to make sure we learned from what's gone on in the last almost three years, we want to learn that,in a sense that moving forward the next pandemic, we don't repeat mistakes. We once again, kind ofelevate the voices of reason and balance, and so on. So, before we get started, I do want to give acouple of instructions for those that are online. If you press NL into the chat box, you will be able to getthis. This recording video and audio sent to you via email. It'll be part of our newsletter. It's ballin, you'll,you'll get the last one the last hurrah or the last dance, you know I'm saying second, secondly, I want togive a quick plug to our new initiative. Our new newsletters now on Substack. Everything is on therenow our podcasts our newsletter. So, all the updates you'll be able to get through there. I'm just goingto put a link in the chat box. Once I find it. Bam, bam, bam. Okay, there we go. There we go. That's itright there, folks. So, I feel like the crew here needs no introduction. We're gonna do it. Anyway, we gotDr. Zain Chagla, we got Dr. Stef Baral, we got Dr. Sumon Chakrabarti back in full effect. Once again, like Isaid, we were we chat a lot. We were on a on a chat group together. We were saying how like, we justneed to close this out, we need to address some of the issues that we've seen during the pandemic. Talkabout how we need to learn and deal with some of the more topical issues du jour. So, I think what we'llstart with, well get Sumon to enter the building. If you're on Twitter, you're gonna get a lot of mixedmessages on why you should be fearful of it or why not you should be fearful of it. So, from an IDperspective, Sumon what's your what's your viewpoint on? B 115?SC: Yeah, so, first of all, great to be with you guys. I agree, I love doing this as a as a swan song to kind ofmove to the next stage that doesn't involve us talking about COVID all the time. But so yeah, I think thatwe've had a bit of an alphabet soup in the last year with all these variants. And you know, the most oneof the newest ones that we're hearing about recently are BQ 1, xBB. I think that what I talked aboutwhen I was messaging on the news was taking a step back and looking at what's happened in the last 14months. What that is showing us is that we've had Omicron For this entire time, which suggests a levelof genomic stability in the virus, if you remember, variants at the very beginning, you know, that wassynonymous with oh, man, we're going to have an explosion of cases. Especially with alpha for the GTAdelta for the rest of, of Ontario, and I'm just talking about my local area. We saw massive increases inhospitalizations, health care resources, of patients having been sent all over the province. So, it was itwas awful, right. But you know, I think that was a bit of PTSD because now after anybody heard theword variant, that's what you remember. As time has gone on, you can see that the number ofhospitalizations has reduced, the number of deaths has reduced. Now when omicron came yeah, therewas an explosion of cases. But you know, when you look at the actual rate of people getting extremely illfrom it, it's much, much, much less. That was something that, you know, many of us were secretlythinking, Man, this is great when this happened. So now where we are is we're in January 2023, we'vehad nothing but Omicron, since what was in late November 2020, or 21? Maybe a bit later than that.And x BB, if you remember, be a 2x BB is an offshoot of BH two. Okay. Yeah, if you're noticing all thesenew variants are their immune evasive, they tend to be not as they're not as visually as, I see this in myown practice, like all of us do here. You know, they are, well, I'm kind of piecemeal evolution of thevirus. Now, there's not one variant that's gonna blow all the other ones out of the water, like Oh, microndid or delta. Right. I think this is a good thing. This is showing that we're reaching a different stage of thepandemic, which we've been in for almost a year now. I think that every time we hear a new one, itdoesn't mean that we're back to square one. I think that this is what viruses naturally do. And I thinkputting that into perspective, was very important.KK: Absolutely. Zain just to pick your brain to like, I got this question the other day about, like, what toexpect what future variants like, obviously, is there's no crystal ball, but someone alluded to the ideathat this is what we're to expect. You feel the same?ZC: Yeah, absolutely. It's interesting, because we have not studied a Coronavirus this much, you know, inhistory, right. Even though we've lived with coronaviruses, there probably was a plague ofcoronaviruses. What was the Russian flu is probably the emergence of one of our coronaviruses areseasonal coronaviruses. You know, I think we had some assumptions that Coronavirus is when mutate,but then as we look to SARS, cov two and then we look back to see some of the other Coronavirus has,they've also mutated quite a bit too, we just haven't, you know, put names or other expressions tothem. This is part of RNA replication of the virus is going to incorporate some mutations and survival ofthe fittest, the difference between 2020, 2021, 2022, and now 2023 is the only pathway for this virus tokeep circulating is to become more immune evasive. This is what we're seeing is more immune evasion,we're seeing a variant with a couple more mutations where antibodies may bind a little bit less. But Ithink that the big difference here is that that protection, that severe disease, right, like the COVID, thatwe saw in 2020/2021, you know, that terrible ICU itis, from the COVID, you know, for the level ofantibody T cell function, non-neutralizing antibody functioning mate cell function, all of that that's builtinto, you know, humanity now through infection, vaccine are both really, you know, the virus can evolveto evade some of the immunity to cause repeat infections and, you know, get into your mucosa andreplicate a bit, the ability for the virus to kind of, you know, cause deep tissue infection lead to ARDSlead to all of these complications is getting harder and harder and harder. That's us evolving with thevirus and that's, you know, how many of these viruses as they emerge in the population really have kindof led to stability more than anything else? So, yes, we're going to see more variants. Yes, you know, thisis probably what what the future is, there will be some more cases and there may be a slight tick inhospitalizations associated with them. But again, you know, the difference between 2020/2021/2022/2023 is a syrup prevalence of nearly 100%. One way or another, and that really does define how thisdisease goes moving forward.KK: Yeah, absolutely. Maybe Stef we could pipe it a bit on, the idea that, first of all, I just want toreinforce like as an ICU doc in Ottawa with a population of over a million we really have seen very littleCOVID pneumonia since February 2022. Very minimal and it just goes to show know exactly whatSumon and Zain were alluding to less virulent with the immunity that we've established in thecommunity, all reassuring science. One question I want to throw towards Stef, before getting into it. Youdid an interview with Mike Hart. As you were doing this interview, I was going beast mode. I was hearingStef throw down. I don't know if you were, a bit testy that day, or whatever. There was the raw motionof reflecting on the pandemic, and how we responded and far we've gone away from public healthprinciples, was just like this motivator to say, we cannot have this happen again. I gotta tell you, boys,like after hearing that episode, I was like ‘Yeah, let's do this'. Let's get on. Let's go on another, doanother show. I'm gonna leave this fairly open Stef. What has been some of the keyways we'veapproached this pandemic that has really triggered you?SB: Yeah, I mean, so I guess what I'd say is, in some ways, I wish there was nobody listening to this rightnow. I wish there was like, I don't know what the audience is. I don't know if it's 10 people or underpeople, but I think it's like, I wish nobody cared anymore. I want Public Health to care. I want doctors tocare, we're going to keep talking because you know, Kwadwo, you've had folks in the ICU we we'vewe've seen cases in the shelters, we have outbreaks, like public health is always going to care aboutCOVID, as it cares about influenza cares about RSV, and other viruses, because it needs to respond tooutbreaks among vulnerable folks. That will never stop COVID, it was just clear very early, that COVID isgoing to be with us forever. So that means tragically, people will die of COVID people. I think that, youknow, there's that that's a reality, it's sometimes it's very close to home for those of us who areproviders, as it has for me in the last week. So COVID never ends. I think the issue is that like when doesCOVID And as a matter of worthy of discussion for like the average person? The answer is a long timeago. I mean, I think for the folks that I've spoken to, and the way that we've lived our lives as a family isto focus on the things that like bring folks joy, and to kind of continue moving along, while also ensuringthat the right services are in place for folks who are experiencing who are at risk for COVID and seriousconsequences of COVID. Also just thinking about sort of broader systems issues that I think continue toput folks at risk. So, one: I think it's amazing, like how little of the systematic issues we've changed,we've not improved healthcare capacity at all. Amazingly, we've not really changed any of the structuresthat put our leg limitations on the on the pressures on the health system, none of that has changed. Allof it has been sort of offset and downloaded and just like talking about masks and endless boosterswhen we've never really gotten to any of the meaty stuff. As you said three years into it, andeverybody's like, well, it's an emergency. I'm like, it was an emergency and fine. We did whatever wasneeded, even if I didn't agree with it at the time. But irrespective of that, whatever that was done wasdone. But now it's amazing that like the federal money expires for COVID In next few months, and allwell have shown for this switch health guys got became millionaires like a bunch of people, I don't mindnaming and I don't care anymore. These folks, these Grifters went out and grabbed endless amounts ofmoney. These cash grabs that arrival, the ArriveCan app with, like these mystery contractors that theycan't track down millions of dollars. So it's like all these folks like grabbed, you know, huge amounts ofmoney. And I think there's a real question at the end of it of like, what are we as a country? Or youknow, across countries? What do you have to show for it? How are you going to better respond? Andthe answer right now is like very little, like we have very little to show for all this all these resources thathave been invested, all this work that has been done. That I think should be the conversation. That tome needs to be this next phase of it is like billions and billions and billions of dollars trillion or whatever,like 10s of billions of dollars were spent on what? and what was achieved? And what do we want to donext time? And what do we have to show for it? that, to me feels like the meat of the conversationrather than like silly names for these new variants that do nothing but scare people in a way that isn'thelpful. It does not advance health. It doesn't you know, make the response any more helpful. It justscares people in a way that I think only detracts them from seeking the care that we want them to beseeking.KK: Yeah, I think you brought up a point to about or alluded to how some of this was the distraction.That was one of the points that really stuck home is that we, we didn't really dive into the core s**t, thecore issues. This is why at the end of it all, are we that much more ready for the next pandemic that wellsee, you know, and so like maybe Sumon, what do you think in terms of another tough one, are weready for the next pandemic? Do you think we've done enough? do we think are in terms of what we'veinvested in, how we've communicated to the public. The messaging to the public. Are we learning? Is myquestion, I guess.SC: I'm a clinician and I don't work with the public health and the policy aspect as closely as Stefan does.But I will say that, obviously, I've been in this realm for quite a long time, since in ID, I think that, youknow, what that's important to remember is that for SARS 1 we actually had this document thatoutlined all of this, you know, masking, social distancing, what to do with funding and all that kind ofstuff. Basically, I was actually interviewed about this, I remember back way back in 2020, and half of itwas basically just thrown out the window. I think that a lot of what happened is that fear came indecisions were made from emotion, which is, by the way, understandable, especially in April 2020. I'veshared with you guys before that, in February 2020, I was waking up at night, like nervous, that I wasgonna die. I that that's where I was thinking I it was, it was terrible. I completely understand makingthose decisions. I think as time went on, I wish that, you know, there's a bit more of public healthprinciples. You know, making sure that we're dealing with things without, you know, stepping onpeople's bodily autonomy, for example, you know, doing things in an equitable way, where you, youknow, we all know that every intervention that you do is squeezing a balloon, you must remember theunintended consequences, I think that we did. So, kind of putting that all together. I think, right now, aswe stand in Canada if we do have another pandemic. I fear that a lot of these same mistakes are goingto be made again, I should say, a disruptive pandemic of this because it's not forgotten H1N1, thepandemic it that was a pandemic, right. It wasn't nearly as disruptive as COVID was, but I do think thatinquiry and like you mentioned at the beginning, Kwadwo was talking about what we did, well, we didn'tdo well, and making sure the good stuff happens, and the bad stuff doesn't happen again, because this islikely not the last pandemic, in the information age in our lifetimes.KK: Zain, was there anything that stuck out for you? In terms of what you'd really want to see usimprove? Or whether it is messaging, whether it is public health principles, does any of those stick out inyour mind?ZC: Yeah, I mean, I think the one unique thing about this pandemic that is a lesson moving forward andfor us to kind of deal with I think we talked about messaging. This was the first major pandemic thatoccurred with social media and the social media era, right, and where, information, misinformation,disinformation, all the things that were all over the place, you know, we're flying, right, and there doesneed to be some reconciliation of what's been we have to have some reconciliation of some of thebenefits of the social media era in pandemic management, but also the significant harms the people,you know, we're scared that people got messaging that may not have been completely accurate, thatpeople had their biases as they were out there. I will say even that social media component penetratedinto the media. This is also the first time that I think we saw experts you know, including myself andSuman and all of us you know, that you know, could be at home and do a news interview on NationalNews in five minutes and be able to deliver their opinion to a large audience very quickly. So, you know,I think all of that does need a bit of a reconciliation in terms of what worked, what doesn't how youvalidate you know, good medical knowledge versus knowledge that comes from biases how we evaluatepsi comm and people you know, using it as a platform for good but may in fact be using it you know,when or incorporating their own biases to use it for more, more disinformation and misinformationeven if they feel like they have good intentions with it. I you know, I think this is a, you know, for thesociologists and the communications professionals out there, you know, really interesting case exampleand unfortunately, I don't think we came out the other side. Social media being a positive tool, it mayhave been a positive tool, I think in the beginnings, but, you know, I think I'm finding, it's nice tocommunicate with folks, but I'm finding more harm and more dichotomy and division from social mediathese days is compared to the beginnings of the pandemics where, you know, I think, again, there's justbeen so much bias, so much misinformation so much people's clouds and careers that have been, youknow, staked on social media that it's really become much, much harder to figure out what's real andwhat's not real in that sense.KK: Absolutely, I fully agree Zain. At the beginning, in some ways, I'll tell you, ICU management, thatwhole movement for us to delay intubation, as opposed to intubation early, I really think it was pushedby in social media. So, I think it saved lives, right. But then, as we got through more and more thepandemic, wow, like it, like the amount of just straight up medieval gangster s**t that was going on thatin that circle, in that avenue was crazy. Then just like, I mean, this might be controversial to say, I don'tknow, but news agencies got lazy, they would use Twitter quotes in their articles as, evidence, or asproof of an argument. It's like, what is happening? It? Honestly, when you think about it, it was it wascrazy. It still is crazy.ZC: Yeah. And I think expertise was another issue. Right. And, you know, unfortunately, we know of, youknow, certain experts that were not experts that weren't certified that weren't frontlines and a varietyof opinions and various standpoints and epidemiology, public health, intensive care, infectious diseases,whatever is important. But, you know, there were individuals out there that had zero experience thatwere reading papers and interpreting them from a lens of someone that really didn't have medicalexperience or epidemiologic experience, that chased their clout that made money and, we know someexamples that people that eventually had the downfall from it, but you know, at the end of the day,those people were on social media, and it penetrated into real media, and then that is a real lesson forus is that validation of expertise is going to be important. You know, as much as we allow for anyone tohave an opinion, you know, as they get into kind of real media, they really have to be validated that thatopinion comes from a place that's evidence based and scientific and based on a significant amount oftraining rather than just regurgitating or applying one small skill set and being an expert in many otherthings.KK: SumonSC: So we're just gonna add really quickly is that, in addition to what Zain saying. When this stuff bledover from social media to media, the thing that I mean, at least what it seemed like is he was actuallyinfluencing policy. That's, I think that's the important thing is, so you can have 10 people 20 peopleyelling, it doesn't matter if they're extreme minority, if it's influencing policy that affects all of us, right.So, I think that's important.KK: I'll be honest with you, like, I got to the point where I really hated Twitter, I still kind of hate Twitter.Okay. It was conversation. I remember Sumon that you and I had I don't remember it was we weretexting. I think we talked about this. But the fact that policy could be impacted by what we're throwingdown the facts or the messages that we were doing on media that this can impact policy, you had tolike, especially when there was some badness happening, we had to step up. We had to be a voice oflogic, whether it was mandates, whether it was you know, lockdown school closures, whatever it mighthave been like, the politicians, we heard about this politicians looking at this, the mainstream medialooking at this, and for us not to say anything at this point, like we had, we had to do something Sorry,Stef, you're gonna jump in?SB: Yeah, I think I think what was interesting to me to see and I think a clear difference between H1N1was that in a lot of places, and including in Ontario, across the US, where this sort of emergence of theselike the science tables, these task forces, these whatever you want to call them, it was like a new bodyof people often whom had never spent a day in a public health agency. Often academics that you know,are probably good with numbers, but really don't have a lot of experience delivering services, you know,all of a sudden making decisions. So I think there's a real interesting dynamic that when you compare,for example, Ontario and British Columbia, one has this science table one does not, and just howdifferent things played out, I mean, given it's a, you know, an end of have to, or no one in each camp,but I think what you see is like, there's a place there where like public health or you know, let's say,Sweden, you know, as a public health agency that didn't strike up its own taskforce that used itstraditional public health agency. I think was in a place to make more like reasoned and measureddecisions, and just was better connected, like the relationships exist between the local healthauthorities and the provincial health authorities and the national ones. I think when you set up these,the one thing that I hope we never do, again, is that something like the science table never happensagain. That's not to sort of disparage most of the people. Actually, most of the folks on the science tableI like, and I respect, say many of them, maybe not most, but many of them, I like and respect, but it isthe case that there was it was they weren't the right group of people. They weren't representativeOntarians he was like, ten guys and two women, I think, I don't know many of them white, they weren'trepresentative socio economically, racially diverse, anything. They didn't have the right expertise onthere. I would have liked to see some like frontline nurses on there to say ‘listen, this stuff is silly' orsome frontline, whoever just some frontline folks to be say ‘listen, none of the stuff that you're sayingmakes any sense whatsoever'. And luckily, there was some reason, voices on there, but they were theminority. But luckily, they prevailed, or we would have had outdoor masking and even tougherlockdowns. I don't know how folks really; it was really close. I think we fortunately had thatrepresentation, but that should have never even happened, we should have had public health Ontario,being its agency and making recommendations to the ministry and to the government. There shouldhave never been a science table. Then second thing, I just want to say I've we've talked about thisforever and I do think we should talk about this more, not in the context of like this, this podcast, but isalso just absolutely the role of the media. I do want to say that, like historically, media had to do a lot ofwork, they had to go to universities or hospitals and ask for the right expert, and then the media orcomms team, ‘you should really talk to Zain Chagla' Because he has good example, you know, it givesgood expertise on this or you start to like, I don't know, like Dr. so and so for this or that, and they puttogether the right person, they organize the time and then they talk. Now you know that it was reallylike the story I think was more organically developed on based on what the experts had to say. Nowyou've got reporters, for people who are not from Ontario, there's a sports reporter in the city ofToronto that I looked historically, I can't see that they've ever done anything in public health suddenlybecame like the COVID reporter in the city of Toronto, for a major newspaper. It's like this person hasnot a clue of what they're talking about, just like has no clue they've never trained in. I don't disparagetheir sports reporter like why should they? but they became the voice of like public health for like theaverage person. It just it set us up where that person just had a story and then just found whateverpeople on Twitter that they could to like back up their story irrespective to drive controversy, to driveanger towards the government based on sort of political leanings. Even if maybe my political leaningsare aligned with that person, it's a relevant because it's not about politics, it's about public health. So Ithink the media, we have to think about, like, how do we manage the media's need for clicks and profit,you know, during this time, in with, like, their role as like, the responsible are an important part of like,you know, social functioning, in terms of the free press. So, I, there's no easy answers to that. But I'll justsay, I think there was a fundamentally important role that the media played here. And I have to say, itdidn't play out positively, in most places.KK: I gotta say, like, this is gonna be naive talk. But we're in a pandemic, there had to be so many of ushad a sense of duty, like, I was surprised at the lack of sense of duty, to be honest with you. Even if youare about your cliques, ask yourself, is this is this about the greater good here? Is this really gonna get usfurther ahead? I've said this a few times on my platform, I would have a balance of a mess. The balancedmessage on was usually one specific network that would bail on the interview. They would literally bailon the interview because my message might not be as fearful. What the actual f you know what I mean?Like it's crazy.(?) I will say there were some good reporters. I don't want to say that that you know, there were someincredible folks. I was talking to someone the other day, I won't mention who but I think the mark of thegood reporter was, you know, they have a story, they want to talk about it. They contacted us. And theysaid, what time can we talk this week, right? They didn't say I need to get this filed in three hours. If yousay you need to get this filed in three hours, the expert you're gonna go to is the one that's available inthe next three hours, right? They wanted to hear an opinion, they wanted to get multiple opinions onthe table, but they would carve out the time so that everyone could give their story or, what theiropinion was or what evidence they presented. They made sure it rotated around the experts rather thanthe story rotating around being filed. I think it's important and, you know, you can get a sense of certainthings that are on the need to be filed this day, or even on the 24/7 news cycle, where they may not beas well researched, they're they're a single opinion. They're quoting a Twitter tweet. Now, I think insome of these media platforms, you can just embed that Twitter tweet, you don't even have to, youknow, quote it in that sense, you just basically take a screenshot of it basically. Versus again, thosearticles where I think there was there more thought, and I think there were some great reporters inCanada, that really did go above and beyond. Health reporters, particularly that really did try to presenta picture that was well researched, and evidence based, you know, with what's available, but therecertainly are these issues and it's not a COVID specific issue, but with media ad reporting, in that sense.Yeah, it's and it's important to say like, it's not actually just the reporter, it's the editors, its editorialteams, like I had said, OTR discussions with reporters very early on, I've tried to stay away from themedia, because I think the folks who have done it, I've done it well. But it was interesting, because BobSargent, who sadly passed away, an internal medicine physician, and an amazing mentor to manyclinicians in Toronto. Put me in touch with a couple of reporters. He's like, you know, you're a publichealth person, you should really talk to these reports. We had this; can we talk to you privately? It wasso weird. This was summer of 2020. So, we had a very private discussion where I said ‘Listen, I haveconcerns about lockdowns for like, these reasons' I think it's reasoned, because it's not it, I've got noconspiracy to drive, like, I've got no, there's no angle in any of it. So, but it was just fascinating. So, theywere like we might be able to come back to you, and maybe we'll try to do a story around it. Then theycame back and said, we're not going to be able to pursue it. I said that's fine. It's no problem. It just sortof showed that I think, similar as academics, and clinicians, and all of us have been under pressure basedon everything from like CPSO complaints, the complaints to our employers, to whatever to just saw, youknow, the standard attacks on Twitter. I think there was also a lot of pressure on reporters based on thiswhole structure, and of it. So I think, I don't mean to disparage anybody, but I do think the point thatyou made is really important one is. I'll just say, in our own house, you know, my wife and I both werelike talking at the beginning of this and being like, what do we want to know that we did during thistime? So, my wife worked in person, as a clinician alter her practice all throughout her pregnancy? Shenever didn't go, you know, she did call she did all of that, obviously, I have done the work I've done interms of both clinically and vaccine related testing. But this just idea of like, what do you want toremember about the time that you would like what you did when s**t hit the fan? And, you know,because first, it'll happen again, but just also, I think it's important to sort of, to be able to reflect andthink positively about what you did. Anyways,KK: I hear you both, part of it, too, for me, I'll just straight up honesty. In some ways, I'm just pissed, I'mpissed that a lot of the efforts that were that a lot of people put into to try and get a good message outthere. The backlash. Now people reflecting saying, ‘Oh, I guess you did, you know, many of you do tohad a good point about lockdowns not working out'. I know it may be childish in some way, but it's just,you know, a lot of us have gone through a lot to just try and create a balanced approach. I think therewas a little bit of edge in this voice, but I think it comes with a bit of a bit of reason to have a bit of edge.I think in terms of the next couple questions here are areas to focus on. A lot of people in terms of like,decisions regarding mandates, boosters, and so forth, like we talk a lot about it on public health, it's thedata that helps drive decisions, right. That's really what you would think it should be all about. So, one ofthe many questions that were thrown to us, when we announced that this was happening was, the needfor like, almost like universal boosters, and Sumon, I'll put you on the spot there, at this stage in thepandemic, where I'm gonna timestamp this for people on audio, we're on January 10th, 2023. There aresome questions that we get, who really needs to push through to we all need boosters? What's yourthoughts on that?SC: So, I think that one of the things that I said this, as Zain makes fun of me throughout the pandemic, Icame up with catchphrases, and my one for immunity is the way that we've conceptualized immunity inNorth America. I think a lot of this has to do with an actual graphic from the CDC, which likens immunityto an iPhone or a battery, iPhone battery. So, iPhone immunity, where you have to constantly berecharging and updating. I think that has kind of bled into the messaging. That's what we think of it. Iremember back in I think it was October of 2021, where they were also starting to talk about the thirddose. The third dose, I think that at that time, we knew that for the higher risk people, it was probablythe people who would benefit the most from it. We had Ontario data from it was I think, was ISIS.There's vaccine efficacy against hospitalization, over 96% in Ontario in health care workers 99%, if you'reless than seventy-seven years of age, yet this went out, and everybody felt like they had to get thebooster. So, I think that the first thing that bothered me about that is that there wasn't a kind ofstratified look at the risk level and who needs it? So now we're in 2023. I think that one of the big thingsapart from what I said, you know, who's at higher risk, there's still this problem where people think thatevery six months, I need to recharge my immunity, which certainly isn't true. There wasn't a recognitionthat being exposed to COVID itself is providing you a very robust immunity against severe disease, whichis kind of it's coming out now. We've been we've all been talking about it for a long time. And you know,the other thing is that the disease itself has changed. I think that I heard this awesome expression, thefirst pass effect. So, when the COVID first came through a completely immune naive population, ofcourse, we saw death and morbidity, we saw all the other bad stuff, the rare stuff that COVIDencephalitis COVID GB GBS tons of ECMO, like 40-year old's dying. With each subsequent wave asimmunity started to accrue in the population, that didn't happen. Now we're at a different variant. Andthe thing is, do we even need to be doing widespread vaccination when you're with current variant, andyou can't be thinking about what we saw in 2021. So, putting that now, all together, we have as Zanementioned, seroprevalence, about almost 100%, you have people that are well protected against severedisease, most of the population, you have a variant that absolutely can make people sick. And yes, it cankill people. But for those of us who work on the front line, that looks very different on the on the frontlines. So, I really think that we should take a step back and say, number one: I don't think that thebooster is needed for everybody. I think number two: there are under a certain age, probably 55 andhealthy, who probably don't need any further vaccination, or at least until we have more data. Numberthree: before we make a widespread recommendation for the population. We have time now we're notin the emergency phase anymore. I really hope that we get more RCT data over the long term to seewho is it that needs the vaccine, if at all. And you know, who benefits from it. And let's continue toaccrue this data with time.KK: Thanks Sumon. Zain, are you on the along the same lines assume on in terms of who needs boostersand who doesn't?ZC: Yeah, I mean, I think number one: is the recognition that prior infection and hybrid immunityprobably are incredibly adequate. Again, people like Paul Offit, and we're not just talking about youknow, experts like us. These are people that are sitting on the FDA Advisory Committee, a man thatactually made vaccines in the United States, you know, that talks about the limitations of boosters andprobably three doses being you know, The peak of the series for most people, and even then, you know,two plus infection probably is enough is three or even one plus infection, the data may suggest maybe isas high as three. Yeah, I think, again, this is one of these things that gets diluted as it starts going downthe chain, if you actually look at the Nazi guidance for, you know, bi-Vaillant vaccines, it's actuallyincorporates a ‘should' and a ‘can consider' in all of this, so they talked about vulnerable individuals,elderly individuals should get a booster where there may be some benefits in that population, the restof the population can consider a booster in that sense, right. And I think as the boosters came out, andagain, you know, people started jumping on them, it came to everyone needs their booster. Andunfortunately, the messaging in the United States is perpetuated that quite a bit with this iPhonecharging thing, Biden tweeting that everyone over the age of six months needs a booster. Again, wereally do have to reflect on the population that we're going at. Ultimately, again, if you start pressing theissue too much in the wrong populations, you know, the uptake is, is showing itself, right, the peoplewho wanted their bi-Vaillant vaccine got it. Thankfully the right populations are being incentivized,especially in the elderly, and the very elderly, and the high risk. Uptake in most other populations hasbeen relatively low. So, people are making their decisions based on based on what they know. Again,they feel that that hesitation and what is this going to benefit me? and I think as Sumon said, theconfidence is going to be restored when we have better data. We're in a phase now where we can docluster randomized RCTs in low-risk populations and show it If you want the vaccine, you enter into acluster randomized RCT, if you're in a low-risk population, match you one to one with placebo. You wecan tell you if you got, you know, what your prognosis was at the end of the day, and that information isgoing to be important for us. I don't think that policy of boosting twice a year, or once a year is gonnaget people on the bus, every booster seems like people are getting off the bus more and more. So, wereally do have to have compelling information. Now, as we're bringing these out to start saying, youknow, is this a necessity? especially in low-risk populations? How much of a necessity is that? How muchdo you quantify it in that sense? And again, recognizing that, that people are being infected? Now, thatadds another twist in that sense.KK: Yeah, and we'll talk a little bit about public trust in a bit here. But Stef, you were among someauthors that did an essay on the booster mandates for university students. As we've both alluded toZain, and Sumon there's this need to be stratified. From an RCT booster point of view that we're not wellestablished here. When Stef's group looked at university mandates and potential harm, when we'redoing an actual cost benefit ratio there, their conclusion was that there's more room for harm thanbenefits. So, Stef I want you to speak to that paper a bit.SB: Sure. So, I will say this, I don't actually have much to add other than what Zain and Sumon said. Runa vaccine program we are offering, you know, doses as it makes sense for folks who are particularlyimmunocompromised, multiple comorbidities and remain at risk for serious consequences related toCOVID-19. We'll continue doing that. And that will, you know, get integrated, by the way into like, sortof a vaccine preventable disease program, so offering, shingles, Pneumovax, influenza COVID. And alsowe want to do a broader in terms of other hepatitis vaccines, etc. That aside, so this, this isn't about, youknow, that it was really interesting being called antivax by folks who have never gotten close to avaccine, other than being pricked by one. Having delivered literally 1000s of doses of vaccine, so it'salmost it's a joke, right? but it's an effective thing of like shutting down conversation. That aside, I thinkthere's a few things at play one as it related to that paper. I find it really interesting, particularly foryoung people, when people are like, listen, yes, they had a little bit of like, inflammation of their heart,but it's self-resolving and self-limiting, and they're gonna be fine. You don't know that. Maybe sure we'llsee what happens with these folks twenty years later. The reality is for younger men, particularly, thishappens to be a very gender dynamic. For younger men, particularly, there seems to be a dynamicwhere they are at risk of myocarditis. I don't know whether that's a controversy in any other era for anyother disease, this would not be a controversy would just be more of a factual statement, the data wereclearer in I'd say, probably April, May 2021. I think there's lots of things we could have done, we couldhave done one dose series for people who had been previously infected, we could have stopped at two.There are a million different versions of what we could have done, none of which we actually did. In thecontext of mandating boosters now for young people, including at my institution, you were mandated toget a booster, or you would no longer be working. So obviously, I got one. There's a real dynamic ofwhat is it your goal at that point? because probably about 1011 months into the vaccine programbecame increasingly clear. You can still get COVID. Nobody's surprised by that. That was clear even fromthe data. By the way, wasn't even studied. I mean, Pfizer, the way if you just look at the Pfizer, Moderna,trials, none and look to see whether you got COVID or not, they were just looking at symptomaticdisease. That aside, I think that it just became this clear thing where for younger men, one or two doseswas plenty and it seems to be that as you accumulate doses for those folks, particularly, it's alsoimportant, if somebody had a bad myocarditis, they're not even getting a third dose. So, you're alreadyselecting out, you know, some of these folks, but you are starting to see increased levels of harm, as itrelated to hospitalization. That what we basically did, there was a very simple analysis of looking ataverted hospitalization, either way, many people say that's the wrong metric. You can pick whatevermetric you want. That's the metric we picked when terms of hospitalization related to side effects of thevaccine versus benefits. What it just showed was that for people under the age of 30, you just don't seea benefit at that point, as compared to harm that's totally in fundamentally different. We weren't talkingabout the primary series, and we weren't talking about older folks. So indeed, I think, you know, thatwas that was I don't know why it was it was particularly controversial. We it was a follow up piece tomandates in general. I'll just say like, I've been running this vaccine program, I don't think mandateshave made my life easier at all. I know, there's like this common narrative of like mandates, you know,mandates work mandates work. I think at some point, and I'll just say our own study of this is like we'rereally going to have to ask two questions. One: what it mandates really get us in terms of a burdenCOVID-19, morbidity, mortality? and two: this is an important one for me. What if we caught ourselvesin terms of how much pressure we put on people, as it relates to vaccines right now, in general? Thevery common narrative that I'm getting is they're like, oh, the anti Vax is the anti Vax folks are winning.And people don't want their standard vaccines, and we're getting less uptake of like, MMR andstandard, you know, kind of childhood vaccines, I have a different opinion. I really do at least I believesome proportion of this, I don't know what proportion, it's some proportion, it's just like people beingpushed so hard, about COVID-19 vaccines that they literally don't want to be approached about anyvaccine in general. So, I just think that with in public health, there's always a cost. Part of the decisionmaking in public health as it relates to clinical medicine too. It's like you give a medication, theadvantage and then you know, the disadvantages, side effects of that medication. In public health, thereare side effects of our decisions that are sometimes anticipated and sometimes avoidable, sometimescan't be anticipated and sometimes can't be avoided. You have to kind of really give thought to each ofthem before you enact this policy or you might cost more health outcomes, then then you're actuallygaining by implementing it.KK: Yeah, number one: What was spooky to me is like even mentioning, I was afraid even to use a termmyocarditis at times. The worst part is, as you said, stuff, it's young folk that were alluding to, and for usto not be able to say, let's look at the harm and benefit in a group that's low risk was baffling. It reallywas baffling that and I'm glad we're at least more open to that now. Certainly, that's why I thought thatthe paper that you guys put together was so important because it's in the medical literature that we'reshowing, objectively what the cost benefit of some of these approaches are. Sumon: when you think ofmandates and public trust, that Stef was kind of alluding to like, every decision that we madethroughout this thing. Also has a downside, also has a cost, as Stef was mentioning. Where do you thinkwe are? In terms of the public trust? Talking about how the childhood vaccines are lower. I don't knowwhat influenza vaccine rates are like now, I wouldn't be surprised if they're the same standard, but whoknows them where they're at, currently. Based on your perspective, what do you think the public trust isright now?SC: Yeah, as physicians, we obviously still do have a lot of trust in the people we take care of. People arestill coming to see us. I wish they didn't have to because everyone was healthy but that's not the case. Ido think that over the last two and a half, we're coming up on three years, I guess right now, that peoplethat we have burned a lot of trust, I think that mandates were part of it. I do think that some of it wasunavoidable. It's just that there's a lot of uncertainty. There was back and forth. I think that one thingthat were that concern me on social media was that a lot of professionals are airing their dirty laundry tothe public. You could see these in fights, that doesn't, that's not really a good thing. We saw peoplebeing very derisive towards people who were not listening to the public health rules. You know what Imean? There's a lot of that kind of talk of othering. Yeah, I think that that certainly overtime, erodedpublic trust, that will take a long time to get back, if we do get it back. I think that the bottom line is that,I get that there are times that we have to do certain things, when you have a unknown pathogen comingat you, when you don't really know much about it. I do think that you want to do the greatest good forthe, for the population or again, you always must remember as Stefan alludes to the cost of what you'redoing. I do think that we could have done that much early on. For example, Ontario, we were lockeddown in some areas, Ontario, GTA, we were locked down in some regard for almost a year and a half. Ifyou guys remember, there was that debate on opening bars and restaurants before schools. It's just like,I remember shaking my head is, look, I get it, I know you guys are talking about people are going to beeating a burger before kids can go to school, that might ruin everything. But the problem is, is that youmust remember that restaurant is owned by someone that small gym is someone's livelihood, you'remoralizing over what this is, but in the end, it's the way somebody puts food on the table. For a yearand a half, we didn't let especially small businesses do that. I'm no economist, but I had many familymembers and friends who are impacted by this. Two of my friends unfortunately, committed suicideover this. So, you know, we had a lot of impact outside of the of the things that we did that hurt people,and certainly the trust will have to be regained over the long term.KK: It's gonna take work. I think, for me, honestly, it's, it's just about being transparent. I honestly, I putmyself in some in the shoes of the public and I just want to hear the truth. If we're not sure aboutsomething, that's okay. We're gonna weigh the evidence and this is our suggestion. This is why we'resaying this, could we be wrong? Yes, we could be wrong but this is what we think is the best pathforward, and people could get behind that. I honestly feel like people could get behind that showing alittle bit of vulnerability and saying ‘you know, we're not know it alls here' but this is what our beststrategy is based on our viewpoint on the best strategy based on the data that we have in front of usand just be open. Allowing for open dialogue and not squash it not have that dichotomous thinking ofyou're on one side, you're on the other. You're anti vax, you're pro vax, stop with the labels. You know,it's just it got crazy, and just was not a safe environment for dialogue. And how are you supposed to he'ssupposed to advance.SB: Yeah, I do want to say something given this this is this idea of our swan song. I think there was thissort of feeling like, you know, people were like ‘you gotta act hard, you gotta move fast' So I thinkeverybody on this, you guys all know I travel a lot. I like to think of myself as a traveler. In the early2020's I did like a COVID tour, I was in Japan in February, then I was in Thailand, and everywhere Ilanded, there were like, COVID here, COVID here, COVID here. Then finally, I like got home at the end ofFebruary, and I was supposed to be home for like four days, and then take off. Obviously things got shutdown. It was like obvious like COVID was the whole world had COVID by, February, there may have beena time to shut down this pandemic in September 2019. Do you know what I mean? by November 2019,we had cases. They've already seen some and Canadian Blood Services done some showing someserological evidence already at that time. There was no shutting it down. This thing's gonna suck. Thereality is promising that you can eliminate this thing by like, enacting these really like arbitrary that canonly be described as arbitrary. Shutting the border to voluntary travel, but not to truckers. Everythingfelt so arbitrary. So, when you talk about trust, if you can't explain it, if you're a good person do it. If youdon't do it, your white supremacist. Kwadwo you were part of a group that was called ‘Urgency ofNormal' you are a white supremacist. It's so ridiculous. You know what I mean? It creates this dynamicwhere you can't have any meaningful conversation. So, I really worry, unless we can start having somereally meaningful conversations, not just with folks that we agree with. Obviously, I deeply respect whateach of you have done throughout this pandemic, not just actually about what you say, but really whatyou've done. Put yourselves out there with your families in front of this thing. That aside, if we can't dothat, we will be no better off. We will go right back. People will be like ‘Oh, next pandemic, well, let'sjust get ready to lock down' but did we accomplish anything in our lock downs? I actually don't think wedid. I really don't think we got anything positive out our lock downs, and I might be alone in that. I mightbe wrong, butut that said it needs to be investigated and in a really meaningful way to answer that,before it becomes assume that acting hard and acting fast and all these b******t slogans are the truthand they'd become the truth and they become fact. All without any really meaningful evidencesupporting them.KK: I gotta say, I'll get you Sumon next here, but I gotta say the idea of abandoning logic, I think that'sthat's a key point there. Think about what we're doing in restaurants, folks. Okay, you would literallywear your mask to sit down, take off that bloody thing. Eat, chat, smooch even, I mean, and then put itback on and go in the bathroom and think this is meaningful. Where's the logic there? You're on a plane,you're gonna drink something, you're on a six hour flight, you know what I'm saying.(?) During the lockdown, by the way, you're sending like 20 Uber drivers to stand point. If you ever wentand picked up food, you would see these folks. It'd be like crowding the busy restaurants all like standingin there, like arguing which orders theirs, you know what I mean? then like people waiting for the foodto show up.KK: I mean, that's the other point. The part that people forget with the lockdowns, tons of people willwork. I'm in Ottawa, where 70% are, could stay home, right? That's a unique city. That's why we werevery sheltered from this bad boy.(?) Aren't they still fighting going back to the office?KK: Oh, my God. Folks, I'm sorry. Yeah, it's like 70% could stay home, but you're in GTA your area. That'sa lot of essential workers. You don't have that option. So, how's this lockdown? Really looking at the bigpicture? Anyway, sorry. Sumon you're gonna hit it up.SC: We just wanted to add one anecdote. I just think it kind of talks about all this is that, you know therewas a time when this thing started going to 2020. Stefan, I think you and I met online around that time.You put a couple of seeds after I was reading stuff, like you know about the idea of, you know, risktransfer risk being downloaded to other people. That's sort of kind of think of a you know, what, like,you know, a people that are working in the manufacturing industry, you're not going to receive them alot unless you live in a place like Brampton or northwest Toronto, where the manufacturing hub of, ofOntario and in many cases, central eastern Canada is right. So, I remember in, I was already starting touse this doing anything. And when I was in, I guess it would have been the second wave when it was itwas pretty bad one, I just kept seeing factory worker after factory worker, but then the thing that stuckout was tons of Amazon workers. So, I asked one of them, tell me something like, why are there so manyAmazon workers? Like are you guys? Is there a lot of sick people working that kind of thing? Inretrospect, it was very naive question. What that one woman told me that her face is burned into mymemory, she told me she goes, ‘Look, you know, every time a lockdown is called, or something happenslike that, what ends up happening is that the orders triple. So, then we end up working double and tripleshifts, and we all get COVID' That was just a light went off. I was like, excuse my language, guys, but holys**t, we're basically taking all this risk for people that can like what was it called a ‘laptop class' that canstay home and order all this stuff. Meanwhile, all that risk was going down to all these people, and I wasseeing it one, after another, after another, after another. I'm not sure if you guys saw that much, but Iwas in Mississauga, that's the hardest, Peele where the manufacturing industry is every single peanutfactory, the sheet metal, I just saw all of them. That I think was the kind of thing that turned me andrealize that we what we'll be doing. I'll shut up.ZC: Yeah, I would say I mean, I think Stefan and Sumon make great points. You know, I think that thatwas very apparent at the beginning. The other thing I would say is 2021 to 2022. Things like vaccinationand public health measures fell along political lines. That was a huge mistake. It was devastating. Iremember back to the first snap election in 2021. Initially great video of all the political partiesencouraging vaccination and putting their differences aside. Then all of a sudden, it became mudslingingabout how much public health measure you're willing to do, how much you're willing to invest in, andit's not a Canadian phenomenon. We saw this in the United States with the Biden and Trump campaignsand the contrast between the two, and then really aligning public health views to political views, andthen, you know, really making it very uncomfortable for certain people to then express counter viewswithout being considered an alternative party. It's something we need to reflect on I think we havepublic health and public health messengers and people that are agnostic to political views but are reallythere to support the health of their populations, from a health from a societal from an emotional fromthe aspects of good health in that sense. You really can't involve politics into that, because all of asudden, then you start getting counter current messaging, and you start getting people being pushed,and you start new aligning values to views and you start saying, right and left based on what peopleconsider, where again, the science doesn't necessarily follow political direction. It was a really bigmistake, and it still is pervasive. We saw every election that happened between 2021 to 2022 is publichealth and public health messaging was embedded in each one of those and it caused more harm thangood. I think it's a big lesson from this, this is that you can be proactive for effective public healthinterventions as an individual in that society that has a role, but you can't stick it on campaigns. It reallymakes it hard to deescalate measures at that point when your campaign and your identity is tied tocertain public health measures in that sense.KK: Amen. I am cognizant of the time and so I'm gonna try to rapid fire a little bit? I think, there's only acouple points that people hit up on that we haven't touched on. There was a push for mass mandates inthe last couple months because of of RSV and influenza that was happening. It still is happening in,especially in our extreme ages, really young and really old. Any viewpoint on that, I'll leave it open toalmost to throw down.(?) I think mass mandates have been useless. I don't expect to ever folks to agree with me, it's like it's aninteresting dynamic, right? When you go and you saw folks who were on the buses, I take the bus to theairport. Our subway in Toronto just for folks only starts at like, 5:50am. So, before that, you gotta jumpon buses. So the construction workers on the bus who were wearing masks during the when the maskmandates were on taking this what's called, it's like the construction line, because it goes down Bloorare basically and takes all the construction workers from Scarborough, before the subway line, get todowntown to do all the construction and build all the stuff that you know, is being built right now.Everyone is wearing this useless cloth mask. It's like probably the one thing that the anti-maskers who Ithink I probably am one at this point. The pro-maskers and all maskers can agree on is that cloth masksare useless. That's what 100% of these folks are wearing. They're wearing these reusable cloth masksthat are like barely on their face often blow their nose. So, to me, it's not so much about like, what couldthis intervention achieve, if done perfectly like saying the study you were involved with the help lead,it's like everybody's like, but all of them got COVID outside of the health care system, they didn't get itwhen they're wearing their N95. That's like, but that's the point, like public health interventions live ordie or succeed or fail in the real world. I was seeing the real world, I would love to take a photo but Idon't think these folks have been friendly to me taking a photo of them, but it was 100%, cloth masks ofall these folks in the morning all crowded, like we're literally like person to person on this bus. It's like aperfect, you know, vehicle for massive transmission. I just I just sort of put that forward of like, that'swhat a mask mandate does to me. I think to the person sitting at home calling for them, they are justimagining, they're like ‘Oh but the government should do this'. But they didn't. The government shouldbe handing out in N95's. How are you going to police them wearing a N95's and how are you gettingthem? It would be so hard to make a massive program work. I would say it's like if you gave me millionsand millions and millions of dollars, for me to design a mass program, I don't know, maybe I could pull itoff you really with an endless budget. But for what? So, I just think that like as these programs went outin the real world, I think they did nothing but burn people's energy. You know because some people itjust turns out don't like wearing a mask. Shocking to other folks. They just don't like wearing a mask.Last thing I'll say is that just as they play it out in the real world, I think we're functionally useless, otherthan burning people's energy. I'm a fervent anti masker at this point because it's just an insult to publichealth. To me everything I've trained in and everything I've worked towards, just saying these two wordsmask mandate, as the fix. That is an insult to the very thing that I want to spend my life doing .ZC: Yeah, I mean, three points, one: you know, masks are still important in clinical settings. I think we allunderstand that. We've been doing them before we've been continuing to do them. So I you know,that's one piece. Second: I mean, to go with the point that was raised here, you know, the best study wehave is Bangladesh, right? 10% relative risk reduction. It's interesting when you read the Bangladeshstudy, because with community kind of people that pump up masking that are really trying to educateand probably are also there to mask compliance. Mask's compliance people, you get to 54% compliance,when those people leave compliance drops significantly. Right. You know, I think you have to just lookaround and see what happened in this last few months, regardless of the messaging. Maybe it's thecommunities I'm in, but I didn't see mass compliance change significantly, maybe about 5%. In thecontext of the last couple of months. You must understand the value of this public health intervention,Bangladesh has actually a nice insight, not only into what we think the community based optimalmasking efficacy is, but also the fact that you really have to continue to enforce, enforce, enforce,enforce, in order to get to that even 10%. Without that enforcement, you're not getting anywhere inthat sense. That probably spells that it's probably a very poor long term public health intervention in thecontext that you really must pump it week by week by week by week in order to actually get compliancethat may actually then give you the effects that you see in a cluster randomized control trial. Again, youknow, the world we live in is showing that people don't want to mask normally. Some people can, i

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: New intervention: paying farmers to not burn crops, published by Karthik Tadepalli on December 22, 2022 on The Effective Altruism Forum. I summarize a recent paper evaluating an intervention to reduce air pollution: paying farmers not to burn their crop residue. A pure conditional contract is ineffective, but when farmers are paid some fraction upfront, they reduce crop burning significantly. The authors calculate that this contract saves a life for $5,000, comparable to GiveWell's top charities; I calculate an even lower cost of $1,500 per life saved using a broader measurement of health benefits, beating GiveWell's top charities. I also calculate promising climate co-benefits; this intervention reduces GHG emissions for roughly $36 a ton, which costs less than the social cost of carbon, but more than the best climate mitigation strategies. I strongly recommend further research and piloting as a way to build on this single study, especially given the lack of scalable air pollution interventions in EA. Air pollution causes at least 7 million premature deaths each year. Despite this, it has only recently surfaced as a top cause for effective altruists, with Open Philanthropy announcing South Asian air quality as its newest focus area last year. Even with this recent focus, grants have focused mostly on research rather than on interventions to actually improve air quality. The problem is that we don't yet have shovel-ready air pollution interventions, demonstrably cost-effective interventions that are feasible and scalable for charities to implement themselves (rather than relying on uncertain advocacy). I think one recent paper offers a cost-effective, feasible and scalable intervention to reduce air pollution, and we should investigate it much more closely. Overview One pernicious source of air pollution in developing countries[1] is crop residue burning, where farmers burn the remnants of their summer crop to quickly clear the fields for their winter crop. The pollution from this burning causes 66,000 premature deaths a year in India alone. Both bans on crop burning and subsidizing alternatives have failed, leaving crop burning in desperate need of a solution. A new working paper by Kelsey Jack, Seema Jayachandran, Namrata Kala and Rohini Pande proposes one solution: paying farmers directly not to burn crop residue, with a partial payment upfront and the remainder conditional on not burning. They show this contract reduces crop burning with an RCT, while purely conditional payments have no effect. Importantly, they also calculate that this approach saves a life for around $5,000, which is competitive with GiveWell's top charities. I believe their approach may actually underestimate the benefits of reduced crop burning by focusing solely on premature deaths; using an alternative approach based on DALYs lost, I estimate that this intervention saves a life for $1,500, which beats GiveWell's top charities. In addition, it has important climate co-benefits that traditional health interventions do not. I think this study poses an important line of research for EA organizations to pursue, and I conclude with some ways for us to use this research. The paper One of the authors has summarized the paper already. In brief: We use a randomized trial to evaluate a program that financially rewarded farmers if they avoided burning their rice stubble. We tried out a standard incentive contract that paid the farmer after we verified that he'd complied with the contract terms. That approach had no impact. However, when the contract was tweaked so that some of the payment was made upfront, the financial rewards program became a very cost-effective way to reduce burning, saving a life for

Chris and Jonathan welcome back Dr. Jonathan Howard to talk about the doctors who repeatedly said the pandemic was ending and who became anti-vaccine in the process. When doctors become brands, narcissism can easily lead them and their fans astray, as these media figures chase an ever elusive limelight. Dr. Howard has been tracking their claims and predictions and brings the receipts.   (2:38) Dr. Vinay Prasad, pre-pandemic (8:41) ZDoggMD, Marty Makary, and Vinay Prasad on vaccine boosters (12:01) Paediatric COVID vaccines (15:00) An appeal to civility on the one hand, mockery on the other (16:56) Dr. John Ioannidis and basic math (27:22) “You have to accept it” (32:27) Classic anti-vaccine talking points (36:10) “Where's the RCT?” (39:37) Jonathan Howard's connection to the anti-vaccine movement (41:53) Audience capture (44:49) Charisma and credibility (49:33) New York City denialism (51:36) Ron DeSantis' Vaccine Accountability Roundtable (55:41) Self-reflection   A quick note on sound quality: the clicking sound on Dr. Howard's end very quickly disappears. The rest of the audio is not up to our usual standards, and for this we apologize. Audio engineering is closer to magic than science, it seems.   * Theme music: “Fall of the Ocean Queen“ by Joseph Hackl.   To contribute to The Body of Evidence, go to our Patreon page at: http://www.patreon.com/thebodyofevidence/.   Patrons get a bonus show on Patreon called “Digressions”! Check it out!     Links: 1) The ZDoggMD Show episode you hear at the beginning: https://youtu.be/cNcVCFLhbAs?t=42 2) Dr. Jonathan Howard's articles on Science-Based Medicine: https://sciencebasedmedicine.org/author/jonathanhoward/ 3) Dr. Jonathan Howard on Twitter: https://twitter.com/19joho  

This episode has been a long time coming! We're talking ultrasound-guided subclavian central lines, and a lot of people have opinions. Are they better than landmark? What should we teach learners? The GEL team discusses through the lens of this fascinating RCT. https://www.ultrasoundgel.org/138 https://pubmed.ncbi.nlm.nih.gov/35562246/

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: On Epistemics and Communities, published by JP Addison on December 16, 2022 on The Effective Altruism Forum. This is a Draft Amnesty Day post. I wrote it in 2020 and ~haven't looked at it since. I'm posting it as-is. An invisible project is one of our most important — let's try to reveal it This community is about doing the most good. We have many conversations about how to do that. In the course of those conversations, we've slowly pushed forward a cultural understanding of "how do we form correct beliefs?" We call that understanding “epistemics.” I want to make a few, hopefully-useful observations around this general space. If you haven't read much about epistemics before, I hope it serves as an accessible introduction. If you're an old hand, I hope it communicates this frame I've found useful. I Why is this hard? Most of the time, figuring out what's true is easy. When was this bridge built? Look it up on Wikipedia (more on that later). When it's not easy, it's often best to just use the tools someone else has already developed. The situations where you really start needing to attack the problem are when: The tools you're used to are inadequate for the task at hand, or You and a collaborator disagree on how to figure out what's true. Once that happens, I claim most people just get really confused. It's like, what the heck is going on? This makes no sense / my collaborator makes no sense. People give up, or can form really deep impasses with those around them. Even if you're fortunate enough to notice the issue for what it is, it can seem really hard to resolve. I think this is what happened when a lot of my friends and I were only half-convinced of AI risk. How the fk are you supposed to weigh "we literally have an RCT here" versus, "this other thing would be big if true"? Many people find the answer obvious, but unfortunately not the same way. I hope at least some point in your life you've viewed it as a hard problem. Then, just when you and your best friend have figured out how to weigh evidence between yourselves, there comes a whole lot of other people. Many new complications arise when this is done as a community: Not all the participants are able to get complete information, or evaluate all the arguments Some participants are probably smarter than others Some participants are probably acting adversarially, or with some level of own-view favoring-bias II All project-oriented communities do this Maybe you've heard people talk recently about epistemics, and it's felt like a fuzzy concept. I hope that presenting the ways in which a bunch of different communities go about forming beliefs. Wikipedia As we've already mentioned, Wikipedia has some outstanding epistemics. What's really useful for us here is that they've written it down. You can see the way that it's meant for Wikipedia's particular situation and how it needs to be legible to outsiders and extremely resilient to adversarial action. Science You can observe humanity making a huge leap forward by improving its epistemics in one important domain. Our species went from just being completely wrong about just about everything in the natural world, to methodically making progress in our understanding. That progress has compounded over time to completely transform the world. It's interesting the note that wasn't obvious with those epistemics should be at first. Are thought experiments valid scientific evidence? And in the soft sciences the epistemics are still controversial. Some might claim that science has figured it all out. But what's the scientific way to predict who you should pick to lead your company? To make most decisions that humans make there is simply too little high quality data. Medicine Perhaps even more so than science, medicine is extremely conservative in its epistemics. There are so many ac...

In October 2022, Ruddick-Collins et al. published results of an RCT looking at the impact of different calorie distributions across the day. This study was from the ‘Big Breakfast Study' project, primarily from the University of Aberdeen. In this study, 30 subjects underwent two 4-week calorie-restricted diets that were matched for calories. One diet was “morning-loaded”, meaning that daily calories were distributed as 45% at breakfast, 35% at lunch, and 20% at dinner. The other was “evening-loaded”, with an opposing calorie distribution; i.e., 20% at breakfast, 35% at lunch, and 45% at dinner. The trial received a lot of commentaries online after it was published. However, much of it lacked sufficient context, nuance, and understanding of the implications. In this episode, Dr. Alan Flanagan, who was one of the researchers involved in some of the work of the Big Breakfast Study, gives an insight into the recently published paper by Ruddick-Collins et al., and highlights some important aspects to be aware of. This is an episode exclusive to Sigma Nutrition Premium subscribers. To listen to the full episode and access the transcript, you must subscribe to Sigma Nutrition Premium. Links: Subscribe to Premium Links to mentioned studies

The acceptance and growth of the Health Coach industry is credited to the influx of research. The value is clear when you provide impact evidence supporting the effectiveness of coaching intervention. But, how do you know which study or journal is a trusted resource? Listen as Dr. Sandi, FMCA Founder and CEO, provides insight into evaluating reports and why it's significant. Randomized controlled trials (RCT) are considered the gold standard because they deliver the highest level of evidence, due to their potential to limit bias and subjective influence. References 1. Effectiveness of Short-Term Health Coaching on Diabetes Control and Self-Management Efficacy: A Quasi-Experimental Trial https://www.frontiersin.org/articles/10.3389/fpubh.2019.00314/full 2. A personalized multi-interventional approach focusing on customized nutrition, progressive fitness, and lifestyle modification resulted in the reduction of HbA1c, fasting blood sugar and weight in type 2 diabetes: a retrospective study https://pubmed.ncbi.nlm.nih.gov/36419152/ 3. Effectiveness of a Health Coaching Intervention for Patient-Family Dyads to Improve Outcomes Among Adults With Diabetes: A Randomized Clinical Trial https://pubmed.ncbi.nlm.nih.gov/36374502/ Supported by data-driven, science-based research, and published studies.

Welcome back to 200th episode of the podcast! A huge thank to all of you for your support and engagement. Three more papers for you this month to challenge thinking across a board range of Emergency Care. First up we take a look at DOSE VF, an RCT look at the best defibrillation strategy for refractory VF. Next we take a look at another RCT looking at the potential benefit of dexamethasone, in order to reduce pain in patients suffering with renal colic. Last up, we've talked a lot about the importance of first pass success in advanced airway management, but what (if any) is the association with mortality in prehospital RSI? Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon & Rob

We often speak of economic development as a phenomenon of sovereign national countries, but the process by which that happens is through what happens at individual firms in the economy. The decisions by firms to upgrade their products (services), export, and adopt new technology are the most important determinants of economic development. The incentives and conditions that shape these decisions are the subjects of my conversation with my guest on this episode. Eric Verhoogen is a professor of economics at Columbia University school of international and public affairs. He is one of the leading thinkers and researchers on industrial development.TRANSCRIPT (edited slightly for context and clarity)Tobi; Usually, in the development literature, I know things have changed quite a bit in the last few years. But there is a lot of emphasis on cross-country comparisons and looking at aggregate data, and a lot less focus, at least as represented in the popular media on firms. And we know that, really, the drivers of growth and employment and the source of prosperity usually are the firms. The firms in an economy, firms are the ones creating jobs, they are the ones investing in technology, and doing innovation. So firms are really important. One of the things you often hear a lot is that one of the reasons poor countries are poor is that the firms are not productive enough. So that's sort of my first question to you, how exactly do we define and also measure productivity, you know, for us to be able to distinguish why firms in the developed countries are more productive than the lower income countries?Eric; Yeah, this is a big important question. So I agree, in principle, that firm productivity is very key. So countries that are going to be doing well are countries that are populated by firms that are being very innovative, and their productivity is rising, they're learning how to do new stuff, they're producing new products, etc. And so there's a reason why people are very focused on this conversation about firm productivity. The sort of, I would say, dirty secret of economics is that it's very hard to measure productivity well, right? And so the productivity measures we have, I think, are very noisy, and most likely fairly biased. But basically, the way you estimate productivity is you run a regression of like sales on inputs, okay, so on how much you're spending on labour and how much you're spending on materials, and then the part that's left over, we call that productivity. So it's like unexplained sales, you know, sales that can't be explained by the fact that you're just purchasing inputs and purchasing workers. But that is actually a very noisy measure of productivity. And so I've been working on a review paper, and a separate research paper kind of pointing out some of the issues with productivity estimation. So in principle, it's exactly what we want to know; in practice, it's very hard to measure. So one argument I was making in that paper is we should go to things that we can actually directly observe. Okay, so sometimes like technology adoption, we can often directly observe whether the firm has adopted this particular new technology, or if they're producing new products, we can directly observe that. Sometimes we can observe the quality of products that can be measured. Now, the standard datasets that we have typically don't have those things. It is possible now, in many countries, to follow manufacturing firms or even other sorts of firms, [to] follow them over time, which is great, at a micro level. But those that have the technology, they don't have quality, they do it now increasingly have like what products they're producing, often they don't have the product people are producing and so it's harder, you have to go out and you have to talk to people, you have to access new sorts of data, there's a lot more work, a lot more shoe leather - we'd say you wear out your shoe is going to talk to people trying to get access to other datasets in order to have these measures that you can observe directly. But I think there's a big advantage to that. Just in terms of measurement. Like, can we measure these things, and record that technology quality and product innovation together? I'm not sure that's answering your question. But, you know, I mean, I totally agree that what firms are doing, that's crucial, right? So the big macro question is, why are some countries rich and some countries poor and how can we make poor ones richer? That's the big question. I think that's kind of too big to be able to say much about. The much more concrete thing, which we need to be focusing on is how can you make firms in countries more innovative and productive. That's the absolutely right question. But that's just hard. There are challenges and research about, you know, how you actually analyze that, and it has to do with these issues of measurement.Tobi; I understand the measurement problem, and of course, TFP, the residual, and so many things like that. But practically, I want to ask you, what can you say, maybe if you have a handy checklist or something? what distinguishes firms in rich countries from firms in poorer nations? Eric; Yeah. So let me say what I don't think first, and then I'll say what I think. So it's become increasingly common to say that firms in poor countries are just poorly managed. The firms in rich countries have better management, and the firms in poor countries have poor management, right? And partly that's coming from the influential paper by Nicholas - Nick Bloom - and others, and David McKenzie and John Roberts. You know, they had consultants go to some factories in India. In some they camped out for four months, some they were there for only one month, and the ones where they camped out for four months ended up doing better, right? And they say that that's because these consultants improve the management of the firms and management matters. And I do agree that sometimes these management practices matter, but I don't think... sort of, one kind of implication of that line of work is somehow, like, the firms in a developing country are just making mistakes. They haven't gone to business school in the United States, and so, therefore, they don't know what they're doing. And I think that's incorrect. I think that's incorrect. I think the problem is, firms in developing countries face many, many constraints that firms in rich countries don't face. Right. So often, for instance, gaining access to high-quality inputs can be very difficult, right? That you just don't have the supply chains domestically producing high-quality inputs. Often skilled workers are very expensive relative to unskilled workers, and even relative to the price that you might pay in rich countries. Having skilled workers, including skilled managers, is very expensive. In addition, you have all these frictions on trying to get your goods to market or trying to, you know, trying to access export markets, often there are, you know, their costs involved in that. In addition, being productive requires know-how and often firms lack that know-how, right and so the question is, how do you get that know-how, you know, like, the distinction I'm trying to make is, it's not that they're making mistakes, it's just that they're doing the best they can given know-how they have, and given the constraints that they face. And so in that sense, I would sort of point to those constraints, right, those constraints both in know-how and both in the input and output markets, rather than just failure of management. So now, one of the constraints I should say, actually, so is often, you know, legal and regulatory institutions are much weaker in many countries. It is true in Nigeria, and it's true in many places, right? And so then that does create a complicating factor also when you're trying to do business with somebody, but you don't have the legal recourse of going to court to enforce whatever contract you write down. And so that creates friction. So then you have to do things differently in part because of that. And so you're likely to be much more based on, like, networks of various types. It might be ethnic networks, or it might be people that you know or that you have long-term relationships with. But then that means you can't necessarily just find the best supplier of something, you actually have to find someone that you trust, and that can complicate your life, basically, if you're trying to do business and develop.Tobi; So one thing I want us to discuss is the issue of firm upgrading. I mean, one of the things that have helped me in reading your work and taking this firm-level view of development is that, okay, on the one hand, if you look at a country like Korea, we can say the average income, the income per capita for Korea 40 years ago versus now and compare with say Nigeria, but also we can look at Korean firms 40 years ago versus where they are today. Today, Korea have global firms that are at the very frontier of technology. Companies like Samsung are innovating and making chips and making electronics and making smartphones and you compare with firms in Nigeria who have not been able to upgrade their products over that same period. And now what I want to ask you is how important is a firm's ability to upgrade productivity. I take your point on the measurement but controlling for that, how important is a firm's ability to upgrade its output? Its products on its productivity?Eric; No, no, I think upgrading is crucial. And upgrading in various ways, you know, more specifically technology, producing higher quality products, producing new products, new innovative products, you know, you might be reducing costs, right, all those things. I do think that's crucial. I think that's crucial to the development process. I mean, much of the conversation in development economics has often been not about firms. It's about, you know, social policy, or it's about education. It's about human capital accumulation. But I'm with you on that, the firm-level upgrading is totally crucial. You know, the question of like, why isn't it happening? Or how could you promote upgrading? That's a very difficult question. There are lots of papers that are sort of speaking to that subject. And this review article I was trying to write was basically all about that. So Alexander Gerschenkron way back in 1962, is a historian writing about late industrialization had this phrase, not very politically correct phrase, but basically, advantages of backwardness. So in principle, if you're a developing country, you should benefit from the fact that technologies have been developed in rich countries, and you should be able to go and adopt them off the shelf. But for some reason, that's difficult, right? It's hard to do. Partly, it's difficult because of, you know, know-how reasons. So I'd say that often, much of the knowledge that you need in order to implement these technologies is not written down anywhere, it's not really in the manual, right? You have to kind of talk to people who know it, rather than just downloading the instruction sheet. That's one reason. It's also true that many times, machines or processes, actually, may be context specific. So like the picker machine, in a very humid environment, they operate differently than in a non-humid environment. And so, you know, there are things that you need to learn. So I'd say that kind of like gaining the know-how is an important kind of constraint on upgrading. And partly that happens through networks or through... there's a ... Juan Carlos Hallak, who's in Buenos Aires (who would be a good person for you to have on your show, actually, I think that he'd be an interesting person to interview) as a very interesting paper. It's basically on like Argentina, looking at industries that have done well, they've been able to upgrade essentially and looking at what was it about them that made it possible, and especially the leading firms, what were the leading firms doing? And what we're basically finding is that often the key person in the firm, like, had been embedded in markets in rich countries, maybe in the US or in Europe or someplace. So they understood very much how those markets work and what consumers want. So one was like making boats, sailboats, or motorboats right, that was one of the interesting things he focused on. But knowing sort of what the people who are buying those boats really want to see in their boats ended up being important for what they're doing. And so that's an important part of the know-how. It's like, yeah, understanding the customer understanding also how if there are firms that are producing there, understand what the competition is. And so that's know-how that often has to be sort of gained in person rather than, you know, just reading a book or talking to somebody on the phone. And so when I think about... I don't know Nigeria very well, but when I imagine, you know, Nigerian producers, I think, partly what might be holding back is, sort of, maybe not having the understanding of what are the requirements, what are the expectations of consumers in the export markets, right, in the rich countries that they may be selling to?We've talked about the barrier, we can talk about the driver of upgrading. So then, like, gaining know-how would be a driver. So that's one. I think, and part of a lot of my work has been about quality upgrading, you know, producing higher quality. And I think that's in part driven by who you're selling to, right? So Mexican firms, you know, if they're selling to Mexican consumers, they produce different products than if they're selling to us consumers, which is their main export market, right? And so, you know, and if you're selling to Mexican consumers who have a certain willingness to pay for quality, we would say, right, they have a certain level of, you know, demand for certain characteristics, the optimal thing to do is keep producing that kind of lower quality stuff, right, rather than producing the higher quality. So I had this famous example of a big Volkswagen factory in Puebla, Mexico, which for a long time, it stopped in 2003, but for a long time been producing the old beetle. The old beetle that had first been produced in 1940, or certainly the 1950s. But for a long time, in the Mexican market, that was the main car that people were buying, and they were happy with that because it was cheaper. It was like, you know, it's very reliable. But that same factory started producing the New Beetle, basically, for the US market, right, for the US and European market, which is much more sophisticated, but also much more expensive. So it depends a little bit on which market you're selling into and whether you're going to upgrade or not. And so accessing export market can, in some sense, like pull the upgrading process, you know, once they access these export markets, they'll start producing higher quality stuff for these consumers. And that I think, actually, generates some learning, and I can talk about one paper that shows that a bit. But it seems to be that by gaining access to markets and producing high quality, then firms learn how to do stuff better. And so that can be an important driver of upgrading. And conversely, not having access to export markets or having a hard time breaking into export [markets] can be a reason why firms failed to upgrade. Let me tell you about one paper that, you know, demand effects can drive learning. Tobi; Yeah. Go ahead.Eric; Okay. It's a paper by David Atkin, Amit Khandelwal and Adam Osman. It's in Egypt. Okay, it's an RCT experiment, a randomized controlled trial. And it's among rug producers, producing rugs. What they did is they randomly allocated initial export contracts, right? So if they work with an intermediary, like a buyer of rugs, you know, among several hundred rug producers, they say, Okay, some guys are gonna get an initial contract, and some guys not. And so that was a way, this is a way of investigating basically what's the effect of exporting on the decisions and in a very clean way, and they found a couple of things. So one is those guys who had the export contracts and started producing higher quality stuff. So that's sort of consistent with my Volkswagen story, too, right? So increasingly, export markets produce higher quality and they did lots of measures of, you know, how thickly packed the rugs were and how straight the edges were - the very dimensions of quality of rugs. That was one thing. And then the other thing that they found which is very interesting is that you know, these weavers of rugs got to be better at producing rugs, basically. So then, when they took them into a laboratory, and they say, okay, produce this identical rug to a whole bunch of producers, both in their treatment group, and in their control group to produce this identical rug, and they found that the guys who had gotten the export contracts were better at producing that rug, they produce sort of higher quality rugs than the other guys. This suggests that demand can drive upgrading, right, in the sense that it induces firms to produce higher quality, but there's also learning involved in that process. These Egyptian rug producers became more productive as a result of having access to these export countries. Tobi; Yeah, I mean, listening to you, I can think of a few things that click in place. When I look at, say, a country like Nigeria, I think about the way the central bank has been running the exchange rate policy, which is messing seriously with the way firms actually source inputs. Some firms actually don't have access to the foreign exchange quota to actually source quality inputs. I mean, from manufacturing firms to agribusinesses who want to buy high-quality seeds overseas, I see how that can be a constraint. But two things I want to get at. Also, if you look at Nigeria whose industrial policy is really about domestic self-sufficiency, you could see that there isn't really an incentive for upgrading, and therein lies my question. If we talk about upgrading and how important it is, even though it's not really discussed as it should, what role do you think industrial or state-directed policies can play in this? Why because industrial policy is back in fashion, you know, it's being discussed everywhere... but usually, at least in my experience and in my opinion, what most scholars and advocates are focused on are [things like] state investments, you know, how the state can put money in one sector or the other. There really isn't so much focus on this sort of micro-level detail and what happens at firms, which your work is about. So for practical purposes, do you see industrial policy as something that can really, really, play a role and incentivize domestic firms to upgrade? For example, something like export quotas, you know, for firms?Eric; I mean, in terms of your question, do I think industrial policy can be helpful? I do. I do think that industrial policy can be helpful. Basically, I think that learning generates spillovers that firms themselves can't fully capture. And so I think there is a role for government to promote learning, basically, in a way. To subsidise learning such that - the socially optimal, or - the best sort of amount of investment in learning for society is more than individual firms to do on their own. And so there's a role for industrial policy. But I agree that it's got to be smart industrial policy, it's not just any old industrial policy. And so many countries have this idea...it's a little bit of nostalgia for import substitute industrialization, or it's very much like inwardly focused industrial policy. We're going to try and guarantee a domestic market for our producers, something like that, right? I'm not a fan. I'm not a fan of imports substitute industrialization or these very inward-focused strategies because then you get to the point where there's just not a lot of pressure on domestic firms to be more productive. They become kind of in a comfortable situation where they have kind of protected markets, not very competitive, they have a lot of market power in that market, and so that is a recipe for stagnation over the long term. So I think the crucial thing is that the targets for industrial policy be export-oriented, you know, outwardly oriented. You want your firms to be successful in world markets, right? I think that should be the key, rather than domestic self-sufficiency. Or rather than just the government investing in well, okay, so I don't have a problem with the government investing in infrastructure, investing in things as long as the aim is always ''what's going to facilitate our firms being successful in world markets'', right, I think that's a good target. Because those world markets are competitive [and] for firms to be able to be successful there, they're going to have to up their game and be more productive and be more innovative, subject to the measurement constraints we talked about, right and to upgrade. And so I think that the smart industrial policies are going to be things that sort of push firms to learn and to be more innovative and to be successful as exporters. Now, the other thing we have to keep in mind in thinking about industrial policy, is that [for] the governments, it's just very hard to [know] in the future what are the sectors that are going to be successful. What are the activities that are likely to have a future? It's just very hard, it's very hard for people who are, you know, private equity firms embedded in the sector... it's very hard to know, it's gonna be even harder for a government official or someone making government policy to do that. So I think we need to think about policies that have this effect of promoting learning or subsidizing innovative activities, but that, you know, don't require too much knowledge and understanding of the future on the part of the people setting the policy. Right. So things like collaborations between universities and firms for, you know, how to train workers to have the skills that the higher tech firms in your country need. That's something that seems like a good idea that's probably going to promote upgrading without having to pick and say, I think this product or this sector is the future of the Nigerian economy and therefore we're going to subsidize that thing. And you also want policies that are somewhat flexible, right, so that if something happens... so I'm working on a project in Tunisia, where the Tunisian Government was trying to promote exports. But the issue that they've had, and it's a matching grant program where sort of half of the costs of exporting of a certain category of costs of exporting will be paid by the government. The problem with that program, though, has been that it was somewhat inflexible. So basically, if something happened, you know, there's a big shock, and in fact, COVID shock, you know, and that changes what firms want to do. And it's very hard for them to switch gears and say, now I want to spend money on something else, can you please subsidize this other thing, and there were a lot of frictions in the program. And so that's often the case for government programs. The government sets a policy and then the world changes, firms want to do something else, but the policy is still stuck, you know, in the old world. So we need to think about how to build in, you know, flexibility into the programs so that if firms decide, actually, the market is moving in this direction, rather than this direction that we were expecting, that the support that they receive could move in the same direction.Tobi; Yeah, I agree. And I don't mean export quotas as hard targets. So I'll give you an example. Nigeria has this policy that we've been running for about six to seven years now, where there are multiple exchange rate windows for different parts of the economy or sectors that the government deems should have priority, you know, to import. And I recall a paper where Korea had a similar arrangement, but it was focused on firms that export. Firms that export to world markets sort of get priorities so that they can source inputs at a very low cost and seamlessly, you know, but it's not just something that we really think about in Nigeria, because we are so focused on the domestic market and how large the population is not minding, you know, how much of that population is poor.Eric; Yes, no, absolutely. So, certainly, Korea did this. But the Korean model, a key part of it, and they definitely picked sectors in a way that, you know, it's, there's a little bit of tension with what I just said about, you know, the government officials are not going to be very knowledgeable, there they seem to have done a good job of picking sectors to advance. But the key part was it really was oriented towards success in export markets. And the industries that were not successful on the export markets, they pulled the plug, they removed the, you know, they removed the support, which is politically hard to do, you need a fairly insulated, like, secure government in order to be able to do that. Because, otherwise, you start providing support, and then the industry lobbies a lot to maintain that support, you know, and so then it becomes politically very difficult to remove it. But I think if the government is committed to ''if these industries are not successful, we're gonna pull the plug on the support'', then this can work. Right. But you're absolutely right, in the Korean model, the key thing is the export orientation rather than the import orientation. And what you mentioned about exchange rates, I didn't comment on that. But I think it is an issue, you know, especially for a resource-rich economy, that the exchange rate can be, you know, highly valued, arguably overvalued, which makes it hard to develop the domestic industry. And so I think that's a real issue that, you know, some countries seem to be able to handle that, you know, ''what do we do with the natural resource wealth a little better than others'', if you just let it accumulate and people are going to spend and that leads to devalues your currency to increase that's going to make it harder to achieve export success in export markets for manufacturing goods or other exporting services. And so that is something that needs to be a focus of thinking about how to upgrade.Tobi; Yeah, I want to talk about technology for a bit. You had this very, very, an interesting paper on the soccer ball, we call it football, the soccer ball producers in Pakistan. And in a bit, you're going to tell me some of the interesting things you learned about that study. But first, Dani Rodrik and Margaret McMillan had this interesting paper about industrialization in Africa, and how domestic manufacturing firms are now shifting more towards capital-intensive technology. So hence, manufacturing firms are not creating jobs as much as historical patterns should suggest, do you see this as sort of a problem? I know so many other people have this worry about automation and how this technology can be exported everywhere, which is really a concern for maybe a continent like Africa with a large, jobless, and young population. So do you see this as a trend that we should worry about, you know, more capital-intensive technologies, or are there opportunities?Eric; Yeah. So I do see it as a trend. I do think it is something to be worried about. You know, Dani Rodrik recently organized a panel with the International Economics Association I participated in, along with Daron Acemoglu and Fabrizio Zilibotti and Francis Stewart from Oxford. And I sort of had two points there. One point was, yes, I think this diagnosis is correct. Basically, economists refer to it as appropriate technology. But the idea is that many technologies are developed in rich countries, you know, given factor proportions, we would say in those rich countries, so basically, skilled workers are more abundant, unskilled workers are less abundant, and so people develop machines that kind of conserve on unskilled workers. That's, in part, the background to the story that Dani Rodrik and Margaret McMillan are saying that in Africa, many firms are using this technology that's been developed in rich countries, that's very skill intensive, but it's not generating a lot of them. Right. So I think the diagnosis there is correct that that happens, right? And so the technology often is inappropriate for poor countries given, you know, their supply of unskilled labour, given how many workers they have that could use employment. On the other hand, the other question, though, was, what do you do about it? And so I was less convinced. So my worry about that. There are two versions of that concern about what you do about it. One is, given the set of existing technologies, you could try to encourage firms to use more labour-intensive technologies. Okay. But the problem is that you may encourage them to be less productive. Maybe they might generate more employment, but they'll be less productive, right? There was an interesting paper that I cited in Brazil by Gustavo D'Souza, which was sort of saying the Brazilian government basically put a tax on international technology licensing. And he shows that sure enough, firms were less likely to use International Technology. They're more like to use domestic technology. They actually generated employment, but they were less productive. Right, and they overall did worse. So there's a worry that you're gonna make firms less productive in an immediate sense. The other worry is that, like, if the Nigerian government starts encouraging Nigerian firms to develop new technologies, which are more labour intensitive, you know, then they'll generate more employment, the worries that you're gonna get sort of fall behind the world technology trajectory, I'll call it that. Like, you can think about the world frontiers moving in whatever, pick an industry, and the world frontier is moving at a particular place, and then, you know, firms are competing with each other and they're, you know, someone gets a patent, someone comes up with a new idea and sort of technology moves in a certain direction. And then Nigeria says, no, no, we want to be on a different trajectory that generates more employment, right? The problem is, you're going to be permanently behind where the technology curve is, right? Where the world frontier is. And I feel like that's worrisome, right, you're likely to have less learning, right, there's gonna be a gap between where the Nigerian firms are and where, you know, the world frontier is that it's gonna be hard for them to catch up afterwards. So in the short term, you might generate more employment, but you're gonna have a less dynamic industry as a result. And so I think, my own view, and this is, it's a feeling rather than something that's very research based at this point. But my own view is, even though it means that firms are not going to generate that much employment, they have to try and stick as close to the technology frontier as possible, or, you know, catch up as quickly as possible to where the world technology frontier is.Tobi; And so talk to me a bit about lessons from your walk with the Pakistani soccer ball manufacturers. What did you learn from that particular experiment, especially on the role of appropriate technology and technology use and the incentives that surround it for firms and investors? Eric; Yeah, so it was a study of technology adoption, what are the factors that encourage technology adoption? And what made it possible was that the football producers, I'll use that word football instead of the soccer ball, these football producers, there are a lot of producers using the same simple technology, right? And this football design is, you know, 85 or 90% are just these hexagons and pentagons. If you can imagine a, you know, a football, it's got hexagons and pentagons. And so the simple technology involves cutting out hexagons and pentagons and then stitching them together. And there were a lot of those and what made the project possible is we came up with a new improved technology, which is basically a way of cutting pentagons from these sheets. The main costs, you know, 50% of the cost are the sheets, they call it rexine. It's like artificial leather, that's the exterior of the ball. But they were cutting pentagons in a way that was wasting some material. Wasting more than they need to and so the new technology is a way of cutting these pentagons so that you can fit more into a given sheet so that you can get basically 8% more pentagons which ended up being about a 1% reduction in total costs. Which wasn't enormous but on the other hand, it's a pretty competitive industry, profit margins are about 8% so we felt like they shouldn't have been paying the 1%. And actually, when we started out, we thought we were gonna be studying technology diffusion, right, which is, you know, one person adopts, then is that their neighbours who adopt or is it their cousins? Or is it the, you know, people who share suppliers, and what are the channels of diffusion, right, and we're trying to keep everything secret, and we thought, okay, when we let it out, it's obviously the people we give it to who are gonna adopt right away, and then it's gonna spread. And so then we gave out this technology, for free, we gave it to 135 firms. And then, you know, we had a few firms adopt, and they started using it, and including one big firm that was producing - I can tell you the name later, but basically had like 2000 employees and is producing for Nike, and as a big producer adopted this technology, and, you know, is basically cutting all of its pentagons using our design and our die for cutting rather than the old one. So after, you know, 15 months, there were six total firms that had adopted. And that was puzzling and thought, you know, why is that? So then we started asking firms, we started talking to people and basically, it was revealed that the reason was that the guys doing the cutting... so the cutters are basically paid piece rates, they're paid per pentagon or per hexagon, or essentially per ball like, which is, you know, 20 hexagons and 12 pentagons they're paid. That was what their salaries were based on. And they didn't have the incentive to reduce waste, like, they weren't penalized if they wasted the material, right? And so they just wanted to go fast. And our die was slowing them down, right, made them go more slowly because they had to be more careful how they placed it and also, it was a different design, it was the design that they were used to. Now, it turns out that within about a month, they could get back up to speed, to the speed they were at before but they didn't know that, and in any case, for that month, their salaries would be way down, they'd just be slower and knowing that if the firm didn't change the contracts, their salaries would be lower. And the workers were figuring this out, the cutters are figuring this out, they said, this is not good for me, right, that my salary is gonna go down if I use this thing, I have no incentive to use this new technology. And so then they started telling their firms, you know, this is bad, bad technology, it doesn't work, it's dangerous, it has all these issues. Okay, so then we realized that this was happening and we said that we were going to do a second experiment. So, you know, half of the people we originally gave the technology to who hadn't yet adopted, we did a second experiment where we said to workers, we're gonna give you a month's bonus, which is not very much it is about $150 US dollar. So these guys are not paid very much we said ''a month's bonus if you can demonstrate to us and the owner of the factory that the technology works.'' And actually, that was enough. The workers were excited about that, you know, they got paid for doing this. Everybody who did it then subsequently passed the tests. So they demonstrated that the technology is working, and then a statistically significant share of the firms that they worked at ended up adopting the technology as a result. So those were the two experiments, those were the facts. What are we learning from that? I think we're learning that, basically, the lack of information flow from workers to their owners, to their managers, was what was getting in the way of technology adoption in this case. Like, the workers knew that the technology was working, but the owners didn't know because they sort of delegated the process of cutting the pentagons to the workers, and given the contracts, the workers didn't have the incentive to share the information. Right. So I think those sorts of, like, information flows or barriers to information flows are actually very important in the learning process. And kind of what our second experiment did when we did this bonus of a month's pay, which induced the workers to share the information and that was sufficient to make the technology be adopted. And so I think the punch line or the one-sentence version of this is, workers need to see that they're going to benefit from the adoption of new technology or from upgrading generally in order for the process to work well. They have to buy into the process. And they have to see that they have the incentive to do so. One recommendation coming out of that would be some sort of profit sharing, or some sort of gain sharing between workers and firms would actually be very useful. And will it help there be more innovation?Tobi; It brings me in a way to another very interesting paper of yours which [they] also had a summary essay about, I think, in VOX or something, which is about wages in poor countries. And I mean, thinking about the soccer ball story and the lesson. One issue and this has generated quite a number of debates between I think Rodrik and a bunch of other scholars who are thinking about Africa, is that the reason Africa is not really industrializing, or firms are not creating jobs is because wages are too high relative to the level of income. But what I learned from your paper, and you can correct me if I'm wrong, is that paying higher wages in poorer countries is not really a disincentive to creating employment and even generating productivity and profit. Tell me a little bit about how that works. Because, usually, we've gotten familiar with this logic that for you to be able to industrialize, if you think about China, and so many other countries, you need to have access to low-wage workers, you know, you need to be able to do very cheaply, and labour is where you can really cut a lot of your costs. And then it becomes a problem if your domestic wages are too high for the level of your income or what firms and investors are willing to pay. So tell me this high-wage, low-wage dynamics, especially... I remember the famous Paul Krugman was it article defending sweatshops in Bangladesh, where if you force firms who are outsourcing to pay higher wages or impose certain conditions, poor people in those countries will lose jobs, and they will lose their livelihoods. And so you should not mess with that process. What are your thoughts on these [issues]?Eric; Yeah, very interesting. So I think the article you were thinking of, it's related to the specific case of the football producers and seal coats. In Pakistan. Tobi; Yeah. Eric; There was a very interesting thing that happened. I mentioned that one firm adopted this new technology. And you know, one very large firm and it was producing for Nike, it's called Silver Star. The interesting thing about that firm is that because they're producing for Nike, which had had sweatshop scandals in the past, Nike required them to do a bunch of things, basically, so that Nike wouldn't be vulnerable to a further scandal, right? And among the things that they had to do was make sure they were paying the minimum wage in Pakistan. And the only way this firm could guarantee that they were paying the minimum wage in Pakistan, which many firms were violating basically, the only way they could is to say, we're not going to pay a piece rate, we're going to pay a fixed wage. Right. So this firm was paying a fixed wage rather than a piece rate. And actually, we talked to them about when they first won the Nike contract. They said their labour costs went up 20 to 30%. So they did a bunch of things. They had this fixed wage, there was a medical clinic on the factory grounds. They had sickness pay, they had some retirement benefits. So a bunch of things, they did raise wages. But the advantage of that was that the workers were much less likely to block the adoption of this new technology. Because in a specific way, they did not have a disincentive, you know, their wage was going to be their wage no matter what happened, rather than in other firms [where] what was happening is that the worker can see if they adopt this technology, their wage would go down. And so we believe, and I wrote this in an article that you saw in the Harvard Business Review, I think that's where it was, that those wages, you know, higher wage payments and fixed wage payments, which were imposed by Nike actually contributed to the process of innovation. The title of the article is how labour standards can be good for growth, and also in the process of upgrading. So that's an example of how having higher wages can actually be good for this upgrading process. Now, there are factors going in both directions, right? On the one hand, you know, the 20 or 30% higher labour costs, I think they did contribute to innovation. On the other hand, 20 or 30% higher labour costs may mean that firms will hire fewer workers or that the industry will be less competitive. So it's not that, you know, this innovation effect is all powerful and it's going to overwhelm anything that's about labour costs. But I think it is something that we need to take into account. And so, you know, labour market institutions that, you know, maybe promote profit sharing with workers, that promote longer-term employment so you have people who are around for longer, that have some job security, the sorts of things that often labour unions want to negotiate, can actually be good for this innovation process. And that's one factor that should be weighed against this issue of, you know, how higher labour costs and how competitive is the sector going to be. You often hear, like, the World Bank or the USAID, the development agencies will often say, you just have to be cheap. Like, you know, the competitive advantage of Nigeria is cheap labour and therefore, you should be focusing on having low wages and producing, you know, garments and textiles and toys and low-end manufacturing. But I think that's kind of a low-road model. You know, and I think that there are viable high road models, which would involve somewhat higher wages, some sort of gain sharing or profit sharing, and being more innovative at the same time. I can't tell you I have it all worked out exactly what that model would look like, I think it's going to vary by country. But I think we need to try to think about and push in that direction of where you can have, it may not be high wage, but it's gonna be higher wage than the market by itself maybe would bring about. So I am optimistic that that can happen. But again, the devil's in the details, you know. So Nigeria needs to think about what are we relatively good at doing right now and let's think about how can we be more innovative and move up to the quality ladder, the technology ladder in those industries. And then how can we get our workers on board to the process of moving up that ladder? And that will probably involve paying those workers more, rather than just trying to cut wages to the extent possible.Tobi; Before I let you go, let me... I know you're a relatively quiet person so let me draw you in a little bit... yeah, I know you're not active on Twitter or anything like that. Let me draw you into a little bit of professional controversy. And one of the things that I admire most about your work, I should confess, is that it's methodologically diverse. You know, you do structural econometrics, you do RCT, you do regular modelling and so many things. So there's this huge debate currently that I think, a lot of my colleagues may not think so but I think has important consequences for the policymaking process on development, which is that - is development research right now focused on the right things? You know, RCTs are like the standard tool for the investigation of development questions. Empirics have sort of taken over the field. But on the other hand, you have folks like Lant Pritchett who are constantly pushing back that this is encouraging researchers to think too small, they are researching cash transfers, and so many other key interventions, whereas we really should be focused on the big questions. And in my experience, these have real-life implications, especially in poor countries where they have budgetary constraints. We might say this is due to corruption, and that will be true, but sometimes they have a real balance of payment crisis, because a lot of these countries are resource-dependent, and it's often cyclical. So a policymaker may really want to know where to spend the most resources to have the maximum benefit for the citizen. So I find these questions very important. What do you think about this debate? As someone who transverses the field very often in your work, how have you been able to navigate this debate? And what do you think is the, maybe right is not the right word here...what do you think is the useful approach going forward?Eric; Yeah, good question. Yeah, in my own work, I've been very question driven rather than methods driven. Right. So I've always thought, you know, I'm interested in this question of from upgrading, what are the barriers to upgrading? What drives upgrading? How can we, you know, learn about that, and if we can learn about that using an experiment, that's great. If we're in about that using other methods, that's great, too. So I, sort of, don't have a dog in the hunt, as Bill Clinton would say about, you know, the methodology. And I'm kind of in the middle of the road, I think, in terms of this debate between, you know, J-PAL and Esther Duflo and Abhijit Banerjee and Lant Pritchett or others on the other side. I think, you know, in situations where you can run an experiment, I think that is the most credible source of information. Okay, so I'd rather have a randomized experiment than do a correlation and put some causal interpretation on a correlation. At the same time, I do think that there are many questions, either that can't be answered with an experiment, or that are just very, very costly to answer with an experiment, right? And so it's very hard to run, you know, it's running experiments on firms. I've tried to do it, but it takes a long time. It can be very costly. You have to give much bigger shocks to firms to get them to react, etc. And so, I've heard Abhijit Banerjee articulate that, like, we should never do a policy that hasn't first been evaluated by random experiment, I think that's too strong. Because we're gonna be waiting years and years and years to get the experiments and with a huge investment of resources in order to get the experiments that would then inform the policy. So we're going to have to make policy and, you know, make decisions based on other sorts of information. And so there, I do think we need to be like small ''c'' Catholic, allow for lots of different types of methods, quasi-experimental methods, you know, even structural methods, and then also experiments. There's this famous joke about the drunk guy with a streetlight, you know, he's looking for his keys, and he's looking under the streetlight, because that's where the light is, maybe not where the keys have been lost. And so I take that point, like, maybe we really care about these big questions about, you know, what's going to drive growth, then in that sense, I'm sympathetic to the sort of the Lant Pritchett view. On the other hand, under the lamppost, we actually are learning stuff, right, I feel like we're more confident that we're making progress by looking under the lamppost. And so I think the, you know, the trick, the art here is to sort of stay near the edge of the lights and we're getting closer to the big questions, but in a way that's still credible, and that we're still, you know, we can believe the answers that we're actually given. To sort of counter the Lant Pritchett view, you can post these big questions, and you can, you know, think big thoughts. But at the end of the day, you have to be able to convince, you know, you have to show us the data, right, you have to show that this is really correct. And that's just very hard to do for many of these big questions. So we need to incrementally build up based on this work. That's why I kind of like this work on firms, we're getting towards these big questions about growth, but in a way that you can actually have some confidence that you understand what's going on.Tobi; In your experience doing this work, what are misconceptions that you have encountered in the field that either the professional development industry, so I'm talking about aid and the think-tank and all the other folks, or it may even be your academic colleagues, what are the common misconceptions that you have encountered? Eric; Yeah. I mean, so one big thought [is] I think that the of field development agencies, right, it's like, how are we going to spend aid dollars in a way that's going to have a positive effect? And I think there's value to that. All right. I'm all in favour of spending, you know, aid dollars, in the most effective way. But I think that you know, a set of questions does limit to some extent the impact of the field of development on the development process. So I actually think we could spend every aid dollar in an optimal way, and would it have a meaningful effect on the material standard of living of people in poor countries? I'm not sure. I mean, maybe a little bit, maybe marginal, right? I think what's really going to matter is, do these countries start getting industrialization happening? Are they getting upgrading? Are they growing? And so in that sense, I sometimes get a little bit frustrated with the development discussions, it's all about this, you know, how do we spend aid dollars, and let's do RCTs to figure out how to spend the aid dollars, rather than these bigger questions, which are going to have a longer-term effect on people's living standards. You know, that's changing a little bit. I'm encouraged. There are more and more people talking about firms, there are more and more people taking sort of industrial policy ideas seriously. They're talking about bigger-picture questions in a kind of micro-founded way. So there are some encouraging signs. But I think a lot of development is still about that issue of like, what's the right way to do social policy? What's the right way to do, you know, aid spending, rather than trying to understand deeply why is it that Korea was able to make this transition from a poor country to a rich country, essentially, in a generation? And why is it that many countries in Africa are not? What is it that's actually getting in the way? And for that, that's not really like how to spend aid dollars question that's more about how firms behave. What are the factors that constrain them? And those sorts of things.Tobi; This is a show about ideas. So I want to ask you, what's the one idea? Just one. One idea that you think everybody should think about and adopt, that you would like to see spread everywhere. What's that idea? It may be from your work, or it may be from other things that inspire you. What's that one idea?Eric; I think the one idea I would choose is, uh, workers have a brain. This goes back to the soccer ball study, that there's knowledge and information that, like, workers have or people who are lower down in the hierarchy have, which is not being taken advantage of. Right, the soccer ball thing was an example. The workers were understanding the technology, but because of the way they were paid, and because of the, you know, institutional arrangements, they didn't have the incentive to share that. And I think the world, including the economics profession, tends to undervalue the intelligence that people have. Even the people who are actually, you know, on the frontlines doing the work. And if we can figure out ways to harness that knowledge and give people incentives to share it and give people incentives to develop their own intellectual thinking about whatever it is they're doing, I think that'll have a big payoff. And so I'm interested in sort of investigating what are the sorts of arrangements, what are the sorts of policies that can lead that to happen more?Tobi; Yeah. Thank you so much, Eric. I mean, tell me a little bit about what you're working on right now.Eric; What am I working on right now? I mean, so one thing related to what we've been talking about that I'm excited about is, again, a paper on technology adoption. This is in Bangladesh, with an energy-efficient motor like sewing machines. They're different sorts of motors that the traditional ones they're kind of spinning all the time. And then people have the foot pedal they like to press the foot pedal and then the needle comes down and stitches right but they're actually wasting a lot of energy because these motors are spinning all the time. And so there's a new type of motor called a servo motor which spins Only when the needle is moving, right, so it's energy efficient, energy efficient motor, but it can just replace the old motor, you don't have to change anything else about the machine, you just put this new servo motor to replace the old clutch motor. And we're studying when new managers or when new owners, when do they make those decisions. And so we're trying to track we're giving them information in different intensities, like including installing the machines in their factory one is just showing a video when it's just providing information, but one is actually installing their machines. And we're seeing how they react to that information. So I think that's a big topic. It's like what's getting in the way of the adoption of energy-efficient technology? These are the people who are making mistakes, or they just don't have good information. Or that basically, maybe if they have the right information, they actually will adapt very quickly. So that's one thing I'm thinking about.Tobi; It's been fascinating talking to you, Eric. I enjoyed it so much.Eric; Thank you, Tobi. Good questions. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.ideasuntrapped.com/subscribe

Au programme de Des Mauls et Débats on revient sur la lutte pour le maintien, avec un CA Brive légèrement décroché et qui a subi un large revers contre un concurrent direct. La question concerne le RCT qui réalise le coup du week-end à Paris. Retrouve-t-il sa grandeur ? Coup de cœur pour Deghmache et Tisseron, coup de gueule contre Verhaeghe. Le prono concerne le dernier match de la journée entre Lyon et Toulouse.Musique : Buffalos - ZebrosPar Baptiste BARBAT. 

In this episode, we discuss a recent RCT on using brexpiprazole to treat borderline personality disorder. Is it safe and effective? Could brexpiprazole be the magic bullet we were waiting for?  Faculty: Jim Phelps, M.D.  Host: Richard Seeber, M.D. Learn more about our memberships here Earn 0.5 CMEs: Quick Take Vol. 40 A Double-Blind Placebo-Controlled Study of Brexpiprazole for the Treatment of Borderline Personality Disorder

In this month's Talk Evidence, Helen Macdonald, The BMJ's research integrity editor, is joined again by Juan Franco, editor in chief of BMJ EBM, and Joe Ross, US research editor. They're straying beyond the pages of The BMJ, and discussing an NEJM paper about colonoscopy for colorectal cancer screening. We have a listener request, asking about evidence for England's " NHS Diabetes Prevention Programme" - what do we know about how lifestyle interventions work at a population level? Juan puts on his Cochrane hat to answer the query. We stay with diabetes, and Joe tells us about his research trying to see if routinely collected observational data could be used to match the outcomes of an RCT into drug treatments. Finally, Helen updates us about what she's been doing about a case of plagiarism in one of BMJ's journals - and what that means for researchers who are writing in multiple journals about their work. Reading list Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death https://www.nejm.org/doi/full/10.1056/NEJMoa2208375 Emulating the GRADE trial using real world data: retrospective comparative effectiveness study https://www.bmj.com/content/379/bmj-2022-070717 Expression of concern about content of which Dr Paul McCrory is a single author https://bjsm.bmj.com/content/early/2022/10/11/bjsports-2022-106408eoc

In this month's Talk Evidence, Helen Macdonald, The BMJ's research integrity editor, is joined again by Juan Franco, editor in chief of BMJ EBM, and Joe Ross, US research editor. They're straying beyond the pages of The BMJ, and discussing an NEJM paper about colonoscopy for colorectal cancer screening. We have a listener request, asking about evidence for England's " NHS Diabetes Prevention Programme" - what do we know about how lifestyle interventions work at a population level? Juan puts on his Cochrane hat to answer the query. We stay with diabetes, and Joe tells us about his research trying to see if routinely collected observational data could be used to match the outcomes of an RCT into drug treatments. Finally, Helen updates us about what she's been doing about a case of plagiarism in one of BMJ's journals - and what that means for researchers who are writing in multiple journals about their work. Reading list Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death https://www.nejm.org/doi/full/10.1056/NEJMoa2208375 Emulating the GRADE trial using real world data: retrospective comparative effectiveness study https://www.bmj.com/content/379/bmj-2022-070717 Expression of concern about content of which Dr Paul McCrory is a single author https://bjsm.bmj.com/content/early/2022/10/11/bjsports-2022-106408eoc

Welcome back to the podcast and to November's Papers Of The Month. First up we're taking a look at a paper that challenges the current American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines that recommend when right ventricular myocardial infarction, that patients are not administered nitrates due to the risks of compromise of cardiac output.  Secondly we look at an RCT, with some really clever blinding, that looks at different BP targets for intubated and ventilated patients in ICU who have sustained a cardiac arrest. Finally we take a look at a paper focussing on healthcare professionals' perceptions  of interprofessional teamwork in the emergency critical incidents. Once again we'd love to hear any thoughts or feedback either on the website or via twitter @TheResusRoom. Simon & Rob

From the entire Protrusive Community - we wish Sanj a speedy recovery - keep smiling Sanj and stay strong! In the previous episode with Sanj Bhanderi on 'how to extirpate properly and efficiently', we briefly touched on postoperative pain control. In this episode, we're focusing more on postoperative pain and the dreaded severe pain after the obturation appointment (or in-between visits). https://youtu.be/RJzQZNhBup0 Check out this full episode on YouTube Need to Read it? Check out the Full Episode Transcript below! Highlight of this episode: 2:27 Post-op pain after endodontic treatment7:43 Flare-ups9:46 Guidelines in antibiotic microbial management11:03 Flare up in between visits (RCT has not been finished yet) 13:40 Crown Down approach Dr Finlay Sutton is coming down South for his one-day signature RPD Masterclass on Saturday 14th of January 2023!  Limited to 12 delegates, reserve your seat now! If you enjoyed this, you might also like my episode with another talented Endodontist, Dr Ammar Al-Hourani, on Is Single Point Obturation Acceptable?  Click below for full episode transcript: Opening Snippet: I wanted to start this podcast with a get well soon message for our guest, Dr. Sanj Bhanderi who did such a brilliant job with our last group function on how to extirpate quickly and properly. Now, unfortunately, after we recorded that episode, and after we recorded this one, Sanj felt acutely unwell. It was actually scary hearing the news of him being ill. But I'm getting some positive updates. And so we the Protrusive Dental Community, and then all dentists around the world. We wish Sanj a speedy recovery. We hope you get well soon. We're so glad you're okay and on the mend. And we want to pass on these wishes to you. It's been quite clear on social media, what a likable guy you are, and how much we all want you to make a speedy recovery mate. So wishing you all the best and get well soon from Team protrusive. Jaz's Introduction:I bet this scenario sounds very familiar to you imagine you're on a course you having a great time. I personally love courses, I think you all know that. You're on your fifth coffee, and everything's going great. And suddenly your pocket starts vibrating. You've got a call from the practice or text message informing receptionist saying that, 'Mrs. Smith, you know, the root canal that you saw yesterday, she's in absolute agony.' And you curse because you think wow, you know, that was a completely straightforward root canal procedure. The patient was asymptomatic before you even started. Why is this happening for me? Look, post-op pain after endodontics is an absolute bitch. It's one of those annoying things ever actually puts me off doing root canal treatment because of the one in harmony of a chance that post op pain instance is going to happen. And I'm going to discuss with Sanj Bhandari who does such a brilliant job in that GF o one six, where we talk about how to extirpate properly and efficiently. So if you haven't listened to that one, oh my goodness, you are in for a treat. Go back and listen to that one. But in this episode, we're focusing more on post op pain like how do you manage that kind of scenario? What do you say to the patient? How can you prevent this from even happening in the first place? You know, it's funny I've actually had four root canals on my own self and before you think, 'Oh, Jaz is disgusting, you got caries, etc.' No, it's actually trauma from orthodontics. Can you believe it? Orthodontics devitalize, my lower four incisors, and I've had all sorts of issues and root canals and fractures, etc, etc. And now have a resin bonded zirconia bridge, hence why I'm so passionate about those bridges. Anyway, I experienced post op pain myself, it was a nasty thing. It was lots of inflammation. And so I've been there and I totally empathize with my patients. Before we joined the main episode I want to say yesterday I released new tickets to Fin...

This week, please join authors Kevin Roedl and Sebastian Wolfrum, as well as Associate Editor Mark Link as they discuss the article "Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary, and backstage pass to the Journal and its editors. We are your cohosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor and Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature, very interesting, a randomized clinical trial of temperature control after in-hospital cardiac arrest. But before we get to that exciting study, let's grab a cup of coffee, and jump in and discuss some of the other articles in the issue. Carolyn, would you like to go first? Dr. Carolyn Lam: Yes. Starting with a great quiz. So Greg, which is better? How about this? It's multiple choice. Is it A; transradial, or B; transfemoral access, in terms of post-procedural mortality? Dr. Greg Hundley: I'm going to go with transradial. It has been, hopefully, I'm okay on this. It just seems so many fewer complications. Dr. Carolyn Lam: But that's exactly that we need to meta-analyze the studies that have been done. Exactly what this paper did, led by Professor Valgimigli, from USI in Lugano, Switzerland. So what they did is, they performed an individual patient data meta-analysis of 21,600 patients, enrolled in seven multi-center randomized control trials, comparing the transradial with transfemoral access, among patients undergoing coronary angiography with or without PCI. And they found that transradial access was associated with a lower incidence of the primary outcome of all-cause mortality, and the co-primary outcome of major bleeding at 30 days, compared to transfemoral access. There was also evidence for reductions in major adverse cardiac and cerebral vascular events, net adverse clinical events, vascular complications, excess site bleeding, and blood transfusion. MI, stroke, and stent thrombosis, did not differ. And crossover was higher in the transradial access group. At predefined subgroup analysis, the authors confirmed that the benefit observed the transradial group was generally consistent across the majority of pre-specified subgroups, except for those with significant baseline anemia. Patients with baseline anemia appear to derive a substantial mortality benefit with transradial access rather than transoral access, compared to those with mild or no anemia. So, the authors concluded, that the meta-analysis provides evidence that transradial access should be considered the preferable access site for PCI, in patients with acute coronary syndrome, supporting most recent recommendations on the preferential use of this radial approach. So you were right, Greg. Dr. Greg Hundley: Very nice, Carolyn. A really important piece of science to disclose to our listeners, in that hurried state, and moving quickly door to balloon times, et cetera. And here we find another positive outcome in study result for transradial approaches. Well Carolyn, as we know, my next paper, it's really going to come to us from the world of preclinical science. And it pertains to hypertension, which is a common cardiovascular disease, and is related to both genetic and environmental factors. But the mechanisms linking the interplay between the domains of genetics and the environment have not been well studied. Now, DNA methylation, a classical epigenetic modification, not only regulates gene expression, but is also quite susceptible to environmental factors. Thereby, linking environmental factors to genetic modifications. So therefore, Carolyn, these authors, including Professor Jingzhou Chen, from Fuwai Hospital, National Center for Cardiovascular Diseases, and the Chinese Academy of Medical Sciences, and the Peking Union Medical College, and their colleagues, felt that screening differential genomic DNA methylation, in subjects with hypertension, would be important for investigating this genetic environment interplay in hypertension. So this study, Carolyn, like many from the world of preclinical science and circulation, incorporated both human and animal model subjects. Methodologically differential genomic DNA methylation in hypertensive, pre-hypertensive, and healthy control individuals, was screened using the Illumina 450K BeadChip, and then verified by pyrosequencing. Plasma oviduct glycoprotein 1, or OVGP1 levels, were determined using an enzyme-linked immunosorbent assay. And OVGP1 transgenic and knockout mice were generated to analyze the function of OVGP1. Dr. Carolyn Lam: Wow. Nice approach, Greg. And what did the authors find? Dr. Greg Hundley: Right, Carolyn. These authors found a hypomethylated site at cg20823859 in the promoter region of OVGP1, and the plasma OVGP1 levels were significantly increased in hypertensive patients. This finding indicates that OVGP1 is associated with hypertension. Now Carolyn, in OVGP1 transgenic mice, OVGP1 over expression caused an increase in blood pressure. Also, dysfunctional vasoconstriction, and vasodilation, remodeling of the arterial walls, and increased vascular superoxide stress and inflammation. And these phenomenon were exacerbated by angiotensin II infusion. In contrast, OVGP1 deficiency, attenuated angiotensin II induced vascular oxidase, stress, inflammation, and collagen deposition. Now pull down, and co-immunoprecipitation assays showed that myosin heavy chain 2A, or MYH9, interacted with OVGP1. Whereas, inhibition of MYH9 attenuated OVGP1 induced hypertension and vascular remodeling. Dr. Carolyn Lam: So Greg, let me try to summarize, is that okay? So hypomethylation, at that specific site in the promoter region of the OVGP1 gene, is associated with hypertension, and induces its upregulation. The interaction of this OVGP1 with myosin heavy chain 2A contributes to vascular remodeling and dysfunction. And so, OVGP1 is a pro hypertensive factor, that promotes vascular remodeling by binding to this myosin heavy chain. So, really cool stuff. Thanks for teaching us. Dr. Greg Hundley: Very good. Dr. Carolyn Lam: Well thanks so much, Greg. And we go back to the clinical world now, and ask the question, what is the efficacy and safety of prophylactic full dose anticoagulation and antiplatelet therapy, in critically ill COVID-19 patients? So I'm going to tell you the results of the COVID-PACT trial. And this was a multi-center, two-by-two factorial, open label, randomized controlled trial, with blinded endpoint adjudication in 390 ICU level patients. So, severely ill patients with COVID-19, from 34 US centers. Patients were randomized to a strategy of full dose anticoagulation, or standard dose prophylactic anticoagulation. And in the absence of an indication for antiplatelet therapy, patients were additionally randomized to either clopidogrel or no antiplatelet therapy. Dr. Greg Hundley: Ah, Carolyn. So what did they find? Dr. Carolyn Lam: Full dose anticoagulation substantially reduced the proportion of patients experiencing a venous or arterial thrombotic event, and there was no benefit from treatment with clopidogrel. Severe bleeding events were rare, but numerically increased in patients on full dose versus standard dose prophylactic anticoagulation, without any fatal bleeding events, GUSTO moderate or severe bleeding was so significantly increased with full dose anticoagulation, but with no difference in all-cause mortality. So in summary, in a population of critically ill patients with COVID-19, a strategy of prophylaxis with full dose, versus standard dose prophylactic anticoagulation, but not the addition of clopidogrel, reduced thrombotic complications, with an increased risk of bleeding, driven primarily by transfusions in hemodynamically stable patients, with no apparent excess in mortality. Dr. Greg Hundley: Very nice, Carolyn. What a important piece of information, as many of us around the world are taking care of critically ill patients with COVID-19. Well, how about we see what is in the mail bag this week? So first, Carolyn, there's a Frontiers piece by Dr. Packer, entitled, “Critical Reanalysis of the Mechanisms Underlying the Cardiorenal Benefits of SGLT2 inhibitors, and Reaffirmation of the Nutrient Deprivation Signaling Autophagy Hypothesis.” Next, there's a Research Letter, from Professor Airaksinen entitled, “Novel Troponin Fragmentation Assay to Discriminate Between Troponin Elevations in Acute Myocardial Infarction and End-stage Renal Disease.” Carolyn, there's another Research Letter, from Professor Solomon, entitled, “Aptamer Proteomics for Biomarker Discovery in Heart Failure with Reduced Ejection Fraction.” Also, Carolyn, [a] wonderful Cardiovascular News summary from Tracy Hampton, reviewing three articles. First, “Mechanisms Behind Cannabis Effects on Heart Health.” The second, “Exercise Inducible Metabolite Suppresses Hunger.” And then lastly, “Piezo1 Initiates the Cardiomyocyte Hypertrophic Response to Pressure Overload.” Dr. Carolyn Lam: Cool. There's also an exchange of letters between Doctors Jha and Borlaug on latent pulmonary vascular disease in therapeutic atrial shunt. And finally, an On My Mind, by Dr. David Kass entitled, “What's EF Got To Do, Got To Do With It.” I love it. You must read it. It's so, so cool. All right. But now, let's go on to our feature discussion, shall we? Dr. Greg Hundley: You bet, Carolyn.   Welcome listeners, to our feature discussion today, and really delving into the world of in-hospital cardiac arrest, and how we manage those patients. And we have with us today, Dr. Kevin Roedl from Hamburg, Germany, Dr. Sebastian Wolfrum from Lubeck, Germany, and our own associate editor, Dr. Mark Link from University of Texas Southwestern in Dallas, Texas. Welcome gentlemen. Kevin, we're going to start with you. Can you describe for us, some of the background information that went into the construct of your study, and what was the hypothesis that you wanted to address? Dr. Kevin Roedl: Thank you, Greg. We thank you for the kind invitation to this podcast. We're very likened to do this podcast with you. And so, talking about the background of hypothermia in-hospital cardiac arrest, we have to go back like two decades almost, because there were two studies in New England Journal of Medicine published 2002, who introduced mild therapeutic hyperthermia to the treatment in post cardiac arrest. Primary, these two studies show the benefit of the therapy in this kind of patients. And then, 2003, it was introduced in also the international guidelines. However, these studies only addressed out-of-hospital cardiac arrest patients, and also, only shockable rhythms. And so, the question arised over the years, what about other patients like non shockable rhythms, or also in-hospital cardiac arrest? And so, that's basically was the primary aim of our study to address this special population. Because when you see the states, the numbers, there are 290,000 in-hospital cardiac arrests a year. So it's actually, a very large population. And there's no randomized control trial to show any benefit, or maybe harm, in this group. There were some observational studies, 2016 in China published. From China, in this group, they looked at the Get With The Guidelines registry, and actually, they saw that there was probably a negative influence of hypothermia in the study. However, it was only observational. So actually, there were no randomized control trials. And that primary hypothesis was, that we wanted to know actually, does thus mild therapeutic hyperthermia work in this group of patients in the in-hospital cardiac arrest setting? And what is the outcome? Is it like in the out-of-hospital cardiac arrest setting, or not? Dr. Greg Hundley: Wonderful, Kevin. And so, can you describe for us then, your study population and your study design? Dr. Kevin Roedl: Yes, of course. We did a randomized control trial. There were over 1000 people screened, and overall, we included 242. So you see how hard it is to get people in there. And actually, in terms of hypothermic temperature control, we are 120 about, and long term at 118, and the final others of the endpoints. And when we look at the baseline characters of these patients, they were well balanced actually, about 72 years. When we look at the initial cardiac arrest rhythm, that's interesting because about 70% non-shockable rhythms, and 25% shockable rhythms. And probably also interesting, the location of the cardiac arrest. Medical boards about 50%, and ICU or ED was 22%. So that's probably summed up the baseline characteristics of our study. Dr. Greg Hundley: Perfect. And so Kevin, can you describe for us what was the hypothermic target for the group that was going to have their temperature recused? Dr. Kevin Roedl: Yes, hypodermic target was 32 degrees to 44. And so two degrees Celsius, basically the same target like in earlier trials. Dr. Greg Hundley: Very nice. Well listeners, now we're going to turn to our second co-author, Dr. Sebastian Wolfrum. And Sebastian, can you share with us the study results? Dr. Sebastian Wolfrum: Yes, Greg. Thank you very much for the opportunity to participate in this podcast. Only wanted to include unconscious patients, and therefore, we took a time and took 45 minutes after their cardiac arrest, to let the patients get away if they did so. We also excluded patients that had severe functional deficit before the cardiac arrest; since we could not really define the neurological outcome if we would've included those. And we didn't see any differences. Neither in mortality, not in the functional outcome, either when they're treated with 33 degrees Celsius, or whether normothermia was used. The death rate after six month was in a range which is comparable to other in-hospital cardiac arrest studies, and higher than those performed in the out-of-hospital cardiac arrest studies. It was about slightly over 70% in both groups. And the number of patients with the good functional recovery after six months was 23% of the patients in the hypothermia group, and 24% of the patients in the normothermia group. And if we look at only the survivors, we see that the ones which are worse functional outcome, were most of them dead after six months. We then also focused on the temperature curves in our patients, and to see whether we have achieved our goal. And we saw that we have reached the target temperature within four and a half hours after cardiac arrest in our hypothermia group. Which is not as fast that we had expected, but still in the range, which is comparable to other studies on this field. And we also saw that our control group was about 37 degrees, within the first 12 and 48 hours. So we truly avoided fever, which has not been done in every previous study on cardiac arrests. Dr. Greg Hundley: Very nice. And any differences between the hypothermia and normothermia groups, related to the age of the patient? Or, whether or not they had a shockable rhythm at the time of presentation? Dr. Sebastian Wolfrum: We saw as a result of our study, that age is a predictive factor for mortality. But age did not differ between our treatment groups, and therefore, did not interfere with our results. And we didn't see differences in the shockable or non-shockable rate in our patients in the different treatment groups.   Dr. Greg Hundley: Thank you. Well listeners, now we're going to turn to our associate editor, Dr. Mark Link, one of our expert electrophysiologists at Circulation. And Mark, you have many papers come across your desk, and what attracted you to this particular paper? Dr. Mark Link: There were a number of things. One, it's hard to do RCTs in resuscitation, and I thought they did a very nice job with this RCT. Two, the subject of hypothermia, or therapeutic temperature management, is a very hot one in resuscitation. It's one of the few treatments in the past that have been shown to make a difference in outcome. And so, all of those trials were done in out-of-hospital arrest. So to have a trial done in in-hospital arrest was very intriguing also. And I think we're all disappointed that it wasn't a positive trial, but we have to take the negative trials also. And I think, part of the reason it may have been a negative trial is because the normal thermic group avoided hyperthermia. And I think that's something that's coming out of a lot of these trials is avoid fever. It may not be so important to get hypothermic targets, actually, looks like it's probably not, but it looks like it's very important to avoid fever. Dr. Greg Hundley: Very nice. Well listeners, we're going to turn back to our expert panel here really, and start with you Kevin. Kevin, what do you think is the next study that needs to be performed in this sphere of research? Dr. Kevin Roedl: Thank you for this interesting question. Yeah, a bunch of studies could be performed, especially maybe in the out-of-hospital cardiac arrest study, because we don't know. This fever harmful, we have to find certain subgroups in which this treatment works. So maybe in this subgroups there is data on this and it could be a benefit. So these are, I think, the two main topics that should be done in the future. Dr. Greg Hundley: Thank you. Sebastian, what are your thoughts? Dr. Sebastian Wolfrum: As Mark said, the hypothermic treatment was, for decades, maybe the only treatment which we could give to cardiac arrest patients, which has been proven to reduce mortality. And all other studies following didn't see any be benefit of hypothermia, not even in a subgroup. Also, the TTM trials did not. So I'm questioning myself, where is the original HACA study group that benefits? Where did this hide in the other studies? So I would think, to do another study in out-of-hospital cardiac arrest patients, whether in ventricular fibrillation that had shown in the HACA trial to reduce mortality. This should be done in a similar way to the original study, to see whether there is this subgroup. People who support the idea of hypothermia also focus very much on the fast onset of their hypothermic treatment. And they say we saw a difference in mortality in the HACA trial, and we could very fast. And I think the other studies have to show that they cool as fast as the HACA study. So the main focus should be on the time calls of hypothermia after cardiac arrest, cooling very fast to a target temperature of 33 degrees, maybe holding on for 24, maybe 48 hours. Dr. Greg Hundley: Very nice, Sebastian. So focusing on the speed and the timing of that cooling. And Mark, anything to add? Dr. Mark Link: Yeah, so if I sit here with my writing group hat on for the HA and say, "What are we going to do for the resuscitation guidelines in 2025?" I think you look at the totality of the data for targeted temperature management. And I think, the main thing you say, walking away from this, is avoid fever. Don't let your patients get hot. I'm not sure you can say much more than that right now, until we get more data. Dr. Greg Hundley: Very nice. Well listeners, a really interesting provocative discussion today. And we want to thank Dr. Kevin Roedl from Hamburg, Germany, Dr. Sebastian Wolfrum from Lubeck, Germany, and our own associate editor, Dr. Mark Link from Dallas, Texas, bringing us the results of this study highlighting that hypothermic temperature control is compared with normothermia did not improve survival, nor functional outcome, at 180 days in patients presenting with coma after in-hospital cardiac arrest. Well, on behalf of Carolyn and myself, we want to wish you a great week, and we will catch you next week On The Run. This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors, or of the American Heart Association. For more, please visit ahajournals.org.

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Covid 10/27/22: Another Origin Story, published by Zvi on October 27, 2022 on LessWrong. The big story this week was a new preprint claiming to show that Covid-19 had an unnatural origin. For several days, this was a big story with lots of arguing about it, lots of long threads, lots of people accusing others of bad faith or being idiots or not understanding undergraduate microbiology, and for some reason someone impersonating a virologist to spy on Kelsey Piper. Then a few days later all discussion of it seemed to vanish. It wasn't that everyone suddenly came to an agreement to move on. All sides simply decided that this was no longer the Current Thing. See the section for further discussion. In the end I did not update much, so I am mostly fine with this null result. There's also more Gain of Function research looking to create a new pandemic. There was a lot of consensus among the comments and those I know that this work must stop, yet little in the way of good ways to stop it. Several people gave versions of ‘have you considered violence or otherwise going outside the law?' and my answer is no. While the dangers here are real, they are not at anything like the levels that would potentially justify such actions. Note on Deleted Post from This Week Finally, I need to address the post that got taken down in a bit more detail. I want to thank Saloni in particular for quickly and efficiently making some of my mistakes clear to me both quickly and clearly, with links, so I could within about an hour realize I'd made a huge mistake and the whole post structure and conclusions no longer made sense, so I took the post down. Please disregard it. Everyone has been great about understanding that mistakes happen, and I want you to know I appreciate it, and hope it helps myself and others similarly address errors in the future. How did the mistakes happen? Ultimately, it is 100% my fault, on multiple counts, no excuses. What are some of the things I did wrong, so I can hopefully minimize chances they happen again? My logic was flawed. I wasn't thinking about the power of the study properly. I let the truly awful takes and absence of good takes defending colonoscopies make me too confident in the lack of available good takes doing so, and let that bias my thinking. I got feedback before posting, but I did not get enough or get it from the right sources. I heard everyone talking about ‘first RCT' in various forms and failed to notice it was only the first to look at all-cause mortality rather than the first RCT. The authors of this one made the mistake of trying to measure all-cause mortality as primary endpoint despite lacking the power to do so, in a way that my brain didn't properly process, compounding the errors. I didn't properly consider the possibility that the main result of a published paper was plausibly highly ‘unlucky' in part due to training on decades of publication bias. I didn't fully appreciate the magnitude of the healthy patient bias, which made certain extrapolations sound patently absurd – I'm still super skeptical of those claims but they're not actually obviously crazy on reflection. And I messed up a few small technical details. In general, the whole thing is really complicated. There is no question that the study was a disappointing result for the effectiveness of colonoscopies, well below what the researchers expected to find. However, there is a lot of room for ‘disappointing but still worthwhile' and a lot of additional past data to incorporate. I genuinely don't know what I am going to think when I am finished thinking about it. Executive Summary New preprint on potential origins of Covid-19, not updating much. Gain of Function research continues. Please disregard this week's earlier post until I can properly fix it. Let's run the numbers. The Numbe...

The JournalFeed podcast for the week of Oct 24-28, 2022. These are summaries from just 2 of the 5 article we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member. Bell's Roids Spoon Feed There was no statistical difference in 1, 3, or 6 month facial recovery with prednisolone vs placebo for children with Bell's palsy in this underpowered RCT. However, with a possible signal of long term benefit, I will keep prescribing steroids in these patients. WATEFALL RCT Spoon Feed Conservative fluid administration in patients with acute pancreatitis can achieve similar clinical outcomes compared with aggressive resuscitation, with less risk of volume overload.

SHOCKING! DRAMA! Not really, so let's dig into the details from NEJM October article on colonoscopy RCT in Europe.

Today, Stefan talks with Saul about his favorite topic (and life's work), contextualizing care. We're re-releasing this conversation (from January of last year) because Saul's research team has just published a new study -- an RCT, titled "Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial," which is open access, so you can read it by clicking on the link. This episode provides a brief "one-stop-shop" for anyone who wants to understand what it means to contextualize care and why it matters.  

This is the first study to test the use of vaginal tadalafil on endometrial thickness and pregnancies in women using IVF to conceive. ResourcesBalduyck J, Ameye A, Decleer W. Effect of vaginal/oral tadalafil on endometrial thickness in IVF patients: a double-blind, placebo controlled RCT: a pilot study. Facts Views Vis Obgyn. 2022;14(2):155-161. doi:10.52054/FVVO.14.2.026Belapurkar P, Jaiswal A, Madaan S. Comparison of Efficacy Between Vaginal Sildenafil and Granulocyte-Colony Stimulating Factor (G-CSF) in Improving Endometrial Thickness (ET) in Infertile Women. Cureus. 2022;14(6):e26415. Published 2022 Jun 29. doi:10.7759/cureus.26415Cialis. Package Insert. Eli Lilly and Company; 2011.Heger A, Sator M, Walch K, Pietrowski D. Smoking Decreases Endometrial Thickness in IVF/ICSI Patients. Geburtshilfe Frauenheilkd. 2018;78(1):78-82. doi:10.1055/s-0043-123762Mostafa T. Useful Implications of Low-dose Long-term Use of PDE-5 Inhibitors. Sex Med Rev. 2016;4(3):270-284. doi:10.1016/j.sxmr.2015.12.005

My guest on this episode is Stefan Dercon - author of the recently published and most excellent book ‘Gambling on Development: Why Some Countries Win and Others Lose'. Development scholars have produced many explanations for why some countries did better than others after the Second World War. Factors like geography, quality or type of institutions, foreign aid, and protective trade policies, have been argued as what explains this divergence in national prosperity between countries. Dercon's contribution will no doubt be plugged into this long-running debate - and in my opinion, he comes closest to having a ‘‘first principles'' explanation than anyone I have read on the subject. Other theories leave you with nagging questions - Where do good institutions come from? Are countries condemned by their histories? Why do some countries use foreign aid better? Why are some countries with rich geographic endowments doing worse? Why does protective trade lead some countries toward becoming industrial exporting giants, and some others into a macroeconomic crisis?Dercon argues that countries that have done better do so by working out a ‘development bargain'. This comes about when the people with power and influence (elites) in a country find a cooperative agreement (bargain) to consciously pursue economic development and national enrichment. Development bargains are not simple, they are often messy. And elites are not a bunch of altruistic do-gooders. Rather, through many complicated networks of intra-elite competitions and cooperation, they decide to gamble on the future by betting that economic development will deliver the biggest win. Dercon does not claim to have found the holy grail of development - and there are still many questions to be answered. But his argument does lead to one inevitable conclusion. Countries and their people will have to figure out what works for them and how that delivers prosperity.Stefan Dercon is Professor of Economic Policy at the Blavatnik School of Government at Oxford University. He was the Chief Economist of the UK's Department of International Development (DFID).TranscriptTobi; Was your experience really what inspired you to write the book?Stefan; Well, you know, what inspired me definitely is just the contrast that I've had in terms of things I do. Because I've been an academic for a long time, I have more than 30 years writing and studying and, you know, I was one of these academics who like to, as one sometimes puts it, you know, like, likes to get mud on their feet, you know, mud on their boots. I used to work mostly on rural households and in most countries, these are amongst the poorest people, and you just get to know what's going on there. I have a policy interest, and I was just lucky 10 years ago, a bit more than that, I got a job as a Chief Economist in the UK aid agency, and it's just that contrast of having had the chance and the opportunity to get involved on the policy side, on meeting all the more senior people...and it's just that contrast between still enjoying being surrounded by people and what they do and understands livelihoods of poorer people, combined with being in the policy space, I felt like, you know, I have a unique perspective that I wanted to communicate. And it was just a quest to communicate, actually. If anything, I wanted just to tell more of these stories because I think, from all sides, we tend to misunderstand a lot of what's going on and how things work in practice. And that's definitely the case on the academic side. We're so far sometimes from reality that I wanted to tell that story a bit more.Tobi; And I mean, after you wrote the book, and after publication, I presume from some of the feedback that your book is actually quite successful. I gave so many copies away, right, I can't even count. I think at some point, I temporarily bought out Roving Heights' entire stock. So how has the reception been generally?Stefan; I mean, look, what you just told me makes it much more worthwhile than if white kids in Oxford are buying the book. So what I'm really pleased with is that it appealed to a much broader group of people. And actually, you know, if I'm really honest, I hadn't expected that people like you or I was in Bangladesh last week that young people there would actually appreciate the book, you know, that you would actually get people that think about these problems in these countries are actually interested in it. And I'm very pleased that people find it both worthwhile to read and quite interesting. Of course, I get some academics. One story last week in Bangladesh, I had a question, you know, how Lenin fitted in my book. Now, I had to struggle with the answer of how Vladimir Lenin would actually fit into the book and thinking, you know, that's an academic typically responding to, you know... I don't know, I'm not a deep theoretician but it was written out of a kind of pragmatic sense of what can I learn from economics and politics that actually is worthwhile communicating. So it's well received. And if I'm really honest, I don't mind that there are pdf copies circulating as well and things like that. Actually, as long as it's read, you know, you write a book, not because you want the highest sales, but you actually want it to be read, and that actually makes it really interesting that people seem to be able to relate to it. Another group that, actually, I found really interesting that can relate to it is people that are either civil servants working in governments like - in yours, as well as maybe aid officials and International World Bank officials, IMF officials, who actually find it helpful as well. You know, and there's usually a huge bridge between them, there's a huge gap between how in Washington when we think about these things, or in London or in Abuja, and so that's pleasing as well. You know, I don't give a solution to the things but I think I touched on something of where a big part of the problem of development lies is that actually, we are, unfortunately, in quite a few countries, still with governments that fundamentally are backed by elites that don't really want to make the progress and do the hard work. And that's an unfortunate message. But at the same time, you have other countries that are surprising countries that make the progress. And so clearly, there is a lesson there that it's not simply like the problem is simple. Actually, the problem is to some extent, simple. It's about, fundamentally, do you want to actually make it work, make this progress work? And I think that echoes with quite a lot of people - the frustration that many of us have, that some countries seem to be stuck and not making enough progress and we need to be willing to call it out for what it is that it's not entirely the fault of those people who are in control, but they could do far more for the better than they actually do.Tobi; For the purpose of making the conversation practical and accessible, in the spirit of the book itself, I'm going to be asking you some very simple... and what I consider to be fundamental questions for the benefit of the audience and people that probably have not read the book. So there have been so many other books on development that have also been quite as popular as yours, Why Nations Fail comes to mind, and so many others, The End of Poverty by Jeffrey Sachs, some of which you actually reviewed in the opening chapters of the book. And at the heart of most of them is some kind of fundamental concept that then defines how the body of work itself or the central idea itself works, whether it's institutions, or culture, or industrial policy, or whatever. For your book, you talked a lot about the development bargain, what is the development bargain? And how does it work?Stefan; So the way I look at any country in the world, and I mean, any country, rich or poor country is that one way or another, there is a group of people, which I call for convenience, ''the elite.'' It's not like a pejorative title or a title to applaud them, but simply as a descriptive title. The group of people, in politics, civil service, in business definitely, maybe the military, maybe even civil society, key universities, public intellectuals, I talk about the group that I refer to as the elite, these are the people that have power, or they have influenced one way or another, that can be quite broad. Now in every society, I think it's that group that tends to determine what politics and the economy will look like, what the direction of a country will look like, in any society. And I call that underlying idea [as] they have essentially a form of an elite bargain, a bargain between the different people, they don't have to agree on everything, but to have some kind of an agreement that this is the principle by which, you know, my country will be run in politics and in the economy. Now we could have lots of these elite bargains. We could have an elite bargain that, for example, is based on: if I happen to have power, then everything that I'll do is to reward the people that brought me to power. I'll give them jobs in government. I'll give them maybe contracts, I'll do something, you know, technically, we call this Clientelist. You could have another one where he's saying, Look, no, we're going to run this country, totally, where everybody gets an equal right or equal opportunity, and in a particular way. And so you could have political systems that are around this. Now you could have all these things coming together. You could have also regimes that basically say, Well, the main purpose for us is to keep us as a small group in power, you know, he could have a particular way of doing it. Or indeed, to make sure we use it entirely to steal anything we can get and we'll actually put it in our own pockets, you could have a kleptocracy. You could have lots of these different things, you know, you could have different societies. Now, what I mean by development bargain, is actually fundamentally where that underlying elite bargain values, the underlying idea is that we want to grow our economy, and we want to do this in quite an inclusive way. We want to have developmental outcomes as well. And we make this a key part of the elite bargain. So basically, I define a development bargain as an elite bargain - the deals that we have in running our economy and our politics, that fundamentally, one big way we will judge it is that when we make progress in the growth of the economy, and also in development for the broader population, and I call that the development bargain. And I want to actually go a step further and say if you don't have this, you will never see growth and development in your country. You could have leaders talk about it. They could make big development plans, but if underlying all this there is not a fundamental commitment by all these key players that actually it's worthwhile doing, we're not going to achieve it. And maybe I'll make a quick difference here with say, how does that difference...(now, you mentioned Why Nations Fail.) Now, that underlying elite bargain, of course, the nature of your rule of law, your property rights, all these things, they clearly will matter to some extent, but Why Nations Fail puts this entirely into kind of some historical process. And a lot of people that talk about getting institutions right, they say, Well, you need to get institutions right before you can develop, and they seem to come from a long historical process. In my concept of elite bargain, I would actually emphasize [that] even if your country is not perfect in these institutions, even if there's still some corruption left, even if there are still some issues with the political system, even with the legal system, we actually have countries that can make progress if, fundamentally, that commitment is there amongst the elite. So you don't have to wait until perfection starts before you can start to develop. And that actually [means that] I want to put much more power into the hands... sorry, agency is the better word, I put much more agency in those who at the moment are in control of the state. History may not be favourable for you, there may be a history of colonialism, there may be other histories, factors that clearly will affect the nature of your country at a particular moment in time. But actually agency from the key actors today, they can overcome it. And in fact, in the book, I have plenty of examples of countries that start from imperfection, and actually start doing quite interesting things in terms of growth and development, while other countries are very much more stagnant and staying behind. Tobi; You sort of preempted my next question. I mean, since say, 1990, or thereabout, when the results of some of the ''Asia Tigers'' started coming in, maybe also through the works of people like Wade, Hamsden and co., countries like South Korea, Taiwan, Hong Kong, Singapore, have become like the standard for economic development, and subsequent analysis around issues of development always look at those countries and also their neighbours who have actually made some progress, maybe not as much as those specific countries. But what I want to ask you about in your book is, you talk about some of the works on development trying to reach for some kind of long history or some kind of historical...I don't want to say dependency or determinism, but you get my point. So my point is, if we go outside of these Asian Tigers, if we go back to say, Japan, or even the second industrial revolution, America, Germany, the Netherlands, can we observe the development bargain as you have described it? Is it also consistent through history?Stefan; I would say Absolutely. I mean, one of the things with when we look at these countries with longer-term success, you mentioned correctly, you know, the Koreas and also Japan, or going back in time to the Industrial Revolution, the second industrial revolution and so on, actually, we take for granted that actually they really wanted to succeed. And it's actually one of these things, and especially in recent history, [South] Korea came out of deep conflict, of course, it was also called War so they got certain support as well. But it was really important for both Japan and Korea after the Second World War, for Japan to re-emerge and for Korea to emerge. It was a form of also getting legitimacy towards their own population. So it was a real underlying deep commitment by that elite in these countries to try to make a success of it. We take it for granted, if we go back in history, take England in the 19th century...I mean, it was a very strong thing, it's like, you know, we wanted to show that actually, we are ruling the world on commerce and all the kinds of things, there was a deep motivation. And of course, also the pressures, you know, remember, the society was being very fractured, and we can't call growth in the 19th century in Britain very inclusive. [There was] a lot of change happening, and indeed, you know, very poor people I think actually initially didn't manage to take up. But especially if we come to the early 20th century became this kind of thing surely [where] development in the form of growth was also when it's a little bit broader shared, became quite part of it. And it's one of these things that when you look at politics, whether it's in the 1930s or 40s or 50s or now, whether it's in England or in America, actually growth and development, I won't take it for granted. People are voted out of office because they are not managing the economy well. There is a lot of political pressure in Europe now. And it's really political because ''oh you're not dealing with the cost of living crisis right or you're undermining the real income increases.'' You know, the US election, we ended up interpreting Trump as an election that actually [served] people [who] had stayed behind in the process of growth and development. Actually, in the politics of most richer countries, it's so much taken for granted that that's a big part of the narrative. So it's an interesting one (maybe, if I may) just to [use] China, I find it a really interesting one. Because, you know, the historical determinism is problematic there. And of course, some people would say, China should never have grown because it has the wrong institutions. But of course, it is growing fast. But if you think of a bit of what would be historical institutions that are relevant? China has had centralized taxation for 2000 years, a centralized bureaucracy for 2000 years, a meritocratic bureaucracy for 2000 years, you know, it actually had a history that actually acquired strong institutions. But funnily enough, when did it start? Just at the moment of deep weakness in the 1970s. When the Cultural Revolution had destabilised the legitimacy of the state, ideology was totally dominating, Mao died in the early 1970s and mid 1970s the Gang of Four came up, which was his widow, it was all turbulence. And actually lots of people thought China would disappear. It's at that moment, it picked up that kind of thing, you know, and actually, fundamentally, if you read all the statements of that periods, they became fundamentally committed, ''we need to make progress in our economy, that's our source of legitimacy.'' So even there there, that's where you see that actually really emerges and this became something that they needed to achieve - a fundamental commitment to growth and development as a form of getting legitimacy to the population. So in a very different way, as some of the other countries, but it's the same principle. Legitimacy of a lot of countries is equated with progress and growth and development, which is essentially a feature of a development bargain.Tobi; Obviously, all societies have some form of elite bargain. Not all elite bargains are development bargains. That's the gist of your book, basically. Now, what I'm trying to get at here is elite bargains that are not for development, that do not benefit the rapid progress of a society, how do they emerge? You talk about the agency of the people that are running the country at a particular point in time. To take Nigeria as an example, a lot of people will blame Nigeria's problems on colonialism. And I'm also quite intolerant of such arguments, at least up to a point. But what I'm trying to get at is that how do elite bargains that are not for development, how do they emerge? Is it via, also, the agency of the elites of those societies? Or are there features of a particular society that kind of determine the elite bargain that emerges? For example, sticking with Nigeria, a lot of people will argue that our elites and our institutions will think and look differently if we don't have oil.Stefan; Yes. Tobi; Right. The state will be less extractive in its thinking, the bureaucracy will be less predatory, right? A lot of people would argue that. So are there other underlying factors or features in a society that shape the kind of elite bargain that emerges, or this is just down to the agency of the people who find themselves with power and influence? They are just the wrong type of people.Stefan; So, Tobi, you make an excellent point here, and, so let's take this a little bit in turn. Leonard Wantchekon, the economic historian at Princeton, from Benin… he gave a nice lecture not so long ago, at Yale, it's on YouTube. And he made this very helpful statement, and he said, you know, if it's between history and agency, I would put 50% history 50% agency, okay. And I will actually add to it [which] is that depending on where you are, history is a little bit more or a little bit less. And so clearly, and he was talking about Africa in general, colonialism will matter. It has shaped your institutions and, you know, the way countries have emerged and the way they decolonized, all these things will have mattered, and they make it harder and easier and so on. But you alluded to it as well [that] at some level, it's already a long time ago now. Of course, it's still there, but it's a long time ago. So over time agency should become much more important. The point though, that you raise about oil makes a lot of sense. So the problem with a development bargain is that actually for a political elite, and for a business elite, dare I say for a military elite, the status quo is, of course, very convenient. Status quo is something that is very convenient because it involves very few risks. So the problem with growth typically is that, actually, new elites may emerge, a new type of business elites may emerge, they may question the economic elite that exists. As a result, it may change the politics. And in fact, if you go back to history, as we were saying, of course, that's the history of Britain where all the time, you know, there has been a shift of who is the elite, there's always a new elite, but it's shifting. So growth is actually a tricky thing. Because it actually, in that sense, changes relative positions in society. Now, that's obviously the case in every society. But it will even more so if the status quo is actually quite of relative affluence, if the status quo is actually quite a comfortable position to be. Now if you have natural resources, you don't need growth, to be able to steal. You can just basically control the resources that come out of the ground. And so your supply chain for stealing money can be very short, you don't have to do a very complicated game. If you need to get it from growth in the economy, it's much more complicated, and it's much more risky. Okay. And so it's not for nothing, that actually clearly, more countries that didn't have natural resources in recent times, over short periods of time, managed to actually get development bargains and basically leads gambling on it. Because actually, the status quo was not as lucrative as the status quo can be if you have a lot of oil or other minerals. And so you're right, and it makes it just really hard...and it actually means in fact [that] even well-meaning parts of the business elite in Nigeria will find it very hard to shift the model entirely. Because you know, you are a business elite, because you benefit from the system one way or another. I'm not saying that you steal, but it's just [how] the economy is based in Nigeria on a lot of non-tradables, is helped with the fact that you have so much to export from oil and so you end up importing a lot, but you can also keep your borders closed or anything you feel like keeping the borders closed for. And that helps for a lot of domestic industries, because protectionism, you know, you do all the things. So the system self sustains it. And with oil, there is not that much incentives to change it. So yes, it is actually harder if you have natural resources to actually reengineer the system to actually go for growth and development. So yes, it is the case. But it hasn't stopped certain countries from not going that route. You know, Malaysia has oil? Yes, it's not a perfect development bargain. But it has done remarkably well. Indonesia, in its early stages, also had oil in the 1970s as an important part, it managed this kind of relationship, and then maybe come the agency in it, you know, do we get enough actors that actually have the collective ability to shift these incentives enough to start promoting more outward orientation, try to export some new things from your country, all that kinds of stuff? And that is indeed what happened in Indonesia. There in the early 1970s, they had oil, but they also learned to export shoes and garments early on, they took advantage of good global situations. And Nigeria didn't, you know, and then agency comes into it, you know, the managers of both the politics and the relationship between politics and business, including from the military, they went in a particular route, and they had choices and they didn't take them. I'm pretty sure if you go back and, you know, there will be moments of choice and we went for another - as people call it - political settlement... another equilibrium that actually didn't involve development and growth as the key part. So yes, it makes it harder. But the agency still, still matters.Tobi; From that point, my next question then would be, what shifts an elite bargain more? That's kind of like do question, right? What shifts an elite bargain? These questions do sound simple. And I'm sorry, but I know they are incredibly difficult to answer. Otherwise, you wouldn't have written an entire book about it. Right. So what shifts an elite bargain more towards development? I mean, you talked about China, we've seen it also in so many other countries where the country was going in a particular direction that's not really pro growth, pro-development, and then there's this moment where things sort of shifts. So it may be through the actions of particular actors or events that inform those. So what... in your experience as a development practitioner and looking at all these places...What are the factors that have the most influence in shifting the elite bargain? Is it just luck? I mean, when I think about China, what if Deng Xiaoping and his colleagues had actually lost that particular power struggle after the death of Mao? So did they get lucky? Is it luck? What's going on?Stefan; You know, I wouldn't use title of gambling but there has to be a little bit of luck involved as well, you know, the circumstances have to play in your direction. But it's not just luck. Okay. So it's an interesting thing when you look at a couple of the countries, what were the moments that people within the elite managed to shift it in another direction? So. China is interesting because it was going through conflict, not deep conflict or violent conflict, but there was a lot of instability in China at the time, at the end of the Cultural Revolution in that period. Other countries like Bangladesh came out of conflict. And so conflict, definitely, or coming out of conflict creates a moment. But of course, there are lots of countries that come out of conflict that make a mess of it. It's a window of opportunity. And it probably is linked with something related to it, which is legitimacy. When you come out of conflict, most of the time, leaders need to reestablish legitimacy. This is clearly something that happened to Rwanda coming out of the genocide, Kagame clearly had to establish legitimacy, you know, he represented a very small group of people within the country and he needed to get legitimacy overall and he chose growth and development to doing that. I think Ethiopia is similar, that actually Meles Zenawi coming from Tigray, he needed, you know, post 2000, coming out of the Eritrean war at a time, and all kinds of other crisis that he was facing in his own party even, he needed to get legitimacy, and they thought he could get legitimacy for his regime through growth and development. So legitimacy-seeking behavior can be quite important. Now it has another side to it. If there's a crisis of legitimacy, that's the moment when the leader can actually take advantage of it. A crisis of legitimacy is actually saying, ''Well, look, we better go to something that begins to deliver to people.'' And why I'm actually suggesting it is that actually, there are in certain countries, a bit of pressure from below also seems to be quite useful. But there is a role there and I find it very hard to define exactly because I'm always scared of autocrats and so on. But the point of leadership is there. So I don't mean it as the strong leader, but more to do with the kind of group of people that manages to take other people along and convince them that is the kind of thing that they need to do. So if you go to Indonesia, I don't think it was Suharto personally, who was the great thinker there that did it. But he clearly surrounded himself with a group of people that included technocrats and also other people from politics, that actually managed to push this in a particular direction in doing it. So how do we get it? While it is actually people taking advantage of windows of opportunity to actually nudge towards it? Okay. But it's hard. We're talking Nigeria, other people have asked me questions about Brazil, about India, you know, large countries like yours with very complicated elite bargains that have national and state level things and so on... it's really complicated. Rwanda in that sense is well defined, you know, we have one well-defined problem and, you know, we could go for a particular model. It can be quite complicated to have some ideas on that on Nigeria, but maybe we can come to that a bit later.Tobi; So, I'm curious. I know you didn't cover this in your book. So let me let you speculate a bit on the psychology of elite bargains or development bargains specifically now. Given that I've also tried to look at some of the societies that you described, and even some others that you probably didn't mention, I don't think there's been a society yet where this is a gamble true, but where the elites have sort of lost out by gambling on development. So why don't we see a lot more gambles than we are seeing currently?Stefan; Actually, unfortunately, we see gambles that go wrong. I mean, for me, and I've worked a lot on Ethiopia, Ethiopia as a gamble that went wrong at the moment. And Ethiopia... you know, just think a little bit of what happened and maybe typify a little bit in a very simplistic way the nature of the gamble. You know, you had a leader under Meles Zenawi, under the TPLF - the Tigray and rebel group - where in the end the dominant force in the military force that actually took power in 1991. And they stayed dominant, even though they only represent, you know, five 6% of the population, they remain dominant in that political deal. Though other groups joined, but militarily, it was the TPLF that was the most powerful. So it also meant that the political deal was always fragile because in various periods of time, you know, my very first job was teaching in Addis Ababa University so I was teaching there 1992 93... you know, we have violence on the streets of students that were being actually repressed by the state, they were demonstrating against the government. You know, over time, we have various instances where this kind of legitimacy, the political legitimacy of that regime was also being questioned. Now, one of the gambles that Meles Zenawi took was to actually say, look, there's a very fragile political deal, but I'm actually going to get legitimacy through growth and development. So he used development as a way of getting legitimacy for something that politically and you know, just as Nigeria is complicated, Ethiopia is complicated with different nationalities, different balances between the regions, that he actually wasn't quite giving the space for these different nationalities to have a role, but he was gambling on doing it through growth and development. How did this go wrong? You know, I kept on spending a lot of time, but in the 2010s after Meles Zenawi died, very young from illness, the government still tried to pursue this. But actually, increasingly, they couldn't keep the politics together anymore. They were almost a different nationality, they were always on the streets, there was lots of violence and so on. And then in the end, you know, the Tigrayans lost power in the central government, and then, of course, we know how it escalated further after Abiy. But in some sense, the underlying political deal was fragile and the hope was that through economic progress, we could strengthen that political deal to legitimacy. That gamble is fine. Now it's a very fractured state and unfortunately, all the news we get from the country is that it's increasingly fractured. And I don't know how we'll put it together again. So that's a gamble that failed. Now, we know more about it. And it was very visible because it lasted quite a long time. Many of these gambles may actually misfire if they don't pick the right political moments. You know, if you don't do it at the right moment, and if you're a little bit unlucky with global circumstances, you fairly quickly could get into a bit of trouble politically, and whatever. For example, with the high inflation we have in virtually every country in the world now, it is clearly not the moment to gamble. It's extremely risky, [and] fragile, and your opponents will use it against you. So it's another thing like, you know, we don't see them gambling, you know, there are relatively few windows of opportunities at which you can gamble. And there are some that will go wrong. And even some that I described as successes, you know, we don't know whether they will last, whether they will become the new Koreas. I'm cautious about that. So, we need to just see it a little bit. Although I don't see Nigeria taking that gamble. So that's another matter.Tobi; No, no. I mean, that's where I was going next. Let me talk to you a bit about the role of outsiders here. We're going to get the aid discussion later. So currently in Nigeria, obviously, the economy has been through a lot in the last several years, a lot of people will put that firmly into the hands of the current administration. Rightly so. There were some very terrible policy choices that were made. But one point that I've quite often made to friends is that, to borrow your terminology, I don't think Nigeria was under the influence of a development bargain that suddenly went astray seven years ago. We've always been heading in this direction, some periods were just pretty good. And one of those periods was in the mid to late 2000s, when the economy seemed to be doing quite well, with high oil prices and also, the government actually really took a stab at macro-economic reforms. But if also you look carefully at the micro-history of that period, you'll see the influence of, should I say, outside legitimacy, you know, trying to get the debt forgiveness deal over the line and, you know, so many other moves that the government was making to increase its credibility internationally was highly influential in some of those decisions and the people that were brought into the government and some of the reform too. And my proof for that when I talk to people is to look at the other things that we should have done, which, we didn't do. We had the opportunity to actually reform either through privatization, a more sustainable model of our energy policy - the energy industry, generally. Electricity? People like to talk about telecommunications and the GSM revolution, but we didn't do anything about electricity, we didn't do anything about transportation. Infrastructure was still highly deficient and investment was not really serious, you know. So it was not... for me, personally, it was not a development bargain. Now, my question then would be, could it have been different if some of the outside influences that are sometimes exerted on countries can be a bit more focused on long-term development, as opposed to short-term macro-economic reforms on stability? You know, institutions like the IMF, the World Bank, I know they have their defined mandates, but is it time for a change? I think they actually have a lot more influence than they are using currently.Stefan; You make extremely valid points. And I think I will broadly agree with you with what you just implied. And I'll take a stance on it now. So the first thing, of course, and you correctly saw that something very misleading in Nigeria's growth figures is that periods of high growth are not at all linked to much action by economic policymakers. But it's still largely linked to oil prices. And we have this unfortunate cyclical behaviour in policymaking. Where the behaviour when prices are really good, is just always missing taking advantage of the opportunity. While when things are bad, we're talking about all kinds of things one ought to be doing but then saying, ''we can't do it because the prices are low.'' And so there is this kind of strange, asymmetric thing about policymaking that we always have the best ideas when we can't do them, and then we don't have the ideas we should have when the going is good. And this is in a way what you're alluding to. Of course, the role of outsiders that gets very interesting is what these outsiders were focusing on, actually, I think it was in the interest of the, call them, semi-outsider inside government...some of these technocrats that were brought in. And I can understand it entirely, you know, there were some really sensible finance ministers at various moments and so on. They were focused on actually things that were relatively easy in that period. So they were actually relatively easy, because the going was quite good. And so actually you created that strange impression, and it's a little bit like together with the outsiders, with World Bank, IMF, but actually, we're dealing with something really dramatic but, actually, we were not at all setting a precedent because it was actually, relatively... relatively politically low cost to do these things at that moment. Okay. So it was progress of sorts, you know, getting the debt relief, and so on. But arguably, you know, it's not a bad thing. But this actually was quite a low-hanging fruit and many of these organizations like these ideas of low-hanging fruits, because actually, politically, it played well, it increased the stature internationally of Nigeria...but, actually, it didn't really cost the elite much. It wasn't really hard for the elite to do these things. [If they did] the difficult things, they would really have started to change Nigeria. And so there is something there that I'm struck by the last sentence you said that some of these outsiders may be focusing on the wrong things. I think it has to be the insiders wanting to focus on these things, on these more difficult things. And then I do agree with you, the outsider should be smarter, and better able to respond to this. There's a problem with the outsiders here as well, take something that clearly you still struggle with and struggled forever with - electricity reform, the electricity sector. It's so complicated, and it's set up so complicated in all kinds of ways and whatever. So much inefficiency, so much waste that then it doesn't function and everybody, you know, complains about it. But it becomes politically very sensitive because there are definitely vested interests linked to it now and it becomes very hard to unravel it. Now the problem is if you ask typically a World Bank or an IMF for advice, they will make it very simple and say, Oh, just privatize the whole thing and do the whole thing. Now. You know that in a politically sensitive environment, you just can't privatize everything, so you privatize a little bit, but anything that's really with vested interests you won't touch. But these are the inefficient bits. So the easy prey, you privatize, and that's someone else making even more money off it because it's actually the efficient part of those systems that gets privatized, and then the inefficient part is still there and costs even more money. And so what I think these outsiders could do better is to have a better understanding of Nigeria's political economy, which is complicated at the best of times, but really understand, where can we start actually touching on something that we are beginning to touch on something vested interests that we begin to unravel a little bit some of the kind of underlying problem of, you know, politically connected business, you know, all the way to party financing or whatever...that you need to start unraveling somehow, where actually the underlying causes of inefficiency lie. Because the underlying causes of inefficiency are not just technical, they're actually not just economic. The underlying causes are these kinds of things. So I think why the outsiders did what they did at that time, it actually suited the government at the time, the technocratic ministers, that's the best they could do because that was the only mandate they had. Together with the outsider, they'd say, Well, that's certainly something we could do. But actually, fundamentally, you didn't really change that much. You don't still have then wherever it goes a bit bad, I'll get six or whatever exchange rates, and I'll get all kinds of other macroeconomic poor management, and, of course, nothing can happen when there's a crisis. There's no way we can do these more micro sector-specific reforms than doing it. So yeah, you're absolutely right. But let's not underestimate how hard it is. But starting to do the things that you refer to is where we need to get to to doing some of these difficult things.Tobi; The way I also read your book is that the two classic problems of political economy are still present, which is, the incentive and the knowledge problem. So I want to talk about the role of knowledge and ideas here. Let's even suppose that a particular group of elites at a particular time are properly incentivized to pursue a development bargain. Right? Sometimes the kind of ideas you still find floating around in the corridors of power can be quite counterproductive. A very revealing part of your book for me was when you were talking about the role of China. Also, I have no problem with China. The anecdote about Justin meme stood out to me quite well, because I could relate to it personally because I've also been opportuned to be at conferences where Justin Lin spoke, and I was slightly uneasy at how much simplification happens. I mean, just to digress a little bit, there was a particular presidential candidate in the just concluded primaries of the ruling party, I'm not going to mention the name, who is quite under the heavy influence of the China model. Right? Always consults with China, always meeting with Chinese economists and technocrats. And my reaction when he lost the primaries was ''thank god,'' right? Because what I see mostly in development thinking locally, I don't mean in academic circles, a lot of debates are going on in academics... is that the success of China and Asia more broadly has brought the State primarily into the front and centre. If you look at this current government, they will tell you seven years ago that they meant well. You know, judging by the Abba Kyari anecdotes where government should own the means of production. He may not believe that, like you said, truthfully, but you can see the influence of what has been called ''state-led development.'' In a state where there is no capable bureaucracy. The government itself is not even optimized to know the problem to solve or even how to solve that particular problem. Right. So broadly, my question is, if an elite chooses to pursue a development bargain, how does it then ensure that the right ideas, which lead to the right kind of policies, and maybe there might not even be the right policies - one of the things you mentioned is changing your mind quickly, it's an experimental process - but, you know, this process needs people who are open to ideas, who change their minds, who can also bring other people in with different ideas, you know, so this idea generation process in a development bargain, how can it be stable even if you have an elite consensus is that chooses to pursue development?Stefan; Look, it's an excellent question. And last week, or 10 days ago, when it was in Bangladesh, I was very struck that, you know, as a country I think that has the development bargain, there was a lot of openness. And you know, I was in the Ministry of Finance, and people had a variety of ideas, but they were all openly debated, there was not a kind of fixed mindset. And it is something that I've always found a bit unfortunate dealing with both politicians and senior technocrats in Nigeria. Nigeria is quickly seen as the centre of the world, there's nothing to learn from the rest of the world, we'll just pick an idea, and then we'll run with it and there's nothing that needs to be checked. And, you know, I love the self-confidence, but for thinking and for pursuit of ideas, you know, looking around and questioning what you hear whether you hear it from Justin Lin, who by the way, I don't think he's malign and he means well, he just has a particular way of communicating but it is, of course, a simplified story that you can simply get, and then you'll pick it up. And of course, if you ask the UK Government, the official line from London, they will also tell you there is only one model when they're purely official, but privately they will be a bit more open-minded, and maybe Chinese officials don't feel they have that freedom to privately encourage you to think a bit broader and so you have maybe a stricter line. So how do we do that? I think we can learn something here from India in the 1970s and 1980s. So when India after independence, it had a very strict set of ideas. In that sense, India was as a child of its time as a state, you know, state control, state-led development, there were strong views around it and India ended up doing a lot of regulation. They used to refer to India as the License Raj. Like a whole system based around licensing and everything was regulated by the state. So the state had far too much say in terms of the activity, despite the fact that the underlying economy was meant to be very entrepreneurship and commerce-led, but you had a lot of licensing rules, and so on. And of course, its growth stayed very low in the 1970s and 80s, it was actually very stagnant. It changed in the 1990s. Partly came with a crisis - in fact, a balance of payments crisis - it needs to reform and Manmohan Singh was the finance minister, then, later on, he became maybe a less successful Prime Minister. But as a finance minister in the early 90s, he did quite amazing things. And then during the 90s, gradually, every party started adopting a much more growth-oriented, more outward-oriented type of mindset. Now, why do I say this? Because actually, during the 1970s, and 80s, you had think-tanks, all the time pushing for these broader ideas. It took them 20 years. But there were really well-known think-tanks that kept on trying to convince people in the planning commission, economists in the universities and so on. And to critically think, look, there must be other ways. So actually, funnily enough, in India, it has a lot to do with the thinking and the public debates, that initially the politicians didn't take up, but actually found the right people to influence... you know, you actually have still in the civil service some decent technocrats there, they don't get a chance. But there are decent people, I know some of them and so on. But there needs to be a feeding of these ideas. And actually, this is where I would almost say there's a bit of a failing here, in the way the public discourse is done [in Nigeria] and maybe voices like you, but also more systematically from universities from think tanks and so on to actually feed and keep on feeding these ideas. There is a suggestion [by] Lant Pritchett - you know he's a former Harvard economist, he is now in the UK - [who] wrote this very interesting paper and he said, some of these think tanks who are actually getting a little bit of aid money here and there and he said, that's probably the best spent aid money in India ever. Because the rate of return and he calculates this number is like 1,000,000%, or something. Because he basically says the power of ideas is there. And I do think there is something there that I'm always surprised by that there are some very smart Nigerians outside the country, they don't really get much of a hearing inside the country, then there are some that are actually inside the country, the quality of debate is maybe not stimulated to be thinking beyond. It has to do probably with how complicated your country is, and of course, the Federal status plays a role. I just wonder whether maybe this is something that needs to start in particular states. You know, there are some governors that are a little bit more progressive than others. Maybe it is actually increasing and focusing attention over this on a few states to get the debate up to a high level and to actually see what they can do and maybe it's where the entry point is, but you need ideas I agree with you and I do worry at times about the kind of critical quality... there are some great thinkers in Nigeria, don't get me wrong, but the critical quality of ideas around alternative ways of doing the economy and so on, and that they get so easily captured by simple narrative, simple national narratives that are really just too simple to actually pursue. I mean...yeah.Tobi; That's quite deep. That's quite deep. I mean, just captures my life's mission right there. It's interesting you talked about Lant Pritchett and the question of aid, which is like my next line of question to you. There was this brief exchange on Twitter that I caught about the review of your book in the guardian, and the question of aid came up. I saw responses from Martin Ravallion, from Rachel Glennerster, I'm not sure I'm pronouncing her name right. So it's sort of then brings me to the whole question of development assistance, aid, and the way intervention has now been captured by what works. One fantastic example I got from your book is on Bangladesh, and how both systems work. You know, there's a broad development bargain, it's not perfect, nothing is, no society is. And there's the pursuit of economic growth. And also, it's a country where aid money and all forms of development assistance is quite active, and is quite huge, and it's actually quite effective. Now, my question is that basic insight from your book, which is for aid spending to be a little bit more biased, not your word... a little bit more bias to countries that have development bargains broadly? Why is that insight so difficult for, I should say, the international NGO industry to grasp? Why is it elusive? Because the status quo, which I would say, I don't mean to offend anybody, but which I will say is also aided by development economists and academics who have sort of put methodology and evidence above prosperity, in my view... because what you see is that, regardless of how dysfunctional the country is, broadly, the aid industry just carves out a nice niche where they do all sorts of interventions, cash transfers, chickens and, of course, you can always do randomized control trials and you say you have evidence for what works. But meanwhile you don't see the broad influence of some of these so-called assistants in the country as a whole. And these are institutions who proclaim that they are committed to fighting extreme poverty and we know what has vastly reduced poverty through history has always been economic growth and prosperity. So why is this elusive? Have those agencies and international development thinking itself been captured?Stefan; Look, I think I should make you do my interviews in the future. Yeah. So I've got to hire you to give...Because, look, I've been inside the aid industry and, in fact, the two people that you mentioned, you know, I would call them my friends, although one of them clearly is very cross at me at the moment. But you know, these are people I've worked with, and so on. And I am worried that there is such an obsession within the aid industry to prove their effectiveness. And I know I've been under pressure, you know, I've worked in it and sitting in London and getting your newspapers to say you're wasting all this money. It's really affecting a lot of people. And it was really hardwork for these 10 years that I sat inside it. But it's about just the humility that you just described, you know, and I want to make this distinction between...I'm about to make two distinctions. So the first one is - you made it well, even Bangladesh, something is going on. And you know, with all the imperfections, the government is trying to do something, and largely by staying to some extent out of the way. And there's some good stuff happening. So there's growth picking up and so on. So you can do all kinds of things. And I think aid in Bangladesh has been great at trying to make sure that the growth that was taking place in that country was a bit more inclusive than it probably would have been. I think it's great. And I think the aid industry should be proud of it. There is a great book that I quote as well also by Naomi Hossein and she calls it The Aid Lab and this is a bit like in praise of it. You know, if we do it carefully with some community and complement what's going on in a country that is deeply poor, you know, you can actually do really good things. Because in the book, I also mentioned Ghana that, actually, aid has been pretty effective because something had begun to change in the 90s, and so on. And we can question that to some extent and, of course, it's none of this perfection. But if you then come to a country where, you know... probably the two of us agree [that] there is some form of stagnation in that kind of [country], there's no development bargain, the elite bargain doesn't really push everything forward. Just be humble to say, look, I have a little niche, and there will be some chicken farmers that are happier, we'll do some good things in health... in health, actually, it's quite straightforward to do good things. But they are to call these good things, don't classify this as if you are leading the fight against extreme poverty, leading the fight against the change in these countries. Because, actually, if the local elite is not leading their change, and those people who have the power and influence not leading their change, the best you can do is doing good things. So I'm happy for us to be able to say we do good things. And it led me in the context of an interview to say like in India, as doing a lot of good things means that aid was actually in itself quite irrelevant, because the real change came, as I described in the 90s, actually, there was a real shift in gear, and suddenly their own development spending became gradually more effective. And of course, you can help them then to make it more effective. But, you know, I was a bit sad, and Martin Ravallion now took issue with it and wanted to emphasize... you know, and I don't want us to ever say, look, we did it. I mean, it's such a lack of humility I'll say this. At some point, we may have been supportive of doing it, but it's always the countries that did it. And the people there that did it. And other times just be humble and say, well, we may be doing something reasonably good, we may improve health outcomes, education outcomes, but not necessarily the whole country may do it in the schools that we work in, or whatever. And it's, that's good, you know, that's just as there are Nigerians that do good things via their own organizations and so on, they do good things. And it's probably teachers in the country, within the state schools that do some of these good things in the best practice stuff. And so yeah, they improve things, but overall, have the humility to say you're not changing Nigeria, because unfortunately, Nigeria is not being changed at the moment.Tobi; So my question then would be, is it reflective of the current intellectual climate in development economics where randomized control trials, they pursue...I know Lant Pritchett has really come down quite heavily on this particular movement, though, sometimes he seems to be the only one standing, maybe not quite literally true and I'll give you two examples from Nigeria, right? In 2012, when the anti subsidy-removal protests broke out, when the government on the first day of January removed fuel subsidy and prices suddenly went up. And the labour movement, the student movement, opposition politicians mobilized the population against that particular move. Some form of resolution that the current president at that time reached was to do what they call a partial removal of subsidy, you know, prices will go up a little bit and the government then did a scheme - an entrepreneurship scheme - where you submit a business plan and you're paid to get $50,000 to do a business.And I read a particular study by David Evans of the World Bank of how fantastically successful this particular scheme was, and of course, no doubt, it was successful. I mean, if you get $50,000 to do business in Nigeria, that's a lot of money. I don't need econometric analysis to know that, but maybe some people do. But the truth is, if you look today, I can bet you that a lot of those businesses are probably dead now due to how the economy as sort of evolved after that. Secondly, at the time we were having these debates and protests in 2012, the subsidy figure there was $8 billion annually, today it is $15 billion. So if you say you have evidence that something works, what exactly is your time horizon for measuring what works? And if you say something works, works in whose benefit, really? The most recent example was in 2018, 2019, where the government was given a small amount of money to small retailers, they call it Trader Moni. I'm sure there were World Bank officials and economists (I have a lot of respect for them) who are measuring the effectiveness of this thing. But you could see clearly that what was politically going on was the government doing vote buying. Right? So if you say something work, works for whom? Right? That was my response to Rachel on Twitter, but she didn't reply me. My question then to you... Sorry, I'm talking too much... Is this reflective of the current intellectual climate in development economics? Stefan; So yes and no? Okay. So, well, i'm going to have to be very careful. Of course, Rachel...I know her very well. And, actually, I have not that many gripes with her. She comes out of, indeed, the whole school of RCTs. By the way, I also actually do RCTs. I like it as a tool to actually study things. And I'll explain in a moment a bit more. So I do these randomized control trials as well. But I am very, very sympathetic. And I actually totally agree with your frustration around this idea to creating that impression about what works. You know, I have it in the book, I even mentioned it, there was a particular minister that at some point announced we're only going to spend our money on what works, you know, like a great slogan, as if you have all the answers, you know what to do. And of course, there is a technical meaning to it. Technical meaning would mean, if I do something and if you haven't done it, what would have been the outcome? And the paper that you refer on the entrepreneurship, this entrepreneurship for the $50,000... I know actually the research very well, the original was from David McKenzie and then other people commenting on it. Yes, relative to a counterfactual, yes, it was actually much bigger than an alternative scheme, you know, then that's something. So you could say, well, you know, as a research question, as a researcher, I find it interesting. From a policy point of view, I'm so much more cautious. And I'm totally with you. You know, first of all, in the bigger scheme of things, how tiny maybe it be... now there are some people who would say, well, we don't know anything, really, what to do in this whole messy environment so at least [to] have something that does a bit better than other things is maybe a useful thing to know. I think it comes back to that humility. As a research tool, it's great at getting exact answers. As a policy tool, I think we need to have much more humility. Because are these ideas tha totally transforms everything, that is actually makes a huge difference? Not really. It probably means that we can identify a little bit and I think even Pritchard wouldn't disagree with [that] sometimes a few things are a little bit better than other things. And if we want to do good, maybe it's helpful in medicine whether we know whether we should spend a bit more money on X or on Y, that it actually does a little bit better in the functioning of a health facility or not, if we spent a bit more money on that practice or on that practice, same in teaching in the school, if we do a little bit more of that in a very constrained environment than something else, that's useful, it doesn't change dramatically. And I categorize it with doing good. With humility, if we do good, it's helpful to know which things are a bit better than other things...when we try to do good. It's an interesting thing, even in Rachel's thread, she actually used it, we can still do quite a lot of good with aid. Actually, funnily enough, I don't disagree that deeply with her and say, Yeah, we may be able to do it good, but don't present it as if we, in the bigger scheme of things, which is where you're getting that, make any difference. And this is where I'm also sympathetic with Lant in saying, Look, sometimes we seem to be focusing on the small trivial things and yeah, it's useful to know but meanwhile the big picture is what you were describing, there's so much going on and, actually, nothing changes there. And so I categorize it in a bit of the same thing. Because I'll now give you an account, which is then go to Bangladesh again. Look, I think it was extremely useful in Bangladesh at some point to really have ... an RCT - a randomized control trial. So really careful evidence to show that a particular program that BRAC, the biggest NGO in the world, the local NGO, was actually what it was actually doing to the ultra-poor. In fact, two weeks ago, I was visiting the program again. And I find it really interesting because it's really helpful for BRAC to know that that program, when I do it in a careful evaluation relative to other things, that actually this program is really effective. And that, actually, we know for BRAC that they can have so much choices to spend their money on poverty alleviation, the things that we can dream up, to actually know this is actually a really good thing. And why of course does it work? Well, it works relative to doing nothing, but of course, it helps in Bangladesh {that] growth is taking place and it actually can get people to become [a big] part of it. In fact, I was visiting people that, whether we use a Nigerian or Bangladeshi definition of extreme poverty, they wouldn't have been in that state 10 years ago and so this is their being six, seven years in that program, and it was really interesting that I was sitting into some interviews they were doing, and I looked over my shoulder, and they now had a TV and a fridge. And I say, okay, an extremely poor person in Bangladesh would not have had this. So there's clearly something happening. Now, that's not simply because of the program. It's also because the whole country is improving. But I'm pretty sure and what the data showed is that those who actually had a program would have found it a bit easier to take part in that progress. And I'm pretty sure that the TV, and the fridge, probably was helped, to some extent, by the programme. In fact, we have very good evidence in the kind of evidence that Rachel Glennerster talks about. So again, I think it's all about a bit of humility, and understanding better what we mean by it. And to be honest, I think there are lots of people who work in that field that are careful with it. And that actually will do it, use it well. It gets just really worrying that people, often more junior people than Rachel, they've never really been in the field properly and then they make massive statements. So they work in big organizations, and they use that evidence, overuse it and overstate it. I think Rachel is actually careful, even her thread was very careful, although your question is a very good one. But it's very careful. But it still allows other people to overinterpret this whole thing. And then I get really worried. I'm actually going to put out a thread on Twitter in the coming days where I'm going to talk about tribalism in development economics... where I'm good to deal with your question as well because I think the way the profession has evolved is that you need to be in one tribe or another, otherwise, you're not allowed to function. I think, you know, you need to be eclectic, you know, no one has this single answer. And there's too much tribalism going on, much more than I've ever known before. You know, you need to be Oh, a fan of that, or you need to be the historical approach, or the Political Economy approach, and the whole... we should learn from all these bits. That's the idea of knowledge that you learn from... as much as possible from the progress in different parts of a discipline, or in thinking.Tobi; I'm glad to have caught you on a free day because having a lot more time to have this conversation has made it quite rich for me personally, and I'm sure for the audience as well. So I just have a couple more questions before I let you get back to your day. The first of those would be...um, when I first became aware of your book on Twitter, it was via a Chris Blattman thread. And he mentioned something that I have also struggled with, both personally in my thought and, in my conversation with people. And somethin

Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: A common failure for foxes, published by Rob Bensinger on October 14, 2022 on LessWrong. A common failure mode for people who pride themselves in being foxes (as opposed to hedgehogs): Paying more attention to easily-evaluated claims that don't matter much, at the expense of hard-to-evaluate claims that matter a lot. E.g., maybe there's an RCT that isn't very relevant, but is pretty easily interpreted and is conclusive evidence for some claim. At the same time, maybe there's an informal argument that matters a lot more, but it takes some work to know how much to update on it, and it probably won't be iron-clad evidence regardless. I think people who think of themselves as being "foxes" often spend too much time thinking about the RCT and not enough time thinking about the informal argument, for a few reasons: 1. A desire for cognitive closure, confidence, and a feeling of "knowing things" — of having authoritative Facts on hand rather than mere Opinions. A proper Bayesian cares about VOI, and assigns probabilities rather than having separate mental buckets for Facts vs. Opinions. If activity A updates you from 50% to 95% confidence in hypothesis H1, and activity B updates you from 50% to 60% confidence in hypothesis H2, then your assessment of whether to do more A-like activities or more B-like activities going forward should normally depend a lot on how useful it is to know about H1 versus H2. But real-world humans (even if they think of themselves as aspiring Bayesians) are often uncomfortable with uncertainty. We prefer sharp thresholds, capital-k Knowledge, and a feeling of having solid ground to rest on. 2. Hyperbolic discounting of intellectual progress. With unambiguous data, you get a fast sense of progress. With fuzzy arguments, you might end up confident after thinking about it a while, or after reading another nine arguments; but it's a long process, with uncertain rewards. 3. Social modesty and a desire to look un-arrogant. It can feel socially low-risk and pleasantly virtuous to be able to say "Oh, I'm not claiming to have good judgment or to be great at reasoning or anything; I'm just deferring to the obvious clear-cut data, and outside of that, I'm totally uncertain." Collecting isolated facts increases the pool of authoritative claims you can make, while protecting you from having to stick your neck out and have an Opinion on something that will be harder to convince others of, or one that rests on an implicit claim about your judgment. But in fact it often is better to make small or uncertain updates about extremely important questions, than to collect lots of high-confidence trivia. It keeps your eye on the ball, where you can keep building up confidence over time; and it helps build reasoning skill. High-confidence trivia also often poses a risk: either consciously or unconsciously, you can end up updating about the More Important Questions you really care about, because you're spending all your time thinking about trivia. Even if you verbally acknowledge that updating from the superficially-related RCT to the question-that-actually-matters would be a non sequitur, there's still a temptation to substitute the one question for the other. Because it's still the Important Question that you actually care about. Thanks for listening. To help us out with The Nonlinear Library or to learn more, please visit nonlinear.org.

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Chris Nosko is a PhD economist. He did his PhD in economics at Harvard in the mid 2010s before going to Chicago Booth take a job as an assistant professor. But for a year prior to taking that job, between Harvard and Chicago, he did a postdoc fellowship at eBay where he, Thomas Blake and Steve Tadelis met and worked together on a project involved a serendipitous event at the company in which eBay quit paying for branded key words (e.g., “eBay Volvo decals”, “eBay typewriters”) on some but not all search engine auctions. They asked for the data on traffic to the site before and after eBay quit paying for branded keywords for all search engines (both those they kept paying and those they didn't), ran a simple event study diff-in-diff and found evidence that search engine marketing at eBay was perhaps not causing increased traffic to the site. They convinced management to field a large RCT which confirmed their diff-in-diff results, and that study was published in Econometrica. Not a shabby way to start a career as an economist. For many of us, a PhD in economics from Harvard, a successful partnership with eBay resulting in a study destined for a Top 5 and a tenure track job at Chicago Booth meant staying at Booth and having a career as an academic. No one outrightly says that the only meaningful life you can have as an economist is to be an academic, as it's vulgar, opinionated and obviously false to talk that way about how someone else should live their life, but the norms are pretty powerful nonetheless. Well, starting around the time that Chris got his job at Booth, tech began experiencing a surge in hiring of PhD economists, largely driven by Amazon's nearly insatiable appetite for them. Talking with people at Amazon, I have learned that behind this push was Pat Bajari, and behind Pat Bajari was Jeff Bezos who had long believed economics, and economists more specifically, had unique value. As Susan Athey said to me, though, in an interview earlier, Bajari though had to do pull a rabbit out of a hat. Whereas the first wave of economists to tech — people like Hal Varian, Susan Athey, Preston McAfee — had largely been micro theorists helping craft the foundations of a business model through auctions and advertising that would support search engines, arguably the core arteries of the internet itself — Bajari would have the task of bringing in young people, fresh out of grad school, and in Athey's words, make them productive. And one of the people Bajari would ultimately tap do that was Chris Nosko, an assistant professor at Chicago Booth and someone trained in structural industrial organization, one of the economics' more interesting experiments of fusing deep microeconomic theory with econometric estimation. Scott's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.Nosko was a Ariel Pakes student at Harvard and was well versed in so many different parts of economics and modern technology that it almost seems predestined that he would ultimately leave Chicago Booth permanently and go to Amazon when Bajari finally convinced him to, but that's all selection on the dependent variable reasoning. When we look back in time at decisions we made, our mind tends to forget that there was a moment when we could've gone left instead of right. The same with Chris — there was a decision that had to be made to leave a career as an academic. The decision materialized into what it materialized, but to pretend it was easy, or that it didn't have risk, or that Chris didn't try to manage that risk in some ways is really unfair to our earlier selves or even our future selves who are in situations facing, not probabilistic risk but more like Knightian uncertainty in which no one truly has a clue what possibly could happen. But Chris did leave. Sort of. He took “a leave of absence” from Booth in 2015 and took a job at Amazon, then permanently left Booth in 2016. He spent four years at Amazon before leaving for Uber, one of the more impressive firms to ever exist for creating an actual open marketplace solving two sided matching problems through algorithms and prices. Algorithms, prices and rules — three ways, no doubt there are others, in which modern economies coordinate productive activity. Is it really so surprising that economics might be valued by tech firms given the complex coordination they try to solve using all three?Thank you for reading Scott's Substack. This post is public so feel free to share it.Chris has been at Uber for four years. He is now Vice President and Head of Science and Analytics for Uber Product there.  Within tech, economists sort into tons of different jobs with titles that to an academic don't make a ton of sense — just like so much of what academics' lives takes place within administrative units that make little sense to anyone else. If Chris isn't the chief economist, though, at Uber, I figure he's probably up there. And he's my guest this week on The Mixtape with Scott as part of my longer, unfolding series I call “Economists in tech”. Our conversation covered a lot of ground. We talked about growing up in rural Oregon, falling into programming early on and working a few years between high school and college during the early wave tech boom of the late 1990s and early 2000s as a programmer. It wasn't exactly what he would do later, as that was more web design and less machine learning and statistics, but the aptitude of programming is very portable and his deep knowledge of tech sectors was anyway established or at least re-invested in while there. We talked about his love for his liberal arts education at the University of Chicago where he did his undergraduate degree, and his broad navigation of economics as a field and a career.  All in all, it was a fun opportunity to talk to Chris, to learn more about his own path, about the world out there outside of academia, what economists do in tech, and how all of these things fit together for both economics but maybe more importantly just for Chris himself. I think a lot of people are going to find Chris's story very interesting and personally intriguing as they may see him in themselves. You can read some of Chris's work here. Thanks again for tuning in! I hope you enjoy this week's interview as much as I did! If you are enjoying these, please consider supporting me by sharing the podcast and/or becoming a paying subscriber!Scott's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber. Get full access to Scott's Substack at causalinf.substack.com/subscribe