How do we know which psychotherapy research is trustworthy? Dr. Alex Williams and Dr. John Sakaluk help us search for evidence in all the logical places: the replication crisis, RCTs, qualitative studies, dolphin therapy, Canadian football, researchers fighting Connor McGregor, and of course, EMDR. This episode is brought to you by MR. BEAR (Meta-analysis, Registered, Big sample size, Experiment, Active control group, Replicated). Thank you for listening. To support the show and receive access to regular bonus episodes, check out the Very Bad Therapy Patreon community. Today's episode is sponsored by Sentio Counseling Center – high-quality, low-fee online therapy in California with immediate availability for new clients. Very Bad Therapy: Website / Facebook / Bookshelf / Tell Us Your Story Show Notes: Alex Williams' Twitter John Sakaluk's Twitter The Heart and Soul of Change: Delivering What Works in Therapy Feeling the Future: Experimental Evidence for Anomalous Retroactive Influences on Cognition and Affect Telling More Than We Can Know: Verbal Reports on Mental Processes (Nisbett & Wilson, 1977) Pim Cuijpers' Publications
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: How much do you believe your results?, published by Eric Neyman on May 6, 2023 on LessWrong. Thanks to Drake Thomas for feedback. I. Here's a fun scatter plot. It has two thousand points, which I generated as follows: first, I drew two thousand x-values from a normal distribution with mean 0 and standard deviation 1. Then, I chose the y-value of each point by taking the x-value and then adding noise to it. The noise is also normally distributed, with mean 0 and standard deviation 1. Notice that there's more spread along the y-axis than along the x-axis. That's because each y-coordinate is a sum of two independently drawn numbers from the standard normal distribution. Because variances add, the y-values have variance 2 (standard deviation 1.41), not 1. Statisticians often talk about data forming an “elliptical cloud”. You can see how the data forms into an elliptical shape. To put a finer point on it: Why an ellipse — what's the mathematical significance of this shape? The answer pops out if you look at a plot of how likely different points on the plane are to be selected by the random generation procedure that I used. The highest density of points is near (0, 0), and as you get farther from the origin the density decreases. The green ellipse on the scatter plot is a level set of equal probability: if you were to select a datapoint using my procedure, you'd be more likely to land in any square millimeter inside the ellipse than in any square millimeter outside the ellipse — and you'd be equally likely to land in any location on the ellipse as on any other location on the ellipse. The line of best fit is a statistical tool for answering the following question: given an x-value, what is your best guess about the y-value? What is the line of best fit for this data? Here's one line of reasoning: since the y-values were generated by taking the x-values and adding random noise, our best guess for y should just be x. So the line of best fit is y = x. Huh, weird. this line is weirdly “askew” of the ellipse, and it doesn't reflect the fact that the y-values are more dispersed than the x-values. Maybe the line of best fit instead passes from the bottom-left to the top-right of the ellipse, along its major axis. It sure looks like the points are on average closer to this line than to the previous one. Which line is the line of best fit, and what's wrong with the other line? I recommend pondering this for a bit before reading on. The answer is that the first line, y = x, is the line of best fit. The problem with the second line is that it doesn't try to predict y given x. I mean, scroll back up and take a look at how low the line is at x = -2: it's way below almost all of the points whose x-value is near -2! This line is instead doing a different, important thing: it indicates the axis of maximum variation of the data. It's the line with the property that, if you project the data onto the line, the data will be maximally dispersed. This line is called the first principal component of the data, but it is not the line of best fit. Instead of going from the bottom-left to the top-right of the ellipse, the line of best fit goes from the left of the ellipse to the right. This is the line that has as much of the ellipse above it as below it, at every x-coordinate. This is what you want, because you want it the true y-value to be below your prediction as often as it is above your prediction. (Huh, what a weird asymmetry! I wonder why the line doesn't instead go from the bottom of the ellipse to the top.) II. You are the director of a giant government research program that's conducting randomized controlled trials (RCTs) on two thousand health interventions, so that you can pick out the most cost-effective ones and promote them among the general population. The quality of the two thousan...
Two studies of cardiac device infections, observational studies, RCTs, and our ways of knowing in Medicine are the topics discussed by John Mandrola, MD in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Cardiac Device Infection Mortality Climbs When CIED Infections Are 'Delayed' After Implant https://www.medscape.com/viewarticle/990692 - Association of the Timing and Extent of Cardiac Implantable Electronic Device Infections With Mortality https://jamanetwork.com/journals/jamacardiology/fullarticle/2803627 - Low Utilization of Lead Extraction Among Patients With Infective Endocarditis and Implanted Cardiac Electronic Devices https://www.jacc.org/doi/full/10.1016/j.jacc.2023.02.042 - Cardiac Implantable Electronic Devices and Infective Endocarditis: A Call to Arms...∗ https://www.jacc.org/doi/full/10.1016/j.jacc.2023.02.043 II. Can RCTs be Emulated with Real World Evidence? - Emulation of Randomized Clinical Trials With Nonrandomized Database Analyses https://jamanetwork.com/journals/jama/fullarticle/2804067 - Randomized Trials vs Real-world Evidence https://jamanetwork.com/journals/jama/fullarticle/2804092 - Reanalyses of Randomized Clinical Trial Data https://jamanetwork.com/journals/jama/fullarticle/1902230 III. Multi-Morbidity Effects in Trials Pivotal CV Trials May Not Apply to Complex Patients https://www.medscape.com/viewarticle/989129 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact: firstname.lastname@example.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: Is CBT effective for poor households? Two recent papers (evaluated by The Unjournal) with contrasting results, published by david reinstein on April 17, 2023 on The Effective Altruism Forum. (Second link: Barker et al) Two more Unjournal Evaluation sets are out. Both papers consider randomized controlled trials (RCTs) involving cognitive behavioral therapy (CBT) for low-income households in two African countries (Kenya and Ghana). These papers come to very different conclusions as to the efficacy of this intervention. These are part of Unjournal's 'direct NBER evaluation' stream. 1. Barker et al, 2022 “Cognitive Behavioral Therapy among Ghana's Rural Poor Is Effective Regardless of Baseline Mental Distress”  From anonymous evaluator 1: This paper uses a field experiment to explore the impact of a 12-week CBT program among poor households in rural Ghana. The authors find that the CBT program increases mental and physical well-being, as well as cognitive and socioemotional skills and downstream economic outcomes. 2. Haushofer et al, 2020 The Comparative Impact of Cash Transfers and a Psychotherapy Program on Psychological and Economic Well-being, Johannes Haushofer, Robert Mudida and Jeremy P. Shapiro. 2020. Originally published as NBER Working Paper 28106 Evaluation summary, linking to individual evaluations from Hannah Metzler and an anonymous evaluator From anonymous evaluator 2: This paper studies the economic and psychological effects of providing two different interventions to low-income households in rural Kenya: a program in Cognitive Behavioral Therapy (CBT, a well-established form of psychotherapy) and an unconditional cash transfer. The authors use a randomized controlled trial with a 2-by-2 design to estimate the effect of each intervention alone and of both interventions combined. ... Strikingly, the authors find no effect of the therapy program on any of their primary economic or psychological outcomes. /.. Unsurprisingly given the null effect of therapy, the combination of cash and therapy has similar effects to cash alone. Thoughts The evaluations of both papers are largely positive, and both appear credible. I hope that this open evaluation of each paper is a helpful input into a more direct comparison of these, as well as possible integration into a larger meta-analysis. Thanks Thanks to the four evaluators of these papers, who did strong and in-depth work, as well as to the evaluation managers (Hansika Kapoor and Anirudh Tagat), and others on the Unjournal team (especially Annabel Rayner and Gavin Taylor). Thanks for listening. To help us out with The Nonlinear Library or to learn more, please visit nonlinear.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: Predicting the cost-effectiveness of running a randomized controlled trial, published by Falk Lieder on April 17, 2023 on The Effective Altruism Forum. TLDR: Research is underrated. Running an RCT to evaluate a digital intervention for promoting altruism could be more than 10x as cost-effective as the best charities working on global health and wellbeing. In the previous post, we found that – in expectation – Baumsteiger's (2019) intervention for promoting altruism is about 4x as cost-effective as GiveDirectly but lower than the cost-effectiveness of the Against Malaria Foundation or StrongMinds. However, the uncertainty about the actual cost-effectiveness of this intervention is still extremely high. The uncertainty is, in fact, so high that the 95% credible interval on the cost-effectiveness of the new intervention ranges from -0.5 WELLBYs/$1000 to 88 WELLBYs/$1000. The upper bound of this credible interval is close to the cost-effectiveness of the presumably most cost-effective mental health charity StrongMinds (90 WELLBYs/$1000; Plant, 2022), and more than twice the cost-effectiveness of the Against Malaria Foundation (39 WELLBYs/$1000; Plant, 2022). Based on these estimates, there is a 5% chance that the intervention might be harmful and a more than 5% chance that it might be at least as cost-effective as the charities recommended by GiveWell and the Happier Lives Institute. Because of this high uncertainty, any decisions based on the current state of knowledge could be highly suboptimal compared to what we would do if we had additional information. However, information can be costly, especially when running a randomized controlled trial (RCT). And the more money we spend on information, the less we can spend on saving lives. This dilemma raises the question, “When is it worthwhile to run an RCT to gather more data, and when should we exploit what we already know?” To answer this question, we introduce a new method for predicting the cost-effectiveness of gaining new information through an RCT and comparing it to the cost-effectiveness of cash transfers and directly promoting global health and well-being. We illustrate this method using the intervention by Baumsteiger (2019) as an example. However, the approach we are illustrating is more general and can also be applied to RCTs on established, emerging, and yet unknown EA interventions, including deworming, motivating parents to vaccinate their children, water purification, and interventions for improving mental health. We develop our method in two steps. First, we apply the established Value of Information framework (Howard, 1966) to obtain an upper bound on the cost-effectiveness of running an RCT. Then, we replace this method's unrealistic assumption of perfect information with more realistic assumptions about the imperfect information generated by an RCT. This yields a new method that can provide more accurate estimates of the cost-effectiveness of evaluation research. As a proof of concept, we apply this method to predict how cost-effective it would be to evaluate the altruism intervention based on Baumsteiger (2019) in RCTs with different numbers of participants. Our method predicts that running such an RCT with 1200 participants would be highly cost-effective. This post is a brief summary of the longer report presented in this interactive notebook. How valuable would it be to know the true exact value of the cost-effectiveness of the intervention by Baumsteiger (2019)? To obtain an upper bound on how valuable it might be to evaluate the intervention by Baumsteiger (2019), I first calculate the value of obtaining perfect information about its cost-effectiveness. The value of perfect information is an established mathematical concept introduced by Howard (1966). It has recently been applied to charity evalu...
How do you design clinical trials in the era of precision oncology? Are prospective randomized controlled trials necessary anymore? Drs. Ray Kurzrock, Vivek Subbiah, and Christopher Booth drop the gloves and debate these questions - beginning with the definition of “precision oncology,” what phase the trials should be when initially designing, and whether accelerated approval and surrogate endpoints are truly helping patients in the precision oncology era. The group also analyzes specific examples of approved drugs and whether randomized controlled trials were and would have been good ideas prior to approval. Check out Chadi's website for all Healthcare Unfiltered episodes and other content. www.chadinabhan.com/ Watch all Healthcare Unfiltered episodes on Youtube. www.youtube.com/channel/UCjiJPTpIJdIiukcq0UaMFsA
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: EA & LW Forum Weekly Summary (20th - 26th March 2023), published by Zoe Williams on March 27, 2023 on The Effective Altruism Forum. This is part of a weekly series summarizing the top posts on the EA and LW forums - you can see the full collection here. The first post includes some details on purpose and methodology. Feedback, thoughts, and corrections are welcomed. If you'd like to receive these summaries via email, you can subscribe here. Podcast version: Subscribe on your favorite podcast app by searching for 'EA Forum Podcast (Summaries)'. A big thanks to Coleman Snell for producing these!Author's note: I'm currently travelling, which means:a) Today's newsletter is a shorter one - only 9 top posts are covered, though in more depth than usual.b) The next post will be on 17th April (three week gap), covering the prior three weeks at a higher karma bar.After that, we'll be back to the regular schedule. Object Level Interventions / Reviews by EJT, CarlShulman Linkpost for this paper, which uses standard cost-benefit analysis (CBA) with detrimental assumptions (eg. giving no value to future generations, only assessing benefits to Americans, and only assessing value from preventing existential threats) to show that even under those conditions governments should be spending much more on averting threats from nuclear war, engineered pandemics, and AI.Their analysis primarily relies on previously published estimates of risks, concluding US citizens alive today have a ~1% risk of dying from these causes in the next decade. They estimate $400B in interventions could reduce the risk by minimum 0.1 percentage points, and that using the lowest figure for the US Department of Transportation's value of a statistical life, this would result in ~$646B in value of American lives saved. They suggest longtermists in the political sphere should change their messaging to revolve around this standard CBA-driven catastrophe policy, which is more democratically acceptable than policies relying on the cost to future generations. They suggest it would also reduce risk almost as much as a strong longtermist policy (particularly if the CBA incorporates an argument for citizens ‘altruistic willingness to pay' ie. some level of addition for the benefit to future generations). by GiveWell The Happier Lives Institute (HLI) has argued that if Givewell used subjective well-being (SWB) measures in their moral weights, they'd find StrongMinds more cost-effective than marginal funding to their top charities. Givewell assessed this claim and estimated StrongMinds is ~25% (5%-80% pessimistic to optimistic CI) as effective as these marginal funding opportunities when using SWB - this equates to 2.3x the effectiveness of GiveDirectly. Key differences in analysis from HLI, by size of impact, include: GiveWell assumes lower spillover effects to household members of those receiving treatment. Givewell translates decreases in depression into increases in life satisfaction at a lower rate than HLI. Givewell expects lower effect in a scaled program, and lower durations of effects (not passing a year) due to the program being only 4-8 weeks. Givewell applies downward adjustments for social desirability bias and publication bias in studies of psychotherapy. These result in an ~83% discount in the effectiveness vs. HLI's analysis. For all points except the fourth, two upcoming RCTs from StrongMinds will provide better data than currently exists. HLI has posted a thorough response in the comments, noting which claims they agree / disagree with and why (5% agree, 45% sympathetic to some discount but unsure of magnitude, 35% unsympathetic but limited evidence, and 15% disagree on the basis of current evidence). Givewell also note for context that HLI's original estimates imply that a donor would pick offering StrongM...
What lies ahead for applied behavioral science? How can we learn from the massive growth in the field over the last 15 years? Our guest, Michael Hallsworth, has very recently published a manifesto on the future of behavioural science and we're privileged to discuss this landmark publication with him on this episode. Dr Michael Hallsworth PhD has been on the forefront of thought leadership and scholarship in behavioral science for many years. Having earned his PhD in Behavioural Economics from Imperial College in London, he has since spent most of his career working in either public policy or on corporate applications around the world. He is now the Managing Director, North America for the Behavioural Insights Team (BIT). Stemming from the original Behavioural Insights Team formed at the heart of the UK government in 2010, BIT has grown into a global company, driving positive change in communities and organizations all across the world. Having grown international teams, demonstrated workable behavioral results and shaken up policies around the world, Michael felt it was a good time for BIT to reflect on how far they had come. In the Manifesto for Applying Behavioural Science, Michael lays out 10 proposals that chart the path forward for behavioral science. We touch on these proposals in our discussion with Michael and the opportunities they present for the future. * Behavioral science is a global field but unfortunately the spelling is not! In an effort to be diplomatic, we are using both spellings in the show notes! Topics (4:54) Why does behavioural science need a manifesto? (7:18) What are some of the major themes? (11:15) How Michael is flipping the prospective on scaling. (16:37) Using behavioral science as a lens. (21:33) Putting randomized controlled trials (RCTs) in their place. (26:02) Choice infrastructure. (30:25) The vulnerability of behavioral science to overconfidence. (35:09) Reframing our language away from rational vs irrational behavior. (39:25) Using algorithms to reduce inequities rather than exploit vulnerabilities. (47:28) Grooving Session with Kurt and Tim on applying behavioral science. © 2023 Behavioral Grooves Links Manifesto for Applying Behavioural Science: https://www.bi.team/publications/a-manifesto-for-applying-behavioral-science/ Misconceptions about the Practice of Behavioral Public Policy: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4328659 EAST Model: https://www.bi.team/publications/east-four-simple-ways-to-apply-behavioural-insights/ Mindscape Framework: https://thedecisionlab.com/reference-guide/neuroscience/mindspace-framework Ruth Schmidt, Zeya Chen, Veronica Paz Soldan (2022) Choice Posture, Architecture, and Infrastructure: Systemic Behavioral Design for Public Health Policy: https://www.sciencedirect.com/science/article/pii/S2405872622000661 Ruth Schmidt & Katelyn Stenger (2021). Behavioral brittleness: The case for strategic behavioral public policy: https://www.cambridge.org/core/journals/behavioural-public-policy/article/behavioral-brittleness-the-case-for-strategic-behavioral-public-policy/200D5BBC2947F7AB0CD4B4CD71B6A607 Behavioral Grooves Patreon: https://www.patreon.com/behavioralgrooves
Hello everyone, and you are listening to Ideas Untrapped podcast. This episode is a continuation of my two-part conversation with Lant Pritchett. It concludes the discussion on education with the five things Lant would recommend to a policymaker on education policy, how to balance the globalized demand for good governance with the design of state functionalities within a localized context - along with RCTs in development and charter cities. I also got an exclusive one of his infamous ‘‘Lant Rants''. I hope you find this as enjoyable as I did - and once again, many thanks to Lant Pritchett.TranscriptTobi;Yeah, I mean, that's a fine distinction. I love that, because you completely preempted where I was really going with that. Now, on a lighter note, there's this trope when I was in high school, so I sort of want us to put both side by side and try to learn more about them. There's this trope when I was in high school amongst my mates, that examination is not a true test of knowledge. Although it didn't help the people who were saying it, because they usually don't test well, so it sort of sounded like a self serving argument. But examination now, or should I say the examination industry, clearly, I mean, if I want to take Nigeria as an example, is not working. But it seemed to be the gold standard, if I want to use that phrase. It's as bad as so many firms now set up graduate training programs. Even after people have completed tertiary education, they still have to train them for industry and even sometimes on basic things. So what are the shortcomings of examination, the way you have distinguished both? And then, how can a system that truly assesses learning be designed?Lant; Let me revert to an Indian discussion because I know more about India than Africa by far. There are prominent people, including the people around JPAL and Karthik Muralidharan, who say, look, India never really had an education system. It had a selection system. And the ethos was, look, we're just throwing kids into school with the hopes of identifying the few kids who were bright enough, capable enough, smart enough, however we say it, measured by their performance on this kind of high stakes examination who are going to then become the elite. So it was just a filter into the elite, and it really meant the whole system was never really in its heart of heart geared around a commitment to educating every kid. I've heard teachers literally say out loud when they give an exam and the kids don't master the material, they'll say, oh, those weren't the kind of kids who this material was meant for. And they leave them behind, right? There's a phrase “they teach to the front of the class.” You order the class by the kid's academic performance, and then the teachers are just teaching to the front of the class with the kind of like, nah, even by early grades. So the evils of the examination system are only if it's not combined with an education system. So essentially, an education system would be a system that was actually committed to expanding the learning and capabilities of all kids at all levels and getting everybody up to a threshold and then worried about the filter problem much later in the education process.So if they're part of an education system like they have been in East Asia, they're not terribly, terribly damaging. But if they're part of a selection system in which people perceive that the point is that there's only a tiny little fraction that are going to pass through these examinations anyway and what we're trying to do is maximize the pass rates of that, it distorts the whole system start to finish. My friend, Rukmini Banerjee, in India started this citizen based assessment where it was just a super simple assessment. You need assessment in order to have an effective education system, because without assessment, I don't know what you know or don't know, right? And if I don't know as a teacher or as a school what my kids actually know and don't know, how is anybody imagining that you're giving them an effective education? So I think the role of early assessment and the drive to integrate teaching with real time assessment, I think is hugely, hugely important. This is why I had the preemptive strike on the question of testing [which] is that I want radically more assessment earlier, integrated with teaching. And there are still some educationists that will push back against that. But if we put in a bundle, formative classroom assessment integrated with effective pedagogy and high-stakes examinations, then everybody's going to hate them both. So we have to really unbundle those two things.And the hallmark of an education system is that it really has targets that every kid can learn and believes every kid can learn, and builds a system around the premise and promise that every kid can learn. There's this example out there, Vietnam does it. And Vietnam did it and continues to do it at levels of income and social conditions that are very much like many African countries. So if I were a country, I'd kind of hate Vietnam as this goody goody, that, you know. You know how you always hated the kid in school who would really do well, and then the teacher would go, well, how come you're not like that kid? On education, Vietnam is that country. It's, like, out there producing OECD levels of learning with very little resources and starting at least in the 1980s, at very low levels of income. So they're proving that it's possible. They're the kid who, like, when everybody goes, oh, that exam was too hard, and like, Bob passed it, like, how hard can it be? Anyway? So I think radically different bases for assessment versus examinations. And to some extent, the only integrity that got preserved in the system wasn't the integrity of the classroom and teaching, it was the integrity of the examination as a filter.Tobi;I want to ask you a bit about the political economy of this a little bit. So if, say, you are talking to a policymaker who is actually serious about education, not in the superficial sense, but really about learning and says, okay, Lant, how do I go about this? How do I design an educational system that really does these things? I've written quite a number of reports here and there that rely so much on your accountability triangle. I would have sent you royalty checks, but it wasn't paid work. Sorry. So how exactly would you explain the political economy of designing a working educational system? I know people talk a lot about centralization versus decentralization, who gets empowered in that accountability triangle? Where should the levers to really push, where are they? So how exactly would you have that conversation?Lant; So let me start with the accountability triangle and design issues. I think people mistake what the accountability triangle and design issues are about in the following sense. If I'm going to design a toaster, and the toaster is going to turn my untoasted bread into toasted bread, and it's going to be an electric toaster, there are certain fundamental things that have to happen, right? I have to have a current. I need to get that current running through something that heats up. I need that heat to be applied to the bread. I need it to stop when I've applied enough heat. Now, those fundamental principles of toaster design can lead to thousands of different actual designs of toasters. So I want people to get out of the notion that there's a single best toaster and that the accountability triangle or any other mode of analysis is to give you the best toaster and then everybody copies the best toaster. The principles are, design your own damn toaster, right? Because there's a gazillion ways to toast bread. Now, [for] all of them to work, [they] have to be compatible with the fundamental principles of electricity and current flow. You know, so I'm trying to get to one size doesn't fit all, but any old size doesn't necessarily fit everything either.You raise the question of decentralization, right? The thing is, if you look across countries that have roughly similar learning outcomes from PISA and other assessments, they're radically different designs. France is an entirely centralized system. Germany is a completely federalized system. The US is almost completely localized system. The Low Countries, Netherlands and Belgium have money follows the student system into the private sector. They have the highest private sector enrollment of any country in the world because they allow different pillars of education between the secular, the Catholic and the Protestant to coexist. So then if you ask is decentralization the best way to design your education system? It's like, no, no, no, you're missing the point. The point is, if you choose a centralized system, there are principles in how you design the flows of accountability that are going to produce success and those that are going to produce failure. If you choose a decentralized system, there are systems of the alignment of accountability that are going to produce success and failure. So the analytical framework doesn't determine the grand design, it determines the mechanics of the design. And I just want to get that straight up front.Second, as a result of the eight year research project of RISE, we have a policy brochure that has, kind of, here are the five kind of principles and here's the 15 minutes if I have five minutes with a minister or leader of a country, here are the five things I want to tell. And the first of those things is, commit. A lot of times we want to skip the most fundamental stage. And what I mean by commit is you actually need to create a broad social and political consensus that you're really going to do this and that you're committed to it. This big research project, RISE, which is based out of Oxford and I've been head of for eight years, we included Vietnam as one of our focused countries because it was a success case. Hence, we wanted our research team to partly do research about Vietnam and issues that were relevant in Vietnam. But we really wanted to answer the question, how did Vietnam do this? Why did they succeed? Right? And five years into the research effort, I was with the Vietnamese team and they had produced a bunch of empirical research of the econometric type. Is Vietnam success associated with this or that measurable input? Nothing really explains Vietnam at the approximate determinant input level. And finally, one of the researchers said to me, Lant, we're trying to get around the fundamental fact that Vietnam succeeded because they wanted to. And on one level it's like, my first response was, I can't go back and tell the British taxpayers that they spend a million dollars for a research project on Vietnam, and the conclusion to why Vietnam succeeded was because they wanted to.[Laughs]Tobi; That's kind of on the nose, right? Lant; Yeah. On another level, it's a deep and ignored truth. The policymakers ignore it, the donors ignore it. Everybody wants to ignore it. Everybody wants to assume it's a technocratic issue, it's a design issue. I think the fundamental problem of these failing and dysfunctional education systems, it's a purpose problem. The purpose of education isn't clear, understood, widely accepted among all of the people from top to bottom responsible for achieving results. And once that leads to what I call norm erosion. Within the teachers, there's this norm erosion of what does it really mean to be a teacher? So again, the first and maybe only thing I would say if I had five minutes with a leader is, how are you going to produce a broad social, political and organizational commitment that you are really going to achieve specific, agreed-upon learning results? The technical design issues have to flow from that commitment rather than vice versa. And you could copy France's system, you could copy the Vietnamese system. I think you've heard the term from me and others, isomorphic mimicry. You can copy other people's systems and not have the same effect if it isn't driven by per purpose. Like, if you don't have the fundamental commitment and you don't have the fundamental agreed-upon purpose, the rest of the technical design is irrelevant.Tobi;It sort of leads me to my next theme. And that is the capability question in development.Lant; Yeah.Tobi; First of all, I also want to make a quick distinction, because lately, well, when I say lately that's a little vague. State capacity is all the rage now in development.Lant; Really? Is that true?Tobi; Yeah,Lant; I'm so happy to hear that. 3s I'm glad that you think so. And I hope that that's true, because it wasn't. It really wasn't on the agenda in a serious way. So, anyway …Tobi; But I also think there's also a bit of misunderstanding still, and usually, again, maybe I'm just moving with the wrong crowd. Who knows? People focus a lot more on the coercive instruments of the state and how much of it can be wielded to achieve certain programmatic results for state capacity. Revenue to GDP in Nigeria is low, how can the states collect more taxes? How much can the state squeeze out of people's bank accounts, out of companies, or the reverse. That, the reason why the state collects very little taxes is because state capacity is low. But, I mean, nobody really unpacks what they mean by that. They just rely on these measures like X to GDP ratio.Another recent example was, I think it was in 2020, when the pandemic sort of blew over and China built a hospital with 10,000 bed capacity in, I don't know, I forgot, maybe 20 days or…Lant; Yeah. It was amazing.Tobi; A lot of people were like, oh, yeah, that's an example of state capacity. It's very much the same people now [who] are turning around and seeing China as an example of failure on how to respond to a pandemic. So I guess what I would ask you is, when you talk about the capability of the state, what exactly do we mean?Lant; In the work that were done and the book that we wrote, we adopt a very specific definition of capability, which is an organizational measure. Because there are all these aggregate country level measures and we use them in the book. But in the end, I think it's easier to define capability at the organizational level. And at the organizational level, I define [that] the capability of an organization is the ability to consistently induce its agents to take the policy actions in response to circumstances that advance the normative objective of the organization. And that's a long, complicated definition, but it basically means can the organization, from the frontline worker to the top of the organization, can it get people to do what they need to do to accomplish the purpose?And that's what I mean by the capability of an organization. And fortunately, unfortunately, like, militaries, I think, make for a good example. It's amazing that highfunctioning militaries have soldiers who will sacrifice their lives and die if needs be, to advance the purpose of the organization. Whereas you can have a million man army that's a paper tiger. No one is actually willing to do what it takes to carry out the purpose that the organization has been put to of fighting a particular conflict. And I think starting from that level makes it clear that, A, this is about purpose, B, it's about inducing the agents to take the actions that will lead to outcomes. And the reason why I'm super happy to hear that capability is being talked about is (you're doing a very good job as an interviewer drawing out connection between these various topics) the design of the curriculum is almost completely irrelevant to what's happening in schools. And so there's been way too much focus in my mind in development discourse on technocratic design and way too little on what's actually going to happen in practice. And so my definition of capability is, you measure an organization's capability of what actually happens in practice, what are the teachers actually going to do day to day? Right? And having been in development a long time, I often sit in these rooms where people are just, you know, I go out to the field and teachers aren't there at the school. Teachers are sitting in the office drinking their tea while the kids are running around on the playground, even during scheduled instructional time. And then I go back and hear discussions in the capital about higher order 21st century skills. You know, I wrote this article about India called Is India a Flailing State?Tobi;Yeah.Lant;And what I meant by flailing is there was no connection between what was happening in the cerebrum and what was being designed at the center. And what was actually happening when the actual fingers were touching the material and the nerves and sinews and muscles that connected the design to the practice were completely deteriorated. And therefore, capability was the issue, not design. So that's what I mean by capability. I mean, you use the example of tax. I think it's a great example. It's like, can you design a tax authority that actually collects taxes? And it's a hard, difficult question. And I think by starting from capability, I was really struck by your description of capability being linked to the coercive power of the state because that's exactly not how I would start it. I would start it with what are the key purposes for which the state is being deployed and for which one can really generate a sufficient integrated consensus that we need capability for this purpose.Tobi; Now, one of my favourite blogs of yours was how you described… I think it was how the US escaped the tyranny of experts, something like that. So I want to talk about that a bit versus what I'll call the cult of best practice…Lant; Hmm.Tobi; Like, these institutions that are usually transplanted all over the world and things like independent central bank and this and that. And you described how a lot of decentralized institutions that exists in the United States, they were keenly contested, you know… Lant Yes.Tobi; Before the consensus sort of formed. So I'm sort of wondering, developing countries, how are they going about this wrong vis a vis the technical advice they are getting from development agencies? And the issue with that, if I would say, is, we now live in a world where the demand for good governance is globalized. Millions of Nigerians live on the internet every day and they see how life is in the industrial rich world and they want the same things. They want the same rights. They want governments that treat them the same way. Someone like me would even argue for an independent central bank because we've also experienced what life is otherwise.Lant; Right. Tobi; So how exactly to navigate this difficult terrain because the other way isn't also working. Because you can't say you have an independent central bank on paper that is not really independent and it's not working.Lant; Your questions are such a brilliant articulation of the challenges that are being faced and the complex world we live in because we live now in an integrated world where people can see what's happening in other places. And that integrated world creates in and of itself positive pressures for performance, but also creates a lot of pressures for isomorphism, for deflecting the actual realities and what it will take to fix and make improvements with deflective copies of stuff that has no organic roots. I've written lots of things and even though you love all of your children, you might have favorites. One of my favorite blogs is a blog I wrote that is, I think, the most under cited blog of mine relative to what I think of it, which is about the M16 versus the AK-47.Tobi;Oh, yeah, I read that.Lant;It's an awkward analogy because no one wants to talk about guns.Tobi;Hmm.Lant;But I think it's a really great analogy because the M16 in terms of its proving ground performance is an unambiguously superior, more accurate rifle. The developing world adopts the AK-47. And that's because the Russian approach to weapon design was - design the weapon to the soldier. And the American approach is - train the soldier to the weapon. And what happens again and again across all kinds of phenomena in development is the people who are coming as part of the donour and development community to give advice to the world, all want them to adopt the M16 because it's the best gun, and they don't have the soldiers that can maintain the M16. And the M 16 has gotten better, but when it was first introduced, it was a notoriously unreliable weapon. And the one thing as a soldier, you don't want to happen is as you pull the trigger and the bullet doesn't come out at the end. That's what happens when you don't maintain an M16. So I think this isomorphism pressure confuses what best practice is with assuming there's this global best practice that can be adopted independently of the underlying capacity of the individuals and capabilities of the organizations. So I think huge problem.Second, I think there is a super important element of the history that the modes of doing things that now exist in the Western world and which we think of as being “modern,” I'm using scare quotes which doesn't help in a podcast, but we think of as being modern and best practice had to struggle their way into existence without the benefit of isomorphism. In the sense that when the United States in the early 20th century underwent a huge and quite conflicted and contested process of the consolidation of one room, kind of, locally operated schools into more professionalized school systems, that was politically contested and socially contested. And the only way the newer schools could justify themselves was by actually being better. There was no, oh, but this is how it has to be done, because this is how it has been done in these other places, and they have succeeded. And so there was no recourse to isomorphism, right. So in some sense, I think the world would be a radically better place for doing development if we just stopped allowing best practice to have any traction at all. If Nigerians just said, Screw it, we don't want to hear about it. Like, we want to do in Nigeria, what's going to work better in Nigeria? And telling me what Norway does and does not do, just no. Just no, we don't want to hear about it. Like, that doesn't help because it creates this vector of pressures that really deteriorate the necessary local contestation. My colleague Michael Wilcock, who is a sociologist, has characterized the development process as a series of good struggles. And in our work on state capability, we say you can't juggle without the struggle. Like, you can't transplant the ability to juggle. I can give you juggling lessons, I can show you juggling videos. But if you don't pick up the balls and do it and if you don't pick up the balls and do it with the understanding that unless you juggle, you haven't juggled, you can never learn to juggle. So I think if development were radically more about enabling goods, local struggles in which new policies, procedures, practices had to struggle their way into existence, justifying themselves on performance against purpose, we would be light years ahead of where we are. And that's what the debate about capability has to be.And I think to the extent the capability discourse gets deflected into another set of standards and more isomorphism, just this time about capability, I think we're going to lose something. Whereas if we start the state capability from discussion of what is it that we really want and need our government to get better at doing in terms of solving concrete, locally dominated problems, and then how are we going to come about creating the capability to do that in the Nigerian context, (I'm just using Nigeria, I could use Nepal, I could use any other country). That's the discussion that needs to happen. And the more the, kind of, global discourse and the global blessed practice gets frozen out completely, the sooner that happens, the better off we'll be.Tobi; So I guess where I was going with that is…Lant; 78:25Yeah.Tobi; One of those also fantastic descriptions you guys used in the book is” crawling the design space” on capability. So now for me, as a Nigerian, I might say I do not necessarily want Nigeria to look like the United States. Because, It wouldn't work anyways. But at the same time, you don't want to experiment and end up like Venezuela or Zimbabwe. It may not work to design your central bank like the US Federal Reserve, but at the same time, you don't want 80% inflation like Turkey. So we're ate the midway, so to speak?Lant; I get this pushback when I rail on best practice. I often get the push back, well, why would we reinvent the wheel? And I've developed a PowerPoint slide that responds to that by showing the tiniest little gear that goes into a Swiss watch and a huge 20 foot large tire that goes on a piece of construction machinery. And then say they're both wheels. Nobody's talking about reinventing the wheel. There are fundamental principles of electricity that a toaster design has to be compatible with. So, again, there is a trade off. There are fundamental principles, but there's a gazillion instantiations of those principles. We don't want to start assuming that there's a single wheel, right? When people say, don't reinvent the wheel, it's like, nobody's reinventing the idea of a wheel. But every wheel that works is an adaptation of the idea of a wheel to the instantiation and purpose for which is being put. And if you said to me, oh, because we're not going to reinvent the wheel, we're going to take this tiny gear from a Swiss watch and put it on a construction machine and expect it to roll, it's like, no, that's just goofy, right? And what I've really tried to do in the course of my career is equip people with tools to think through their own circumstances.Tobi;Hmm.Lant;Coming back, the accountability triangle or the crawling the design space. What I'm not trying to do is tell somebody, here is what you should do in your circumstance, because my experience is what's actually doable and is going to lead to long-run progress is an unbelievably complicated and granular thing that involves the realities of the context. But what I do want to do is help people understand there are certain common principles here and some things are going to lead to, like, Venezuela like circumstances, and we've seen it happen again and again, but there are a variety of pathways that don't lead to that. And you need to choose a pathway that works for you. And the PDAA isn't a set of recommendations, it's a set of tools to help people think through their own circumstances, their own organization, their own nominated problems and make progress on them. The accountability triangle isn't a recommendation for the design of your system. It's a set of tools that equip people to have conversations about their own system. And I have to say, at one time was in some place in Indonesia and it was a discussion of PDAA being mediated by some organization that had adopted it and was teaching people how to do it in Indonesia. And I had the wonderful experience of having this Indonesian woman who was a district official working on health, describe in some detail how they were using PDAA to address the problem of maternal mortality with no idea who I was. And I was like, oh, just for me to hear her say, here is how I use the tool to address a problem I've never thought about in a context, in an organization I've never worked with. So I think equipping people with tools to enable them in their own local struggles is my real objective rather than the imagination that I somehow can come up with recommendations that are going to work in a specific context.So the don't reinvent the wheel is just complete total nonsense. It's like every wheel is adapted to its purpose and we're just giving you tools to adapt the idea of the wheel to your purpose. Adapting a square to the purpose just isn't going to work. So I agree. We want to start from the idea of things that work. And there are principles of wheel design that you can't violate. You can't come in and say, I have a participatory design of a water system that depends on water running uphill. No. Water runs downhill. That's a fundamental principle of water. But I think the principles are much broader and the potentiality for locally designed and organic, organically produced instantiations of common principles are much broader than the current discourse gives the possibility for.Tobi; 83:47 I can't let you go without getting your thoughts on just a few more questions. So indulge me. I've stayed largely away from RCTs because there's a bunch of podcasts where your thoughts can be fairly assessed on that issue, but it's not going away. Right? So for me, there's the ethical question, there's the methodological question, and there's the sort of philosophical question to it. I'm not qualified to have the methodological question, not at all. Maybe on the ethics, well, there's a lot of also biases that get, so I'm not going to go there. For me, when I think about RCTs, and I'm fairly close here in Nigeria with the effective altruism community, my wife is very active, and I have this debate with them a lot. Surprisingly, a lot of them are also debating Lant Pritchett, which is which is good, right now. The way I see it is. The whole thing seems too easy in the sense that, no disrespect to anybody working in this space at all… in the sense that it seems optimizing for what can be measured versus what works.So for me, the way I look at it is, it's very difficult to know the welfare effects for maybe a cohort of households. If you put a power station in my community, which has not had power for a while. So, but it's pretty easy if you have a fund and you distribute cash to households and you sort of divide them into a control group, and you know… which then makes it totally strange if you conclude from that that that is the best way to sort of intervene in the welfare and the well being of even that community or a people generally. I mean, where am I going wrong? How am I not getting it? Lant; No, the people listening to the podcast can't see me on the camera trying to reach out and give you a big hug. I think you have it exactly right. I think we should go back and rerecord this podcast where I ask you questions and your questions are the answer. So I think you've got the answer exactly right. So first of all, by the way, the original rhetoric and practice of RCTs is going away, and roughly has gone away. Because the original rhetoric was Independent Impact Evaluation. All of the rhetoric out of JPAL and IPA and the other practitioners is now partnerships, which is not independent, but essentially everybody's adopted the Crawl the Design Space use of evidence for feedback loops in making organizations better. So they've all created their own words for it because they don't want to admit that they're just, again, borrowing other ideas. So to a large extent the whole community is moving in a very positive direction towards integrating, seeking out relevant evidence for partner organizations in how can they Crawl the Design Space and be effective. And they're just not admitting it because it's embarrassing how wrong they were first, but they've come to the right space. So I want to give them credit.When I gave a presentation at NYU called The Debate About RCTs Is Over And I won. It's not a very helpful approach, it's true, but it's not very helpful because I have to let them do what they're now doing, which is exactly what I said they should have been doing, and they are now doing. So, to some extent, asking people to say, yeah, we changed what we're doing is a big ask. And I'd rather they actually change what they're doing then they admit they did that. So to some extent it is going away. I think it's going away as it was originally designed, as this independent white coat guys, descend on some people and force them to carry out an impact evaluation to justify their existence. They're much more integrated, let's Crawl the Design Space in partnership with organizations, let's use randomization and more AB testing ways. And so I feel it's moving in a very positive direction with this weird rhetoric on top of it.Second, I think you're exactly right and I think it's slightly worse than you said. Because it's not just about what can be measured, but it's about attributability. It's not just what can be measured, but what can be attributed directly, causally to individual actions. And my big debate with the Effective Altruism community is I'm hugely, you know, big, big, big wins from the Effective Altruism movement attacking kind of virtue signaling, useless kind of philanthropic endeavors. I think every person should be happy for them. But if I were African, I would be sick of this philanthropic b******t that you guys are going to come and give us a cow or Bill Gates talking about…Tobi;Or chickens.Lant;Chickens. My wife doesn't do development at all. She's a music teacher. But when she heard Bill Gates talking about chickens, she think, does Bill Gates think chickens haven't been in Africa for hundreds of years? Like, what does he think he knows about chickens that Africans don't know about chickens? That's just such chicken s**t, right? But again, I'll promote a blog. I have a blog called let's All Play for Team Development. And I think what you're raising in your thing is that it's not just what we can measure, it's what we can measure and attribute to the actions of a specific actor. Because, you know, your example of not having power in a village, that we can measure. But all of the system things that we've talked about so far - migration, education, state capability - these aren't going to be solved by individualized interventions. They're going to be solved by systemic things. And with my team on education, we've had this big research project on education standards but I keep telling my team, look, if you're not part of a wave, you're a drop in the ocean. The only way for your efforts to not be a drop in the ocean is for you to be part of a wave [of] other people around you working on the same issue, pushing in the same direction, to build that. And that kind of thing gets undermined by attributability. So with my RISE project, I sometimes tell my funders, you can have success or you can have attributability, but you can't have both, right? Because if we're going to be successful at changing the global discourse in education, we're not going to do it by ourselves. We're going to be part of a team and a network. So, anyways…By the way, like early, early, early in the Effective Altruism movement, I had an interview with Cari Tuna and I think Holden Karnofsky, when they were thinking about what to do, and I made exactly this point. It's like, look, being effective at the individualized interventions that are happening is one thing, but don't ignore these huge systemic issues because you can't measure the direct causal effect between the philanthropic donation and the outcome. And that's your point, I think, which is, Nigeria is not going to get fixed by cash transfers.Tobi;No way.Lant; I mean, for heaven's sakes if Nigeria had the cash to transfer to everybody and fix it, well, then the national development struggle wouldn't be what it is. It's a systemic struggle across a number of fronts.Tobi;Why not just get Bill Gates to donate the money.Lant; But again, even Bill Gates, his fortune relative to the…you know, impact you could have through these programs, relative to what happens with national development, is just night and day. So to the extent that the adoption of a specific methodology precludes serious, evidence-based, hard struggle work on the big systemic issues, it's a net negative.Tobi;Again, to use your term, “kinky ideas in development.” Lant; Yeah.Tobi;I was reading a profile in the FT, a couple of days ago, all about charter cities, right?Lant; About what?Tobi; Charter cities. It was an idea I was kind of into for a while, I mean, from Paul Roma's original presentation at TED. But you strongly argued against it at your CATO debate. So what is wrong with that idea? Because there are advocates, there are investors, who think charter cities are this new thing that is going to provide the space for the kind of organizational and policy experimentation. And China's SEZs are usually the go to examples, Shenzhen particularly. So, what do you have to say about that?Lant;I like discussing charter cities.Tobi;Okay.Lant;And the reason I like discussing charter cities is because they're not kinky. Right. My complaint about Kinky is that you've drawn this line in human welfare and you act as if development is only getting people over these very low-bar thresholds. So conditional cash transfers are an example of Kinky, and conditional cash transfers are just stupid, right? Charter cities are wrong.I mean, conditional cash transfers are just stupid in a trivial way.Charter cities are wrong in a very deep and sophisticated way. So I love talking about charter cities. The reason I love talking about charter cities is A, they have have the fundamental problem posed, right? The fundamental problem is countries and systems are trapped in a low level equilibrium and that low level equilibrium is actually a stable equilibrium and so you need to shock your way out of it. And the contest between me and Charter cities is I think there's good struggle paths out of low level equilibrium. So I'm a strategic incrementalist. I want to have a strategic vision, but I want incremental action. So I'm against the kinky, which is often incremental incremental, it doesn't really add up to a development agenda. So I like, yes, we need to have a way out of this low level equilibrium and state capability in the way education systems work, in the way economic policies keep countries from achieving high productivity, et cetera. But I'm a good struggle guy. And charter cities want Magic Bullet. Right.Now, the rationale for Magic Bullet is that good struggle is hard and hasn't necessarily proved successful. And these institutional features that lead to these low level traps just are resistant to good struggle methods out. And I think that's a really important debate to be having. But I think the right way to interpret China's experience and Yuen Yeun Ang's book on how China did it is, I think, a good illustration of this is China was Good Struggle. Using regional variations as a way of enabling good struggles. It's instructive that difficulty with Charter Cities always goes back. You keep going deeper and deeper of who's going to enforce this, who's going to enforce this, who's going to enforce this, you know. They're caught in their own catch 22 in my mind. So the first proposed, what appeared to be feasible Charter City in Honduras eventually got undermined by governance issues in which the major investor didn't want to actually be subject to rules based decision making. So, I love talking about charter cities. I think they're on the right set of issues of how do we get to the institutional conditions that can create a positive environment for high productivity firms and engagement and improved governance. And they have a coherent argument, which is good, that, it's a low level trap and there's no path out of the low level trap and so we need big shock to get out of it.But I don't think they're ultimately correct about the way in which you can establish the fundamentals. You can't just big jump your way to having reliable enforcement mechanisms and until you get to reliable enforcement mechanisms, the whole Charter City idea is still kind of up in the air. The next podcast I have scheduled to do is with the Charter Cities podcast, so that hopefully…Tobi;Oh. Interesting. Last question. We sort of have a tradition on the show where I ask the guest to discuss one new idea they would like to see spread everywhere. But I think more in line with your own brand, like you said earlier, I think I would like to ask for our own exclusive, Ideas Untrapped Exclusive Lant Rant, something you haven't talked about before or rarely. So you can go on for however long you wish. And that's the last question.Lant; I think if I had to pick something that if we could just get rid of it, it would be this fantasy that technology is going to solve problems. My basic point I make again and again and again is Moore's Law, which is the doubling of computer capacity every two years, has been chugging along, and it might have slowed down, but has been chugging along since 1965. So computing power has improved by a factor of ten to the 11th. And just as an illustration of just how big ten to the 11th is, the speed you drive on a freeway of 60 miles an hour is only ten to the 7th smaller than the speed of light. So ten to the 11th is an astronomically huge number in the sense that only astronomers have any use for numbers as big as ten to the 11th. Okay. My claim is anything that hasn't been fixed by a ten to the 11th change in computing power isn't going to get fixed by computing power. And I ask people sometimes in audiences, okay, particularly with older people, you look a little young for this question, but I ask them, okay, you older people that have been married for a long time, computing power has gone up ten to the 11th over the course of your marriage, has it made your marriage any better. And they're like, well, a little bit, sometimes when we're abroad, we can communicate over Skype easier, but on the other hand, it's made it worse because there's more distractions and more temptations to not pay attention to your spouse.So on net, ten to the 11th of computing power hasn't improved average marriage quality. And then I ask them, has it improved your access to pornography? And it's like, of course, night and day, like, more instantaneous access to pornography. And my concluding thing is a huge amount of what is being promoted in the name of tech is the pornography of X rather than the real deal. So people promoting tech in education are promoting the pornography of education rather than real education. People that are promoting tech in government are promoting the pornography of governance rather than true governance. And it's just like, no, these are deeper human issues, and there's all kinds of human issues that they're fundamentally technologically resilient. And expecting technology to solve human problems is just a myth. It enables salespeople to pound down people's doors, to sell government officials some new software that's going to do this or that. But without the purpose, without the commitment, without the fundamental human norms of behaviour, technology isn't going to solve anything and the pretence that it is is distracting a lot of people from getting to the serious work. So if we could just replace the technology of X with the pornography of X, I think we'd be better off in discussions of what its real potentialities are. How's that for [an] original?Tobi;Yeah, yeah.Lant;You asked for it.Tobi; Yeah, that's a lot to think about, yeah. Thank you so much for doing this.Lant; Thanks for a great interview, Tobi. That was super fun. We could go back and record this with my asking questions and your questions being the answers. Because you're really sophisticated on all these issues. You're in exactly the right space.Tobi;Thank you very much.Lant;Great. 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
“You betrayed us. I've just been a donkey my whole life and you told me my child's life would be different [if they went to school]. But now I've learned that he hasn't learned anything”.Join us in a thought-provoking conversation with Lant Pritchett, Visiting Scholar and Research Fellow at the Blavatnik School of Government and Research Director of the RISE program (Research on Improving Systems of Education). We will discuss development, aid, RCTs, failing education systems and how to turn them around, and monkeys.Prof. Pritchett is a prominent scholar of development and a ******provocateur******, with years of experience in the practice and study of the practice of development, with passages at BSG, the Harvard Kennedy School, the World Bank, and more. He is the author of “Deals and Development: The Political Dynamics of Growth Episodes”, and “The Rebirth of Education: Schooling ain't Learning”, among others.Vitor Tomaz, a candidate for the Master of Public Policy at the Blavatnik School of Government at the University of Oxford, hosts this episode. This episode was produced by Annelisse Escobar, Gloria Wawira, and Vitor Tomaz—edited by Paul Austin (Thanks, Paul!).To keep up with our latest episodes in conversation with public leaders, practitioners, and analysis, follow us on Instagram @oxfordpolicypod_.
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 SoGive is publishing an independent evaluation of StrongMinds, published by ishaan on March 17, 2023 on The Effective Altruism Forum. Executive summary We believe the EA community's confidence in the existing research on mental health charities hasn't been high enough to use it to make significant funding decisions. Further research from another EA research agency, such as SoGive, may help add confidence and lead to more well-informed funding decisions. In order to increase the amount of scrutiny on this topic, SoGive has started conducting research on mental health interventions, and we plan to publish a series of articles starting in the next week and extending out over the next few months. The series will cover literature reviews of academic and EA literature on mental health and moral weights. We will be doing in-depth reviews and quality assessments on work by the Happier Lives Institute pertaining to StrongMinds, the RCTs and academic sources from which StrongMinds draws its evidence, and StrongMinds' internally reported data. We will provide a view on how impactful we judge StrongMinds to be. What we will publish From March to July 2023, SoGive plans to publish a series of analyses pertaining to mental health. The content covered will include Methodological notes on using existing academic literature, which quantifies depression interventions in terms of standardised mean differences, numbers needed to treat, remission rates and relapse rates; as well as the "standard deviation - years of depression averted" framework used by Happier Lives Institute. Broad, shallow reviews of academic and EA literature pertaining to the question of what the effect of psychotherapy is, as well as how this intersects with various factors such as number of sessions, demographics, and types of therapy. We will focus specifically on how the effect decays after therapy, and publish a separate report on this. Deep, narrow reviews of the RCTs and meta-analyses that are most closely pertaining to the StrongMind's context. Moral weights frameworks, explained in a manner which will allow a user to map dry numbers such as effect sizes to more visceral subjective feelings, so as to better apply their moral intuition to funding decisions. Cost-effective analyses which combine academic data and direct evidence from StrongMinds to arrive at our best estimate at what a donation to StrongMinds does. We hope these will empower others to check our work, do their own analyses of the topic, and take the work further. How will this enable higher impact donations? In the EA Survey conducted by Rethink Priorities, 60% of EA community members surveyed were in favour of giving "significant resources'' to mental health interventions, with 24% of those believing it should be a "top priority" or "near top priority" and 4% selecting it as their "top cause". Although other cause areas performed more favourably in the survey, this still appears to be a moderately high level of interest in mental health. Some EA energy has now gone into this area - for example, Charity Entrepreneurship incubated Canopie, Mental Health Funder's Circle, and played a role in incubating Happier Lives Institute. They additionally launched Kaya Guides and Vina Plena last year. We also had a talk from Friendship Bench at last year's EA Global. Our analysis will focus on StrongMinds. We chose StrongMinds because we know the organisation well. SoGive's founder first had a conversation with StrongMinds in 2015 (thinking of his own donations) having seen a press article about them and having considered them a potentially high impact charity. Since then, several other EA orgs have been engaging with StrongMinds. Evaluations of StrongMinds specifically have now been published by both Founders Pledge and Happier Lives Institute, and Str...
Fitness Confidential with Vinnie Tortorich
Episode 2306 - On this Friday's show Vinnie Tortorich welcomes back Dave Feldman, and the two discuss decoding cholesterol, recent studies regarding cholesterol, modeling data, and more. https://vinnietortorich.com/2023/03/decoding-cholesterol-dave-feldman-episode-2306 PLEASE SUPPORT OUR SPONSORS DECODING CHOLESTEROL Vinnie welcomes Dave back and chats a bit about Dave's first appearance on the Dr. Drew podcast. (3:00) Both Dave and Ivor Cummins have brought a lot of attention to understanding cholesterol. Dave's background in coding has helped him decipher how cholesterol works in the system of our bodies. Dave explains what ApoA-1 and ApoB are in simple-to-understand terms and what part it plays in your body. (5:00) A good metabolism is a balance of building up and breaking down of certain materials, specifically fuel, in the body. (10:30) Dave and Vinnie discuss what a CAC score is; Dave is surprised there isn't more interest in it based on what he's learned. (16:00) This leads to a discussion of how statins work and how they may or may not be beneficial, depending on the situation. (LMHR) is, and his recent research around this phenomenon. (22:00) The ad for Villa Capelli leads to a discussion on healthy fats, seed oils, and some companies making misleading claims on their labels. (28:30) Dave also explains research that uses modeled data, vs. epidemiological studies or randomized control trials (RCTs), and the challenges of each kind. (35:00) The conversation leads back to the study Dave is spearheading about LMHR (Lean Mass Hyper Responder) and what the research has shown thus far. (45:00) Vinnie asks Dave if CAC scores can be improved, and if so, how. (1:03:00) Dave also shares info about what variations in testing can affect results. Dave and his work can be found at and . His Twitter is . PLUS... Vinnie reveals an NSNG® FOODS special Promo Code. (LISTEN FOR IT!) [the_ad id="20253"] PURCHASE BEYOND IMPOSSIBLE The documentary launched on January 11! Order it TODAY! This is Vinnie's third documentary in just over three years. Get it now on Apple TV (iTunes) and/or Amazon Video! Link to the film on Apple TV (iTunes): Then, Share this link with friends, too! It's also now available on Amazon (the USA only for now)! Visit my new Documentaries HQ to find my films everywhere: REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter!
RUSK Insights on Rehabilitation Medicine
Dr. Byron Schneider is currently an associate professor with the Department of Physical Medicine and Rehabilitation at Vanderbilt University Medical Center and serves as the Director of the Interventional Spine and Musculoskeletal Medicine Fellowship. Previously, he completed his residency and interventional spine fellowship at Stanford University. He has nearly 100 publications, with a research focus on the safety and outcomes of interventional spine procedures. He has given over 100 lectures at national and international meetings. He currently is on the Spine Intervention Society Board of Directors as the Chair of Research, and within the North American Spine Society is Chair of the Interventional Spine and Musculoskeletal Section as well as Co-Chair for the Coverage Committee. In Part 2 of his presentation, he indicated that the study by Wolf and his group was observational and retrospective, so there are some missing data. They enrolled patients based on provocation discography, which you hope would result in better outcomes. He stated that this number, 50 percent of people saying that they are 50 percent better is very common in pain literature. He wouldn't say it is favorable. Over and over, these are the numbers we see that turn out to be dead ends. These are non-compelling data unless we are able to show they are non-placebo. You need RCTs to do that. He is a huge proponent of observational studies. They can give you very meaningful clinical information, but unfortunately for a new technology like this, we need at least some evidence that these things are doing something beyond placebo. Next, he indicated the discussion in his presentation would shift to discussing some RCTs that have been published more recently. As of right now, however, the totality of evidence because of the negative RCTs in the research done today, stem cells do not work as a treatment for disc-related low back pain. He then described four new RCTs that came out in the last two years that will shed some new light. The first study involved a comparison with saline treatment. Unwanted side effects, such as infections and other complications have occurred as a result of the treatments in the four studies. Safety continues to be a concern in developing effective treatments using stem cell and PRP approaches.
In this episode of the Award-winning PRS Journal Club Podcast, 2023 Resident Ambassadors to the PRS Editorial Board – Rami Kantar, Yoshi Toyoda, and Ronnie Shammas- and special guest Roberto L. Flores, MD, discuss the following articles from the March 2023 issue: “Assessment of “Spin” in Published Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review” by Yuan, Wu, Li, et al. Read the article for FREE: https://bit.ly/SpinPS_RCTs Special guest Roberto L. Flores, MD, who is the Joseph McCarthy Associate Professor of Reconstructive Plastic Surgery, Director of Cleft Lip and Palate as well as the Craniofacial Surgery Fellowship Director at the Hansjorg Wyss Department of Plastic Surgery at NYU. READ the articles discussed in this podcast as well as free related content from the archives: https://bit.ly/JCMarch23Collection
This week, please join author Xuerong Wen, Associate Editor Sandeep Das, and Guest Host Mercedes Carnethon as they discuss the article "Comparative Effectiveness and Safety of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Chronic Liver Disease: A Nationwide Cohort Study." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass of the journal and its editors. We're your co-hosts. 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, Director of the Poly Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, I'm so excited about today's feature paper. It deals with the important condition where atrial fibrillation exists in patients with chronic liver disease and what do we do for anticoagulation in these patients. It's a comparative effectiveness and safety study of direct oral anticoagulants compared with warfarin in these patients. A huge, wonderful, important study that we're going to discuss. But before we get there, I'd like to tell you about some papers in this issue and I'd like you to tell me about some too. You got your coffee? Dr. Greg Hundley: Absolutely. Dr. Carolyn Lam: All right. I'll go first In this paper that describes a quantitative prognostic tool for the mitral valve prolapse spectrum and it's derived from the new mitral regurgitation international database quantitative or MIDA-Q registry, which enrolled more than 8,000 consecutive patients from North America, Europe, Middle East. And these were patients all diagnosed with isolated mitral valve prolapse or MVP in routine clinical practice of academic centers, all of which also did prospective degenerative mitral regurgitation quantification. The MIDA-Q score was calculated based on characteristics collected in routine practice combining the established MIDA score, which integrated guideline based markers of outcomes like age, New York Heart Association status, atrial fibrillation, LA size, pulmonary artery pressure left ventricular and systolic, I mentioned, and ejection fraction. Integrating that with scoring points based on the degenerative mitral regurgitation quantitation that is measuring effective regurgitant orifice and volume. Dr. Greg Hundley: Very interesting Carolyn. So a scoring system that combines clinical information with what we might assess with echocardiography like regurgitant volume or regurgitant orifice area. So how well did this mortality risk score perform? Dr. Carolyn Lam: So the new score was associated with an extreme range of predicted survival under medical management and that ranged from 97% to 5% at five years for the extreme score ranges. And it was strongly, independently and incrementally associated with long-term survival over all the markers of outcomes. So the authors concluded, and these by the way were authors led by Dr. Maurice Serrano from Mayo Clinic, Rochester, Minnesota. These authors concluded that the score should allow integrated risk assessment of patients with mitral valve prolapse to refine clinical decision making in routine practice and ultimately reduce degenerative mitral regurgitation under treatment. Dr. Greg Hundley: Wonderful description Carolyn. Well I'm going to switch to the world of electrophysiology, Carolyn. And so as you know, the Brugada syndrome is an inherited arrhythmia syndrome caused by loss of function variants in the cardiac sodium channel gene SCN5A and that occurs in about 20% of subjects. And these authors led by Dr. Dan Roden at Vanderbilt University School of Medicine identified a family with four individuals diagnosed with Brugada syndrome, harboring a rare missense variant in the cardiac transcription factor, TBX5, but no SCN5A variant. And upon identifying these individuals, their objective was to establish TBX5 as a causative gene in Brugada syndrome and to define the underlying mechanisms by which it would be operative. Dr. Carolyn Lam: Oh wow. So a new gene variant. So what was the relationship? Dr. Greg Hundley: Right Carolyn? So using induced pluripotent stem cell derived cardiomyocytes from members of the affected family, multiple electrophysiologic abnormalities were detected in these cardiomyocytes including decreased peak and enhanced late cardiac sodium current. In these cells these abnormalities were entirely corrected by CRISPR/Cas9 mediated editing of that TBX5 variant and transcriptional profiling and functional assays in unedited and edited pluripotent stem cell derived cardiomyocytes showed direct SCN5A down regulation caused decreased peak sodium current and that reduced PDGF receptor expression and blunted signal transduction to phosphoinositide-3-kinase. And interestingly, PDGF receptor blockade markedly prolonged normal induced pluripotent stem cell derived cardiomyocyte action potentials. And also Carolyn interestingly in this study they did a separate analysis. It reviewed plasma levels of PDGF in the Framingham Heart Study and they found that they were inversely correlated with the QT corrected interval. And so Carolyn, these results established decrease SCN5A transcription by the TBX5 variant as a cause of Brugada syndrome and also reveal a new general transcriptional mechanism of arrhythmogenesis of enhanced late sodium current caused by reduced PDGF receptor mediated phosphoinositide-3-kinase signaling. Dr. Carolyn Lam: Wow. Wow, that's significant. Thanks Greg. So this next paper is also really important and could change the practice in the field of cardiac resynchronization therapy or CRT. You see, it suggests that the practice of what we do now, which is combining right bundle branch block with intraventricular conduction delay patients into a single non-left bundle branch block category when we select patients for CRT, that this may not be the way to go. So let's go back a bit and remember that benefit from CRT varies with QRS characteristics and individual trials are actually underpowered to assess the benefit for relatively small subgroups. So the current authors led by Dr. Friedman from Duke University Hospital and colleagues, therefore performed a patient level meta-analysis of randomized trials of CRT to assess the relationship between QRS duration and morphology with outcomes. Dr. Greg Hundley: Very interesting Carolyn. So another wonderful paper from the world of electrophysiology in trying to understand optimal mechanisms to resynchronize the ventricle in patients with differing bundle branch blocks or intraventricular conduction delays. So what did they find? Dr. Carolyn Lam: They found that patients with intraventricular conduction delays and a QRS duration of 150 milliseconds or more, CRT was associated with lower rates of heart failure hospitalizations and all cause mortality. The magnitude of CRT benefit among these patients with the interventricular conduction delay of 150 milliseconds or more and those with the left bundle branch block of 150 milliseconds or more were similar. In contrast, there was no clear CRT benefit for patients with a right bundle branch block of any QRS duration, although the authors could not rule out the potential for benefit at a markedly prolonged QRS duration. So they concluded that the practice of combining right bundle branch block with intraventricular conduction delay patients into a single non-left bundle branch block category when we make patient selections for CRT is not supported by the current data. And in fact, patients with an intraventricular conduction delay of 150 milliseconds or more should be offered CRT as is done for patients with a left bundle branch block of 150 milliseconds or more. Dr. Greg Hundley: Wow, Carolyn, so really interesting point. No clear CRT benefit for patients with right bundle branch block regardless of the QRS duration. Well we've got some other articles in the issue. I'll describe a couple from the mail bag. There's a Research Letter from Professor Lassen entitled "Risk of Incident Thromboembolic and Ischemic Events Following COVID-19 Vaccination Compared with SARS-COV2 Infection." Also Bridget Kuhn has a wonderful Cardiology News piece entitled "Collaborative Care Model Helps Heart Failure Patients Meet End-of-Life Goals." Dr. Carolyn Lam: There's an exchange of letters between Doctors Donzelli and Hippisley-Cox regarding that risk of myocarditis after sequential doses of COVID-19 vaccine, there's an AHA Update by Dr. Churchwell on continuous Medicaid eligibility, the lessons from the pandemic. There's an On My Mind paper by Dr. Parkhomenko on Russia's war in Ukraine and cardiovascular healthcare. Wow, what an issue. Thanks so much, Greg. Shall we go on to the feature discussion? Dr. Greg Hundley: You bet. Dr. Mercedes Carnethon: Well welcome to this episode of Circulation on the Run podcast. I'm Mercedes Carnethon, associate editor of the journal Circulation and Professor and Vice Chair of Preventive Medicine at the Northwestern University Feinberg School of Medicine. I'm very excited to be here today with Xuerong Wen and Sandeep Das, my fellow associate editor here at Circulation to talk about a wonderful piece by Dr. Wen and colleagues from the University of Rhode Island. So welcome this morning Xuerong and thank you so much for sharing your important work with us. Dr. Xuerong Wen: Thank you Dr. Carnethon. It was great meeting you all and I'm the Associate Professor of Pharmacoepidemiology and Health Outcomes at the University of Rhode Island. I'm happy to introduce my study to everyone. Dr. Mercedes Carnethon: Well thank you so much and thank you as well Sandeep for identifying this fantastic article and bringing it forth. Dr. Sandeep Das: Thanks Mercedes. It's great to be with you. Dr. Mercedes Carnethon: Great. Well let's go ahead and get into it. There's so much here to talk about. So Dr. Wen and colleagues studied the comparative effectiveness and safety of direct oral anticoagulants or DOACs and warfarin in patients with atrial fibrillation and chronic liver disease. So this is such an important topic. Can you tell us a little bit about what your study found? Dr. Xuerong Wen: So our study is a comparative effectiveness and the safety analysis using a national health administrative data from private health plans. So we compared the risk of hospitalized ischemic stroke, systemic embolism and major bleeding between DOACs and warfarin in patients with atrial fibrillation and chronic liver disease. So we also had to had compare to these primary outcomes between apixaban and rivaroxaban in the study population. So our studies show that among patients with atrial fibrillation and chronic liver disease, DOACs as a class was associated with lower risk of hospitalization of ischemic stroke and systemic embolism and major bleeding, compared with warfarin. And when compared risk outcomes between individuals apixaban has lower risks as compared to rivaroxaban. So that's our study results. Dr. Mercedes Carnethon: Well thank you so much. This seems like such an important question. We hear a lot about DOACs and some of their risks as well as their considerable benefits. I think what leaves me the most curious is why did you choose to pursue this question and in particular in patients with both atrial fibrillation and liver disease. So why was the intersection of these two particular conditions of interest to your study team? Dr. Xuerong Wen: That's a great question. So the liver actually plays a central role in both the synthesis of coagulation factors and the metabolism of anticoagulant drugs. And the clearance of the anticoagulants in liver ranges from 20% to 100% for DOACs and warfarin. So in clinical practice anticoagulation abnormalities and elevated risk of spontaneous or unprovoked venous thrombotic complications have been reported in patients with liver disease. While these patients with cirrhosis were excluded from the clinical trials of DOACs and also population based, the real world experience is very limited. So that is why we initiated this retrospective cohort study and based on the real world data in this specific population. Dr. Mercedes Carnethon: Oh, thank you so much for explaining that. I definitely learned a lot and really enjoyed reading the piece. I think it was very well organized and well written and I know that our readership will appreciate it. It obviously stood out to you as well, Sandeep. Can you tell me a little bit about why you thought that this would be an excellent piece for circulation? Dr. Sandeep Das: Yeah, absolutely. Thanks for the question. So in the broad field of what we call observational comparative effectiveness research, so basically that's using large observational data sets to try to answer important clinical questions and it's a really challenging thing to do. I mean we're all very familiar with the idea of using randomized trials to assess important clinical questions because of the structure of that design allows you to mitigate some of the effects of confounding. Here, it has to be done analytically. So what's the important factor that really drives you towards a great observational comparative effectiveness piece? So first the clinical importance. I feel a little guilty because I'm old enough to remember when warfarin was the only option available, but really as a clinician, or every patient, I really prefer DOACs over warfarin just for ease of use and lifestyle. So there's a huge sort of importance to the question. Second, the patients with chronic liver disease were excluded from the larger RCTs and the DOAC trials. So really we don't have the answer to the question already. It's an important question. Obviously the bleeding risk is tied up with the liver, warfarin directly antagonizes vitamin K, so there's real questions about safety and so this is the perfect storm and then on top of it was a really well done and well executed study. So when this came across my desk, the very first thing I thought was not, "Is this something that we're interested?" But rather, "How do we make it better? How do we make it more useful to the reader?" This had me from hello. Dr. Mercedes Carnethon: Well thanks so much. We rarely have the opportunity when we read an article to be able to ask the authors questions. So Sandeep, I know that you had mentioned that you had some follow up questions as well. Dr. Sandeep Das: Yeah. So the real thought that I have then is would you argue based on this that we know enough that we should change our practice? And that do you feel comfortable advocating that people now prescribe DOACs to these patients? Dr. Xuerong Wen: I would say yes. Okay. Although this is not a clinical trial, but our study is actually systematically compare the effectiveness and safety between DOAC users and also the warfarin users. And if you look at our table one, we compare with so many variables between these two users and we use the propensity score adjustment and we after propensity score weighting and the two control group almost balanced. And I know right now FDA actually suggested that emulate the trial using the large real world data to do the emulated trial. So our study actually conducted is based on the large population using large data and we use the propensity score weighting to control all this potential compounding factors. Although there are still some limitations in this study. I think we mentioned that in the discussion section and we discussed all potential compounding factors that still may exist. And also there are some misclassifications and out of all this limitations and we still found the two drugs performed differently in this specific population. So we feel that comfortable to say that a DOAC drug performs better than warfarin. And also I think based on other studies that based on the clinical trial in the general population, DOAC drug is performs much better than warfarin and considering that the clearance in liver for DOAC is less than warfarin. So plus all this information together, I think DOAC may be safer than wafarin in the patients with AF and chronic liver disease. Dr. Sandeep Das: Yeah, I would say that I agree that these data, even if you're skeptical about observational CT generally, which I admit that I tend to be, these are really reassuring data that at least the DOACs are... There's absolutely nothing that suggests that they're any worse than warfarin and all of the sort of soft indications for ease of use and patient happiness really would seem to favor DOACs. So I think this is the sort of rare observational CT paper that may actually change my practice. Dr. Mercedes Carnethon: I have a follow-up question, Xuerong, related to the design and as well your strategy to address differences between the groups. So inverse probability weighting is certainly a standard in the field to be able to manage differences between groups when you have a situation where can't, where it's not a randomized trial. Do you as well, and educate me, I admit I'm an epidemiologist whose methodological skills are sometimes challenged. Do you have the opportunity using this design and with inverse probability weighting to evaluate subgroup effects? So my specific question is were you able to determine whether or not these associations were similar based on age and gender in particular? Dr. Xuerong Wen: That's a great question. We did conducted a lot of subgroup study but not by age or gender. We conducted I think this study in a lot of subgroups using the propensity score weighting, but the subgroup that I think we did a subgroup like a patient with a different chronic liver disease. So that's what we did. And we also tested different methods inverse probability score weighting. So we did trimming and we used a different percentage of trimming and to see how that affect the study results. So we have done a lot of subgroup studies. We did not check the age and the gender, but that's a very good point. Maybe later, well I'll ask my student to do that. Dr. Mercedes Carnethon: Well, you're a good mentor. So I think that is a really certainly an appropriate approach. Sandeep, did you have additional questions? Dr. Sandeep Das: No, I wish I had thought of yours before you did. I think exactly the older age, women, racial ethnic groups that are underrepresented historically in trials. I think that that's really, again, the sweet spot of this observational research. We definitely, and NH definitely working on trying to increase enrollment of all these groups in our CTs. However, while we wait for that, I think that's exactly what we should be doing. Dr. Mercedes Carnethon: Well that's great. And Xuerong, you really alluded to really, I think what is one of my final questions related to what do you think based on what you have observed in this study, what do you see as the next steps in the research field for your team, your students, or other people who are carrying out this type of work? Dr. Xuerong Wen: Well, that's a great question. We currently have a couple of more manuscripts ongoing in this field, and we will continue conducting the comparative effectiveness and analysis to compare drugs head to head as well as developing and implementing new methodologies to this field. And we hope our study provides real world evidence for clinical decision making, prescribing anticoagulants to patients with atrial fibrillation and chronic liver disease. We also expect the physicians and researchers more and more value the real world data studies, especially when clinical trials are not feasible or ethical. Dr. Mercedes Carnethon: Well, thank you so much. That was such an excellent vision that you provided us with and we're just very grateful that you submitted this fantastic work to the journal Circulation. I know that our readers will enjoy really digging in. The podcast is meant as a teaser to bring you to the journal so that you can read about this wonderful work by Dr. Wen and colleagues. So again, thank you. I'm Mercedes Carnethon, joined with my associate editor partner here, Dr. Sandeep Das. And thank you very much for spending your time with us today, Dr. Wen. Dr. Xuerong Wen: Thanks for this great opportunity to disseminate my study with us, thank you. Dr. Sandeep Das: Thanks Mercedes. Dr. Mercedes Carnethon: Thank you for joining us for this episode of Circulation on the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association 2023. 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.
I talk RCTs 101; KM Plots; Blinding: 2:1 randomization: Concealment and more. Then Papa Heme Tells you How to Find your First Job
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: Make RCTs cheaper: smaller treatment, bigger control groups, published by Rory Fenton on February 24, 2023 on The Effective Altruism Forum. Epistemic status: I think this is a statistical “fact” but I feel a bit cautious since so few people seem to take advantage of it Summary It may not always be optimal for cost or statistical power to have equal-sized treatment/control groups in a study. When your intervention is quite expensive relative to data collection, you can maximise statistical power or save costs by using a larger control group and smaller treatment group. The optimal ratio of treatment sample to control sample is just the square root of the cost per treatment participant divided by the square root of the cost per control participant. Why larger control groups seem better Studies generally have equal numbers of treatment and control participants. This makes intuitive sense: a study with 500 treatment and 500 control will be more powerful than a study with 499 treatment and 501 control, for example. This is due to the diminishing power returns to increasing your sample size: the extra person removed from one arm hurts your power more than the extra person added to the other arm increases it. But what if your intervention is expensive relative to data collection? Perhaps you are studying a $720 cash transfer and it costs $80 to complete each survey, for a total cost of $800 per treatment participant ($720 + $80) and $80 per control. Now, for the same cost as 500 treatment and 500 control, you could have 499 treatment and 510 control, or 450 treatment and 1000 control: up to a point, the loss in precision from the smaller treatment is more than offset by the 10x larger increase in your control group, resulting in a more powerful study overall. In other words: when your treatment is expensive, it is generally more powerful to have a larger control group, because it's just so much cheaper to add control participants. How much larger? The exact ratio of treatment:control that optimises statistical power is surprisingly simple, it's just the ratio of the square roots of the costs of adding to each arm i.e. sqrt(control_cost) : sqrt(treatment_cost) (See Appendix for justification). For example, if adding an extra treatment participant costs 16x more than adding a control participant, you should optimally have sqrt(16/1) = 4x as many control as treatment. Quantifying the benefits With this approach, you either get free extra power for the same money or save money without losing power. For example, let's look at the hypothetical cash transfer study above with treatment participants costing $800 and control participants $80. The optimal ratio of control to treatment is then sqrt(800/80) = 3.2 :1, resulting in either: Saving money without losing power: the study is currently powered to measure an effect of 0.175 SD and, with 500 treatment and control, costs $440,000. With a 3.2 : 1 ratio (types furiously in Stata) you could achieve the same power with a sample of 337 treatment and 1079 control, which would cost $356,000: saving you a cool $84k without any loss of statistical power. Getting extra power for the same budget: alternatively, if you still want to spend the full $440k, you could then afford 416 treatment and 1,331 control, cutting your detectable effect from 0.175 SD to 0.155 SD at no extra cost. Caveats Ethics: there may be ethical reasons for not wanting a larger control group, for example in a medical trial where you would be denying potentially life-saving treatments to sick patients. Even outside of medicine, control participants' time is important and you may wish to avoid “wasting” it on participating in your study (although you could use some of the savings to compensate control participants, if that won't mess with your study). Necessarily limited ...
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...
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: Deconfusion Part 3 - EA Community and Social Structure, published by Davidmanheim on February 9, 2023 on The Effective Altruism Forum. This is part 3 of my attempt to disentangle and clarify some parts of what comprises Effective Altruism, in this case, the community. As I've written earlier in this series, EA is first a normative philosophical position that is near-universal, as well as some widely accepted ideas about maximizing good that are compatible with most moral positions. It's also, as I wrote in the second post, a set of causes, in many cases contingent on very unclear or deeply debated philosophical claims, and a set of associated ideas which inform specific funding and prioritization decisions, but which are not necessary parts of the philosophy, yet are accepted by (most of) the community for other reasons. The community itself, however, is a part of Effective Altruism as an applied philosophy, for two reasons. The first, as noted above, is that it impacts the prioritization and funding decisions. It affects them both because of philosophical, political, and similar factors belonging to those within the community, and because of directly social factors, such as knowledge of projects, the benefits of interpersonal trust, and the far less beneficial conflicts of interest that occur. The second is that EA promotes community building as itself a cause area, as a way to build the number of people donating and directly working on other high-priority cause areas. Note: The posts in this sequence are intended primarily as descriptive and diagnostic, to help me, and hopefully readers, make sense of Effective Altruism. EA is important, but even if you actually think it's “the most wonderful idea ever,” we still want to avoid a Happy Death Spiral. Ideally, a scout mindset will allow us to separate different parts of EA, and feel comfortable accepting some things and rejecting others, or assisting people in keeping identity small but still embrace ideas. That said, I have views on different aspects of the community, and I'm not a purely disinterested writer, so some of my views are going to be present in this attempt at dispassionate analysis - I've tried to keep those to the footnotes. What is the community? (Or, what are the communities?) This history of Effective Altruism involves a confluence of different groups which overlap or are parallel. A complete history is beyond the scope of this post. On the other hand, it's clear that there was a lot happening. Utilitarian philosophers started with doing good, as I outlined in the first post, but animal rights activists pushed for taking animal suffering seriously, financial analyst donors pushed for charity evaluations, extropians pushed for a glorious transhuman future, economists pushed for RCTs, rationalists pushed for bayesian viewpoints, libertarians pushed for distrusting government, and so on. And in almost all cases I'm aware of, central people in effective altruism belonged to several of these groups simultaneously. Despite the overlap, at a high level some of the key groups in EA as it evolved are the utilitarian philosophers centered in Oxford, the global health economists, the Lesswrong rationalists and AI-safety groups centered in the Bay, and the biorisk community. Less central but at some-point relevant or related groups are the George Mason libertarians, the animal suffering activists, former extropians and transhumanists, the EA meme groups, the right-wing and trad Lesswrong splinter groups, the leftist AI fairness academics, the polyamory crowd, the progress studies movement, the democratic party funders and analysts, post-rationalist mystics, and AI safety researchers. Getting into the relationship between all of these groups is several careers worth of research and writing as a modest start, but ...
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: Karma overrates some topics; resulting issues and potential solutions, published by Lizka on January 30, 2023 on The Effective Altruism Forum. TL;DR: Karma overrates “lowest-common-denominator” posts that interest a large fraction of the community, leading to some issues. We list some potential solutions at the bottom. Please see the disclaimer at the bottom of the post. Posts that interest everyone — or discussions where everyone has an opinion — tend to get a lot more Forum karma (and attention) than niche posts. These posts tend to be about the EA community accessible to everyone, or on topics where everyone has an opinion Why does this happen? There are different groups with different niche interests, but an overlapping interest in the EA community: When a post about the EA community is published, many people might have opinions, and many people feel that they can vote on the post. Most people upvote, so more people voting usually means that a post will get higher karma. Similarly, if the topic of the post is something that doesn't require particular expertise to have an opinion about, lots of people feel like they can weigh in. You can think of these as “lowest-common-denominator posts.” This is related to bike-shedding. This leads to some issues This misleads people about what the Forum — and the EA community — cares about 10 of the 10 highest karma posts from 2022 were community posts, even though less than ⅓ of total karma went to community posts. When someone is trying to evaluate the quality of the Forum, they often go to the list of top posts and evaluate those. This seems like a very reasonable thing to do, but it's actually giving a very skewed picture of what happens on the Forum. Because discussions about the community seem to be so highly valued by Forum readers, people might accidentally start to value community-oriented topics more themselves, and drift away from real-world issues Imagine an author posting about some issue with RCTs that's relevant to their work — they'll get a bit of engagement, some appreciation, and maybe some questions. Then they write a quick post about the font on the Forum — suddenly everyone has an opinion and they get loads of karma. Unconsciously, they might view this as an indicator that the community values the second post more than the first. If this happens repeatedly or they see this happening, they might shift towards that view themselves if they defer even a bit to the community's view. Now imagine this happening on the scale of the thousands of people who use the Forum; these small updates add up. This directs even more attention to community-oriented, low-barrier topics, and away from niche topics and topics that are more complex, which might be more valuable to discuss Karma is used for sorting the Frontpage: higher-rated posts stay on the Frontpage for longer. This is useful, as it tends to hide the most irrelevant posts, and generally boosts higher quality content — more people see the better posts. But because posts that hit the middle sections in the Venn diagrams above get more karma, they tend to stick around for longer, which then gets them more karma, etc. (We didn't try to make this list of issues as exhaustive as possible.) Note that karma is not perfect even within a much more specific topic — pretty random factors can affect a Forum post's karma, and readers aren't always great at voting, but that is a separate issue. (We might write a post about it later.) Solutions we're considering or exploring Create something like a subforum or separate tab for “community opinion” posts, and filter them out from the Frontpage by default Or otherwise move in this direction Rename “Top” sorting to more clearly indicate what karma actually measures We tend to have a somewhat higher bar for sharing “community” posts ...
Yale School of Medicine physician and researcher F. Perry Wilson, MD, MSCE, chats with Trey Elling about HOW MEDICINE WORKS AND WHEN IT DOESN'T: LEARNING WHO TO TRUST TO GET AND STAY HEALTHY. Topics include: Goal with the book (0:00) Pharma's role with patient mistrust (1:57) Pharma's influence on doctors (6:49) Generic drugs not such an easy fix (10:22) How medical errors commonly lead to death (12:34) Surrogate outcomes (15:50) Getting patients to change their minds for GOOD reasons (17:44) Combatting motivated reasoning (20:44) The “biggest secret in medicine” (26:22) Factoring in side effects when considering a drug (29:32) Doctors' responsibility to help patients with despair (31:28) Randomized controlled trials, aka RCTs (37:48) How RCTs go wrong (44:19) The difficulty with replication (47:29) Why “open data” isn't already the standard with RCTs (50:35) The problem with the “middle man” in patient care (53:39) An alternative to the current US healthcare system (57:06) How patients can move closer to doctors by embracing uncertainty (1:00:15)
The following question refers to Section 7.1 of the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. The question is asked by New York Medical College medical student and CardioNerds Intern Akiva Rosenzveig, answered first by Cornell cardiology fellow and CardioNerds Ambassador Dr. Jaya Kanduri, and then by expert faculty Dr. Clyde Yancy.Dr. Yancy is Professor of Medicine and Medical Social Sciences, Chief of Cardiology, and Vice Dean for Diversity and Inclusion at Northwestern University, and a member of the AHA/ACC/HFSA Heart Failure Guideline Writing Committee.The Decipher the Guidelines: 2022 AHA / ACC / HFSA Guideline for The Management of Heart Failure series was developed by the CardioNerds and created in collaboration with the American Heart Association and the Heart Failure Society of America. It was created by 30 trainees spanning college through advanced fellowship under the leadership of CardioNerds Cofounders Dr. Amit Goyal and Dr. Dan Ambinder, with mentorship from Dr. Anu Lala, Dr. Robert Mentz, and Dr. Nancy Sweitzer. We thank Dr. Judy Bezanson and Dr. Elliott Antman for tremendous guidance.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #5 Ms. L is a 65-year-old woman with nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 35%, hypertension, and type 2 diabetes mellitus. She has been admitted to the hospital with decompensated heart failure (HF) twice in the last six months and admits that she struggles to understand how to take her medications and adjust her sodium intake to prevent this. Which of the following interventions has the potential to decrease the risk of rehospitalization and/or improve mortality? A Access to a multidisciplinary team (physicians, nurses, pharmacists, social workers, care managers, etc) to assist with management of her HF B Engaging in a mobile app aimed at improving HF self-care C Vaccination against respiratory illnesses D A & C Answer #5 The correct answer is D – both A (access to a multidisciplinary team) and C (vaccination against respiratory illness). Choice A is correct. Multidisciplinary teams involving physicians, nurses, pharmacists, social workers, care managers, dieticians, and others, have been shown in multiple RCTs, metanalyses, and Cochrane reviews to both reduce hospital admissions and all-cause mortality. As such, it is a class I recommendation (LOE A) that patients with HF should receive care from multidisciplinary teams to facilitate the implementation of GDMT, address potential barriers to self-care, reduce the risk of subsequent rehospitalization for HF, and improve survival. Choice B is incorrect. Self-care in HF comprises treatment adherence and health maintenance behaviors. Patients with HF should learn to take medications as prescribed, restrict sodium intake, stay physically active, and get vaccinations. They also should understand how to monitor for signs and symptoms of worsening HF, and what to do in response to symptoms when they occur. Interventions focused on improving the self-care of HF patients significantly reduce hospitalizations and all-cause mortality as well as improve quality of life. Therefore, patients with HF should receive specific education and support to facilitate HF self-care in a multidisciplinary manner (Class I, LOE B-R). However, the method of delivery and education matters. Reinforcement with structured telephone support has been shown to be effective. In contrast the efficacy of mobile health-delivered educational interventions in improve self-care in patients with HF remains uncertain. Choice C is correct. In patients with HF, vaccinating against respiratory illnesses is reasonable to reduce mortality (Class 2a, LOE B-NR). For example, administration of the influenza vaccine in HF patients has been shown to reduce...
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: Evaluating StrongMinds: how strong is the evidence?, published by JoelMcGuire on January 19, 2023 on The Effective Altruism Forum. A recent post by Simon_M argued that StrongMinds should not be a top recommended charity (yet), and many people seemed to agree. While I think Simon raised several useful points regarding StrongMinds, he didn't engage with the cost-effectiveness analysis of StrongMinds that I conducted for the Happier Lives Institute (HLI) in 2021 and justified this decision on the following grounds: “Whilst I think they have some of the deepest analysis of StrongMinds, I am still confused by some of their methodology, it's not clear to me what their relationship to StrongMinds is.”. By failing to discuss HLI's analysis, Simon's post presented an incomplete and potentially misleading picture of the evidence base for StrongMinds. In addition, some of the comments seemed to call into question the independence of HLI's research. I'm publishing this post to clarify the strength of the evidence for StrongMinds, HLI's independence, and to acknowledge what we've learned from this discussion. I raise concerns with several of Simon's specific points in a comment on the original post. In the rest of this post, I'll respond to four general questions raised by Simon's post that were too long to include in my comment. I briefly summarise the issues below and then discuss them in more detail in the rest of the post 1. Should StrongMinds be a top-rated charity? In my view, yes. Simon claims the conclusion is not warranted because StrongMinds' specific evidence is weak and implies implausibly large results. I agree these results are overly optimistic, so my analysis doesn't rely on StrongMind's evidence alone. Instead, the analysis is based mainly on evidence synthesised from 39 RCTs of primarily group psychotherapy deployed in low-income countries. 2. When should a charity be classed as “top-rated”? I think that a charity could be considered top-rated when there is strong general evidence OR charity-specific evidence that the intervention is more cost-effective than cash transfers. StrongMinds clears this bar, despite the uncertainties in the data. 3. Is HLI an independent research institute? Yes. HLI's mission is to find the most cost-effective giving opportunities to increase wellbeing. Our research has found that treating depression is very cost-effective, but we're not committed to it as a matter of principle. Our work has just begun, and we plan to publish reports on lead regulation, pain relief, and immigration reform in the coming months. Our giving recommendations will follow the evidence. 4. What can HLI do better in the future? Communicate better and update our analyses. We didn't explicitly discuss the implausibility of StrongMinds' data in our work. Nor did we push StrongMinds to make more reasonable claims when we could have done so. We acknowledge that we could have done better, and we will try to do better in the future. We also plan to revise and update our analysis of StrongMinds before Giving Season 2023. 1. Should StrongMinds be a top-rated charity? I agree that StrongMinds' claims of curing 90+% of depression are overly optimistic, and I don't rely on them in my analysis. This figure mainly comes from StrongMinds' pre-post data rather than a comparison between a treatment group and a control. These data will overstate the effect because depression scores tend to decline over time due to a natural recovery rate. If you monitored a group of depressed people and provided no treatment, some would recover anyway. My analysis of StrongMinds is based on a meta-analysis of 39 RCTS of group psychotherapy in low-income countries. I didn't rely solely on StrongMinds' own evidence alone, I incorporated the broader evidence base from other similar interventions t...
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: 2022 EA conference talks are now live, published by Eli Nathan on January 18, 2023 on The Effective Altruism Forum. Recordings from various 2022 EA conferences are now live on our YouTube channel, these include talks from London, San Francisco, Washington, D.C., EAGxBoston, EAGxOxford, EAGxBerlin, and EAGxVirtual (alongside many other talks from previous years). Listening to talks can be a great way to learn more about EA and stay up to date on EA cause areas, and recording them allows people who couldn't attend (or who were busy in 1:1 meetings) to watch them in their own time. Recordings from other EA conferences will likely be live on our channel soon, and we recommend subscribing if you'd like to be notified of these. Some highlighted talks are displayed below: EA Global: London Presenting big ideas & complex data to the public | Edouard Mathieu and Hannah Ritchie In this talk, Edouard Mathieu discusses the lessons of data communication in the COVID-19 pandemic. Hannah and Edouard then have a fireside chat and Q&A on Our World in Data and how it fits with the EA framework. The state of aquatic animal advocacy | Sophika Kostyniuk, Andrés Jiménez Zorrilla, Alex Holst, and Bruce Friedrich Addressing aquatic animal welfare is important, as it is highly neglected, and tractable. Estimates vary, but there are approximately 100 billion fin fish and 350–400 billion shrimps farmed annually, which is far more than all of the land animals combined (more than 7x as many at the upper estimation). For the most part, farmed aquatic animals are treated like inanimate objects — their suffering is almost unimaginable. This session discusses why aquatic animal welfare is critical to address, and some of the priority interventions that can alleviate vast amounts of suffering. EA Global: San Francisco Betting on AI is like betting on semiconductors in the 70's | Danny Hernandez Danny discusses the three exponentials driving AI progress: hardware, algorithmic, and spending. He considers extrapolating these trends 10–20 years out and translates effective compute progress into GPT-2 to GPT-3 sized jumps and builds an intuition for such jumps. Danny uses the extrapolations and jump intuitions to think about what capabilities normal progress in effective compute are likely to yield. This session is likely to be particularly relevant to people very concerned about AI, considering working in AI, or choosing an agenda within AI. Science of scaling | Ahmed Mushfiq Mobarak and Heidi McAnnally-Linz Mushfiq Mobarak and Heidi McAnnally-Linz speak to learning from cutting edge research on the science of scaling using examples from scaling interventions targeted at addressing seasonal poverty and from the NORM model targeted at increasing community-level mask wearing during the COVID-19 pandemic. They draw on these experiences to make the case for innovation through research as well as working with existing at-scale partners. They emphasize the importance of using direct evidence from RCTs as well as exploring other complexities of scale such as national impacts, spillovers, etc. EA Global: Washington, D.C. Safeguarding modern bioscience & biotechnology to prevent catastrophic biological events | Jaime Yassif, Beth Cameron, and Jaspreet Pannu Bioscience and biotechnology advances are vital for fighting disease, protecting the environment, and promoting economic development — and they hold incredible promise. However, these innovations can also pose unique challenges — increasing the risks of accidental misuse or deliberate abuse with potentially catastrophic global consequences. This session begins with a talk by Dr. Jaime Yassif highlighting these issues and discussing effective strategies for improving bioscience governance and reducing emerging biorisks — including through the establishment of t...
Solving Healthcare with Dr. Kwadwo Kyeremanteng
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
Real world data (RWD) is data that's collected outside of clinical trials, whereas randomized controlled trials (RCTs) are conducted to measure the effectiveness of a specific medication or treatment. But how can these two work together to improve patient outcomes?In this episode of the Real World Talk podcast, our host Mandy Kelly welcomes Seshamalini Srinivasan, Laura Fernandes, and Karla Feghali to talk about the importance of combining RWD and RCTs to bring life-saving treatments to patients faster.
Bangladesh has transformed tremendously in the last twenty-five years. Average incomes have more than quadrupled, and many of its human development indicators have improved alongside. It has also become an export powerhouse with its garment industry, and generally a shining example of development - though things are far from perfect. Five decades ago, when Bangladesh became an independent country, many were not hopeful about its chances of development. So how did Bangladesh turn its story around? Well, it turns out the history of its transformation is longer than credited - and the process is more complex than what is cleanly presented.I could not think of a better person to help me unpack the Bangladeshi miracle than Dr. Akhtar Mahmood. He is an economist and was a lead private sector specialist for the World Bank Group - where he worked in various parts of the world for three decades on privatization, state enterprise reforms, investment climate, competitiveness, and more broadly private sector development. He has written some excellent books (see embedded links), and his column for the Dhaka Tribune is one of my wisest sources of economic development commentary.TranscriptTobi;Welcome to the show Akhtar Mahmood. It's a pleasure talking to you. I am very fascinated and curious about Bangladesh, and you are my number one option for such a journey. It's a pleasure, personally, for me to be having these conversations. I've been reading your column for about a year now with the Dhaka Tribune, and I've learned so much. They are very perceptive, and I'm going to be putting up links to some of my favourites in the show notes for this episode. Welcome once again, and thank you so much for doing this.Akhtar;Thank you very much for having me. Thanks, Tobi.Tobi;There's so much that I want to talk to you about, as you'd imagine, but let me start right at the end, which is now. There has been a lot of attention on Bangladesh, recently, at least in my own orbit, there have been two quite detailed and interesting columns in the Financial Times about Bangladesh. There is also Stefan Dercon's book, which used Bangladesh as a positive case for what he was describing about the development process. But also, there's the issue of what's going on right now with the global economy. First, it started with COVID and how the economy suddenly stopped, and all the reverberation that comes with that - the supply chain, and now, a lot of countries are going through a sort of sovereign debt crisis and Bangladesh, again, is in the spotlight. So, I just want you to give me an overview, and how this, sort of, blends with countries that put so much into development…you know, in terms of policy, in terms of the things they are doing right, in terms of investment and attracting investment, and the exposure to these sorts of global economic risks and volatility. [This is] because, usually, what you get in Western discourse is that a lot of countries are victims of some of these risks because of some of the wrong policy decisions they make. But in the case of Bangladesh, at least to my knowledge, nothing like that is going on. And yet, it is usually talked about as a very exposed country in that regard. I know you wrote a column recently about this. So I just want you to give me a brief [insight]—is there anything to worry about? How do countries that are trying to get rich, that are trying to do things right, how do they usually manage these sorts of global risks?Akhtar;Right? I think, inevitably, we'll have to go a bit into the history of how we came here. But since you started with the current situation, let me briefly comment on that, and then maybe I'll go to the history. Right now, yes, like most other countries, we are facing challenges, but I think there has been a bit of hype about how serious the challenge is, in terms of the risk of a debt default, the risk of foreign exchange reserves going down very sharply. And I think there is a bit of the Sri Lanka effect, and then also the Pakistan effect, as people are trying to put Bangladesh in the same bracket, which I think is very, very misplaced. I think the IMF has made it clear, [not only] in its latest country report, which came out in March 2022 but also in many recent statements, that Bangladesh has both a solvency situation and a liquidity situation. As you know [that] the solvency is typically measured by the external debt to GDP ratio, one of the ratios is external debt by GDP and the liquidity is measured by debt service requirements - the external debt service requirements by the export earnings ratio. And there are these certain thresholds, and if you go beyond that, it's considered a bit risky. Bangladesh on both these accounts is much below the threshold. So there's already a lot of headroom in the sense that even if things get worse over the next few months and maybe a year or two, Bangladesh would still be able to manage the situation. So I just wanted to make that clear at the beginning. Now, that doesn't mean that there aren't other issues in Bangladesh, issues which have been brewing for quite some time. For example, many of us are concerned with the efficiency of public expenditures. We know of projects where there have been cost overruns. Some of it may be for genuine reasons, some of it may be related to corruption, which sadly still remains a serious problem in Bangladesh. I feel that I've written about it, and you may have read some of these articles about the spectre of rising cronyism, which, again, is not surprising; when an economy grows as fast as Bangladesh's has, there are certain people who become economically powerful. And at some stage they acquire political power as well, and then you start seeing the problem of cronyism. So we have that, we have a serious problem in the banking sector with a lot of non-performing loans. I'm not suggesting that we don't have serious problems, we do. But there is a disconnect between the typical headlines and where the real problems lie in Bangladesh. Now, this may be a good moment to bring up a little bit of history, and I can go deeper into it. The Bangladesh economy has certain resilience. And I just want to comment on that. One which is not discussed much, because the story often is about garments and remittances, is the transformation that has happened in the rural areas. It started with agriculture, it actually started with rice production, which is the most important crop in Bangladesh. And then it expanded into other crops, and then even non-farm activities in the rural areas, we can go into the details of this later. But agriculture provides a certain resilience. And we saw that again during COVID. Because the agricultural activities in Bangladesh were not affected that much by COVID, and that was a big benefit. The other is the unleashing of an entrepreneurial spirit in Bangladesh. And this spirit has been unleashed across the board, so it's not just some large conglomerates or some large government manufacturers who have become entrepreneurial. This is something which has happened across the board, from small farmers to large conglomerates. And that, I think, is a big asset for the country. Because we don't have natural resources; unlike Nigeria, we don't have natural resources. In some ways, it's actually a good thing. Because then we are forced to use other assets and latent entrepreneurship… you know, Albert Hirschman, the famous economist, wrote a book in 1956, which is a classic, on the strategy of economic development, and he made a very interesting comment. He said, in developing countries, you have a lot of latent resources. In developed countries, the task is how to allocate the resources you have; how to best allocate them. In developing countries, it is about bringing out the latent resources you have; and entrepreneurship is one of the latent resources developing countries have, but many countries have not been able to bring that out and make use of it. Bangladesh has, and that gives a certain resilience to the economy. So yes, the shocks are going to affect us, especially because our major industry, in fact, is export-oriented, which is garments. So that is affected by the shocks, but unlike commodity prices, export earnings don't fluctuate that much. And the industry has proven to be resilient over the years.Tobi;Yeah, I'm glad you touched on history because, really, that's where I wanted to start. But I just want to get the pulse of the moment and how to make sense of all the headlines that we're seeing around. So usually, and I'll refer to the two pieces I've read in the FT [Financial Times] recently that I referenced in my first question. The development trajectory of Bangladesh is usually dated as something that started around 1990. But Bangladesh became an independent country two decades before that. So my question then is: that intervening period before that sort of consensus about the takeoff point, what were the things that were brewing in the background that culminated in that takeoff? I know a lot of things went down, and just to mention that one of the reasons I'm very interested in Bangladesh is that it sort of defies some of the seductive examples of development and progress - the Asian tigers, you know, so to speak - where things seem to be very clear, the prescriptions are very precise, you need to do this and do this. Bangladesh seems like a regular country - like Nigeria, with its history, its complexities, its problems like every other country in the world, but that has also managed, despite a situation that has seemed hopeless, at first, to people who look at these things in terms of hard boundaries - that has emerged as this fantastic example of economic growth and development. So what were the major things that happened before 1990 that sort of made this takeoff possible?Akhtar;Now, one may debate on whether 1990 is the point of the takeoff. In any case, it's very difficult to pinpoint. But anyway, it's good. So 1990, twenty years after independence and also a transition to democratic rule after fifteen years or so of military or quasi military rule. So that's another reason people take that as a counterpoint. But it's a good counterpoint to start discussing these things. Professor Stefan Dercon, whom I think you had on your show recently, who wrote this book Gambling on Development; he has been saying that actually, in some ways, it's a Bangladesh experience which may be more relevant for many developing countries than the East Asian [experience]. And one of the reasons he mentions is, I think, what you just alluded to - that there is a certain messiness, and yet Bangladesh developed. So countries which think that they are also in a somewhat messy situation, or whatever dimensions, say in governance or other dimensions - whether it's possible for them to develop. And that's why the Bangladesh example may be more relevant and encouraging than the East Asian, where one common characteristic has been the strong capabilities of the state. In China, it has been there for hundreds or more, thousands of years. In East Asia, yes, I'm sure they also have that but they certainly acquired that quite fast. So how do you develop in a country context where the state capacity, the governance quality are not that great, and then you have many other problems as well. So you're right. In that sense, Bangladesh may be very relevant. I think I'd like to first start with, um, even deeper history, because if you look at the region which now constitutes Bangladesh, it used to be part of a province in British India. So it was East Bengal, and then you had West Bengal and then together it was Bengal. Now there was a time in history when Bengal including East Bengal was supposed to be reasonably rich, perhaps the richest province in [the] whole of India before the British came. But if we go back to the beginning of the twentieth century, East Bengal was actually quite backward economically and in many other ways. And if you look at the political discourse in the first half of the twentieth century, before the British left, the political and intellectual discourse in what is now Bangladesh, you'll see there's a lot of talk about peasants being exploited. We were a very peasant dominated economy and society. In many ways we still are, although there has been a lot of urbanisation and industrial activity. At that time it was very much peasant dominated, and the theme which dominated the discourse was exploitation of the peasants. And the aspiration that the leaders whether political or intellectual had is how can we improve the conditions of the poor people. And that sort of got ingrained in the minds of the leaders, and that continued during the time when we were a part of Pakistan. Because you may have heard that there was a lot of disparity and there was a lot of discriminatory treatment by the Pakistani establishment. So that theme was there. When we became independent in ‘71, you could think of the political leadership, you could think of the professional leadership, the bureaucracy, the intellectuals, the media, this theme of doing something for the poor, was actually very strong. So right at the beginning, and, I heard somewhere that our first prime minister, Sheikh Mujibur Rahman, was asked by a foreign journalist: what is the number one problem of your country? And he said, I actually have two number one problems. One is food security, and one is population. And we need to take care of that. So right from the beginning, even in the midst of all the turmoil in the first few years, and all the challenges of relief and rehabilitation, work had started on ensuring agricultural growth and food security. And we were fortunate that the HYV rice, the high yielding variety of rice, had been introduced just before independence, so we had something to work with. So that was very important. And there was a strong program to bring down the rate of growth of [the] population and we succeeded on both counts. So by the time we come to 1990, agriculture is taking off. Rice production had taken off significantly, farmers were diversifying into other crops. And we had started to see the beginnings of a rural non farm sector. So agriculture and non agriculture together. And, Bangladeshis had been going out as migrants, and they're sending back remittances, most of it going into the rural areas. So there was a vibrancy in the rural area by the time you come to 1990. Secondly, sometime in the late 70s, the government decided that not only should we move away from the early talk about socialism, [but] towards a more private sector-oriented or market-oriented economy. They also understood that industry has to grow to absorb the surplus labour in agriculture, and export orientation has to grow, because the market in Bangladesh is simply not large enough. So there was an early emphasis on exports. And of course, fortuitously, you know, the South Koreans were running out of their garment quota, so they wanted to relocate some of the production to Bangladesh, but we were ready to take advantage because by then the government and let's say the elite of the class had decided that we need to industrialise and the major driver of industrialization is going to be exports. And then throughout the 80s, we saw the takeoff of the garment industry. The third thing which happened was the liberalisation of policies, mostly in the 80s. So, privatisation was done, the banking sector was open to the private sector. The agricultural input market, which was previously dominated by the government, was gradually liberalised and towards the late 80s, there was a significant liberalisation of that. And finally, as remittances started coming in, our foreign exchange constraint was relaxed. So that also gave government some comfort that we can decontrol certain things. And we can allow industry to move ahead without too many controls. So all these things coming together sort of created the context in which we entered the 1990s. So a lot of the preconditions - the population growth rate had fallen significantly by the time it came to the 1990s, agricultural growth had taken off, industry was taking off, especially the labour intensive garments, which is export-oriented, that industry was taking off.Tobi;That was such a loaded answer, which has preempted some of my further questions. But let me quickly make one digression on agriculture, because over the past seven years or so, in Nigeria, there's been this debate. There's been a huge debate about agriculture, the current administration sort of prioritised agriculture and a lot of resources (capital) was allocated to that sector. And there's been challenges and there's been critics, sometimes I've found myself on the critic's side of things. Now, what I want to know from you is that,the link between agriculture, especially investment and the agricultural productivity that is necessary for the vibrance of that particular sector, how was the Bangladeshi experience? How did Bangladesh achieve food security, especially in terms of improving yield and productivity?Akhtar;Right, so a few things. Firstly, as I said, the high yielding variety of rice had been introduced in the late 60s, and then just after independence, government continued, but more vigorously with a model of… it was more [of a] public sector driven model, where the public sector would import the major inputs. One is irrigation equipment, because this rice needed irrigation, and the other was fertiliser. So, they're imported by the public sector, then they're distributed by the public sector going all the way to the farmers. Maybe at the last mile, there were some private traders who act as dealers on behalf of the government. So, the government took that responsibility. Later on, as I said, in the 80s, they started liberalising it. We'll come to that later. Second is, there's been quite a bit of investment in agricultural research. Now the HYV rice came from abroad, but as it was being applied in Bangladeshi farms, in many cases, we realised that there was some adaptation needed, because the conditions were not always well suited for this variety. The crop conditions varied even within Bangladesh, even though it's a small country, lots of variation. Later on, for example, salinity became a problem, because a lot of water was coming from the Bay of Bengal into Bangladesh. So there are all kinds of problems - there's flooding also. There were many areas where after floods, the waters don't recede that fast, so they remain underwater for a long time. So the agricultural scientists in Bangladesh, and they were all in the public sector, they came up with innovations to come up with rice varieties and later other varieties like maize varieties or vegetables, which are better suited to the conditions in Bangladesh. And then the public sector effort was also complemented, supplemented by NGO efforts. You may have heard about BRAC [Bangladesh Rural Advancement Committee], which is the largest NGO in the world, and we often talk about their activities in the health sector, in education, in microfinance. They were actually doing a lot of work in the economic sphere as well. R&D in agriculture was one of the things that we're doing, in collaboration with the government often, so there was R&D. Another thing happened, which I forgot to mention, when I mentioned sort of the run up to the 90s. In the 80s, the government started a massive program to build rural roads, connecting the rural areas to the small towns and the small towns to the bigger towns. So,a huge rural road network was built starting from the late 80s. And it continued into the 90s, which broadened the markets of the farmers. So in all of this, the core player was the small farmer. As I said, Bangladesh is a peasant, small farmer dominated economy, so it is remarkable that these farmers were willing to innovate, they were willing to move away from what their parents and grandparents had done for many, many years, and adopt these new varieties. So the combination of the government with some NGOs and the farmers, I think that created the basis for productivity improvements in agriculture. And that was sustained because the market was sustained. There were lots of public policies. And at some point, when the government thought the public sector delivery model was not working that well, they allowed the private sector to come in.Tobi;I don't want to infer anything, but from your answer, I can tell what Nigeria is doing wrong, but maybe we'll get to that later. So let's talk about the conditions, which you've also sort of answered for me but I want to know if there is more. Dercon in his book, I'm talking about Professor Stefan Dercon, talked about elite consensus that sort of becomes the bedrock of deciding to pursue economic development. So this broad consensus amongst the Bangladeshi political elites to improve the conditions of the poor, and, which, I'm speculating sort of enabled an ecosystem of policy consistency, even if there are deviations at the margins, how did it emerge? And how was it sustained?Akhtar;Okay, as I had mentioned to Professor Dercon ‘cause I also had a conversation with him for our Bangladeshi group. And I said that – and, he agreed that, it's really difficult to define if there was an elite consensus because it's not that the elite are sitting in a room discussing and bargaining and one day they come out and say, okay, here is an agreement, we have agreed on these three things, it doesn't happen. And there is a bit of tautology in his book as well. And he agreed with that, that in his country chapters, he says, these countries had an elite bargain. And then he says, Okay, this is how the countries grew. And if they have grown, therefore, they must have had a bargain. So there's a bit of tautology there. But coming back to this, I think, I started giving you a flavour of that when I brought in history, even before the British left and how in East Bengal, there was this deeply ingrained feeling that something has to be done for the poor people. And then just after independence in ‘74, we had a big famine. And that sort of strengthened this feeling amongst Bangladeshis. And you know, you mentioned the word elite and it's a bit difficult to define the elite. I would say that it's a broader… I'm talking about people who can influence policy, both the formulation and the quality of implementation. There are a lot of people in the bureaucracy who may not, in that sense, be called part of the elite, but they do have some authority. Now, most of these people, they actually are not too far away from the poor people of Bangladesh. Many of them still have very strong connections with their villages. They go back regularly. They know what the conditions are there. And in a densely populated country like Bangladesh, you see poverty all around you. So all these things, I think, have ingrained in the minds of the elite, however you define it, this commitment to doing something to safeguard the interests of the poor, but that is the security side - food security, [to] address the vulnerability. But somewhere down the line, people started recognizing that Bangladeshis also have an entrepreneurial potential. And there was a feeling that we should try and help unleash that potential. So, as I said, it's difficult to pinpoint a particular period where there has been a consensus but in a subtle way, there has been this consensus that to achieve food security, to help take advantage of the latent entrepreneurship of Bangladeshis, we should be focusing a lot on growth and more generally on development. And that has survived the transitions in administrations, from one government to another, that common element has been there.Tobi;It's not exactly a push back, and I should note that there is a lot more; there's vastly a lot more to Bangladesh than Dercon's book. So, and I don't want to be caught in debating his book. But, why I find that particular line of thought relevant is that, from what you have described, it's amazing to me, so maybe you can help me understand the difference. Now, how a country can set out to do some of these things; invest in agriculture, agricultural R&D, and all these other support programs with big macro effects. Whereas a Nigeria can set out to do those same things and then you find divergent outcomes in their implementation, particularly the inability to execute. You know? There's always a plan. We want to improve the lot of the poor. We want to invest in agriculture. We want to improve productivity. We want to build infrastructure, you know, this, that, they are always so nice and interesting. But the difference is always at the end of the day, countries often don't do these things, right, they never stay true to these things. And of course, we can talk about various reasons why it fell astray - corruption, state capacity, and all that. But what I… which you mentioned in your last sentence [is] how policies survive, even though there are political transitions, election cycles come and go, the particular direction that policy goes, survives this transition, I think that's really what I'm trying to get at.Akhtar;Okay, so I don't know that much about Nigeria. Now, people say that the fact that you have natural resources may have been in some ways a curse, I don't know if it's true or not, but certainly, that sometimes gives governments a sense of complacency and therefore, even if they start on a certain course, they may not have the discipline to stay that course. Now Bangladesh, we never had the advantage of having natural resources. Nowadays, certain things have improved, you know, foreign exchange reserves have been at comfortable levels for several years. So, that may induce a certain degree of complacency, but for a long time, the government knew that we were operating with very narrow degrees of freedom. So that was the context in which Bangladesh had to operate. Which also meant that we were somewhat dependent on donors and that certainly imposed an additional set of disciplines on Bangladesh. But later on, I may come and comment on exactly the kind of relationships I think existed between donors and Bangladesh. But maybe the best way to answer your question would be to say a little bit about the way in which policies have evolved in Bangladesh. And in a sense, it's a bit of a “muddling through” process. And I wrote a blog for the Brookings Institute a year ago, where I said that Bangladesh did it, alluding to that famous song of Frank Sinatra - “I did it my way.” So what was that “my way?” We all know that the Bangladeshi Government has never been tremendously competent, there's always been corruption problems as well. So the way it has happened is the following. Things happened in the economy, let's say agricultural productivity is improving. But then it hits certain constraints, and the economic actors, or people acting on behalf of the actors; like academics, donors, journalists, will bring up those issues. And they will probably say that, “here are ten things which need to be done.” Now what the governments in Bangladesh have done, successive governments, [is] they have responded to that, not by doing all the ten things. No. They may have picked up two or three things. And they may have done a little bit. Why a little bit? Because they were risk averse. They wanted to test out what would happen in the market, how the market players respond. [As the government], if I do just three or four things and not everything, and then see the response…and here comes the entrepreneurial side - the response was usually quite good, and when the response was good, the government felt encouraged. And then the government said “okay, let's do a few more of the things that were demanded.” The other thing which happened was, as the response came, newer constraints were revealed, or constraints which were not binding before became binding. For example, initially when the agricultural growth was not that great, when production wasn't that huge, the fact that we did not have a good rural road network connecting the rural areas to broader markets wasn't that big a constraint, because you're not producing enough to go out in a big market. When you started producing a lot of marketable surplus, you needed a broader market. And that's when you started feeling the constraint. And people started talking about the need to build up the rural road network. And to the credit of the government, they responded. So, this is what I call the sort of back and forth, policy dynamics - things happen in the economy, government notices it or it is brought to their notice, they react not in a grand way, just doing a little bit here and there;nd then the market responds, may be much more than in many other countries, because of the entrepreneurial spirit, and then the government responds. And that process has gone on uninterrupted throughout the last fifty years. And so, once you accumulate, even if these are modest steps, once you accumulate all of that, you'll see a tremendous result. And that's what we're seeing here. So, what it means is countries – the governments don't have to be very competent, they just have to pick the signals. So, you know, you have this phrase called “picking the winners” and a lot of people say, no, governments should not be in the business of picking winners. I say, in Bangladesh, that what the government just does is pick signals. They've picked signals from the private sector, from the farmers, and they have acted accordingly. And I think the accumulation of all these, the synergies created by all these is, I think, what has made the difference.Tobi;That's interesting. So, generally, the usual story with development is structural transformation. That is, for you to grow rich, the economy has to transform from a largely agrarian, low productivity economy to preferably an industrial high productivity economy. And, I mean, to an extent, we've seen the same process also in Bangladesh. Manufacturing, particularly the garment industry, is eighty or so percent of exports and employment is largely created also in that industry. Now, what I want to ask you is, the role of foreign direct investments in that cannot be understated. You talked about South Korea earlier, and how it played a role in that. For South Korea, so many other scholars would cite the role of Japan in kickstarting the South Korean garment industry; garment and textile industry itself. So, my question then is, is there a link here? I mean, also in your columns, I've read about the role of Samsung, and the electronics industry in Vietnam. Right. So the role of FDI in development, and especially getting industrialization started, what are the favourable conditions? To what degree is it external and internal? I guess that would be my question.Akhtar;Okay. Well, you use the term kickstarting, because in Bangladesh, in the garment industry, a foreign investor helped kickstart that industry, but didn't do much beyond that. So, Bangladesh's Government has been largely domestic…[it is] a case of domestic entrepreneurship leading the sector to the heights that it has achieved now. Yes, we have some Export Processing Zones where we have a number of foreign invested garment factories, but the bulk of it is domestic entrepreneurship. But you're right. The initial thrust came from this partnership with Daewoothe IU. It was a five year partnership. Daewoo trained Bangladeshis, (they) took them to their plants in Korea, trained them. They obviously had the market connections and market knowledge, all that was very useful. But what many people don't know is that the Bangladeshi partner actually quit that agreement just one year into that five year period. So after one year, he thought that he had learned everything that needed to be learned. Now, if he hadn't done that, I believe Daewoo had other plans of coming into other sectors, which we may have lost. But then we did end up with this vibrant mostly domestic-owned garment industry. But foreign investment had a role in jumpstarting that. If you go a little beyond industry, think about sectors which facilitate industry. The entire mobile phone development in Bangladesh, which is also remarkable, was foreign investment led. So, foreign investment played a major role there. So, I agree that foreign investment can play an important role in kickstarting industries, and that is something very important now that we want to diversify our exports, make them more sophisticated, we can come to that subject later. Now, you asked me about what are the conditions which are conducive for foreign investment. And this is where I would say that in Bangladesh, the conditions are still not that conducive. In the case of garments in the late 70s, it was the exhaustion of the South Korean quota of garments, which was the major inducement for them to come in. But also, as I said, the new government, which came into power in ‘75 was talking a lot about export promotion. So, that was there. But the most important constraint that Bangladesh faces, and it's true of many other countries, is policy and regulatory uncertainty. So, Bangladesh often says that we have got a policy regime which is very friendly to foreign investors. And that may well be true. But the execution has problems. And there are a lot of case by case decisions which are taken, which affect the foreign investors adversely. And that creates uncertainty. And those stories are told to other prospective investors. And when they hear those stories, they get discouraged. And the World Bank where I used to work, in fact, the last unit that I worked on, they did a survey of CEOs of multinational corporations just a few years ago, asking them about what are the factors which are very important for you when you decide to invest or not invest in a country, and policy and regulatory uncertainty was top of the list. So that is where Bangladesh still has got a lot of work to do. It is attractive in many other ways - very large domestic market, relatively cheap labour, the labour is quite fast at learning, a lot of good things there. But I think the policy environment, particularly the implementation, the certainty, that has to be ensured.Tobi;I have a further question, particularly on that point, and referencing another one of your columns, I think I'll just stick to your columns today for all my questions. For example, in Nigeria, I'll give you an example. In Nigeria, recently, foreign airlines are threatening to quit. Over the past three, four years, foreign investment (FDI) has plummeted. It's barely a billion dollars, currently, one of the lowest even in Africa. And of course, a lot of these things you mentioned are the problems that investors and business people talk about - policy uncertainty, especially around the control of the exchange rates and inability of companies to repatriate their capital, and to fund their operating expenses, and so forth. So, I mean, that's one constraint. But one distinction you made is like the types of FDI. There are different categories of FDI; market-seeking FDI, natural resource-seeking, efficiency-seeking [FDI]. And the reason I'm asking this is that there seems to be one problem, which, to my mind, Bangladesh has solved, it's not perfect, that Nigeria is struggling with, which is this inertia to get things started, you know, once you start on a journey, you can muddle through, but the inertia to get that process going is still something that Nigeria struggles with, in my opinion. So, now talking about FDI, if I were a policymaker today talking to you; advise me, what kind of FDI should I prioritise in trying to lure investors into my country, for them to create jobs and [create] a nest of high productivity manufacturing industry? So is it market seeking? Is it natural resources seeking? Is it efficiency seeking? Which one is the best in terms of the necessary incentives for sustainability?Akhtar;Okay, so one of the articles, not as part of the regular column, I think, but I wrote for the same newspaper a few years ago, was titled “investment for what?” So that's a question the governments have to ask. Because everyone talks about attracting FDI. It's a mantra all over the developing world. But governments need to ask why exactly do we want FDI? How is it aligned with our development aspirations and development programs? I wanted to just emphasise that because often governments just go blindly trying to attract foreign investors. And whoever comes in, we welcome that. That's not necessarily a good strategy always. For example, in Bangladesh, if we now have a lot of foreign investors coming in, to make jeans and T-shirts, using the same technology as before, we don't really need that, we can't afford to give our scarce land and utility and other things to do things which our domestic entrepreneurs have become reasonably good at doing. So it has to be something new that comes in. Now, at the same time, we also have to recognize that the foreign investors also have their own interest and their own calculations. So we have to come to a balance between the two as well. Now, it's difficult to say a priori that we prefer market-seeking or efficiency-seeking. On a natural resource, it's a slightly different issue if you have natural resources, and if you don't have the capacity to develop them yourself, you may need foreign investors. And obviously, we all know why foreign investors are often very attracted to that. But let me confine my answer to the choice between market-seeking and efficiency-seeking. Now, let's take the case of Bangladesh. We are now talking about diversifying our exports. And we are talking about going into more sophisticated products like electronics. If that is our objective, we may want to target some people who come and make electronics. Now they may come for two reasons. Bangladesh has a huge market, our per capita income may not be that high, but our total economy size is actually pretty large. We are amongst the top 40 economies in the world. And if you look at the size in the purchasing power parity terms, we're actually in the top 30. That's a very large economy. So, naturally foreign investors would come in looking at the market as well. But if our objective in this sector is to make a breakthrough in the global value chains, and not just serve the domestic market, then we'd like to have foreign investors come in with an efficiency-seeking objective that, in Bangladesh, we can make these things more efficiently, at lower cost, than in other places. So that Bangladesh then can ride on the backs of the foreign investors, who know the markets, who have the brand recognition and show the world that things can be made efficiently in Bangladesh. And, then once we have shown that with the help of foreign investors, maybe Bangladeshi entrepreneurs can also start doing it. So here you see I give you an example, where you have a strategic objective, and you attract foreign investors of a particular type. Now, there are also many needs in the domestic market. Bangladesh needs to develop a very good logistics system. And we may need foreign investors to come in and invest there, but will be more market-seeking. I mentioned the case of mobile telephones, that was not an export-oriented industry, although it may have facilitated exports, that was domestic market-oriented. And we encouraged foreign investors to come in, who were obviously coming in as market-seeking investors. So the answer would vary depending on the sector or the activity. But that brings me back to my first point, the government should have a clearer idea of what is the role of foreign investment in implementing the various dimensions of your development strategy. And accordingly, you're going to target efficiency-seeking investors in some cases, and market-oriented investors in other cases.Tobi;So, now, from a policy perspective, because really, that's what's sort of dominating this conversation. One thing that keeps coming up is the role of government, the strategy it pursues, you know, this, that. But inevitably, that leads to the question of what… in terms of economic development, what role does the government play by itself? Now, China, and, of course, other East Asian economies are very, very popular in the development discourse and these are largely autocratic governance. Right. And, to an extent the gospel of state-led development has travelled far and wide, sometimes in contrast to what is generally called the neoliberal or the Washington Consensus-type policies. But at the same time, at the nexus of all this is the role of markets, how the economy is regulated, liberalisation. How does a government approach regulation and policymaking generally, with the right incentives for the government to take the lead in areas where, maybe because of access to market or not seeing the prospect of returns, private actors are reluctant? And also at the other end, this sort of control, excessive control, that you see in so many developing countries, like Nigeria, and so many others in Africa, where government sees itself as the primary player in the economy, right? What is the balance? What is the heuristic generally, in trying to, [or] should I say, make policy and regulations to encourage economic development, and, of course, your Bangladeshi experience of that?Akhtar;Okay. So, when you say state-led, there are many ways you can define that. One is the direct participation of the state in productive activities. And in China, that is still pronounced, there are different models of state-owned enterprises, including public private partnerships, but the state plays a dominant, or at least an important direct role in the production of activities. That's one thing. The other is playing a direct role, not in production, but in things that facilitate production. So I had mentioned the case of research and development in the agricultural sector of Bangladesh, which was there right from the beginning. It was largely a private sector activity, but that was meant to facilitate productive activities by the private sector, in this case, thousands and thousands of farmers. So, the whole spectrum of things that the government does and, of course, there is the whole regulatory function of the government. And I think in choosing the balance, and the balance itself may shift over time as the economy develops. And I give an example of that, again, from the agricultural sector of Bangladesh, how the government moved away from the direct import and distribution of agricultural inputs, giving more and more space to the private sector over time. So initially, in the 70s, maybe that was the right thing to do. And then later on, the right thing to do was to withdraw and create space for the private sector. So the balance, (a) has to be thought of carefully, in terms of the capacity of the government, that's very important. And, again, if I [could] mention Stefan Dercon, he talks about the self awareness of [the] government. Are governments aware of what they can do and what they cannot do? And that answer would vary by country. Often governments make the mistake of thinking that they can do a lot of things, and therefore they; (a) go into productive activities themselves directly, and (b) also controlling too much the activities of the private sector. Controlling is not that easy. It requires a lot of skills, and many governments actually don't have the skills of doing that. The thing that may have happened in Bangladesh is the government has been more or less self aware, not always, but more or less self aware of what they can do and what they cannot do. And that has led to a certain division of labour between the government and the private sector, and the NGOs. With that division of labour also changing over time. That's very important. So the government needs to be aware of where its capacities are, and they need to also have some faith that the private sector, if given the opportunity, can come and do certain things. Because governments often say, okay, but if we don't intervene, the private sector is not going to come in. Or we have a big factory, if we close it down, then a lot of people will lose their jobs, and the private sector will not be forthcoming to create jobs for them. If you want, I can give you a good example of that kind of thinking. In Bangladesh, we had the world's largest jute mill called the Adamjee Jute Mill, and it was bleeding like hell, and every year the government had to subsidise. So there was lots of debate on whether the factory should be (a) privatised, and there was no taker, then the question is whether it should be closed down. Then, about 20 years ago, exactly 20 years ago, a very bold decision was taken to actually close down the factory. It was a controversial decision. About 26,000 workers lost their jobs. Some of them were ghost workers, maybe 20,000. Now the story of what happened after that is very interesting. That land was converted into an export processing zone. And now the latest figures are that about 65 to 70,000 jobs have been created there. So you had lost about 20 [thousand jobs] and you have created so many. These are all private sector firms, they're all export oriented firms, the government doesn't need to subsidise them. So you can see once given the opportunity what the private sector can come and do. So you don't have to hold on to a loss making enterprise just because you're worried about job losses.Tobi;Let me sort of ask you a big picture question on this particular point, which is the role of democracy in development, generally. Democracies have been taking a beating recently, so maybe you can speak up for it, somewhat. Do you think democracy has some kind of unique weakness in terms of trying to engineer economic development, particularly because of elections? I mean, to cite the example of the jute mill you mentioned, some regime that is sensitive, maybe in an election year, or maybe that wants to appeal to a particular constituency, or, maybe workers Union or something might actually kick the can down the road. An example is (fuel) petrol subsidy in Nigeria, which the bill keeps increasing, but I mean, each government promises to remove it or reduce it, and then kicks it to the next government because nobody wants to annoy the workers union, nobody wants to lose votes, the party wants to remain in power, you know, and these incentives that are common in democracies. So, do you think this makes democracies weak in a way, in trying to develop the national economy? Because a lot of people will say that's why China has developed much faster than India, for example. What's your take?Akhtar;Okay, let me start by giving you an anecdote. So this is from about I think it was 2008 or so, 2007 maybe. Bangladesh then had a quasi military government, it was called a caretaker government, whose major responsibility was to conduct free and fair elections. So they were in power for about two years. And I was actually working in Bangladesh at that time. And we had, I think we had a natural disaster, or maybe we had floods. So conditions were pretty bad. And one of the… well, they were called advisors, but they were de facto ministers, who was having to deal with this problem of getting food to poor people, dealing with rising prices [and] all that; he said to me, “I can feel a certain handicap being part of this kind of government.” What is the handicap? Right now what I need a lot is information from the grassroots, I need to know what is happening in different parts of the country, and I need that information very fast. I need it right now, about what's happening earlier today, or what has happened yesterday. Fortunately, I have some connections in the NGO world, this gentleman was an academic. I'm getting some information. But if this was a political campaign, I would rely on my political network, my workers, my small town leaders, and within a few hours, I'll be getting information from all over the country on what the conditions are. Now, why do I mention this anecdote? Because in a democratic system, your feedback mechanisms may work very well. Yes, there can also be a lot of noise. But otherwise, the feedback which is very, very important for government, they need to know what's going on throughout the country with different groups of people, with different localities etc. That is something that autocratic governments lack. Yes, information flows, flows from lower level bureaucrats, but I'm sure they are modified on their way. Because, the boss often doesn't want to hear certain things. It may happen in political democratic setups, but generally, the flow of information is much better for politicians. Now, how they act upon that information is another issue, but that's very important. Secondly, politicians operating within a democratic setup, (a) they develop a lot of empathy, because of their interactions with people, [b] they also get a good idea of what the trade-offs can be. And these are very, very important in decision making. So those are the good sides of democracy. Now, yes, in democracy, you also need to cater to your political constituencies, and that may lead to certain decisions, which technocrats may feel are sub optimal. But that is the price you pay for democracy. Compared to the gains for having a democratic system, that is sometimes a small price to pay, although sometimes that can get out of hand. But if it gets out of hand, it's usually where you may in name have a democracy system, but in practice, you don't. So the kinds of disciplines that democracy imposes on the government are lacking there. So that is my answer. Now, as you can see, implicit in my answer was some definition of democracy. It's not just about electoral politics. It's not just about having regular elections and free and fair elections. It is the monitoring mechanism. Are governments picking the signals, are they getting the information? How wide is the information that they're getting? That's a very important characteristic of development.Tobi;So another one of my sort of big picture questions to you, and in this case, using the Bangladeshi experience and example, is, in the last couple of years, there has been this big debate in development over, oh, do you prioritise the big things or the small things you can measure? You were with the World Bank, I'm sure you have some familiarity with the so-called empirical revolution and how it has sort of taken over the field of development economics where, yeah, there is a lot more preference in terms of international aid funding for interventions, things that you can measure. So, the RCTs, or, whether it is conditional cash transfers, and all these things – and the atmosphere with which this debate happens sometimes, personally, I find it frustrating because it makes it seem like a zero-sum kind of thing. Like, you can either have one or the other. You either pursue growth, or you forego that and choose to do all these small scale, local and domestic interventions. But Bangladesh, like you mentioned, the issue of BRAC and also people like Naomi and co. have written about – Naomi Hussein [that] Bangladesh managed both. There was a sort of productive combination of both frameworks, that is, the role of non governmental organisations who were able to provide some support for the rural communities. And of course, there was the big macro policies that were explicitly designed to pursue economic growth, get businesses going, create jobs, you know, and all the other things that happen in the private sector. So, my question would be, how did that sort of synergy happen in Bangladesh? How was that cooperation, so to speak… I mean, you talked about the role of BRAC in R&D and agriculture, you know, how did that happen? How did, perhaps, it wasn't intended, but in practice, how does it work?Akhtar;Okay. Let me start by recounting something I heard Abhijit Banerjee, the Nobel laureate, who got a Nobel prize for his work on RCTs, said something about the rationale for going into RCTs. And he's saying that the kinds of interventions that we talk about in the context of RCTs, they're not the only interventions that bring about development. In fact, the most profound development impact may come from other kinds of interventions and policies, and other factors. But his point was that, let's say, as a development practitioner, we are not able to influence these big things. So I'm going to focus on the things that we can influence. So I'm doing a project here, a project there, and we can change the parameters of the project in certain ways that we achieve the most significant impact. And how do we change the parameters or what parameters we choose or how do we design the project? That's where randomised control trials can give us very useful insights. And we can get more bang for the buck from the development expenditures in those kinds of projects. Now, he never said that that's all about development. There are many other things that need to be done. And governments, in their collective wisdom, may have a better idea of what those things can be. And that's different from a particular project team trying to do a project. They won't have all that knowledge, which can lead them to think about much bigger things, but governments can; not perfectly, but governments can. Or large organisations like BRAC can within certain spheres of operation. So, yes, I agree with you that this is a false dichotomy, that you either completely forget about RCTs or you get completely immersed into RCTs. So, one has to find the right places where the randomised control trials, which are after all an instrument, one of the tools in your toolbox… which is the best time and place to deploy it. I would say in Bangladesh, yes, the scope for applying them is more than the actual application so far, which means that we have a scope to improve the efficiency and effectiveness of public spending by using these techniques judiciously in certain areas. Now, coming back to, I think you mentioned the question of BRAC in the context of R&D, but also BRAC has played an important role in market development through their social enterprise world. So, as I said before that the part of BRAC's work which is not discussed much is the work on the economic sphere. So what happened there? I'll just give one or two examples. I think giving concrete examples is the best way to illustrate this. So, they got into, let's say, they got into dairy [farming]. Actually, the way BRAC started most of these activities was from a livelihood concern. They wanted to create livelihood opportunities for the poor people in the rural areas of Bangladesh. So they said, okay, we have dairy farmers whose incomes are limited, we want to do something to help enhance their inputs [output]. So they came up with certain small interventions, which helped improve the productivity of their dairy farming, and they ended up with more production, then they had a problem. Now, milk is not something that you can preserve for a long time, you need to have some cold storage facilities, some refrigeration facilities, and that was lacking. So a lot of these increased output was actually being wasted. That led BRAC to start thinking about what else it needs to do. So then it went into refrigeration plants. So, they set up refrigeration plants, where the dairy farmers would come from adjoining villages and store their milk. And that led to other things also down the road. So there are many examples of BRAC where they went into a certain activity, they went into poultry, for example, and then discovered that there isn't a good supply of day old chicks, which is an important ingredient in poultry. So they went into that. And the interesting thing is, in many cases, BRAC was the first one to go into that, later the private sector came in and came in in a big way. And when they did, BRAC withdrew. Because BRAC thought, okay, we have played the role of a pioneer, we have catalysed the entry of private enterprises, we can now withdraw and attend to certain other things. So what's going on here? What's going on here is, you have value chains, which are underdeveloped - there are gaps in the value chain. And one aspect of development is to make the value chains more complete. And here you have an actor, BRAC, which has entered the market… [enters] one part of the market, trying to do something, discovering that there is not much it can do unless it intervenes in other parts of the value chain. Well, it can do something but the impact will not be that great, so then it intervenes. But at one point, it realises that other players who are better at scaling this up have entered the field so let me withdraw. So judicious entry, and judicious withdrawal. And that is also true of the government. It's also true of BRAC. I think that's the kind of dynamics of development which is very important. And somewhere there, yes, you may have some trials, which may be randomised control trials, it may be just informally observing from your own experience of what is working, what is not working, but this idea of learning by doing, learning by doing, the government has done it in Bangladesh, BRAC and other BRAC-type institutions have done it. The private sector is also doing it.Tobi;The last of my big-picture questions to you is– Another dichotomy that I have observed is the business cycle concerns of an economy and policy and these sorts of other long-run development growth policies. For example, in Nigeria, it's a common refrain that we had growth in some years, but we never really had development. Income didn't grow as fast as GDP, and growth has been cyclical, it's not sustained. And some of the issues that really plague governments and policymakers is that even in trying to make policies that are tolerant and favourable to long-run growth, there are short term issues that you have to deal with [like] foreign exchange policy, inflation, and sometimes I've heard people say that, Oh, as a developing country, you have a lot more tolerance for inflation than developed economies. I think you'll have to tell me whether that's true or not. Because inflation does not happen in a vacuum, it affects the purchasing power of people, poor people even more so. Right. So how do policymakers in growing countries manage these tensions in terms of – and, I'm working my way through your book with Gustav Ranis on this – how policymakers mine through these everyday concerns of the economy, versus the long-term prospects and the projects you are trying to put forth as a government?Akhtar;Okay. Well, since you alluded to that book, I will first briefly mention the main theme of the book, and then come to this specific [question]. The main theme of the book, which we illustrated through a comparative study of East Asian countries and Latin American countries, [was that] we talked about the East Asian pattern of government behaviour and the Latin American pattern of government behaviour. And the period covered was from the mid 60s to the mid 80s so things may have changed after that. And in any case, it's difficult to talk about (a) East Asian pattern, and (b) Latin American pattern. But what we were talking about is that during the course of a business cycle, or terms of trade cycle, as your terms of trade improve, your foreign exchange reserves go on increasing, obviously, growth accelerates. The question is what does a government do when things are good? Do they let growth accelerate according to some normal – “normal trajectory”, or they get excited, and they try to push growth beyond the “normal trajectory”-- making it higher than what the good times normally would make it? So, in the “Latin American” scenario, when things were good, growth was happening, government wanted to have more of it. So they went for expansionary fiscal policies, expansionary monetary policies to push growth beyond what the natural trajectory is. And then inevitably, because we are talking of cycles, inevitably a time came, where things started going down. And conditions were not as conducive as before. At that time, what the East Asian countries did– but first– they never tried to artificially push growth above the natural level. When the downturn came, they allowed the growth to fall. So they went for contractionary policies, they allowed the growth to fall. But in the Latin American scenario, having pushed growth beyond the natural path, it's almost like being intoxicated, you could not get rid of that habit. So, you try to artificially maintain growth even though the signs were all pointing downwards. And then the time came when things just crashed. And you fell into a deep crisis. Whereas the East Asians, they had their ups and downs, but they didn't have a serious crisis at that time. They had later, but not at that time. So that was the main thing about how you conduct your policies during the upturn, and then also during the downturn. Now, coming back to the specific situation like the one we observe now, when there are many economic challenges facing countries, and what can governments do to ensure that the course on which they had been before the crisis started, or the challenges started, and hopefully it was a course of development, how can they stay on that course as best as they can? First is, governments should look for existing inefficiencies. For example, in your public expenditures, there may be a lot of inefficiencies, and if you can identify those and get rid of those [inefficiencies], then you can bring things under control in the context of the challenges without sacrificing growth. Most developing countries, including Bangladesh, do have inefficiencies in their public expenditures. So the question is, do you target those inefficiencies and curtail them? Or, do you target those parts of expenditures which are actually very useful? So that's number one. And that's why we often have this phrase, “don't let a crisis go to waste.” Because a crisis can often focus attention better than good times can. And a crisis can also create the political and social consensus to take some tough decisions. So that's one thing. Second is the importance of social protection. And we must remember that for people at the margin, and in our kind of countries, Nigeria, Bangladesh, a lot of people are still at the margin. Even a small shock which takes them below the threshold is not a temporary damage that after some time they can come back [from], often it's a permanent damage. They have to sell off their productive assets, which means even when things start improving, their conditions won't improve. So that's why it's very, very important to have good social protection systems in place.Third, coming back to a point I made earlier, it's very important to have good monitoring systems. ‘Cause we really want to know what's going on, how the lives of different people across the country is being affected by the tough conditions in which you are, without that your policies will be suboptimal. So that monitoring is very, very important. And it's very important to engage different stakeholders in society. And for two reasons. One is part of the monitoring, because economists, business people, journalists, and others, would know a lot beyond what the government knows and it's important to tap into that knowledge, but also to build consensus about some of the tough decisions that need to be taken. So, at the end of the day, it is a lot about governance. It's a governance challenge that countries face when they're facing an economic challenge.Tobi;My final question to you, I have a couple of other questions, but… from a policy-making perspective, how do you then make knowledge count? Because from everything you have talked about, the role of knowledge… which takes me back to where we started, you know, talking about agriculture. The role of knowledge is actually very important. But you have situations where you can have knowledgeable people in government, world class economists, and the government itself might be making policies that are clearly wrong, which means there's a disconnect somewhere. And I mean, in Bangladesh, it's often talked about how there is a policy knowledge ecosystem that informs the public and shapes their accountability and expectations, and also informs policymakers at the other end of that spectrum. How does a country build and nurture that? Especially, how does knowledge of, whether it is knowledge of economics, whether it is knowledge of society and other programs, how it transmits to the key decision makers, and influence some of the actions or policies, or regulations, that are taken? How does that happen?Akhtar;Okay, so you mentioned the sort of the ecosystem linking policy and knowledge in Bangladesh. We have an ecosystem, I wouldn't say it always functions very well. And we do have many instances where people in government feel that the
Research continues to support the feasibility and effectiveness of health coaching. The results are suggesting a greater level of immerging value. Listen as Dr. Sandi, FMCA Founder and CEO, summarizes three studies (RCTs) with health coaching as the intervention addressing lifestyle factors: improving risk management and combatting chronic conditions. Supported by data-driven, science-based research, and published studies. FMCA is providing this podcast as a public service, but it is neither medical advice nor a statement of FMCA policy. Reference to any specific product or entity does not constitute an endorsement or recommendation by FMCA. The views expressed by guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed during the podcast do not necessarily reflect the view of FMCA or any of its officials.
In part 1 of their annual review, cardiologists Bob Harrington and Mike Gibson discuss in-person meetings, wearables and AI, COVID lessons for medical research, and the growth of RCTs from China. This podcast is intended for healthcare professionals only. To read a transcript or to comment, visit https://www.medscape.com/author/bob-harrington COVID Therapies Therapeutic Anticoagulation With Heparin in Noncritically Ill Patients With Covid-19 https://www.nejm.org/doi/full/10.1056/NEJMoa2105911 Effect of Intermediate/High Versus Low Dose Heparin on the Thromboembolic and Hemorrhagic Risk of Unvaccinated COVID-19 Patients in the Emergency Department https://doi.org/10.1186/s12873-022-00668-8 Two Old Meds and a DOAC a Bust Across Range of COVID Severity: The ACT Trials https://www.medscape.com/viewarticle/980049 Effect of Ivermectin vs Placebo on Time to Sustained Recovery in Outpatients With Mild to Moderate COVID-19: A Randomized Clinical Trial http://jamanetwork.com/article.aspx?doi=10.1001/jama.2022.18590 FDA Halts Use of Some COVID Monoclonal Antibodies Due to Omicron https://www.medscape.com/viewarticle/967210 CT Surgeons Rise to Challenge, Lead Way in COVID Clinical Trials https://www.sts.org/publications/sts-news/ct-surgeons-rise-challenge-lead-way-covid-clinical-trials What Do We Know About Long COVID: A Cardiovascular Focus https://www.medscape.com/viewarticle/981435 COVID-19 and the Heart: Is Cardiology Ready? https://www.medscape.com/viewarticle/969206 The Stanford RECOVER Trial https://recovercovid.org/ The Heroes Study https://heroesresearch.org/ Artificial Intelligence Age and Sex Estimation Using Artificial Intelligence From Standard 12-Lead ECGs https://doi.org/10.1161/CIRCEP.119.007284 The Heartline Study https://www.heartline.com/about Evolution of Single-Lead ECG for STEMI Detection Using a Deep Learning Approach https://doi.org/10.1016/j.ijcard.2021.11.039 Recognizing a Ruler Instead of a Cancer https://menloml.com/2020/01/11/recognizing-a-ruler-instead-of-a-cancer/ Machine Learning Did Not Beat Logistic Regression in Time Series Prediction for Severe Asthma Exacerbations https://doi.org/10.1038/s41598-022-24909-9 A Systematic Review Shows No Performance Benefit of Machine Learning Over Logistic Regression for Clinical Prediction Models https://doi.org/10.1016/j.jclinepi.2019.02.004. Multinational Federated Learning Approach to Train ECG and Echocardiogram Models for Hypertrophic Cardiomyopathy Detection https://doi.org/10.1161/circulationaha.121.058696 Detection of Hypertrophic Cardiomyopathy Using a Convolutional Neural Network-Enabled Electrocardiogram https://doi.org/10.1016/j.jacc.2019.12.030 Here's Why We're Not Prepared for the Next Wave of Biotech Innovation (by Matthew Herper) https://www.statnews.com/2022/11/03/why-were-not-prepared-for-next-wave-of-biotech-innovation/ RCTs from China Bivalirudin Plus a High-Dose Infusion Versus Heparin Monotherapy in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Randomised Trial https://doi.org/10.1016/S0140-6736(22)01999-7 Chinese Herbal Medicine May Offer Benefits in STEMI: CTS-AMI https://www.medscape.com/viewarticle/983619 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine Hear John Mandrola, MD's summary and perspective on the top cardiology news each week on This Week in Cardiology https://www.medscape.com/twic Questions or feedback? Please contact email@example.com
In this episode, Marc and Mo discuss several recent articles that caught their eye. The first part of the discussion focuses on selected highlights from the recent meeting of the OTA (specifically, the treatment of humeral shaft fractures), and the second part focuses on genetic factors related to adhesive capsulitis of the shoulder. Links: OTA 2022: Key Findings from This Year’s RCTs and Meta-Analyses. OE Insights. 2022. Available from: https://myorthoevidence.com/Insight/Show/148 Kulm S, Langhans MT, Shen TS, Kolin DA, Elemento O, Rodeo SA. Genome-Wide Association Study of Adhesive Capsulitis Suggests Significant Genetic Risk Factors. J Bone Joint Surg Am. 2022 Nov 2;104(21):1869-1876. doi: 10.2106/JBJS.21.01407. Epub 2022 Nov 2. PMID: 36223477. https://bit.ly/3URMnD6 OrthoJoe Episode 43: Physician Etiquette and Attire https://bit.ly/3Ak3gy9 Subspecialties: Basic Science Shoulder Trauma Orthopaedic Essentials
The "gold standard" of study design, the Randomized Controlled Trial. What is it, and is it really the gold standard? -o-Twitter: EverythingisPHInstagram: Everything is Public Health Patreon: https://www.patreon.com/everythingispublichealth Email: EverythingIsPublicHealth@gmail.com Support the show
ASCO Guidelines Podcast Series
Dr. Judith Paice and Dr. Eduardo Bruera discuss the latest evidence-based recommendations from ASCO on the use of opioids in managing cancer-related pain. They review the safe and effective use of opioids, including when clinicians should offer opioids, which opioids should be offered, how opioids should be initiated and titrated, management of opioid-related adverse events, modifying opioid use for patients with specific comorbidities, management of breakthrough pain, and how opioids should be switched. Additionally, they address barriers to care, considerations of health disparities, cost, and patient-clinician communication in achieving optimal pain management. Read the full guideline, “Use of Opioids for Adults with Pain from Cancer or Cancer Treatment: ASCO Guideline” at www.asco.org/supportive-care-guidelines. TRANSCRIPT Brittany Harvey: Hello, and welcome to the ASCO Guidelines Podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today, I'm interviewing Dr. Judith Paice from Northwestern University Feinberg School of Medicine in Chicago, Illinois and Dr. Eduardo Bruera from the University of Texas MD Anderson Cancer Center in Houston, Texas, co-chairs on “Use of Opioids for Adults with Pain from Cancer or Cancer Treatment: ASCO Guideline.” Thank you for being here, Dr. Paice and Dr. Bruera. Dr. Judith Paice: Thank you. Dr. Eduardo Bruera: Thank you for having us. Brittany Harvey: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Paice, do you have any relevant disclosures that are directly related to this guideline topic? Dr. Judith Paice: I have no relevant disclosures. Brittany Harvey: Thank you. And then Dr. Bruera, do you have any relevant disclosures that are directly related to this guideline topic? Dr. Eduardo Bruera: Regrettably, I don't. Brittany Harvey: Great. Then getting into the content of this guideline, to start us off, Dr. Paice, can you provide an overview of the purpose and the scope of this guideline? Dr. Judith Paice: The use of opioids has become so complicated, so controversial, and just so associated with so much stigma that we wanted to provide oncology clinicians some guidance about safe and effective use of opioids. We wanted to help people be aware of the current literature, and so we conducted a systematic review and identified randomized controlled clinical trials and other systematic reviews. And we found that there were 31 systematic reviews in 16 RCTs. We carefully reviewed all of these literature and all of these studies, and our expert panel met via the web and via numerous conference calls and emails, and we came to consensus regarding these recommendations related to the use of opioids for people with cancer. Brittany Harvey: Great. Sounds like there was a lot of effort that went into developing this and to tackle an important topic. So, then Dr. Bruera, I'd like to review the key recommendations of this guideline for our listeners. This guideline addresses seven different clinical questions. So, let's review these questions starting with; in what circumstances should opioids be offered? Dr. Eduardo Bruera: That's a very important point because the reality is that although opioids have been around for more than 300 years in different modalities, they continue to be the mainstay of care of patients with severe pain. So, it's very important to try to figure out in the clinical practice why the patient has a pain syndrome. But in the great majority of patients who have pain that is due to the presence of the primary cancer or metastatic disease. And also, in the vast majority of patients who develop severe complications from treatment such as mucositis from radiation and chemotherapy, an opioid will be needed. And the oncologist and the oncology clinician is in perfect conditions to safely prescribe that opioid so the patient can achieve fast relief of their pain. Brittany Harvey: Great. Thank you for that explanation. So, then the next clinical question that the panel addressed, Dr. Paice, which opioids does the panel recommend clinicians should offer? Dr. Judith Paice: Yeah, thank you. This is a really important question, one that gets asked all of the time, and yet, the data are insufficient to really suggest that there is one preferred opioid over another. So, a patient with moderate to severe cancer-related pain is a candidate for any of the approved medications either approved by the FDA or because our audience also includes international experts, other regulatory agencies for pain treatment. We did call out a couple agents for which there is some concern or for issues where they are less than desirable in some settings. So, one of those drugs is tramadol. And our rationale for identifying tramadol as a potential agent of concern is that it's a prodrug. It has a threshold, a ceiling unlike most of the other opioids, and that threshold is pretty low for neurotoxicity, which is of particular concern in the person with cancer. And it also, has a significant amount of drug-drug interactions. So, we were concerned about tramadol, even though it is an agent that many, many people are using, in part, because it is a lower schedule on the controlled substance scheduling system, and there's a perception that it is less potent, and it is less potent. The other drug that we call out is codeine. And our rationale for identifying it as an agent that may be of difficulty in certain populations of patients, is that it is also a prodrug and it is metabolized through the cytochrome P450 system, particularly through the isoenzyme CYP2D6. And that's what allows codeine to be metabolized to morphine, which allows it to be analgesic. The challenge is there are some individuals who are poor metabolizers, and so they will not receive an analgesic effect. And then there are others who are ultra-rapid metabolizers, and they may actually experience a greater prevalence of adverse effects. So, for those reasons, we call out tramadol and codeine. Now, we don't call out methadone as an agent that we're concerned about in terms of not being desirable. It is an agent that has a role in cancer pain management. However, we do caution clinicians that it is a complex drug to use. And so, as result, people should obtain some guidance either from their palliative care program, their supportive care program, pain experts, or pharmacists, whomever can assist them in the dosing associated with this really important, but somewhat complicated drug to use. Brittany Harvey: Understood. And I appreciate you reviewing where there's a lack of evidence and where there is evidence in identifying those potential agents of concern or where clinicians need to seek other expertise in this area. So, then following those recommendations, after identifying patients who should be offered opioids, Dr. Bruera, how should opioids be initiated and titrated? Dr. Eduardo Bruera: One possible way to do this is to give the patient an immediate release opioid. That could be a combination of hydrocodone with acetaminophen, a combination of other opioids or a straight strong opioid in a low concentration. And ideally, we suggest that you use it as needed for the first few days and see if the patient needs to take it frequently. And there is a magic number around 30 milligrams of morphine equivalent per day. Once the patient needs to take that opioid on a more frequent basis and gets through that threshold of needing about five, six tablets a day of immediate release opioid, then it might be necessary to start a regular opioid that is to stay on top of the pain. And the way we do that are two ways; if the patient can afford it and insurance covers it, an extended release opioid is a wonderful option, because then, the patient can take the opioid a couple of times a day or put a patch for three days and they're going to be comfortable. But if that is not an option, taking the immediate release opioid around the clock, not anymore as needed. But now, around the clock, will maintain that blood level and allow the patient to have less episodes of breakthrough pain. An important thing to remember is that whether we decide to go with the extended release opioid or immediate release, it's nice to tell the patient that there might be moments in which the pain might break through. And so, giving that extra prescription and advice might help if there are moments in which the patient might break through. Brittany Harvey: Understood. And then the next clinical question that the guideline panel addressed, Dr. Paice, how should opioid-related adverse events be prevented or managed? Dr. Judith Paice: So, Brittany, I'm glad you asked me that question because I am called the pain and the poop nurse in the clinic, and it is so important whenever we can to prevent the adverse effects of opioids, and constipation is one where we can implement some preventive measures, and then treat unfortunately if your measures have not been totally effective. But we wanted to address the gamut of potential adverse effects. So, we included not only constipation, but delirium, endocrinopathies, sedation, nausea, vomiting, itching, and urinary retention. And we've included a table with very specific suggestions about how to prevent in some cases, and how to manage these adverse effects. Again, we wanted to make this document of the most use for all oncology clinicians who might be prescribing opioids for people with cancer. Brittany Harvey: Absolutely. And that's key to maintaining quality of life for patients. So, then Dr. Bruera, what does the panel recommend regarding modifying opioid use in patients with either renal or hepatic impairment? Dr. Eduardo Bruera: That's a great question, Brittany, and I think we have some evidence that some opioids are particularly desirable when the patient has renal dysfunction. One of the ones that comes to mind is methadone because it has almost no major renal elimination, and therefore, that might be a wonderful option. One of the challenges is that changing from one opioid to another sometimes is a little bit more complex than maintaining the opioid that is being used. And so, in absence of a major and fast deterioration, one option is to carefully titrate the dose of the opioid we're using to reduce the risk of accumulation in a given patient. There are some opioids that have traditionally been associated with a little bit more accumulation in cases of renal failure and traditionally, morphine is included, but there are other opioid agonists that also produce metabolites that are massively eliminated by urine that might be a little bit less desirable in patients with renal failure. With regards to liver failure, it's very hard to find a complete consensus about the opioids that are less desirable or potentially more desirable. And we could say that careful titration is important. But the one that was so good for renal failure might be the one you might not want to use for liver failure, and that would be methadone, because a vast majority of its metabolism happens in liver. So, I think cautious individualized titration might be a nice recommendation to our patients. And perhaps, the most important thing is that there might be a little bit of renal failure or liver failure, but it's very, very important that we maintain the opioid therapy, that we don't give up on the opioids. Brittany Harvey: Yes, those are important clinical considerations for individualized patient care. So, then Dr. Paice, Dr. Bruera touched on this a little bit earlier, but what are the recommendations regarding management of breakthrough pain? Dr. Judith Paice: So, breakthrough pain is very common in the person with cancer. We see this when the individual has bony metastases and they place pressure on that limb or joint. And the patient who's normally well-controlled with either a regularly scheduled immediate release agent or a long-acting agent, now experiences what we call breakthrough. And that's probably the most common type of breakthrough pain. There are also other breakthrough pains where the short-acting agent that's given regularly doesn't provide the relief that lasts four hours or six hours. Or similarly, if a long-acting agent is given every 12 hours, we may see that the pain breaks through prior to the next dose. But for that patient who requires breakthrough medication, unfortunately, the literature does not reveal that one agent is superior to another. So, any immediate release opioid that's appropriate for that patient can be used for breakthrough-related pain. Now, a common clinical conundrum is - which dose? What's the correct dose for the breakthrough medication? And again, the literature has a wide range of appropriate doses, and our committee established a range of 5 to 20% of the daily regular oral morphine equivalent daily dose. And our rationale for that was that you really cannot come up with one figure. Every patient is different. So, on average it's somewhere around 10%, but the range is five to 20% of the daily regular morphine equivalency. And so, what you need to do as you're examining the patient and exploring their needs is to look at the patient's frailty, the patient's pain, of course, their function when these breakthrough episodes occur. What about the comorbid kinds of organ dysfunction that Eduardo just spoke about? So, all of those other factors need to be considered when selecting the appropriate opioid for the breakthrough as well as the appropriate starting dose. Brittany Harvey: Definitely, it's important to consider all of those factors that you just mentioned. So, then the last clinical question that the panel addressed, Dr. Bruera, when and how should opioids be switched or rotated? Dr. Eduardo Bruera: Thank you, Brittany. This is a hugely important issue because for many, many years, we believe that since opioids stimulated an opioid Mu receptor, and they all had a similar effect, there will be limited rationale for changing. The answer to increasing pain was what we call opioid dose escalation. Just give more of the same. And we realized that that had serious limitations. And one of them is the development of side effects. And a lot of those side effects are neurotoxic side effects. Patients get unduly sedated, get hyperalgesia, paradoxical increase in pain due to active metabolites and changes in their receptors, and they also get sometimes myoclonus, hallucinations, confusion. And so, there are moments in which the side effects require us to say, okay, this opioid has done a good job for a while, but now, we have to change. And so, changing can be done due to side effects. But also, sometimes, since we're all different and there's a lot of interpersonal variation in response — as some patients may just not be controlled, their pain syndrome might not be controlled well-enough with one type of opioid because we know there are multiple sub-Mu receptors, and they might really benefit from another. So, the two main reasons are the development of toxicity to the opioid that so far was working reasonably well. And the second is failure, inability to control the pain, and in that case, going cautiously respecting the fact that there is limited cross-tolerance so that the dose of one opioid is not always exactly equivalent to the dose of the other opioid that you find in the actual tables that are published around is necessary to understand that that's a general guideline. But the most important thing is to go progressively and monitor your patient frequently when you change from one opioid agonist to another opioid agonist. There is limited understanding in the literature about the exact equianalgesic dosing. And because of that, a new guideline is being produced that addresses opioid rotation and deals exactly with trying to find out consensus from all the different existing tables on how to change what is the dose that is most likely to be appropriate when you move from one opioid, for example, morphine to hydromorphone or to fentanyl, or to oxycodone or vice versa. We dealt with great trepidation to give all our oncology clinicians some kind of a fixed table, but the evidence is unfortunately not there at this point. It is sad because these medications are not that new, but the evidence unfortunately, is not there. And that's why I think what we can tell you is go through your guidelines, use in a very careful monitoring of your patient to see if the dose you're giving is clearly not enough or it's a little bit too much. And you will learn that very rapidly — in a couple of days, you'll learn if you're doing okay or if you're doing too much or not enough. And stay tuned because hopefully, very soon, ASCO, together with MASCC and a couple of other organizations will provide you with a little bit more evidence around this. Brittany Harvey: Definitely, we'll look forward to that future guideline on opioid conversion tables as it is a confusing and complicated area, but it sounds like a lot of these recommendations are about providing individualized care for your patients. So, I want to thank you both for reviewing all of those recommendations that the panel came up with. So, then Dr. Paice, what does this guideline mean for both clinicians and for patients with pain from cancer or their cancer treatment? Dr. Judith Paice: Well, speaking on behalf of the panel, our wish is that this will improve the management of cancer-related pain, that people will feel more comfortable in safe and effective use of these agents, and they'll be used more effectively. There are other barriers that we've addressed, in addition to all of these recommendations. We talk about the care of people who have multiple chronic conditions. We address the disparities that we see in cancer pain management, and we talk about cost as another consideration, as one is developing a treatment plan for patients. We also address the patient-clinician communication that is so essential. This is definitely a team effort, and we guide our clinicians and offer for patients the need to have clear communication, open dialogue throughout the development of a treatment plan, and then throughout the course of treatment while we reassess whether the plan has been effective. Brittany Harvey: Absolutely. And it's really key what you just said about the safe and effective use of opioids for patients. So, then finally, Dr. Bruera, you've both mentioned this throughout our conversation today, where the literature is either inconclusive or evidence is insufficient. So, what are the outstanding questions about the use of opioids for pain from cancer or cancer therapies? Dr. Eduardo Bruera: I think there are questions that relate to the relative lack of specificity of the opioids for the different receptor pathways, and there are very likely considerable differences because they're chemically quite different, but they're considerable differences. But we have not done an awful lot of the head on comparisons that would be so wonderful to do. And I think we need more studies comparing the different existing medications, and more importantly, we need a lot of translational work to get to specific areas. Wouldn't it be fantastic if we were able to stimulate the Mu receptor all along the nociceptive pathway to reduce nociceptive input, but avoid completely the limbic system and avoid those Mu receptors in the area where reward is going to happen, an anti-reward and the possibility of developing non-medical use and eventually, opioid use disorder. That would be, to me, the corollary, the ability to dissociate those receptors along the nociceptive pathway from those receptors in the areas where we would like our opioids to not go, but we cannot avoid it because they're a bit dummy drugs. And so, hopefully, getting smarter opioids would be wonderful. Brittany Harvey: Absolutely. Well, I want to thank you both so much for your work developing this guideline, addressing these important questions for optimal pain management in patients with cancer. And thank you for your time today, Dr. Paice and Dr. Bruera. Dr. Judith Paice: Thank you. Dr. Eduardo Bruera:Thank you so much. Brittany Harvey:And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast series. To read the full guideline, go to www.asco.org/supportive-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. Voiceover: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.
Perhaps the most interesting episode so far.Byrne Hobart writes at thediff.co, analyzing inflections in finance and tech.He explains:* What happened at FTX* How drugs have induced past financial bubbles* How to be long AI while hedging Taiwan invasion* Whether Musk's Twitter takeover will succeed* Where to find the next Napoleon and LBJ* & ultimately how society can deal with those who seek domination and recognitionWatch on YouTube. Listen on Apple Podcasts, Spotify, or any other podcast platform. Read the full transcript here.Follow me on Twitter for updates on future episodes.If you enjoy this episode, I would be super grateful if you shared it. Post it on Twitter, send it to your friends & group chats, and throw it up wherever else people might find it. Can't exaggerate how much it helps a small podcast like mine.A huge thanks to Graham Bessellieu for editing this podcast.Timestamps: (0:00:50) - What the hell happened at FTX?(0:07:03) - How SBF Faked Being a Genius: (0:12:23) - Drugs Explain Financial Bubbles (0:17:12) - On Founder Physiognomy (0:21:02) - Indexing Parental Involvement in Raising Talented Kids (0:30:35) - Where are all the Caro-level Biographers? (0:39:03) - Where are today's Great Founders? (0:49:05) - Micro Writing -> Macro Understanding (0:52:04) - Elon's Twitter Takeover (1:01:28) - Does Big Tech & West Have Great People? (1:12:10) - Philosophical Fanatics and Effective Altruism (1:17:54) - What Great Founders Have In Common (1:20:24) - Thinkers vs. Analyzers (1:26:17) - Taiwan Invasion bets & AI Timelines TranscriptAutogenerated - will not be perfectly accurate.Dwarkesh Patel 0:00:00Okay, today I have the pleasure of interviewing Bern Hobart again for the second time now, who writes at thediff.co. The way I would describe Bern is every time I have a question about a concept or an event in finance, I Google the name of that event or concept into Google, and then I'd put in Bern Hobart at the end of that search query. And nine times out of 10, it's the best thing I've read about that topic. And it's just so interesting. It's just like the most schizophrenic and galaxy brain it takes about like how, you know, the discourses of, you know, Machiavelli's discourses relate to big tech or like how sour