#186 – Dean Spears on why babies are born small in Uttar Pradesh, and how to save their lives

By Luisa Rodriguez and Keiran Harris · Published May 1st, 2024 ·

#186 – Dean Spears on why babies are born small in Uttar Pradesh, and how to save their lives

By Luisa Rodriguez and Keiran Harris · Published May 1st, 2024

Image credit: Lovey Pant of r.i.c.e.

I work in a place called Uttar Pradesh, which is a state in India with 240 million people. One in every 33 people in the whole world lives in Uttar Pradesh. It would be the fifth largest country if it were its own country. And if it were its own country, you’d probably know about its human development challenges, because it would have the highest neonatal mortality rate of any country except for South Sudan and Pakistan. Forty percent of children there are stunted. Only two-thirds of women are literate. So Uttar Pradesh is a place where there are lots of health challenges.

And then even within that, we’re working in a district called Bahraich, where about 4 million people live. So even that district of Uttar Pradesh is the size of a country, and if it were its own country, it would have a higher neonatal mortality rate than any other country. In other words, babies born in Bahraich district are more likely to die in their first month of life than babies born in any country around the world.

— Dean Spears

In today’s episode, host Luisa Rodriguez speaks to Dean Spears — associate professor of economics at the University of Texas at Austin and founding director of r.i.c.e. — about his experience implementing a surprisingly low-tech but highly cost-effective kangaroo mother care programme in Uttar Pradesh, India to save the lives of vulnerable newborn infants.

They cover:

The shockingly high neonatal mortality rates in Uttar Pradesh, India, and how social inequality and gender dynamics contribute to poor health outcomes for both mothers and babies.
The remarkable benefits for vulnerable newborns that come from skin-to-skin contact and breastfeeding support.
The challenges and opportunities that come with working with a government hospital to implement new, evidence-based programmes.
How the currently small programme might be scaled up to save more newborns’ lives in other regions of Uttar Pradesh and beyond.
How targeted health interventions stack up against direct cash transfers.
Plus, a sneak peak into Dean’s new book, which explores the looming global population peak that’s expected around 2080, and the consequences of global depopulation.
And much more.

Producer and editor: Keiran Harris
Audio engineering lead: Ben Cordell
Technical editing: Simon Monsour, Milo McGuire, and Dominic Armstrong
Additional content editing: Katy Moore and Luisa Rodriguez
Transcriptions: Katy Moore

Highlights

Why neonatal mortality is so high in Uttar Pradesh

Dean Spears: So neonatal mortality comes from largely being low birthweight, and underweight babies largely come from underweight moms. And in this district where we work, about a third of the moms are underweight, in the sense of having a body mass index below 18.5.
So why are moms underweight? Well, some of the reasons that moms in Uttar Pradesh are underweight are the reasons that sort of everybody in Uttar Pradesh has worse net nutrition than they might, such as the disease environment and poor sanitation. So moms and babies and dads all sort of live in a place where sanitation — and yes, there’s still open defecation here — means that people are exposed to germs that use up their nutrition, that sap their nutrition and their energy through diarrhoeal disease, or just fighting infections. But it’s not just the poor sanitation and disease environment that’s causing so many moms to be underweight. Very importantly, it’s also social forces like gender inequality and the moms being socially low-ranking people.
So mothers in India tend to have their babies at younger ages. Unlike in, for example, sub-Saharan Africa, where childbearing careers are more spread out in age, a lot of the babies in India are born to moms in their early 20s. And that’s a time where women in India tend to be particularly likely to be underweight.
You might just be thinking it’s a poor country, and that’s why there’s undernutrition. But there’s more undernutrition in India amongst women of childbearing age than in, for example, sub-Saharan Africa or the rest of the developing world. And what we see in India is this distinctive pattern where, especially in a place like Uttar Pradesh, the youngest women in their early 20s are particularly likely to be underweight. And as they get older, gain more social status, have children, they become less likely to be underweight. So the likelihood that a woman is underweight falls in age in a way that we just don’t see in the same way in the rest of the developing world. So India has this double challenge, where mothers tend to have babies young and that’s when they tend to be underweight.
Luisa Rodriguez: Right. And why is it that this is happening in India and not in countries in sub-Saharan Africa, for example?
Dean Spears: I think a very big reason is social status and women’s status in the sort of hierarchy that you find, especially in traditional households. Not all households are like this, but let’s zoom in on a special case that it’s easy to learn from, which is joint households.
So Diane Coffey and Reetika Khera and I wrote a statistical paper about learning from joint households: where you have two brothers, they grew up together into adults, they got married, and they all lived together. So in a household like this, the wife of the older brother is socially higher ranking than the wife of the younger brother. And the wife of the younger brother, the lower-ranking daughter-in-law, is expected to do more work for the family, and is later in line for getting the food she needs to eat, even during pregnancy.
So that’s a situation where we can see an effect of a difference in women’s social status, even comparing cousins — their kids who live in the same family, live in the same house, live in the same village, so a lot of things would be held constant. So what do we see? Well, we do see that the lower-ranking daughters-in-law are thinner, and that’s even though they have the same height. And so it’s not about their early life nutrition; it’s about what happens to them in adulthood.
It’s like we have a little experiment here. We can look in these families as petri dishes to see, holding these other things constant, what’s the effect of mom being underweight for these social reasons? So what is the effect? Well, we see that the children of the lower-ranking daughter-in-law are more likely to die neonatal deaths. And we see that they’re more likely to be stunted and small in other ways. So in a situation where we’re pretty sure that the difference in maternal nutrition is coming from these social forces, we’re seeing it all the way through into neonatal mortality.

Evidence of KMC's effectiveness

Dean Spears: So there was a 2021 study in The New England Journal of Medicine that was the iKMC programme, or the immediate KMC programme. And basically what they were studying was the benefits of doing kangaroo mother care even sooner than it might otherwise happen. So it’s not like kangaroo mother care versus nothing; it’s kangaroo mother care versus conventional care in a radiant warmer machine.
So the control group in this study was still in a hospital, still under medical supervision, and was in a radiant warmer. And then the treatment in this iKMC study was KMC: skin-to-skin contact on the mother’s chest and all of that. And it’s in poor countries. They did it in five hospitals: four in Africa, and one that I would consider to be a relatively privileged public hospital in India because it’s in Delhi. It is in this context. What they found is that there was less neonatal death amongst the babies who got immediate KMC than amongst the babies who got conventional care — even with radiant warmers and machines and medical care.
This is so good that it’s at least holding its own against conventional care with the radiant warmer. In fact, they stopped the trial; they decided that we couldn’t ethically continue doing this experiment because the KMC was so good. And even in developed countries where there are lots of resources, a lot of the conversation right now is, “Let’s, at least for a little bit, take the baby out of the incubator or the radiant warmer and put it on mom’s chest for a little while.”
Now, I’m not a medical professor. I’m an economics professor. I’m a social scientist. And what I think is interesting, and what an economics professor can talk about, is why wasn’t this thing happening before? And how do we understand the social science of making it happen and getting families involved? But if you look at what the medical literature says, they wouldn’t be surprised that this is helping, because that’s what they find when they look at experiments for this. And the frontier that they’re asking about is: is this maybe even better than conventional care in some cases?
So, amongst the babies in this programme, 11% of them die neonatal deaths. It is possible to do better than that, and 11% is a lot better than what would have been likely to happen otherwise. So this doesn’t mean that the project of neonatal health care is done forever, but it means that we have something wonderful available, if it can be organised and brought to the babies who need it.

How cost effective is KMC?

Dean Spears: Yeah, let’s talk about that cost-effectiveness number. The highly cost-effective things that you might be familiar with include maybe giving out insecticide-treated bed nets to save lives against malaria. And one of those nets I think costs on the order of $5. But if you give out a lot of them, then the low probability of saving a life for each one all works out that you can save a life for something in the low thousands, right?
This is a different way of getting to a cost-effectiveness number in that ballpark. It costs our programme about $5,000 a week to run. That’s the cost of staffing and management and some supplies. So when we did our cost-effectiveness computations, at that time, we were able to have about 11.5 babies a week passing through the programme. That works out to $430 per baby of average cost. So the average cost of the programme when we did the cost-effectiveness calculation is $430 per baby.
Now, how you get from that number to a cost per life saved depends on how many lives the programme is saving. Here is one sort of really basic way to think about it: a plausible bound for saving lives is that is one in 10: a 10-percentage-point difference in neonatal mortality, like on the order of one in 10 lives are being saved. I actually think it’s better than that, but that’s going to make the math easier. And a plausible bound for the cost is in the hundreds of dollars per baby. So hundreds of dollars of cost per baby times one in 10 lives saved gets you a cost in the low thousands of dollars per life saved. And that’s basically the whole story of the cost effectiveness.
But going forward, the programme is helping more babies than 11.5 per week. So that means a few things. It means that there’s an opportunity to put more funding to good use in order to really reach all of the babies who are appearing. Babies from the smaller clinics are coming instead, we’re catching more of them that pass through. We’re persuading more families to stay instead of leaving. For all of these reasons, more babies are coming. So that means we need more nurses.
Now, the good news is, in economics we have average costs and marginal costs. The average cost is the average cost per baby — that’s that $430 number that I said before. The marginal cost is the extra cost of reaching another baby. And this is a programme where there are lots of scale effects. Once we have a manager who is organising the shifts of which nurse is on home visits and which nurse is on the overnight shift — and believe me, this is a big and thankless task — but once we have that nurse doing it, that is done. So the marginal cost of helping another baby, we don’t have to hire another person to do the scheduling, so chances are the marginal cost of helping more babies is even lower than that $430 average cost.
And so we’re in a situation where, on the one hand, because the programme is successful in attracting more demand, and doing a better job of finding the babies that can be helped, we’re able to help more babies than we thought would be the case. On the other hand, we’re probably helping or treating the marginal baby for less expensively than the average baby.
So that means there’s a real opportunity here to cost effectively save lives. So if a listener out there is eager to find a way to make a cost-effective, life-saving donation in a place where there is an opportunity to absorb the funding and put it to good use, riceinstitute.org — and we think we have that right here.

Is KMC better than direct cash transfers?

Luisa Rodriguez: So we interviewed Paul Niehaus last year about the organisation he cofounded, GiveDirectly, and he made the case that, in many cases, global health and development is better served by people just directly giving people cash, rather than trying to figure out how to deliver a specific programme to them. Why do you think that is not the case here?
Dean Spears: First off, I think he’s right that that is probably often the case. So I don’t disagree with him in any sort of big-picture way. In this case, it goes back to the fact that healthcare involves a lot of market failures.
The idea behind giving someone cash is that then they’re going to be the customers who can go out and make sure they’re getting a good product, and getting the product that’s actually valuable for them. But there’s no real way you could take the $430 that on average this programme is spending per baby, and buy something like this in the market. The private providers here aren’t providing this quality of care, or even a very high-quality of care at all: babies born in private facilities in Uttar Pradesh are actually more likely to die than babies born in public facilities in Uttar Pradesh, even though their families are better off. And then there’s just the well-known market failures of, do the parents know that they need this?
So yes, it probably is true that in a lot of cases, giving cash is a good idea — but it’s not going to provide this outcome of neonatal survival. This is a case where there’s a special opportunity of these moderately underweight babies — not the very most underweight babies, but these moderately underweight babies — where this sort of intervention of low-cost neonatal care can save their lives. But it’s not going to happen if it doesn’t happen in an organised way.

Articles, books, and other media discussed in the show

Dean’s work:

Codirector of r.i.c.e. — the nonprofit research organisation implementing kangaroo mother care with the government hospital in Uttar Pradesh, which has received a grant from GiveWell but has room for more funding
Director of the Population Wellbeing Initiative — a global priorities research centre interested in children, parenting, and the future of population growth and social wellbeing
Where India goes: Abandoned toilets, stunted development, and the costs of caste (with Diane Coffey)
Mothers’ social status and children’s health: Evidence from joint households in rural India (with Diane Coffey and Reetika Khera)
Neonatal death in India: Birth order in a context of maternal undernutrition (with Diane Coffey)
The world’s population may peak in your lifetime. What happens next? — op-ed in The New York Times
Long-term population projections: Scenarios of low or rebounding fertility (with coauthors)

Evidence of the effectiveness of kangaroo mother care:

Kangaroo mother care — review of the evidence from GiveWell
Kangaroo mother care to reduce morbidity and mortality in low birthweight infants — Cochrane Review of 21 randomised controlled trials by Agustin Conde‐Agudelo and José L Díaz‐Rossello
Immediate “kangaroo mother care” and survival of infants with low birth weight by the WHO Immediate KMC Study Group
Brief report: Kangaroo mother care with limited resources by Lincetto, Nazir, and Cattaneo
Neonatal mortality of low-birth-weight infants in Bangladesh by Sohely Yasmin et al.

Social factors related to underweight babies and mothers in India:

Prepregnancy body mass and weight gain during pregnancy in India and sub-Saharan Africa by Diane Coffey
Understanding demand for healthcare among families of high-risk newborns by Taha Ibrahim Siddiqui, Nayana Nair, and Diane Coffey

Other 80,000 Hours podcast episodes:

Transcript

Table of Contents

1 Cold open [00:00:00]
2 Luisa’s intro [00:00:42]
3 The interview begins [00:01:58]
4 Why is low birthweight a major problem in Uttar Pradesh? [00:02:45]
5 Neonatal mortality and maternal health in Uttar Pradesh [00:06:10]
6 Kangaroo mother care [00:12:08]
7 What would happen without this intervention? [00:16:07]
8 Evidence of KMC’s effectiveness [00:18:15]
9 Longer-term outcomes [00:32:14]
10 GiveWell’s support and implementation challenges [00:41:13]
11 How can KMC be so cost effective? [00:52:38]
12 Programme evaluation [00:57:21]
13 Is KMC is better than direct cash transfers? [00:59:12]
14 Expanding the programme and what skills are needed [01:01:29]
15 Fertility and population decline [01:07:28]
16 What advice Dean would give his younger self [01:16:09]
17 Luisa’s outro [01:18:00]

Cold open [00:00:00]

Dean Spears: A plausible bound for saving lives is that is one in 10: a 10-percentage-point difference in neonatal mortality, like on the order of one in 10 lives are being saved. I actually think it’s better than that, but that’s going to make the math easier. And a plausible bound for the cost is in the hundreds of dollars per baby. So hundreds of dollars of cost per baby times one in 10 lives saved gets you a cost in the low thousands of dollars per life saved. And that’s basically the whole story of the cost effectiveness.

Luisa’s intro [00:00:42]

Luisa Rodriguez: Hi listeners, this is Luisa Rodriguez, one of the hosts of The 80,000 Hours Podcast.

In today’s episode, I speak with economist Dean Spears about the surprisingly low-tech and low-cost intervention, “kangaroo mother care,” or KMC, which is currently saving the life of at least one newborn infant every week in Uttar Pradesh, India.

We talk about:

The shockingly high neonatal mortality rates in Uttar Pradesh, and how social inequality and gender dynamics plays a role.
How teaching new moms about skin-to-skin contact and offering breastfeeding support can be such a game-changer for babies who are born small and vulnerable.
How kangaroo mother care compares to giving cash directly to poor households
And how the currently small programme might be scaled up to save many more newborns’ lives in other parts of Uttar Pradesh.

At the end of the interview, I also ask Dean about his work on the looming global population peak — which he expects to be around 2080 — and why we should start a conversation now about the global depopulation that will follow.

All right, without further ado, I bring you Dean Spears.

The interview begins [00:01:58]

Luisa Rodriguez: Today I’m speaking with Dean Spears. Dean is an associate professor of economics at the University of Texas at Austin. He’s also the founding director of r.i.c.e., a nonprofit research organisation focused on early life, health, and wellbeing in India; and the director of the Population Wellbeing Initiative, a global priorities research centre interested in children, parenting, and the future of population growth and social wellbeing, among other things. He is also the coauthor of the award-winning book Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste. Thanks for coming on the podcast, Dean.

Dean Spears: Thanks so much for having me. I’m looking forward to it.

Luisa Rodriguez: I hope to talk more about what KMC is, and the evidence behind it, but first, why is low birthweight such a big problem in Uttar Pradesh?

Why is low birthweight a major problem in Uttar Pradesh? [00:02:45]

Dean Spears: So my work is about babies in India and health and survival at the start of life. So I work in a place called Uttar Pradesh, which is a state in India with 240 million people. One in every 33 people in the whole world lives in Uttar Pradesh. It would be the fifth largest country if it were its own country.

If it were its own country, you’d probably know about its human development challenges, because it would have the highest neonatal mortality rate of any country except for South Sudan and Pakistan. Forty percent of children there are stunted. Only two-thirds of women are literate. So Uttar Pradesh is a place where there are lots of health challenges.

Luisa Rodriguez: That’s really horrible. And I actually found it extremely useful and enlightening for you to compare it to other countries, because I guess there’s this annoying thing happening where I know India has human development problems, but I think of it as middle income, and I don’t assume it has the worst neonatal outcomes in the world. But if you get more granular, there are still places big enough to be huge and important and large enough in scale that we might want to really think about how to direct resources to them effectively.

Dean Spears: That’s right. Nobody’s the ambassador to Uttar Pradesh, let alone the ambassador to Bahraich district. There’s no World Bank mission or UNICEF mission in Bahraich district. But it’s a place with a country-sized population of people, and a lot of them are babies that face threats and challenges at the beginning of life.

Luisa Rodriguez: OK, yeah. That is, again, just really helpful. Can you talk about why neonatal mortality is so high in Uttar Pradesh?

Dean Spears: So around the world, prematurity and low birthweight are the second largest killer of children. But in India, they’re the first killer of children, and it’s a particularly large challenge in Uttar Pradesh. Babies that are born too small don’t have the ability to do as well as they need to do. And there are a lot of babies that are born underweight here, in part because moms are so underweight. So in short, a huge part of the problem is a lot of underweight babies.

Luisa Rodriguez: Right. And can you explain the mechanism there? Why is it that being underweight can cause neonatal mortality?

Dean Spears: There are a few reasons why being underweight is dangerous for a baby. One is that a baby who’s premature might not be developed enough to suckle, to swallow, to breathe. Another is that it might lack strength. An underweight baby might not be able to keep itself warm enough. A baby’s got to eat to grow and to avoid infections and keep breathing. And a baby that’s either born premature or is just too small might not have the strength and the abilities it needs to grow and survive.

Neonatal mortality and maternal health in Uttar Pradesh [00:06:10]

Luisa Rodriguez: OK, I’m interested in zooming out and understanding why neonatal mortality is so disproportionately concentrated in India. Again, I think of India as being middle-income and doing reasonably well on lots of these things. And I’m really taken aback that it’s actually one of the worst in the world on neonatal mortality. Do we understand why that is?

Dean Spears: Yeah, it is surprising that there’s so much neonatal mortality in India. And the thing to keep in mind is that it’s not just India, but there’s a lot of differences within India, and it’s in particular in this northern India area, for example where Uttar Pradesh and Bihar are, where there is a lot more neonatal mortality than you would expect.

So neonatal mortality comes from largely being low birthweight, and underweight babies largely come from underweight moms. And in this district where we work, about a third of the moms are underweight, in the sense of having a body mass index below 18.5.

So why are moms underweight? Well, some of the reasons that moms in Uttar Pradesh are underweight are the reasons that sort of everybody in Uttar Pradesh has worse net nutrition than they might, such as the disease environment and poor sanitation. So moms and babies and dads all sort of live in a place where sanitation — and yes, there’s still open defecation here — means that people are exposed to germs that use up their nutrition, that sap their nutrition and their energy through diarrhoeal disease, or just fighting infections.

But it’s not just the poor sanitation and disease environment that’s causing so many moms to be underweight. Very importantly, it’s also social forces like gender inequality and the moms being socially low-ranking people.

Luisa Rodriguez: Can you say more about that?

Dean Spears: Yeah. So mothers in India tend to have their babies at younger ages. Unlike in, for example, sub-Saharan Africa, where childbearing careers are more spread out in age, a lot of the babies in India are born to moms in their early 20s. And that’s a time where women in India tend to be particularly likely to be underweight.

You might just be thinking it’s a poor country, and that’s why there’s undernutrition. But there’s more undernutrition in India amongst women of childbearing age than in, for example, sub-Saharan Africa or the rest of the developing world. And what we see in India is this distinctive pattern where, especially in a place like Uttar Pradesh, the youngest women in their early 20s are particularly likely to be underweight. And as they get older, gain more social status, have children, they become less likely to be underweight. So the likelihood that a woman is underweight falls in age in a way that we just don’t see in the same way in the rest of the developing world.

So India has this double challenge, where mothers tend to have babies young and that’s when they tend to be underweight.

Luisa Rodriguez: Right. And why is it that this is happening in India and not in countries in sub-Saharan Africa, for example?

Dean Spears: I think a very big reason is social status and women’s status in the sort of hierarchy that you find, especially in traditional households. Not all households are like this, but let’s zoom in on a special case that it’s easy to learn from, which is joint households.

So Diane Coffey and Reetika Khera and I wrote a statistical paper about learning from joint households: where you have two brothers, they grew up together into adults, they got married, and they all lived together. So in a household like this, the wife of the older brother is socially higher ranking than the wife of the younger brother. And the wife of the younger brother, the lower-ranking daughter-in-law, is expected to do more work for the family, and is later in line for getting the food she needs to eat, even during pregnancy.

So that’s a situation where we can see an effect of a difference in women’s social status, even comparing cousins — their kids who live in the same family, live in the same house, live in the same village, so a lot of things would be held constant.

So what do we see? Well, we do see that the lower-ranking daughters-in-law are thinner, and that’s even though they have the same height. And so it’s not about their early life nutrition; it’s about what happens to them in adulthood.

Luisa Rodriguez: Interesting.

Dean Spears: Yeah. It’s like we have a little experiment here. We can look in these families as petri dishes to see, holding these other things constant, what’s the effect of mom being underweight for these social reasons?

So what is the effect? Well, we see that the children of the lower-ranking daughter-in-law are more likely to die neonatal deaths. And we see that they’re more likely to be stunted and small in other ways. So in a situation where we’re pretty sure that the difference in maternal nutrition is coming from these social forces, we’re seeing it all the way through into neonatal mortality.

Luisa Rodriguez: That is fascinating and depressing.

Dean Spears: Well, I mean, I’m optimistic that in the long run, it won’t always be like this. It is the case, especially in other parts of India, that maternal undernutrition has gone down. These things are changing over time. A few years ago, 35% of women in Bahraich were underweight. In the most recent survey, only 30% of women in Bahraich are underweight. So it’s moving in that direction. And hopefully, in coming decades, this will not be such a challenge anymore. In the meanwhile, there’s going to be a lot of low birthweight babies in Uttar Pradesh who need this sort of professional nursing.

Luisa Rodriguez: Yeah, that makes sense.

Kangaroo mother care [00:12:08]

Luisa Rodriguez: But you’re part of this project, r.i.c.e., that is addressing this, at least in the district that you’re working in. What exactly is this project doing?

Dean Spears: That’s right. I’m part of a group, r.i.c.e., that’s partnered with a government medical college in this district to do a programme of low-cost neonatal health care. And that’s what the good news is: medical science knows what to do about this challenge of low birthweight. A lot of people come here on The 80,000 Hours Podcast and tell you about some amazing new technology. But I’m here to tell you about an amazing old technology, which is professional nursing care and lactation consulting, and helping moms keep babies warm and clean and fed, so that they get what they need to grow.

Luisa Rodriguez: Can you make that a bit more concrete? What specifically are these nurses helping with that has such a big impact on neonatal mortality?

Dean Spears: The centrepiece of this care is a set of techniques called kangaroo mother care. Kangaroo mother care combines two things. One thing is skin-to-skin contact between the mom and the baby, where the baby is right on the mom’s chest, and maybe only wearing a hat. So the mom’s body is keeping it warm, the mom’s heartbeat is helping it breathe, and the baby is right there for breastfeeding. And the other part of kangaroo mother care is breastfeeding and lactation consulting, helping moms breastfeed, encouraging them and troubleshooting the breastfeeding when they get going, so that the baby can grow and eat and stay warm, and have what it needs.

Luisa Rodriguez: I guess it’s not that surprising that the babies can’t stay warm. I’m kind of surprised that the solution is to put the baby on the mom’s chest.

Dean Spears: Well, when you’re cold, what do you do? I bet you put on a coat.

Luisa Rodriguez: Yeah, I put on a jumper.

Dean Spears: Wrap yourself in a blanket. Sure. So people have this idea if they have a little bitty baby, that maybe they should wrap it in a blanket. But the reason that putting on a coat keeps you warm is that you’re generating heat from your body, and the coat’s keeping it there. An underweight baby isn’t generating the heat it needs, but the mom’s body is. So putting the baby right on the mom’s body relieves the baby of that little bit of work, and uses the mom to regulate the baby’s temperature.

Luisa Rodriguez: Yeah, OK. The other thing you said that piqued my interest was the mom’s heartbeat helps regulate the baby’s breathing. How does that work?

Dean Spears: That’s right. Especially a premature baby that isn’t as neurologically developed might not breathe, might have gaps in its breathing. Neonatal apnea is when there’s spaces in a baby’s breathing. One of the challenges of caring for an underweight or premature baby is making sure it’s breathing. So the rhythm of the mom’s chest and mom’s heartbeat supports the baby breathing.

Luisa Rodriguez: Wow. It does seem too simple to work, but I guess that is one of the things that is so cool about this programme, is that it is very low-tech.

Dean Spears: Yeah, it’s stunning. It’s surprising. You wouldn’t think that you could save so many lives with an intervention like this, but the thing to understand is that these low-birthweight babies do face a real challenge of death. So if you can help them, if you can get them what they need, there’s an opportunity to do a lot of good.

Luisa Rodriguez: Yeah. OK, makes sense. Is there any more to the programme worth pulling out?

Dean Spears: One exciting part about this programme is that it’s not just care in the hospital, but also followup care at home. Some of the nurses call the moms on the phone, some of the nurses go out and visit the moms in the village. So after the baby is out of the hospital, there’s still support to make sure that the family can keep up kangaroo mother care, can keep up what they need to do to keep the baby safe and growing.

What would happen without this intervention? [00:16:07]

Luisa Rodriguez: What is the counterfactual in hospitals like these? Because you’re not providing a machine —

Dean Spears: That’s right.

Luisa Rodriguez: It’s like a nurse giving concrete advice: “Keep the baby on your chest and have skin-to-skin contact. And here’s a bit of support with breastfeeding; especially young babies have trouble early on.” Why do you need to provide a programme?

Dean Spears: Exactly. What’s surprising here isn’t that that sort of thing helps. What’s surprising here is what would happen otherwise. And what would happen otherwise is, unfortunately, that a lot of these babies and their families would just leave the hospital and go home to their houses, maybe in a village somewhere. There just wouldn’t be an interaction where the baby is flagged for needing special care. And that would have been true in this hospital before this programme, and it still is true in a lot of the other hospitals like this in north India, where programmes like this aren’t happening.

It’s surprising to somebody who might picture neonatal care in a rich country — where a baby would be in an incubator with a feeding tube, with oxygen support, maybe getting antibiotics if it needs them — it’s surprising that that would be what would be happening for babies who really could use the help. But there are lots of constraints, and although things are getting better in early life survival, even in Uttar Pradesh, unfortunately the situation is that for various reasons, there wouldn’t be a programme there to help these babies. So when we think about how much good this professional nursing care and kangaroo mother care is doing, what’s important to keep in mind is that it’s doing this good relative to, unfortunately, not a lot of healthcare at all.

Evidence of KMC’s effectiveness [00:18:15]

Luisa Rodriguez: Yeah. Right. And then I’m curious how much of the benefits that you get from an incubator and a breathing tube and these more complicated technologies does KMC offer? Is it kind of worse overall, but worth implementing because it’s relatively cheap? Or is it comparable?

Dean Spears: That’s a great question. How happy should we be with this outcome, right? And I think what’s amazing is that kangaroo mother care and the support that goes along with it seems to stack up very well, even against conventional, resource-intensive neonatal care.

So there was a 2021 study in The New England Journal of Medicine that was the iKMC programme, or the immediate KMC programme. And basically what they were studying was the benefits of doing kangaroo mother care even sooner than it might otherwise happen. So it’s not like kangaroo mother care versus nothing; it’s kangaroo mother care versus conventional care in a radiant warmer machine.

So the control group in this study was still in a hospital, still under medical supervision, and was in a radiant warmer. And then the treatment in this iKMC study was KMC: skin-to-skin contact on the mother’s chest and all of that. And it’s in poor countries. They did it in five hospitals: four in Africa, and one that I would consider to be a relatively privileged public hospital in India because it’s in Delhi. It is in this context. What they found is that there was less neonatal death amongst the babies who got immediate KMC than amongst the babies who got conventional care — even with radiant warmers and machines and medical care.

Luisa Rodriguez: That is wild.

Dean Spears: That’s wild, right? This is so good that it’s at least holding its own against conventional care with the radiant warmer. In fact, they stopped the trial; they decided that we couldn’t ethically continue doing this experiment because the KMC was so good. And even in developed countries where there are lots of resources, a lot of the conversation right now is, “Let’s, at least for a little bit, take the baby out of the incubator or the radiant warmer and put it on mom’s chest for a little while.”

Now, I’m not a medical professor. I’m an economics professor. I’m a social scientist. And what I think is interesting, and what an economics professor can talk about, is why wasn’t this thing happening before? And how do we understand the social science of making it happen and getting families involved? But if you look at what the medical literature says, they wouldn’t be surprised that this is helping, because that’s what they find when they look at experiments for this. And the frontier that they’re asking about is: is this maybe even better than conventional care in some cases?

So, amongst the babies in this programme, 11% of them die neonatal deaths. It is possible to do better than that, and 11% is a lot better than what would have been likely to happen otherwise. So this doesn’t mean that the project of neonatal health care is done forever, but it means that we have something wonderful available, if it can be organised and brought to the babies who need it.

Luisa Rodriguez: Digging into what we know about the evidence in a bit more depth, I think KMC has been studied in over 20 randomised control trials, so has this very rich evidence base. What exactly is the evidence about the impact of KMC, both on mortality and on morbidity — so things like hypothermia and severe infections? Maybe start out with mortality?

Dean Spears: Great. Yeah. So when we’re thinking about the evidence base for KMC, we can think about what the randomised controlled trials tell us. And there’s also something interesting to think about about what we’re not going to learn from randomised controlled trials.

So, starting from what the randomised controlled trials can tell us: you’re right, in [2016], there was a Cochrane Review that reviewed 21 RCTs with more than 3,000 infants in them, all told, from places around the world. They were looking at low-birthweight babies, and they were comparing babies that were in a place where they would either get conventional neonatal care — that was the control group — or kangaroo mother care, as the treatment group.

And they found that mortality was improved, that babies were about a third less likely to die, or had a relative risk of two-thirds as much if they were getting the kangaroo mother care, the treatment, instead of conventional neonatal care, the control group. So that’s amazing. That’s life saving. And in a place where there is a lot of neonatal mortality or infant mortality — these studies had different endpoints — that’s going to be a lot of lives saved, and that’s amazing already.

But something to notice is that the control group there is conventional neonatal care.

Dean Spears: In our setting, the counterfactual of what would have happened without this programme — and what probably is happening in other districts — is that there just isn’t the space or the staff to provide conventional neonatal care to many of the babies who need it, to these low-birthweight babies. Remember, this is a hospital where there are a lot of births each day. And so because this programme increased the staffing and the management and the space that was available to the paediatricians and available to these babies, it would probably have had an even larger effect than in the places that would be in the Cochrane Review, where they were able to compare kangaroo mother care straight to conventional neonatal care.

It’s also the case that studies like this happen in places that can do studies like this, which is probably going to be a little bit more advantaged of a population.

Luisa Rodriguez: Yeah. So is it the case that we just don’t have evidence where the control is what you’d see in Uttar Pradesh otherwise, or at least in this kind of underprivileged hospital where maybe these babies aren’t even getting special attention despite being so small?

Dean Spears: We have evidence. We have evidence of how many babies with these properties die. So there’s a study in a WHO journal of low-birthweight babies in Dhaka, looking at ones that would have been comparable, and would have been the same weight range, and they’re finding that more than a quarter of babies die that would have been in a comparable weight range in that study.

So we know what happened in Mozambique when they were implementing a kangaroo mother care programme in 2000 — and they were able to do it in some ways, yes; in some ways, no — and the babies who ended up getting this kangaroo mother care in Mozambique were 50 percentage points, half more likely to survive. And 70% of the ones who didn’t get it died.

And you can look at demographic and health surveys and just observational studies and see that there is a lot of neonatal mortality amongst babies who don’t get this care in poor country settings and are low birthweight. And you can see that the survival rates in our programme are a lot better. The way that we think about it is that it could be a third of these babies dying in the absence of the programme, and it’s a lot less with it.

Luisa Rodriguez: Right. So I’m curious: what is our best guess at the ballpark number of lives that your programme is able to save, given we don’t have perfect information, but we have pretty good information about what this intervention can do and how bad the problem is in this area?

Dean Spears: So we know that the neonatal death rate for the babies in the programme is 11%, and we think there’s good reason to think it would be in the ballpark of a third without the programme — you know, if you look at data from before or data from demographic surveys. So I like to think that a floor is 10 percentage points of survival: that this programme probably has a 10-percentage-point effect on survival.

Luisa Rodriguez: And how many babies are in the programme?

Dean Spears: When we first did our cost-benefit calculations, we were averaging 11.5 babies a week coming in. And then a few months ago, when we redid them, it was up to 16 babies a week. More people are coming to the programme, more people are hearing about it. We’re doing a better job of getting families to stay. So we think there’s a pretty good chance that the programme is preventing a neonatal death per week on average, and maybe more than that.

Luisa Rodriguez: That’s just very moving.

Dean Spears: It is moving. I feel grateful to get to be part of it, and to get to, in a small way, support these moms who put a lot of effort into staying in this ward, day in, day out. It’s hard, it’s boring, it’s scary. The nurses who show up and do it, and not just in the hospital, but on the phone calls to the families after they leave, and the visits out to the village. It’s a great team of nurses with great paediatricians behind them. And it is moving.

Sometimes we get a picture from the graduations. A graduation is when, as part of the home visit programme, a nurse goes out to the baby’s house in the village to take the baby’s weight one last time and collect the stuff — get the kangaroo mother care wrap back, maybe get the scale back, whatever we’ve let them borrow — and do the final entry into the statistics and take a picture. And sometimes in these pictures, the mom is pretty stoic in the picture, because taking a lot of pictures from nurses from a government hospital is not an everyday occurrence for them. But sometimes you really see a smile — and you can see how grateful the mom is for this baby who started out looking so little, and by the time of a graduation, would finally have a little bit of chubbiness to it. It is really moving to see these pictures from the graduations as they come in from the nurses.

Luisa Rodriguez: Nice. Yeah, that sounds really special. Talking a bit more about the concrete evidence that we do have: so there are these benefits that we have on the mortality front, but then there are also benefits on the morbidity front. I think probably we should really acknowledge that those are real and important benefits too. So what do we know about that? What is the impact of KMC on morbidity?

Dean Spears: Right. So paediatricians who work with low-birthweight babies know the sorts of things that low-birthweight babies die of: hypothermia, being too cold, is an important predictor; infection, sepsis is an important predictor. And so when the Cochrane Review was studying the benefits of kangaroo mother care for survival, it would only be credible that there’s an effect on survival if you’re also seeing an effect on the sorts of steps along the way, the things that we know are the real signs of a risk for a baby.

So yes, they find the overall one-third reduction in mortality, but they also see the steps along the way that an average baby in the Cochrane Review studies was only half as likely to have one of these severe infections, they were a lot more likely to avoid that really big threat; and they were only about a quarter as likely to be hypothermic, to be too cold. That’s a really big reduction: they’re 28% as likely to be dangerously cold after experiencing kangaroo mother care. So we see the sorts of benefits along the way that make it plausible that there’s a mortality benefit.

Luisa Rodriguez: OK, so it’s the kind of evidence that again contributes to this overall evidential picture that it’s pretty clear that this has big impacts, and we’re not just seeing magical reduction in mortality, we’re also seeing the kinds of things that could have caused that mortality going down.

Longer-term outcomes [00:32:14]

Luisa Rodriguez: I’m curious if studies find any impacts on longer-term outcomes, like cognitive development in childhood or even income later in life?

Dean Spears: I often hear this question of: if you prevent a neonatal death amongst a premature underweight baby, is it going to go on to have challenges or irregularities later in life? I was born at 29 weeks. I was born 10 weeks premature. And I guess, listeners, you might wonder whether this guy has irregularities later in life, but I’m actually pretty grateful to be alive.

And the evidence is that, insofar as we know that, people do what’s called “non-inferiority studies” of whether babies who are getting this sort of intervention end up worse on other dimensions, like neurological dimensions later on — and there doesn’t seem to be any evidence that getting kangaroo mother care is bad for you, in the sense that you end up worse than another baby as a developing child.

Now, that’s about kangaroo mother care. About low birthweight, you’re absolutely right that one of the reasons that an economist like me thinks and cares so much about the size of babies is because the size of babies is a very important predictor of not just health, but human capital accumulation: being able to go to school and learn from it, being able to be a productive adult all through life.

So I like to say that my favourite economic development statistic isn’t GDP per capita; it’s the average height of children. Because a place where the children are taller is a place where we know that good things are happening in terms of early life health, and where we can look forward to seeing them growing up to be healthy, productive adults with higher human capital. So birthweight in particular, and the size of children in general, is enormously important for economic development and human development. But there doesn’t seem to be any evidence that by keeping these babies alive, we’re causing harm or slating them for bad lives.

Luisa Rodriguez: Sure. The not-causing-harm thing makes sense to me. But yeah, I’m interested in this overall question of whether, not only are you saving this baby’s life, but are you also potentially giving them longer-term benefits? Like, maybe because they were really hungry or really cold as a baby, their cognitive development suffered, or maybe they would have had some slightly worse overall cognitive development trajectory that would have made them worse off in the long term?

And there’s maybe a hint at evidence in that direction from the fact that you’re saying height is an important predictor of how well a particular child or adult is doing, but it also seems totally possible that the actual reason that height is such a good predictor is because it goes along with other things like the income of the family that the child is born into.

So the thing I’m really curious about is: if you make it less likely that this infant starts out life really underweight, really cold, more likely to have infections, then are they likely to have these lifelong benefits? Or is it the case that they’re more likely to be healthy when they’re babies, and that is wonderful, but they’ll still have difficult lives because of the underlying circumstances that led to them being low birthweight? And those things are all still present. Does that make sense?

Dean Spears: I’m glad you asked about that, because that’s the sort of question that got me thinking about children in developing countries. I was interested in the effects on the survivors of being exposed to things that might harm a kid’s health in early life. I got into this because I was wondering about the average height of children in India compared to other developing countries. Children in India are shorter — and that has to be a story about survivors, because you’re only measuring the height of the survivors. So it really is a really important area in the nutritional literature and the development economics literature and the public health literature — just how important these early-life markers of growth and development are for subsequent outcomes like learning and productivity.

Now, if we think in our case, where this project in a government medical college is doing this intervention to prevent neonatal deaths, we can divide the babies who they’re helping into three groups. There’s the group who unfortunately would have died without the programme and unfortunately still die with the programme — so the ones who still end up dying, and that’s a smaller group than it otherwise would have been. There’s the middle group, who would have died without the programme and who now survive — and that’s the great and most important benefit of the programme. But there’s also going to be some babies who get the kangaroo mother care treatment who would have survived without the programme and survived with the programme — and those babies are going to be healthier and stronger; they won’t have been exposed to as much infection; they probably do have faster and better weight gain than they would have had without the programme.

And it would be a very long-term and very expensive study to track those all the way into adulthood. But from everything we know from the public health and demographic and economic and nutritional literature, a baby that’s getting less infection in neonatency and better nutrition in neonatency is going to grow up to be healthier and achieve a little bit more of its height potential, and a little bit more of its cognitive and learning potential, and maybe even live longer in older adulthood.

So for that third group of babies, when we do our cost-effectiveness computations, we’re not counting them as a benefit — we’re just counting the survivors — but it probably is helping those babies who would have survived otherwise have better, healthier, richer, and more productive lives.

Luisa Rodriguez: Yeah. I guess, as you said, it would take an incredibly expensive and long-term study, and we probably won’t actually ever know this with certainty, at least not anytime soon. But it sounds like there’s at least some theoretical reason to think that those babies who might have survived but are getting extra care might lead them to be stronger and healthier, and those effects might last.

But it also seems really hard to tease that apart from something else. Like babies who get better nutrition and other general support that leads them to be taller, it might just be that they get that better nutrition and support throughout their lives, and that long-term effect is what causes them to be taller and better off.

Dean Spears: Right. It’s a long-term effect. What I would say is we know from a lot of studies, many of which are very careful and persuasive about cause and effect, that having better health and nutrition in early life leads to important long-run benefits. And so while we don’t have all of the dots connected from this intervention — none of these babies are 20 years old yet; we don’t have all the dots connected for this particular intervention — it would be completely consistent with all of that high-quality evidence about cause and effect if improving the health and nutrition of these babies also led to really big benefits for later health, for childhood learning, for adult productivity, in all the ways that we know that early-life wellbeing matters.

Luisa Rodriguez: Yeah, OK. That makes sense to me. And I agree it seems at least like a totally reasonable possibility, and I hope it’s true.

Are there any benefits we haven’t covered yet? We’ve talked already about hypothermia, sepsis. Obviously the huge one is reducing the risk of death and then potentially these longer-term benefits that are a bit hard to know whether they’re happening or not, but hopefully are. Are there any others?

Dean Spears: Well, when we think about the cost effectiveness of this programme, we’re basically valuing the neonatal survival. But I have to think that there are important benefits for the moms and the families, of their babies being more likely to be alive, and having this supportive experience where after you give birth, there are nurses and ward assistants who are there to help you and make sure that you eat and make sure that you’re taken care of. If the counterfactual is not as good of an experience for the moms, then that’s a benefit that counts too.

Luisa Rodriguez: Nice.

GiveWell’s support and implementation challenges [00:41:13]

Luisa Rodriguez: OK, so based on the programme’s costs, GiveWell found that your programme is able to save a baby’s life for just $2,500 per life saved, which is incredibly cost effective. How did this happen? How did GiveWell end up evaluating you? How’d you get put in touch with them?

Dean Spears: This is really amazingly cost effective. And GiveWell had a suspicion that kangaroo mother care could be. Before they had heard of us, and before this project had even started, GiveWell had done a deep investigation of kangaroo mother care, and had concluded that it really looks like it could be very cost effective.

But the problem is, just like with so many things in policymaking in developing countries, it looked like it just wasn’t going to actually happen and be implemented. This is a well-known challenge. Some of the first randomised controlled trials in development economics were about getting teachers to show up for school in government schools in India, or getting nurses to show up for work.

So it’s a well-known challenge, and this is one case of it: GiveWell had concluded that kangaroo mother care looks life saving, and it wouldn’t be surprising that if somebody implemented it, it would be amazing. But it looks like there are really serious implementation challenges, and just announcing a programme or drawing up the guidelines might not be enough to make it happen. So they wrote up a review to that effect on the internet and put it out there.

A little while later, they got an email or a call from another contact in the philanthropic world that said, “We hear about this government medical college in Uttar Pradesh where there’s a project, and they claim that they’re implementing this, and doing it cost effectively and saving lives.” And to the credit of the folks at GiveWell, they were eager to change their mind and learn that it could be happening. They wanted it to be, right?

So we started a conversation with them, between this programme happening in Uttar Pradesh and the folks at Givewell who are experts on kangaroo mother care. We sent them a spreadsheet about how many babies are passing through the programme; we sent them a spreadsheet about what happens with those babies; we sent them a spreadsheet about the costs and the money that we spend. And we sent them a spreadsheet, and we sent them a spreadsheet…

And it sort of all made sense that it was having a big effect, because the programme was being implemented. So what we had been able to do, that might have been hard or challenging in other circumstances, was to build this professional culture amongst the nurses and the paediatricians who were leading it, and get everybody on the same page of providing and managing and staffing professional nursing care,and getting the parents to come and be involved too.

So when GiveWell saw that, they wouldn’t have been surprised, given all of the medical evidence out there that that’s saving lives. So we were delighted they made the decision to fund the programme, and that meant that we were able to keep going and continue to meet payroll. Most of the expense is just the nurses, and making some other investments in a refrigerator and a car to drive out to the villages, and things like that.

Luisa Rodriguez: Yeah. What exactly was the implementation challenge that GiveWell was worried about, and how specifically does your programme get around it?

Dean Spears: So there’s a more concrete answer, and there’s a more conceptual answer. The concrete answer about the implementation challenges is that this is a public hospital where 30 babies a day are born. And one amazing thing that’s happened is that a lot more babies are being born in facilities, rather than at home, than used to be the case. So when I started working with demographic data about India from their 2005 study, about one in five babies in Uttar Pradesh were born in a facility of some kind, any kind, rather than at home. Now it’s flipped: it’s more than 80%.

So a lot more babies are being delivered in institutions. And that’s really good: the mom gets obstetric care, the baby gets early-life vaccinations, vitamin K injections, maybe some slight encouragement to breastfeed, and that’s a lot better. That’s one of the ways in which the world is getting better.

It also means that 30 babies a day are born in this government medical college, and they’re just not going to be able to have the staffing and the attention to focus on all of the good that they can do. So the government of India’s kangaroo mother care guidelines are excellent, and they do outline what should happen. It’s just going to be really hard in practice to make something like that happen for all the babies who need it, when there are so many babies and moms coming through, and getting the care that they need to get with the staffing that they get. So in that sense, it’s not a surprise, given all of the demand, that there’s more good that could still be done.

Luisa Rodriguez: Yeah. So the hospital staff, do they not know what the guidelines say? Do they not have time to implement the guidelines, because it takes time to explain KMC, or to give lactation support? Or is it something else?

Dean Spears: There are just a few paediatricians who work there, and they had just a few nurses working with them. And that’s just not going to be enough for this many babies. The government of Uttar Pradesh recognises this; the Department of Medical Education is working hard to open more new medical colleges and new nursing colleges. And hopefully one day that’ll happen, or one day when all of that happens, that’ll be a lot better for these babies. But there wouldn’t have been enough staff, and there aren’t in other places to make this happen.

Luisa Rodriguez: OK, that makes sense. So that is kind of the problem that this programme through r.i.c.e. is trying to solve.

Dean Spears: It’s a good problem to have when a lot more babies are being born in facilities. Most of them are getting what they need, but the ones in this birthweight range aren’t.

Luisa Rodriguez: OK, so that’s the concrete problem that r.i.c.e. is trying to solve. What’s the more conceptual one that you alluded to?

Dean Spears: The more conceptual problem is that there are well-known market failures and incentive problems in healthcare. That’s something that every health economics class starts with. And that’s why a really positive development in development economics has been investigating when it would be better to just give families cash instead of paying for programmes, and why we think this isn’t one of those cases. Because you’re not just going to be able to go out and buy this sort of healthcare, and that’s because of these market failures.

So part of that is what economists call “information asymmetries,” where families might not know that their baby faces a threat, and they might not know the threat that it faces. A huge part of the work that the nurses in this programme do is helping families understand the challenge, and that it can be helped, and motivating them to participate.

So that’s one reason why it might not have happened independently: because people wouldn’t be clamouring for this to happen, because they wouldn’t know that their babies had a problem that needed solved.

Another reason more broadly for why this doesn’t exist: it wouldn’t have to be in the government clinic; why wouldn’t this have already existed from a private provider, for example, you might ask? But the challenge there too is getting right back to these market failures in health economics: what a private provider has incentive to do is get customers and provide the appearance of medical care. But if there isn’t the right culture or regulation, then they might not actually be doing that much good. And a stunning fact about the statistics of early-life death in Uttar Pradesh is that babies born in private facilities are more likely to die at the start of life than babies born in public facilities.

Luisa Rodriguez: Oh my gosh.

Dean Spears: Even though it’s richer families, healthier families paying money for it. So something’s really going wrong at the care of these private facilities in Uttar Pradesh. So that’s not going to solve the problem; that wasn’t going to be there either, for the same basic reason of market failures in health economics.

The third reason that I think about why this wouldn’t have otherwise been happening — and I think it tells us something that could be important to anyone who’s trying to do something like this — is what microeconomics would call a “coordination equilibrium”: where I might want to do good, you might want to do good, but the good can only happen if we both do it together. So if we’re not on the same page of both doing it at the same time, then there’s no opportunity for me to solve the problem by myself; there’s no opportunity for you to solve the problem by yourself.

And the way that this is a coordination equilibrium is that I think the paediatricians there wanted to be providing better care, but it doesn’t make sense for them to do it if they’re not going to have the nursing staff and not going to have the patients. I think families want their babies to survive, but they just might not understand that they’re going to be able to get this medical care. And if one family just shows up all by themselves, nothing’s going to change. And these great nurses who the programme employs, who went to nursing school and want to do good things, they want to be able to have a job where they can do good work.

So all of these things sort of need to happen at the same time, in a context where the leadership of the medical college is excited and the state government is excited. So putting together all of these pieces creates what economic theory calls a coordination equilibrium, where it’s reinforcing to everyone that it’s all happening.

And so why did this programme happen? Because it got coordinated into happening, and once it started going, it reinforces one another. I think that happens a lot in international development, where situations stay worse than they could — because that’s a coordination equilibrium — and they could be a lot better if there could be another coordination equilibrium.

Luisa Rodriguez: Yes, that makes sense, and is a sad thing, but I guess also an opportunity.

How can KMC be so cost effective? [00:52:38]

Luisa Rodriguez: Getting back a bit to the cost effectiveness of this programme and to GiveWell’s support for it. As I understand it, GiveWell’s $2.5 million grant was intended to cover the programme for five years, including an evaluation of the programme, which is very cool and exciting. But it sounds like you have room for more funding than you expected. How is that?

Dean Spears: Yeah, let’s talk about that cost-effectiveness number. The highly cost-effective things that you might be familiar with include maybe giving out insecticide-treated bed nets to save lives against malaria. And one of those nets I think costs on the order of $5. But if you give out a lot of them, then the low probability of saving a life for each one all works out that you can save a life for something in the low thousands, right?

This is a different way of getting to a cost-effectiveness number in that ballpark. It costs our programme about $5,000 a week to run. That’s the cost of staffing and management and some supplies. So when we did our cost-effectiveness computations, at that time, we were able to have about 11.5 babies a week passing through the programme. That works out to $430 per baby of average cost. So the average cost of the programme when we did the cost-effectiveness calculation is $430 per baby.

Now, how you get from that number to a cost per life saved depends on how many lives the programme is saving. Here is one sort of really basic way to think about it: a plausible bound for saving lives is that is one in 10: a 10-percentage-point difference in neonatal mortality, like on the order of one in 10 lives are being saved. I actually think it’s better than that, but that’s going to make the math easier. And a plausible bound for the cost is in the hundreds of dollars per baby. So hundreds of dollars of cost per baby times one in 10 lives saved gets you a cost in the low thousands of dollars per life saved. And that’s basically the whole story of the cost effectiveness.

But going forward, the programme is helping more babies than 11.5 per week. So that means a few things. It means that there’s an opportunity to put more funding to good use in order to really reach all of the babies who are appearing. Babies from the smaller clinics are coming instead, we’re catching more of them that pass through. We’re persuading more families to stay instead of leaving. For all of these reasons, more babies are coming. So that means we need more nurses.

Now, the good news is, in economics we have average costs and marginal costs. The average cost is the average cost per baby — that’s that $430 number that I said before. The marginal cost is the extra cost of reaching another baby. And this is a programme where there are lots of scale effects. Once we have a manager who is organising the shifts of which nurse is on home visits and which nurse is on the overnight shift — and believe me, this is a big and thankless task — but once we have that nurse doing it, that is done. So the marginal cost of helping another baby, we don’t have to hire another person to do the scheduling, so chances are the marginal cost of helping more babies is even lower than that $430 average cost.

And so we’re in a situation where, on the one hand, because the programme is successful in attracting more demand, and doing a better job of finding the babies that can be helped, we’re able to help more babies than we thought would be the case. On the other hand, we’re probably helping or treating the marginal baby for less expensively than the average baby.

So that means there’s a real opportunity here to cost effectively save lives. So if a listener out there is eager to find a way to make a cost-effective, life-saving donation in a place where there is an opportunity to absorb the funding and put it to good use, riceinstitute.org — and we think we have that right here.

Luisa Rodriguez: That is really exciting.

Programme evaluation [00:57:21]

Luisa Rodriguez: OK, so pushing on a bit: you’re also doing this evaluation that GiveWell funded. How’s that going? Do you have any results yet?

Dean Spears: We don’t have any results yet. Some excellent medical professors in Lucknow, Uttar Pradesh, along with the staff of this government college and the leadership of it, are excited about putting together a team that’s going to do a matching-based impact evaluation of going to government medical colleges in nearby districts and looking at babies that have the same observable properties — so the same gestational age at birth, the same birthweight, moms that are observably comparable, the same birth order and things. And these variables explain a lot of the variation in early-life survival, so if we can match on these variables, we won’t have a randomised controlled trial, but we will have a pretty good idea of what’s going on with comparable babies in neighbouring places — which, of course, we already have from big-picture demographic data sources.

So once we get all of that data collection machine going and running for a year or however long, to see what happens, then this collaboration with medical university in Lucknow and this government medical college and all the people involved will be able to take this situation where we have really great reason to believe that there’s a positive effect, and be more quantitatively precise about it.

Luisa Rodriguez: Nice. Cool. That sounds really exciting.

Dean Spears: But just to be clear, as long as the life-saving effect is at least as good as one in 10, then the cost-effectiveness numbers are going to be in that ballpark.

Is KMC is better than direct cash transfers? [00:59:12]

Luisa Rodriguez: So we interviewed Paul Niehaus last year about the organisation he cofounded, GiveDirectly, and he made the case that, in many cases, global health and development is better served by people just directly giving people cash, rather than trying to figure out how to deliver a specific programme to them. Why do you think that is not the case here?

Dean Spears: First off, I think he’s right that that is probably often the case. So I don’t disagree with him in any sort of big-picture way. In this case, it goes back to the fact that healthcare involves a lot of market failures.

The idea behind giving someone cash is that then they’re going to be the customers who can go out and make sure they’re getting a good product, and getting the product that’s actually valuable for them. But there’s no real way you could take the $430 that on average this programme is spending per baby, and buy something like this in the market. The private providers here aren’t providing this quality of care, or even a very high-quality of care at all: babies born in private facilities in Uttar Pradesh are actually more likely to die than babies born in public facilities in Uttar Pradesh, even though their families are better off. And then there’s just the well-known market failures of, do the parents know that they need this?

So yes, it probably is true that in a lot of cases, giving cash is a good idea — but it’s not going to provide this outcome of neonatal survival. This is a case where there’s a special opportunity of these moderately underweight babies — not the very most underweight babies, but these moderately underweight babies — where this sort of intervention of low-cost neonatal care can save their lives. But it’s not going to happen if it doesn’t happen in an organised way.

Luisa Rodriguez: Paul did talk about exceptions, where it does seem possible for organisations wanting to do good to beat cash — and where they do, I think he’s excited for people to fund those directly rather than give cash. So I wouldn’t be that surprised at all, actually, if in the end you two agree on this being a case where you can beat cash, and so you should.

Expanding the programme and what skills are needed [01:01:29]

Luisa Rodriguez: So I know that GiveWell was excited about funding even more of this type of programme, but there just aren’t many good opportunities, good versions of it being implemented. Can you imagine expanding the programme further?

Dean Spears: Yes, I think this is something that could happen in a lot of different places. A district like this is a home for millions of people. It’s the size of many Central American or sub-Saharan African countries, and nobody would think that in a country you would want only one programme like this. So there are community health centres and there are other places within the district where you could expand this programme to. This is only one of many districts in Uttar Pradesh, to say nothing of the districts in Bihar and Madhya Pradesh and other places. And so there are lots of babies in north India who could benefit from this sort of programme.

Luisa Rodriguez: And is that something that you hope to do? Do you want others to come fill that space?

Dean Spears: I think the most important thing is for hospitals and doctors to be excited about doing it. We’re partners with this government medical clinic, and they’re really the leaders here in wanting to do something exciting and improve the care they’re offering. So if there were another place in Uttar Pradesh, or Bihar for that matter, where the doctors and the leaders of a district hospital or a government medical college were excited about doing this, then yeah, that would be a place where something like this could happen.

Luisa Rodriguez: Nice. So if there were hospitals excited about that opportunity, and in theory, one of our listeners were excited about playing the role that you’ve been playing, where should they start? What would they need to know? How could they even begin to think about whether they could be helpful here?

Dean Spears: It would have to start with the hospital. And the thing that could make it happen is an organisation that would provide the management to hire nurses and the support staff for them and make them happen. So it’s a lot of management. At r.i.c.e., we are not nurses, we’re not doctors — we help the nurses and doctors do the great work that they do. And that is pretty nitty gritty — doing the hiring, making sure there are the resources, doing the scheduling and the staffing — so it has to be somebody who had an aptitude for that sort of management, and for doing something like that while letting the hospital take the leadership of the programme and the development of the programme and the pace of the programme.

Luisa Rodriguez: Yeah. So it’s something like a lot of natural ability to get a bunch of operations-y type tasks done, and also, ideally, a way to connect a hospital like this with the resources to support these hires.

Dean Spears: One of the people who we work with, Nikhil, is just one of these natural leaders of operations tasks. We happenstantially met him more than a decade ago. We were driving from one place to another and we stopped in to see a nutrition programme about double-fortified salt, and we saw such a great job Nikhil was doing on that. And the r.i.c.e. team has been collaborating with Nikhil ever since, and he’s been making wonderful things happen. The first most important people making this programme happen are the moms and the nurses. The second most important people making this programme happen are the doctors and leaders of this government college. But Nikhil, if you’re listening, he’s the next most important ingredient in making this happen. And he has amazing management and operational skills.

So to do something like this, maybe not a kangaroo mother care programme, but maybe something in someplace, what you need are those sorts of real skills of management and people. You also need an important humility in your place in somebody else’s system — in this case, the medical college’s system. And you need experience getting things done in disadvantaged parts of India, which at a bare minimum involves language skills like Hindi, but also very pragmatic skills.

Luisa Rodriguez: Yeah, makes sense. Is there anything else you’d want to flag to someone who is interested in trying to expand something like what you’re doing?

Dean Spears: Well, this isn’t exciting in the same way that some of the things you might hear about on The 80,000 Hours Podcast are exciting. This isn’t about AI risk or new forms of currency. This is about hiring nurses, planning their shifts, planning who’s going to go on leave for which religious holiday or wedding at which time, and who has the night shifts and who has the village shifts, and who’s happy about that and who isn’t happy about that, and making sure that they have their food, and making sure that they have their supplies — and doing that all again next week, and doing that all again the next week.

So if you think that you can do that, if that’s the skill for you, then find a way to contribute that management skill to making something amazing happen — either KMC or one of the other things where coordinating a great new programme and overcoming these coordination constraints can really cause something wonderful to happen.

Fertility and population decline [01:07:28]

Luisa Rodriguez: OK, turning to a completely different topic: you’re coauthoring a book on fertility and population decline. And the basic idea of the book is that population growth is going to continue until around 2080, at which point it’ll peak, and then it’s apparently going to shrink. And supposedly it’s not going to plateau — it’s going to keep shrinking — which I find really weird and counterintuitive and hard to believe. Why is that?

Dean Spears: So at the beginning of this podcast, I told you that Uttar Pradesh is a place with some of the highest neonatal mortality rates in the world. So you might think that birth rates would also be very high there. But in fact, the total fertility rate in the most recent demographic survey from Uttar Pradesh was only 2.4 births per woman on average. And since the amount that is required to hold the population size stable is a little bit more than two, that means even Uttar Pradesh, a place where neonatal mortality is high, is getting close to that stabilising birth rate.

Is it going to stop at two? Well, probably not, because it hasn’t stopped at two anywhere else. Two-thirds of people around the world live in a country where the birth rate is now below that level that would stabilise the population. And if you look in these demographic surveys from India, even young women in Uttar Pradesh say on average they want 1.9 children. So the world is moving towards low birth rates, and even Uttar Pradesh is no exception.

Luisa Rodriguez: Yeah. I guess I can still imagine people finding it really counterintuitive that even if you get below two, why wouldn’t you expect this to plateau at some point? How small could the population get, realistically? I think when I first read this article, I had the reaction that surely there must be some bottom, some plateau?

Dean Spears: Well, humans reproduce sexually, and so as long as that’s the case, it’s going to take two grownups to make one kid. And so if two grownups aren’t on average having two kids, or each grownup isn’t on average having one kid, then the size of the population is going to get smaller. So as long as you think it’s plausible that the world could converge towards a situation where, on average, the whole world is having less than one kid per grownup — and as long as you think it could stay that way — then the size of the world population could fall.

That might be surprising, because you’re used to the idea that the size of the world population is growing fast. Now, it’s growing more slowly now than it was last decade, and growing more slowly last decade than it was the decade before that.

But even during that whole time when the size of the world population has been increasing, birth rates haven’t, over any long period, been going up. The reason that the world’s been getting more populous is because mortality rates have been falling: we’ve all been doing a better job of keeping one another and our babies alive because of programmes like neonatal health care. So it shouldn’t be that surprising that the population size could fall once birth rates get low enough that the number of human deaths per year is greater than the number of human births per year.

Luisa Rodriguez: OK, yeah, that does make sense. How small could the population get?

Dean Spears: Nobody knows. And one of the reasons why I think it’s important to be having a conversation about birth rates and population size is exactly because it could be an unprecedented future. If we do have a future where birth rates are below two, and no other future looks more likely, then that would cause exponential population decline. So what I think is important is to start a conversation now about these questions, so that we can all be part of understanding what to expect and what to think.

Luisa Rodriguez: To make this more concrete, the population peak is meant to be around 2080. And then after that, how quickly does this decline happen?

Dean Spears: It depends on exactly what happens to birth rates. So the UN projects a peak in the 2080s, but other demography groups predict an earlier peak, in fact. What will happen after that depends on exactly where birth rates go. The size of the world population quadrupled over the past 100 years. The same exponential math could apply afterwards.

Now, you might be thinking, this isn’t going to happen for a few decades, so there’s no immediate crisis. And I think that’s right. I don’t think that what we should be doing is declaring a crisis or an emergency. I think what we should be doing is starting a conversation about this, just like you and I are doing.

A lot of the people who talk about low birth rates in public are using that as an excuse to further some sort of agenda of nationalism or exclusion or inequality or control. And it makes sense that people would be very worried about a conversation about birth rates and global depopulation because of those voices. So here’s my message: don’t leave the conversation to them. Join the conversation.

Luisa Rodriguez: Right. OK, nice. I like that. I guess I actually can hear other people who might be listening to this conversation and deciding what they think about it, thinking that depopulation could be good — maybe it’ll help with climate, maybe it’ll help with other problems in the world. Do you buy this?

Dean Spears: I don’t think it’s right to think that population change is going to save us from our environmental challenges. I think that climate change is not merely a potential crisis: climate change is an actual urgency, and we need to be working on it right now. Nothing that’s going to happen with population size is going to happen quickly enough to be a solution to our environmental challenges. And so for people out there who are thinking depopulation will in some sense buy us out of having to decarbonise quickly: no, we need to be decarbonising long before we’re going to be hitting these population peaks. Let’s do that now. And while we’re working on decarbonising, start a forward-looking conversation about the future of population.

Luisa Rodriguez: I guess regardless of whether depopulation is going to solve our problems now, I don’t think it’s obvious to lots of people that major depopulation is necessarily negative. But is there a reason to think that it might be?

Dean Spears: I think that’s right, that it’s not obvious. So in writing this book, we’ve thought about a lot of different perspectives and a lot of different things it’s going to impact. One very important question is gender inequality, and the fact that there’s a sad history of coercion, where governments around the world have tried to control people’s most private decisions. If changing birth rates turns out to be a situation where people call for more of that coercive control — and it’s not just an if; we already hear people saying things like that — that attempt to coerce people’s private decisions would be a crisis and would be a tragedy. So one reason to start talking about it now is to not leave the conversation to the people who would be advocating those sorts of things.

More broadly, there’s a lot to think about: there’s the consequences for the environment, there’s the consequences for gender inequality, there’s the consequences for global health and poverty, there’s the consequences for the economy. The fact that when we all work together, we can do great things. And I think amongst all of those, one consequence to think about is the value in getting to live a life, and if we think it’s better when more people get to be alive and enjoy a good future.

Those are hard questions. And in this book, we don’t pretend to have all the answers — but we do think that those are questions that more people should be engaging with, so that as we go towards a world of lower birth rates, all of those perspectives on all of those questions are part of the conversation.

Luisa Rodriguez: OK, well, we will leave this here for now, and hopefully come back to it when your book comes out in 2025.

What advice Dean would give his younger self [01:16:09]

Luisa Rodriguez: For now, a final question: what is a piece of advice that you wish you could give to your younger self?

Dean Spears: My younger self didn’t really know how things were going to go for me, and my present-day self looks back and sees a lot of surprise. I think the situations where my friends and collaborators and I have managed to sometimes accomplish something, it’s often been pretty surprising and serendipitous. So I think one piece of advice is to be looking for that serendipity and have openness to the randomness. When you have a success, don’t take it too seriously.

Another piece of advice is to have the friends and collaborators who are going to be able to take advantage of that with you. I told you about meeting Nikhil randomly at a programme; or Mike, my collaborator on the book about birth rates, who happened to be my cubicle mate in grad school; or just so many of the collaborators in the r.i.c.e. family — and all of it are people who I’ve met happenstantially, or we’ve taken advantage of something randomly together.

So I think Pablo Picasso said something like, “Inspiration strikes, but it should find you at work,” or something like that. I would say, yes, inspiration and randomness happens — and when it comes, be sure that you have the friends and the teammates that you can take advantage of it with. Because I know that if I didn’t, I wouldn’t have been able to do such useful things.

Luisa Rodriguez: Nice. I like that. My guest today has been Dean Spears. Thank you so much for coming on, Dean.

Dean Spears: Thank you.

Luisa’s outro [01:18:00]

Luisa Rodriguez: If you want to learn more about other GiveWell-recommended interventions, I strongly recommend Rob’s interview with Elie Hassenfeld on two big-picture critiques of GiveWell’s approach, and six lessons from their recent work.

All right, The 80,000 Hours Podcast is produced and edited by Keiran Harris.

The audio engineering team is led by Ben Cordell, with mastering and technical editing by Milo McGuire, Simon Monsour, and Dominic Armstrong.

Full transcripts and an extensive collection of links to learn more are available on our site, and put together as always by Katy Moore.

Thanks for joining, talk to you again soon.

Learn more

Global health

Founding effective nonprofits (international development)

Academic research

Policy-oriented government jobs

Related episodes

October 18, 2021

#113 – Varsha Venugopal on using gossip to help vaccinate every child in India

Listen now

June 2, 2023

#153 – Elie Hassenfeld on two big picture critiques of GiveWell's approach, and six lessons from their recent work

Listen now

March 21, 2022

#124 – Karen Levy on fads and misaligned incentives in global development, and scaling deworming to reach hundreds of millions

Listen now

October 22, 2021

#114 – Maha Rehman on working with governments to rapidly deliver masks to millions of people

Listen now

July 12, 2021

#105 – Alexander Berger on improving global health and wellbeing in clear and direct ways

Listen now

July 16, 2018

#37 – GiveWell picks top charities by estimating the unknowable. James Snowden on how they do it.

Listen now

August 13, 2020

#84 – Shruti Rajagopalan on what India did to stop COVID-19 and how well it worked

Listen now

October 26, 2023

#169 – Paul Niehaus on whether cash transfers cause economic growth, and keeping theft to acceptable levels

Listen now

About the show

The 80,000 Hours Podcast features unusually in-depth conversations about the world's most pressing problems and how you can use your career to solve them. We invite guests pursuing a wide range of career paths — from academics and activists to entrepreneurs and policymakers — to analyse the case for and against working on different issues and which approaches are best for solving them.

Get in touch with feedback or guest suggestions by emailing [email protected].

What should I listen to first?

We've carefully selected 10 episodes we think it could make sense to listen to first, on a separate podcast feed:

Check out 'Effective Altruism: An Introduction'

Subscribe here, or anywhere you get podcasts:

If you're new, see the podcast homepage for ideas on where to start, or browse our full episode archive.

On this page:

Highlights

Why neonatal mortality is so high in Uttar Pradesh

Evidence of KMC's effectiveness

How cost effective is KMC?

Is KMC better than direct cash transfers?

Articles, books, and other media discussed in the show

Transcript

Cold open [00:00:00]

Luisa’s intro [00:00:42]

The interview begins [00:01:58]

Why is low birthweight a major problem in Uttar Pradesh? [00:02:45]

Neonatal mortality and maternal health in Uttar Pradesh [00:06:10]

Kangaroo mother care [00:12:08]

What would happen without this intervention? [00:16:07]

Evidence of KMC’s effectiveness [00:18:15]

Longer-term outcomes [00:32:14]

GiveWell’s support and implementation challenges [00:41:13]

How can KMC be so cost effective? [00:52:38]

Programme evaluation [00:57:21]

Is KMC is better than direct cash transfers? [00:59:12]

Expanding the programme and what skills are needed [01:01:29]

Fertility and population decline [01:07:28]

What advice Dean would give his younger self [01:16:09]

Luisa’s outro [01:18:00]

Learn more

Global health

Founding effective nonprofits (international development)

Academic research

Policy-oriented government jobs

Related episodes

About the show

What should I listen to first?