Transcript

Cold open [00:00:00]

Sarah Eustis-Guthrie: If you think about how exhausting it is to run a new programme, then that’s assuming that it’s going to potentially be really good. Now it’s like, imagine running a new programme, but you think it’s actually not helping people that much. And assuming that you’re living in a world where there is counterfactual funding, and you really believe in that — and I do really believe in that — where people funded our project and they could have instead funded our friends’ projects, which also looked really exciting.

So I’m living in this world where I have this burden of, I feel like we have to be constantly living up to running a programme that’s good enough for that money. And if that programme is worse off, then maybe instead of sacrificing a bunch to make the world better, I am sacrificing a bunch and then actively making the world worse, because we’re not spending this money well.

We didn’t want to run a programme that didn’t work. And I think that felt so natural to us that it was surprising to us that people would think differently.

Luisa’s intro [00:00:58]

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

At 80,000 Hours, we often encourage people to make bold career moves in pursuit of greater impact — whether that’s leaving a finance career to develop software for animal welfare organisations, stepping away from a PhD to work on AI safety, or launching a global health charity.

We encourage people to make these choices knowing there’s no guarantee of success, and that things not working out — not getting that job, for example — is painful and costly. We think that taking those leaps anyways, despite the risks, is a very brave thing to do. And in addition to celebrating the instances where people have taken those risks and gotten that high-impact job, we also want to celebrate people who take the risk, but don’t accomplish the thing they set out to do; those people too have been brave and ambitious in their pursuit of impact!

In today’s episode, we’re celebrating an ambitious attempt to have a big impact that didn’t work out. I’m joined by Sarah Eustis-Guthrie, who cofounded the global health charity Maternal Health Initiative. The organisation aimed to deliver postpartum family planning services in Ghana, but after Sarah and her cofounder ran several pilots that showed the intervention wasn’t working as well as she hoped, they decided to shut down.

We talked through the full story with all its ups and downs, including:

• The evidence that made Sarah and her cofounder Ben think their organisation could be impactful and cost-effective — both from a health perspective and from an autonomy and wellbeing perspective.
• Early yellow and red flags that suggested they didn’t have the full story about the effectiveness of their intervention.
• All the steps Sarah and Ben took to build the organisation — and where things went wrong in retrospect.
• Dealing with the emotional side of putting so much time and effort into a project that ultimately failed.
• Why it’s so important to talk openly about ambitious projects that don’t work out, and Sarah’s key lessons learned from the experience.

Sarah is amazingly candid and thoughtful about all of this. I got so much out of this conversation, and I think anyone who struggles with the challenges of having an impactful career will too.

Without further ado, I bring you Sarah Eustis-Guthrie.

The interview begins [00:03:43]

Luisa Rodriguez: Today I’m speaking with Sarah Eustis-Guthrie, one of the cofounders of Maternal Health Initiative, a nonprofit incubated through Charity Entrepreneurship. Thanks for coming on the podcast, Sarah.

Sarah Eustis-Guthrie: Thanks so much for having me. I’m thrilled to be here.

Luisa Rodriguez: So you and your cofounder, Ben Williamson, made the incredibly brave decision to found a charity, and then you made the decision to shut it down — which I think, for me, would probably have taken even more courage. So we’re going to talk about the full story today, including a bunch of lessons you learned and what the experience of that was like. But before we dive in, just at the high level, why do you think it’s important to share this experience?

Sarah Eustis-Guthrie: We live in a really messy, complex world, and it is hard to get things right. And when you’re trying to make things better, often you’re going to do your best and figure out, oh, wow, this didn’t turn out the way that I hoped that it would. And when you get to those moments, I think you have this choice: you can kind of paper it over and be like, “Everything is fine,” or you can try and be upfront with everyone and say, “Hey, this thing didn’t work out. If you’re trying to make things better, maybe don’t try this thing.”

And I think there’s a lot of factors in human nature. I know that’s certainly true in myself. I don’t like talking about the times things didn’t work out. But I also think that there’s a lot of factors that are specific to development that make it hard for folks to be transparent about when things aren’t working out. And I think that’s a shame, because there’s so much that we can learn from these, I guess you could call them “failures,” but maybe just times things didn’t totally work out. There’s so much we could learn.

And so I think we were excited about the chance to talk about how things didn’t work out for us, in the hope that this could become more of a norm.

The case for postpartum family planning as an impactful intervention [00:05:37]

Luisa Rodriguez: Yeah, I love it. Let’s go ahead and dive in. So you and your cofounder, Ben, who I believe you met through Charity Entrepreneurship, explored a bunch of different potentially cost-effective interventions together over probably something like a month or more. And you eventually settled on postpartum family planning as an intervention you wanted to implement through a new charity.

Just to make sure we’re on the same page, postpartum family planning is basically an intervention that involves integrating counselling about birth control into postnatal care and child immunisation appointments to increase contraceptive uptake and reduce short-spaced pregnancies — so, pregnancies that happen one after the other. Short-spaced pregnancies come with higher chances of preterm births, low birth weights, and infant and maternal mortality, so reducing short-spaced pregnancies seems good — especially if getting pregnant very soon after having had a baby isn’t what the mother wants!

What did you understand as the basic case for postpartum family planning when you looked into it?

Sarah Eustis-Guthrie: We were really excited about postpartum family planning. That’s why we ended up picking it, as you mentioned, over some other really exciting interventions. But we thought it had a really compelling case for not only having really great benefits for women’s health, but also helping them have greater access to their own autonomy, greater ability to live the kinds of lives that they want to live.

So let me talk about family planning first. Around the world, one in 10 women of reproductive age — so that’s 218 million women — want to postpone or avert a pregnancy, but aren’t using modern contraception. So that’s what’s known as “unmet need for family planning.” And that’s a big concern, because having a kid, that’s not a minor thing: it has a huge impact on people’s lives. People have a right to choose if they have kids, when they have kids. And access to family planning is a great way to make sure that women can live the kinds of lives that they want to lead. So we think that there are great autonomy benefits there.

But there’s also health benefits, especially in low- and middle-income countries. Unfortunately, pregnancy and birth are dangerous for women and their kids in low- and middle-income countries: there’s about 300,000 deaths per year that are related to pregnancy, related to childbirth. So if you give people access to family planning, that allows them to reduce these risks.

So there’s both the autonomy benefits and the health benefits. And there’s been a lot of investment in family planning, and a lot of different ways people try to make this happen.

One context that’s really widely recommended is postpartum family planning. And what does that mean? So postpartum family planning means that you are giving women counselling and giving them access to contraceptives in the first year post birth. So for the record, when people say “postpartum,” usually that means the first six weeks, when they’re just talking about that. But “postpartum family planning” is like the first year.

So why is that an exciting time? First of all, for a lot of women in low- and middle-income countries, unfortunately, they don’t get to go to health facilities very often. It’s expensive, maybe it’s difficult to get to. But in recent years, there’s a lot of coverage of women going to health facilities at some point around a birth — maybe they’re going right before birth, when they’re doing delivery, for an immunisation checkup — so it’s a really exciting opportunity to meet women where they are.

But the main reason for postpartum family planning is that it’s actually riskier for women to give birth soon after a birth. That’s what’s known as a “short-spaced pregnancy.” Typically, the usual definition is if she gets pregnant two years after she gave birth. But all the different agencies like to kind of extend that: it’s three years; it’s whatever.

And it’s riskier for women if they have these short-spaced pregnancies. But actually, family planning usage is often way, way lower soon after a birth. So that’s a big concern. Women are at higher risk, they’re using family planning less, and it’s an opportunity when you can actually talk to them. So postpartum family planning is a pretty widely recommended intervention. It’s known as a “proven high-impact practice” in family planning by folks like WHO and Gates. And Charity Entrepreneurship looked at that, they ran some of the numbers, and they said, “Hey, we think this is a really exciting intervention.”

Luisa Rodriguez: So that all makes a lot of sense to me. But what exactly is the reason that having another baby soon after having maybe a first one is dangerous?

Sarah Eustis-Guthrie: That’s a great question. You’ll be excited to know that doctors are also wondering about this, so it’s not totally known.

Part of it is this idea of nutritional depletion. One thing to flag is that it’s a lot riskier to have short-spaced births in low- and middle-income countries than in higher-income countries, and it tends to lead to worse health outcomes. And I think generally, the idea is that if women are malnourished, or maybe they’re close to malnourished, it’s really taxing on the body to be pregnant, supporting a developing foetus, and then to give birth itself. So the idea is that if a woman gives birth really soon after, her body doesn’t have time to rebuild her stores of vitamins, even just calories, so that it leads to a higher likelihood of things going wrong, just because the body isn’t as prepared.

But this is an active area of research.

Deciding where to start the charity [00:11:34]

Luisa Rodriguez: OK, so that’s the basic picture. How did you then decide where to found this charity?

Sarah Eustis-Guthrie: That was what we spent the first three months of our time thinking about. It’s a really important question. And the way that we thought about it is you want to find the place to work that’s as cost effective as possible, but where it’s also feasible to implement it.

So we made this ginormous spreadsheet — you’ll find everyone in the Charity Entrepreneurship sphere loves spreadsheets — and we put in data on a lot of countries in sub-Saharan Africa on issues of how cost effective it would be. What that looks like is how high are rates of family planning? So all considered, you want to go to an area where there’s currently lower rates and there’s room for them to get higher. You also want to look at areas that have relatively higher maternal and child mortality, because that’s driving the effects of the intervention. You also have to think a bit about cost: is it going to be really expensive to implement?

And then you have to think about the feasibility side of things. So there’s kind of this ongoing known fact that if you just say, really for any health intervention, what country should I work in? It’s often really likely that if you do a bit of a naive thing, you’ll end up saying you should definitely work in Afghanistan or South Sudan — countries where it’s really tough to work, and unfortunately have tragically high levels of various mortalities. So you have to say, is it actually feasible to work here? Would the government want to work with me? That’s especially sensitive with family planning.

So we did this massive spreadsheet, then we ranked things, and we ended up with three top countries: Nigeria, Sierra Leone, and Ghana. Each of these countries had a different risk profile and a different set of pros and cons.

Nigeria was maybe the one that we were most excited about — but unfortunately, circumstance intervened, which is the fact that there was a federal election in Nigeria that was about to happen, and Nigeria has had some political instability. We really wanted to go visit that fall, and folks told us, “Look, it is just not safe for you to go to Nigeria right now. And there’s a decent possibility that it still won’t be safe six months after the election.” And we looked at each other and we said, we can’t run a programme and not be able to visit. So we told ourselves that if the programme works somewhere else, we can scale to Nigeria in the future.

Luisa Rodriguez: Yep. Nice.

Sarah Eustis-Guthrie: Then the situation with Ghana and Sierra Leone was that Ghana is a relatively better off country, doing better economically. That means that the cost effectiveness is potentially a bit lower, but it also means that it’s more feasible to work in and potentially much more feasible to scale in. And what we were really excited about is not a programme that works in one or two hospitals, but a programme that can scale up to cover the entire country. So Ghana, we think, had this really compelling case for we could potentially scale up, we could cover the entire country.

But Sierra Leone, on the other hand, they’re in a tough spot. They had a really brutal civil war about 25 years ago. And when you go there, it’s just apparent how much they’re struggling. So it has some of the lowest human development index in the world for a place that’s not actively in civil conflict. You spend time even in the capital and the electricity is really unreliable; the hospitals have trouble getting things like gloves and running water.

So we had these questions about whether we should work in Ghana or Sierra Leone. And we can’t decide these questions through desk research, so we ended up going on trips to visit both countries, speaking to government implementation partners — and we ended up deciding that Ghana made more sense. We felt like we had better choices for implementation partners and a better chance of having a really great programme in the medium term.

Luisa Rodriguez: OK, so you decided postpartum family planning in Ghana, maybe scaling up to other countries if it goes well.

Did you have specific hopes for how cost effective a successful charity implementing that intervention in Ghana might be?

Sarah Eustis-Guthrie: Definitely. This was very important to us: What’s the cost-effectiveness analysis? What’s that number? We hoped that it could be cost competitive with some of the most effective global health charities. And if you want the technical side of it, what that looks like is we estimated a number of about $70 per DALY averted. DALY means “disability-adjusted life year.” Basically, the idea is that for every $70 that you feed into the programme, you help someone have an additional year of healthy life.

So that’s a really exciting number. I no longer endorse that number, but that was the number we had. But not just that, we also genuinely believed that there were real autonomy and also income benefits from the programme. So we estimated that it would cost $50 through the programme to avert an unintended birth — which to me is a really exciting number when you think about how much that affects someone’s life.

And I just want to throw in here that there’s a lot of people, myself included, who sometimes critique effective altruism by saying that you often seem really focused on these interventions that are just about health — but health challenges are not the only challenges that people are facing. And so people are often excited about programmes to improve rights or improve wellbeing, but often it’s really hard to pin them down, in an evidence sense, or how expensive are they?

So I think what made me really excited about family planning was that it’s potentially this intervention where you can robustly improve people’s lives in a way that’s about more than just health.

Luisa Rodriguez: Yeah. Oh, it’s really compelling.

Sarah Eustis-Guthrie: Oh, just you wait to hear how it didn’t end up working out! But yeah, we were really excited about it.

Luisa Rodriguez: I mean, when I try to actually wrap my head around $50 per unintended birth… I spend $50 on, I don’t know, a dinner out with my husband each week, probably more often than that. And actually fully grappling with, like, there’s a person who was going to have to have a baby that they didn’t necessarily want to have, and that’s all it costs to avert that birth, it’s incredibly compelling.

How do you even start implementing a charity programme? [00:18:33]

Luisa Rodriguez: So after one makes all of those decisions, what happens next? How do you go from deciding to found a charity in Ghana to actually implementing a working programme?

Sarah Eustis-Guthrie: That’s exactly the question I was asking myself two years ago! It was pretty daunting to be in this space of, I’ve now got a bunch of money and I now get to start this organisation. Also have to start this organisation.

I think one thing I loved about my cofounder, Ben, is he’s just one of the most entrepreneurial people I’ve ever met. And so when he was faced with that question, he was like, “Cool, we’ll figure it out. You know, all we have to do is ask people who’ve done it before, think in a big-picture way, what do you have to do? And we’ll just go from there.” Meanwhile, I’m sitting there being like, “How did I get into this situation? This is terrifying!”

Luisa Rodriguez: Yeah, yeah.

Sarah Eustis-Guthrie: But we figured it out, and I do think he was genuinely right: that a lot of it is more simple than you might think it is. So if you just sit down and think, how would you start a health organisation? Well, I’m going to have to get permissions from the government. I’m going to have to figure out where I want to work. There’s a lot of really concrete questions there.

So we reached out to a bunch of potential partners. These are local nonprofits that had implemented similar programmes in the past. And once we had these partners, we were tasked with figuring out exactly what the programme should actually look like. Because going from “we want to run postpartum family planning” to building an actual programme has a lot of questions. When you look at the studies, you’ll find that postpartum family planning can look like infinitely different iterations.

And one thing that we realised is that because we wanted to devise our programming based on the evidence base, based on the studies, what we found is that studies tend to be very good at telling you the numbers about how the programme did or did not work out, but they often don’t have a lot of details in terms of what was actually in the programme. So we found that we were lucky if it would say things like, the providers were trained for one day versus one month, and then extremely lucky if they would say anything about what the providers were even trained in.

So this process involved a lot of desk research, it involved a lot of talking to experts. We would email someone and say, “We’re implementing this programme. Can you talk to us and tell us what exactly it was that you did?”

And I found myself feeling quite insecure throughout this process. I had this perennial fear that I would email people and they would say, “Who are you to found this programme? You don’t know what you’re talking about!”

Luisa Rodriguez: Totally. Yeah, I would feel the same way.

Sarah Eustis-Guthrie: Yeah. It got a bit better as time went on. I do think this was something that we struggled with, and maybe was a bit of a mistake, that we kind of perennially felt so insecure that it made us afraid to ask silly questions.

Because Charity Entrepreneurship has this model that not everyone agrees with. It gets people who are often generalist — you know, sometimes they get folks who have years of experience in a particular health programme, but often it’s people who are generalists — maybe they’re on the younger side. And Charity Entrepreneurship makes the case — and I think I believe it now even more than I did back then, because to be honest, I was a little sceptical — but they make the case that what you need is folks who are competent, who are willing to listen to experts, and will really make programming that’s based on those experts.

But you need people who are willing to make tough calls, willing to maybe relocate across the world. And in general, it can be hard to find people who are both an expert in some particular programme and who are willing to uproot their lives and do this really risky, uncertain endeavour.

So I totally endorse this model, but also I think it’s tough to be in that position of saying, “I’m on the younger side; I don’t have prior experience in this” — and meanwhile, you’re across the table from someone who has 30 years of experience and a medical degree, and you’re telling them that you want them to do things differently. So that could be a bit of an anxious part of the process.

Luisa Rodriguez: Totally. Oh, yeah. I actually just hadn’t thought of that, and I think that would be paralysing for me.

Early yellow and red flags [00:22:56]

Luisa Rodriguez: So at this point, were you having hesitations about the programme?

Sarah Eustis-Guthrie: We were starting to have some hesitations. So we initially founded it at the end of summer of 2022. We were super excited, we got a lot of funding, everything seemed to be going well. But then that fall, as we started digging into things further, there started to be some things that were concerning — in fact, quite concerning.

And one challenge for us is for things that seemed like maybe yellow flags, maybe red flags, it was hard to know how seriously to take them — because we were in this situation where we were now founding a charity in an area that neither of us were experts in, and there was so much new information. Sometimes there would be something that seemed like a big problem, and then I talked to someone and realised that’s not a problem at all. And then there would be something that seemed like a big problem, but other people maybe didn’t totally agree, and it was kind of a grey area.

I would say the first thing that was a red flag for us was related to our favourite part, of course: the cost-effectiveness analysis, our big spreadsheet where we were figuring out how effective the programme was.

Charity Entrepreneurship is the one who originally made the cost-effective analysis when they were deciding whether to support the programme, and Charity Entrepreneurship really pushes for doing research that’s as quick and actionable as possible. So they say, there’s a real tradeoff: if you take forever to do the research, then it makes things happen in the world slower. But they try to do research that’s as good as it needs to be to make things happen, and I think that often works out really well.

But I think we maybe started to enter some of the failure modes of this. So we found that we didn’t like the way that they were modelling basically the most important part of the cost-effectiveness analysis, which is how you translate from increased contraceptive uptake to reduced pregnancies. Because if you think about this — and this is going to become really important later — in an ideal world, the studies that are looking at how useful the programme is would say, “This is how much they reduced unintended pregnancies.”

But that’s hard to measure, and it takes a lot of women. And most of the studies we were looking at get around that by just saying, how does it affect the contraceptive uptake? And that’s pretty reasonable. But once you start thinking about how to convert that into the numbers of how many unintended pregnancies are reduced, it gets really challenging.

Luisa Rodriguez: Just to make sure I get that point: it’s easy to measure the impact of an intervention on the number of women who decide immediately after the intervention to start using birth control; that’s a very straightforward thing to measure. It’s much, much harder to get a sense of how many women then didn’t get pregnant, because there’s a long lag between the intervention and the women actually getting pregnant, or knowing decisively that they didn’t get pregnant. Is that right?

Sarah Eustis-Guthrie: Yeah, that’s roughly the picture. So we realised that we were uncertain in how to exactly model the translation from increasing contraceptive uptake to reducing pregnancies. But we decided that we were decently confident that the programme could be relatively useful, and that we’d wait and circle back to get the modelling exactly right later on.

Luisa Rodriguez: OK, so that was it sounds like a yellow flag, something that you thought might end up making a difference to the cost effectiveness, but that was pretty hard to reason about, especially before you’d gone a bit deeper. Were there other yellow or red flags worth talking about here?

Sarah Eustis-Guthrie: Yeah. So one interesting, kind of funny thing that happened is we ended up going on a trip to Ghana even before we decided on it as a country, because there was another family planning charity that was going on a trip. This was actually only a couple weeks after the Charity Entrepreneurship programme had ended, but they said, “Hey, we’re going to Ghana. We know you’re considering it. You want to just tag along?” So we thought, let’s tag along.

So we went on this trip, we went to some hospitals, we spoke to some experts — and we both got kind of a bad gut feeling from the trip, if that makes any sense. It’s a bit hard to pin down, but I think some of it is that we were struck by how high the baseline level of family planning access was. And to be clear, we were mostly in the capital, Accra. So that’s going to be very different from other regions of the country. But you’re just walking around, you see a billboard for family planning. Or I did this thing where I went into a bunch of different pharmacies and I asked if I could get family planning, which was a slightly awkward experience, but really interesting.

So that was in September. And then as we worked on the geographic analysis, we realised there’s actually really strong fundamental reasons to do it. Also, as people who are evidence based, we don’t want to over-update on gut feelings.

And honestly, even now I don’t really know what to do with this. I think we actually made a pretty reasonable call in still going with it, because one thing we found later, and you can see has a kind of obvious truth, is that there’s so much variation within countries. So later on, when we’d go to more rural regions, it’s like you’re in a totally different country in terms of the access. And our programme was mainly working in the northern parts of the country where the situation is totally different.

But still, in retrospect, it does make me feel a little silly to say that we had this bad gut feeling, and then in some senses, that bad gut feeling panned out.

And in fact, and I am almost a little embarrassed to say this, but what ended up happening is that we had so many doubts — the ones I mentioned, but also a number of other ones — that we sat down in that fall and we said, “Is this still a good idea? Should we still do this project?” I think we felt a lot of feelings about this, because people had been so excited about it, we’d been so excited about it — but we were starting to say, “Are we kind of in over our head? Is this less promising than we thought?”

So we sat down and did some desk research, we talked to some experts, and ultimately we said that we think that there’s still a decent chance that this is a phenomenal opportunity, and we think that we just can’t resolve these uncertainties until we actually run a programme on the ground. So let’s go run a programme on the ground, and in a year we’ll circle back and we’ll see, were we right about these uncertainties? We thought that there was a decent chance that we would say, “We were totally wrong, and this is actually phenomenal,” and then some chance that maybe we’d look back and say, “We’re fools! We should have shut down back then.” And some chance we’ll be somewhere in the middle.

And so we ended up saying that we have these concerns, but we’re going to set them aside. We’re really going to commit to running this programme.

Luisa Rodriguez: Yeah. I mean, from where I’m sitting, and from what you said, that to me sounds like a very reasonable way to reason about this. And I will ask you more about how you look at that decision after the fact. I’m sure it’ll be tempting to be like, “We were fools” — but I’m not sure that you should be concluding that.

Luisa Rodriguez: OK, so before we get to those on-the-ground tests, any other yellow flags worth mentioning?

Sarah Eustis-Guthrie: One other thing that came up is this factor of postpartum abstinence. And this is something that I’m going to talk about a lot later. But one thing that just popped up when I was literally just reading through various data on pregnancies and birth in sub-Saharan Africa was that there is a very common norm of postpartum abstinence, where a couple doesn’t have sex for a period following a birth. And in sub-Saharan Africa, the average duration of postpartum abstinence is nine months.

Luisa Rodriguez: That’s pretty long.

Sarah Eustis-Guthrie: It’s pretty long. And I read that, and I was like, “Wait a minute. I’m not a total expert yet, but if you’re not having sex, I’m pretty sure you can’t get pregnant.” And it seemed like potentially a big problem just on a very basic, a priori way of looking at this.

So the concern here — and I do think that we’ll talk about this a lot more later as we dig into this — is basically that maybe if you have a programme that’s all about increasing women’s contraceptive uptake, maybe you’re increasing that uptake among, in part, women who are currently abstinent. And that isn’t that useful, right? So you could have a programme that looks really useful — like we increased uptake for women at nine months post birth — but maybe half those women are abstinent. And so the impact on pregnancies is half of what you would expect. Something like that.

But there was very little discussion of it in the literature. So we talked to a couple experts about it, and we said, “Hey, is this a concern?” And when in those conversations, I remember thinking, I couldn’t tell if it was a really dumb question to ask or a really important question to ask, because I’m sitting there thinking, why aren’t people talking about this more? This seems really important.

And the experts were not that concerned. They were like, “Eh, it’s not a big factor. That’s only for some women.” And it is important to point out that that is a mean — so what that means is that half of women aren’t abstinent. And it is true that this whole thing is because of short-spaced pregnancies, and short-spaced pregnancies are happening; we’re confident in that. So in that sense, it’s not that big of a factor in that the pregnancies are still happening, right?

But still, this was one of the biggest red flags, where in the months to come, I would sometimes just have this thought of, “What about postpartum abstinence? We never really figured that thing out.” But we kind of decided to set it aside, mainly because we were deferring to experts.

I think it’s hard to say, when you’re in that position… There’s so many things where we didn’t have this background, and we had to decide on any given decision how much to defer to experts. We tried to err on the side of deferring more in the very beginning. And I think that’s kind of a reasonable call, just in the sense that there was so much we didn’t know. But sometimes it did lead to these situations where we’re sitting there thinking, this seems like a problem, and the experts don’t think it’s a big problem. And it’s hard to know how to square those two perspectives.

Luisa Rodriguez: Yeah, yeah, yeah. And I’m sure you have this feeling of like, “I’m a generalist.” You know, maybe this is my first trip to Ghana, and I’m learning about family planning in this in-depth way for the first time ever. And experts are telling me this is a nonissue. So is it the case that, despite being a generalist who’s very new to these topics, I’m somehow getting something that the experts are missing?

Sarah Eustis-Guthrie: What’s more likely? That I’ve made this radical discovery that the experts haven’t figured out, or that I’m just making a silly mistake? Because there were a lot of times when I just made silly mistakes.

Luisa Rodriguez: Right, right. So that sounds like a very significant yellow flag, but also one that I would not know what to do with, given that people were telling me not to worry about it.

Proof-of-concept tests and pilot programme in Ghana [00:34:10]

Luisa Rodriguez: OK, so let’s get to how you planned two proof-of-concept tests and a pilot in Ghana, hoping to resolve a bunch of these uncertainties and just narrow down on exactly which version of this thing is going to work. Can you talk through what these are and why you did them, starting with the proof-of-concept tests?

Sarah Eustis-Guthrie: Right. So in the first year of our programme, we thought about it like we were trying to resolve two uncertainties: one is we wanted to develop the best possible programme that we could, and the other one was that we wanted to figure out whether that programme actually worked.

So when we were trying to figure out what kind of programming we wanted to run in the first year, we wanted to design a plan of programmes that would both allow us to iterate a bit to try and figure out how can we make this programme as good as possible, while also giving us the opportunity to robustly test and get some evidence on how well the programme worked.

So what we wanted to do was to run programming in the field as quickly as possible — because we had the sense that we’d done a tonne of desk research, and at this point, the uncertainties were about what it really looks like in the field. And I think the other motivation for the proof-of-concepts was being realistic about this fact that we were learning how to do this as we went along, and we anticipated that we would make a bunch of mistakes — and we didn’t want to end up in a situation where we were just running a pilot to start with where we were doing all of our evidence generation, and then you’re two weeks in and you realise, “Oh no! I’ve made this terrible, obvious mistake, and now all of this evidence is useless.”

Luisa Rodriguez: Totally, yeah. Did you feel like you learned a bunch? Did it feel like you ruled some things out, made huge mistakes, changed the thing?

Sarah Eustis-Guthrie: All of the above. I would characterise charity founding as this experience of building the plane while flying the plane, while learning how to fly a plane at the same time. So for me, at least, that was simultaneously stressful and thrilling. I was learning so much and it felt so meaningful to be doing this work in the real world that was hopefully going to be really impactful. But it was also pretty stressful, because you’re sitting there and suddenly your decisions aren’t just affecting you or your coworkers, but maybe if you mess something up, someone is going to give incorrect healthcare information to a client, right?

Luisa Rodriguez: Yeah.

Sarah Eustis-Guthrie: So I would be sitting there designing the training for the healthcare providers and thinking, “Who am I to be doing this?” I dealt with a lot of those concerns by building in checks, like we would have doctors review our materials, all that jazz. But it definitely was a little bit stressful. OK, very stressful.

So in our first proof-of-concept project, we were trying to figure out a bunch of big questions. So what kind of programming did we want to run, and then where did we want to run it? So, in any country, there’s going to be a variety of types of health facilities. So in Ghana in particular, there are more community-focused facilities, where you have one in most towns or rural areas, you have these health clinics that are kind of in between, and then you have hospitals where you have a lot of folks going in.

So for our first proof-of-concept, we actually worked at two of each type of facility, because we wanted to get a sense of what it was like to work at these different facilities.

And then we also just wanted to figure out what do we want to train healthcare providers in and how is it going to turn out.

So our first proof-of-concept was pretty modest. We developed a one-day training for healthcare providers, and this was healthcare providers that work before a birth, during a birth, and after a birth.

So before birth, that’s what’s known as antenatal care, and then around labour and delivery, and then post birth. And so in Ghana, post birth includes both this first six weeks post birth, that’s the immediate postnatal care where a woman’s going to go, she’s going to get a checkup from a nurse, maybe a doctor will come in if there’s some concerns. And that usually happens at two weeks following a birth and then six weeks following a birth.

And then in that longer postpartum period, they have these immunisation clinics. These immunisation clinics in many ways are a real success story, because in Ghana they’ve managed to get it where even women who are very rural and quite poor, nearly all women will come into an immunisation session at some point. I think there’s a real belief in how this vaccine is going to help my baby. So we were excited about those immunisation sessions as a time to give that counselling, because that counselling could potentially reach even the poorest women, even women in these really rural areas.

So in that first proof-of-concept, we ran this training. We got a local expert — a nurse who also worked with the government a bunch — to run this training. And we were working with women, with nurses from all these different touchpoints. And I would say it went well. We did not focus a lot on evidence generation. We did not focus at all on evidence generation. This was mainly: Can we run a training? Do people seem to find it helpful? And I think it was generally true that, yeah, we were able to run the training, and it did seem generally helpful.

Luisa Rodriguez: OK, that went pretty well.

Sarah Eustis-Guthrie: Yeah, that went pretty well. After that first proof-of-concept, we said that we wanted to start making decisive decisions about what the programme is going to look like, and we want to run a much bigger proof-of-concept. We called it our mini pilot, that would basically look the same as the pilot in terms of what kind of care was actually being delivered, but where we wouldn’t focus a lot on evidence generation.

Because one thing to just flag here is that if you’re trying to generate a lot of evidence about a programme, especially a small programme, that evidence generation can actually be just as expensive or more expensive than running the programme itself, which I don’t think I had fully processed before this. But if you want to do surveying, where you’re surveying enough women to get a big sample size, you might have to have surveyors in the field for weeks on end. You know, you have to develop these surveys and have them deploy it versus if you’re doing a relatively light touch intervention, that might just be a one day training. So that, yeah, that was. That was a learning for me, and I think actually maybe speaks to why people sometimes don’t do a lot of evidence generation.

And so we made a couple decisions. One decision that we made is that we wanted to focus on hospitals rather than any other touchpoint. We basically made that decision because they reach many more women per day, so it’s easier to get to a cost-effective programme just because the reach is a lot higher. The tradeoff there is that they tend to be busier, maybe they have less time per person.

I think this actually reflects a lot of the choices that we made throughout the programme. We were really focused on how can we make something that’s cost effective and scalable. And we knew that there was some chance that it would be so light touch that it wouldn’t actually make the changes happen at all — but for us, because the programme was only worth doing if it was cost effective and scalable, I think that led to a different set of incentives than someone who’s just running a study and trying to make things happen at all costs.

So we were struggling a lot with this question of what specific touchpoint should we focus on in terms of when are women getting counselled, because we found that there were really substantial tradeoffs at play here. We had a sense that at that immediate postnatal care, that that was the best chance to have really in-depth conversations with women. These tend to be one-on-one appointments, and maybe a woman has 20 minutes, 40 minutes to sit there with a nurse to really talk through the concerns.

And when it comes to family planning, confidentiality is really important and really helpful, because there can be a lot of social pressures. I remember talking to one expert who said something like, in some contexts, you don’t want your neighbours to be walking by and saying, “Oh yeah, that’s the woman who’s using family planning. What does that mean?” And of course, there’s a lot of variation in the social pressures, but we were very cognizant of wanting women to have a chance where they could really go in depth to talk about their concerns.

I think this points to something larger that’s important to flag: when it comes to family planning use, experts hypothesise that some amount of women in low- and middle-income countries using contraceptives less is about not having access to start with — where if they wanted something, they might not be able to get it at the local pharmacy, or it might be tough for them to get it.

But another chunk of the lack of use or lower use comes from people having misconceptions or misgivings. So maybe they’ve heard rumours in the local community that if you use a certain type of family planning, that it’ll make you infertile, or that it’ll cause you to gain a lot of weight, or that sort of thing. So a lot of family planning programmes, including our own, have a component where they’re trying to make sure that they can address women’s misgivings.

And we were really excited about this one-on-one opportunity as a way to address those misgivings. But of course, as always, there are tradeoffs. The tradeoff here is both that there’s lower reach with that immediate postnatal care — because not everyone delivers in a facility; some women are just coming back for those immunisations — and also it’s more of a lift to get providers to add in this in-depth conversation.

If you’re thinking about a busy hospital where there’s a lot going on and providers have a lot of priorities, getting them to have this longer conversation, they might not be fully bought into that. So we were concerned. Are we going to be able to make this happen? Will providers actually do it?

And so we were comparing the postnatal care to those immunisation sessions, because the immunisation sessions offered the chance of a lot of reach. A huge chunk of women come, and many of them might come back either every month in the first year post birth, or just throughout the vaccination schedule. So there’s a couple different shots that kids get and women are often pretty good at coming back for those shots.

And so we were excited about the high reach, but were even more concerned about actually making it happen at these immunisation sessions, because if you go, and we went to them, they’re incredibly busy. You know, imagine you’re in this outdoor pavilion, because a lot of these clinics, it’s not even fully indoors, it’s an outdoor pavilion. There’s tiny babies screaming, there’s women talking. Maybe they’re trying to weigh the baby and also give the baby a shot. And the baby is not happy about this.

So there’s a lot going on and there’s a lot of pressures. So we were worried about, can we actually make this happen? And also can we have as high quality of an encounter, if you’re sitting there with the squalling baby getting the shot and all of your neighbours are nearby, do you really have the opportunity to have this in depth conversation where you can say, hey, I have these real concerns, and the provider can respond to them?

So we ended up kind of cheating in response to being uncertain: we said, let’s try both. And we sort of similarly to earlier on, with our trip and visiting both countries, we said, look, we have these fundamental uncertainties and we think the best way to resolve these uncertainties is actually to try both options and to get some real-world data on how they work out. And also because we were really freaked out by the idea of running one programme and it not working out at all. So we thought, hey, if we run two, then it has a higher likelihood of working out.

So we ended up deciding for both the mini pilot and the pilot, we’d do both of these arms: one of them at the immediate postnatal care and one of them at the immunisation sessions.

Luisa Rodriguez: Great. Did it seem like things were going well? Did you have any yellow flags at that point?

Sarah Eustis-Guthrie: Definitely. I think we felt kind of mixed as things were going. One thing we found is that our providers and our local partners loved to tell us how well things were going. They would say, “Things are going great. We’ve hugely increased the family planning uptake in this one location.” We of course had some amount of scepticism of this, because we understood how strong the incentives are — and I think real pressures, including both cultural pressures and financial pressures — for providers to feel like it’s frankly rude to say, “We have these concerns about this programme.”

This was one of the big challenges for us. What we wanted more than anything was the providers to tell us, “We have this concern about the programme. We think maybe if you changed this thing, it could go better.” But they’re there, and I don’t know exactly what they were thinking, but I think they were thinking something along the lines of, “It would be rude to say things aren’t going as well. It would be like I’m criticising their sense of authority. Also they’re paying me. There’s these financial incentives. If they think the programme’s going really well, then they’re more likely to scale it.”

So what happened is we ended up continually saying, “Please, please, please tell us when things aren’t working out.” And we’d ask questions to say, “What was one thing that went well this week? What was one thing that went poorly this week?” And we did get some genuine useful information that way, but it was a consistent challenge.

So we had some folks on our local partner team who were quite frank, and some of the issues that they were raising was feeling like the providers weren’t totally convinced of the value of adding in this additional counselling.

Partly because even if you imagine a scenario in which the programme is wildly successful, what it still involves is providers have a lot of conversations with women in which women are not at all convinced and don’t change their behaviour at all. And sometimes, some fraction of the women do change their behaviour. But what this experience often is for the provider on the ground is, five times out of six, nothing happens and they get this resistance. We actually got quite interesting, through word of mouth, words from women about this. For example, at the immunisation sessions, they would say, like, “Look, I need to get home so I can work, so that I can feed my family. Why are you making me listen to this spiel?”

And I think that gives a sense of both how some women were thinking of it, but also is an important reminder that the costs of running these programmes aren’t just the costs of what else you could spend the money on. Programmes like these impose genuine costs on both providers and just the women who are involved. So I think that’s a call to be really thoughtful about when you’re taking up people’s time. Because when I would hear that sort of thing, I would not feel great.

Luisa Rodriguez: Yeah, it’s also. Yeah, I don’t like the fact that that hadn’t occurred to me as a cost of the programme. I don’t think it’s very common for people to be like, I’m going to deliver this intervention, but I should think really hard about whether it’s worth the beneficiaries’ time.

Sarah Eustis-Guthrie: Right, absolutely. And I think this is something that has come up as we’ve talked to other people about the programmes, people who are more bought into the programmes, who have this attitude of, well, it seems vaguely useful, why not do it?

And one question is, how do you fully account for the costs? What are these costs? And I think when you’re working in a resource-limited context, you have to be particularly sensitive to this, because some of the other stuff that they’re doing is quite important for health. You don’t want to take time away from giving vital immunisations in order to do family planning. Like, the ideal is that you do both, but you don’t always live in that ideal world.

And so every week I would be exchanging messages on WhatsApp with these nurses, and as I said before, they’d often be quite positive. But it was also just really interesting to get this ongoing feedback. For example, they might message me and say, “I told eight women this week about family planning, and I was very sure to talk about all of the benefits, but most of the women told me that they didn’t need it because they were still breastfeeding or they were still living away from their husband. But next week I’ll be even more persuasive and it’ll be different.”

But I do think there’s an easy failure mode where you’re very divorced from what’s happening on the ground. By having these ongoing communications, it definitely changed my perception of how things were going, just to get this communication directly from the source of what’s going well and what’s not going well. That was quite interesting.

Luisa Rodriguez: And was that enough to make you worried?

Sarah Eustis-Guthrie: I mean, I was definitely worried. I think it’s always this balance where there’s a lot of programmes where people give qualitative feedback and maybe they’re grumpy about it. You know, maybe there’s a big vaccine push, and someone says, “I don’t want to take the time to get this vaccine” — but then you look, and it’s reduced mortality by 5%. And at the end of the day, the complaints are useful insofar as they point to wider truths, but we wanted to really wait for the data to get that sense of those wider truths.

So I think genuinely during the programme it was somewhat mixed. We had some positive signals — including some genuine positive signals, and not just fake positive signals, although always difficult to distinguish — and we had some signals that were concerning. But we were saying we’re going to reserve judgement until we get more of these results and see how things turn out.

Luisa Rodriguez: So then you wanted to actually do the version of the pilot where you kind of roll out the programme as you intended it, and actually measure your results. What was the rough setup?

Sarah Eustis-Guthrie: We did a pretty straightforward pre-post study, where we surveyed about 200 women at the facilities, but before we’d actually rolled out the programme, and we asked them a bunch of questions about their knowledge, their attitudes towards contraception, and then also their actual contraceptive use and their intended contraceptive use. So we asked them all these questions, and then we rolled out the programme and then we got a different set of women who were hopefully being exposed to the programme — at least in theory being exposed to the programme — and we asked them those exact same questions about their knowledge, their attitudes, and their contraceptive uptake.

Luisa Rodriguez: And did you have a number in mind when waiting for that evidence to come in? You’re like, we’ve got these positive and negative signals, but we’re going to wait for the evidence, and we need the evidence to say that some percentage of women change their contraception plan. Did you have a sense of where that threshold for, like, “this is good / this is good enough” was?

Sarah Eustis-Guthrie: Yeah, absolutely. We thought about this a lot and we settled on that we hoped the programme would increase contraceptive uptake by about 10%. And if it did it more than that, we’d be enthused. If it did it somewhat less than that, there was maybe room for we can improve the programme. But that 10% was the target that we were really hoping for.

Dealing with disappointing pilot results [00:53:34]

Luisa Rodriguez: OK. So my sense is that at the point where you start getting the results from the pilot is where things started clearly looking disappointing. Can you talk through what those results looked like?

Sarah Eustis-Guthrie: Definitely. So we ended up with two sets of results: we had the results for the immediate postnatal care and then the results for the immunisation session.

The results for the immunisation sessions looked pretty clearly not good. So we found both that while implementation was happening on the day that we did the surveying — so the surveyors show up; the providers would give the group talks, they would do this one-on-one counselling with women about family planning — the implementation was happening that day, so we felt like we could trust the results on how much it changed people’s behaviours. But we felt decently confident that it wasn’t reliably happening on other days. So the implementation for immunisations, that’s a bummer.

And then, in terms of the results themselves, it showed no statistically significant effects on either people’s actual contraceptive uptake or what they said their plans for the future would be. So not great.

Luisa Rodriguez: Yep.

Sarah Eustis-Guthrie: Then on the postnatal care arm, things looked not great, but a lot more complicated. What happened is, when we asked women on that day of the surveying, we would survey them right as they were leaving facilities. And when we asked them about their intended contraceptive uptake, we found that there was no difference between the women who hadn’t been exposed to the programme and the women who were exposed to the programme.

But we also called women up two weeks after the programme and asked them then about their uptake. And the reason we did this is because when we talked to folks on the ground, we learned that, especially in the context where we were working, women often consult with their partner to varying extents before they take up a method. So maybe they’re there and they get intrigued by family planning, but they say, “I have to go ask my husband’s permission.” They go ask their husband’s permission. So we wanted to make sure we were capturing that.

And what we found is that the data from that phone survey did show an increase in contraceptive uptake — and actually a decently large increase: about 20%. But the problem is that data is much lower quality, because about only half of women picked up the phone, and we were worried that the women who picked up the phone were a very different sample.

We also had implementation challenges with this arm. So we were doing postnatal care in three hospitals. And in one of the hospitals, it seemed to work really well; it was happening the day we were there, but we’re also pretty confident it was happening most of the time at other times. And then at two of the hospitals, it basically wasn’t happening. And it even wasn’t happening very well on the days that they were surveying, which is a bummer.

But again, this is where it gets complex, because when we looked at the data from just the hospital where it was actually being implemented, there was a real increase in contraceptive uptake — one that was even larger than 10%. But we didn’t power it so that we’d be able to trust it on a facility-by-facility level. So what I can say to you here is that there’s suggestive results that show that maybe this is working in this facility where it’s happening, but I can’t say with a lot of confidence that it’s happening.

So overall, we’ve felt that those results from postnatal care were a disappointment, because they showed that there were real challenges in implementation. There were real challenges despite us going to a lot of effort to try and make sure that things happen. And then also the results on the effects were, at the very least, mixed.

Luisa Rodriguez: How did this feel?

Sarah Eustis-Guthrie: Not great. I remember it was around Thanksgiving, and I was visiting my family, and I remember I was sitting and parsing the results — because it’s not like just a number pops up; you have to do some amount of analysis. I was seeing these numbers, and I was just scrolling through the surveys, and they’d be like, “Not using, not using…” And I just felt terrible.

Luisa Rodriguez: Gut wrenching. It must have just felt really awful.

Sarah Eustis-Guthrie: I think part of it is that when you run an organisation, you feel very personally responsible for what’s happening with that organisation. I think this felt extra strong for us because not only had we decided to found this organisation, but we decided to found this organisation as opposed to other organisations that could have been really good. So that was my cofounder and I kind of staking our claim for like, “We think that this is good. We think that this is so good that we want you to give money that you otherwise could give to these other really compelling organisations.”

And then not only that, but I’m good friends with a lot of other folks in the Charity Entrepreneurship community — which is great, they’re an awesome group of people — but what that means is that sometimes I’ll be chatting with someone, and in the nicest possible way, it’s like their programme’s going phenomenally, they’re helping so many people, they’re getting this huge grant. And even though I think people make an effort to make it non-stressful and non-competitive, it’s such a warm community, it also just is inherently, you’re sitting there and you’re thinking, “Man, is it the intervention or is it me?” Yeah, not the best feeling ever.

Luisa Rodriguez: Yeah, yeah. Just to give me a sense, were the results like, maybe this is still plausible? Or were they like, this is not changeable into a version of the programme that’s worth running?

Sarah Eustis-Guthrie: That’s a really important question, and that’s a question that we did not immediately know the answer to, especially with those postnatal care results being so complex and nuanced. Initially I saw the results and I said, “This is all terrible, it’s pointless, none of it worked out.” And then I started digging into the facility-by-facility level things, and I said, “This is exciting. Maybe actually it’s fine.” But then I realised there are these concerns about it.

So those next two months, there was this real sense of seesawing back and forth on how promising is this? And I will flag that I don’t think you should expect that every pilot for a great programme will go well. There’s so much that’s random, that’s contingent. We picked these facilities maybe through random chance. Some of these facilities were less likely to be successful. And I think you can look at a tonne of programmes that have had less successful initial pilots that turned out to be really good.

So I think if it had just been the numbers weren’t as good as we wanted, but we really believed that structurally it was a really phenomenal programme, there would have been a tonne of space to say, “Can we make changes to just make the programme look better?” But what ended up happening for us was we took those less promising pilot results — because at the very least I would say they were somewhat disappointing; they weren’t as good as we’d hoped — as an opportunity, as an invitation to sit down and look harder at some of these questions that we’d worried about last fall, that had been the kind of thing that I thought about when I couldn’t fall asleep in the middle of the night and say, “Now we can finally dig into this.”

The ups and downs of founding an organisation [01:01:09]

Luisa Rodriguez: Yeah. Just on that, because I’m really interested in the experience of this, are you being literal? Was this really keeping you up at night?

Sarah Eustis-Guthrie: Sometimes, yeah. I think my overall experience with Charity Entrepreneurship, with founding an org, was that the benefits were a lot bigger than I’d expected and then the downsides were a lot bigger than I expected. I think I would go back and do it again, and I would recommend other people do it. But also I did not comprehend how big of a change in my life it would be.

And I don’t want to say that this happens for everyone, because I think people have very different experiences with it. But I think for me, that sense of responsibility, that sense of feeling like the results really reflected on me — which I don’t fully endorse as a take, and was something that I was trying to shift away from — I found really tough. Because it was just true that for some aspects of the programme, how well they went were a direct reflection of how good of a job I did — and sometimes I would make a mistake, and that would have bad effects in the world, and that was really stressful. And then some aspects of the programme had very little to do with how hard I was working or how smart I was about making a particular choice.

And I think that I found that to be immensely stressful, and I found it hard to turn off thinking about the organisation. I would try to do these things like, “I won’t check Slack after I stop work for the day” and that kind of thing. But what I found is I’d just be walking around in my life, and because this was the most interesting and felt like the most important thing coming up in my life, that’s what I would think about.

So yeah, I did have this experience of, I would wake up in the middle of the night to get a drink of water, and before I was even fully conscious I would find that I was thinking about the organisation, or I was thinking about some of these issues, and then it would be hard to fall back asleep. And I’ve talked to other people who say, “Yeah, I have that exact same experience.”

Luisa Rodriguez: Wow. Yeah. I’m trying to think of an analogy, and I’m finding it hard to. But it sounds closer to like having a child or something. Like you’re trying to create this thing, and there’s so much responsibility and personal ownership in a way that you just don’t have in most cases when you are employed by a place to do a thing, and the bottom line responsibility isn’t with you.

Sarah Eustis-Guthrie: Right. And I think there’s a lot of jobs where people have that sense of real responsibility. I do think that there are good aspects of this. I found it deeply satisfying and deeply fulfilling. I remember when I was thinking about applying to jobs before this, I was thinking, I want to have this feeling that if I’m working extra hard, that that’ll make more good things happen in the world. I don’t want to have this feeling of, I’m accruing additional profit to a corporation, or it doesn’t really matter that much how hard I work. But this is the flip side of that: when it matters how good of a job you do, it’s hard to let go of.

And also I do just think there is a big difference between being the person who’s running the organisation and being someone who has a really substantial role. Because ultimately so much of your job is making these really tough calls — tough calls that you could potentially invest infinite time into. So it’s really hard to know when did I make a good decision? When did I invest the correct amount of time into making a decision? There’s a lot that’s really tough.

And I think having a cofounder does make a big difference. There are some folks that solo found. I have so much respect for that. I could not have done that with MHI. But having a cofounder makes a big difference, because you can really share that burden.

And I also think having a community makes a big difference, where I would talk to other folks running orgs and say, “I found this thing immensely stressful, and I don’t know if I made the right call,” and they would say, “I felt the exact same way.” And then also having advisors who we could turn to. I think that helps take on some of that responsibility. That’s similar to having a manager, but I didn’t totally trust that our advisors would be telling us in the frankest possible way if we were totally messing up.

So it was hard. I felt like I had to carry that burden myself. I ended up doing a lot of second guessing myself, a lot of asking myself, “Am I messing up? Am I doing a good job?” And in retrospect, I wish I’d done more to try and offload that, but I think it’s fundamentally just a super tough challenge.

Luisa Rodriguez: Yeah, it sounds brutal.

Post-pilot research and reflection [01:05:40]

Luisa Rodriguez: OK, so you’ve got these results, and then you decide to spend some more time thinking about these questions that you were unsure about before. What exactly did that look like?

Sarah Eustis-Guthrie: So we had these pilot results. We took a bit of time to just do the direct interpretation of what are these pilot results telling us? That took a couple weeks. Then we sat down and we said, we have some serious concerns. We have some serious reservations. We want to circle back to all of these red flags, yellow flags from earlier on.

So we devised this research and reflection process. We made a ginormous Google Doc, and we had this elaborate plan. And then of course, we got one week into the plan and said, “This plan is too elaborate. We’re going to make it less elaborate.”

But we had two main questions, I’d say. One of them was: Do we still think that postpartum family planning has the potential to be a really cost-effective, exciting opportunity? That’s question one, and that’s a question that has a lot to do with research questions, with digging into the literature, talking to more experts.

And then we had a separate question, which was: What are we going to do with MHI? Maybe if we think postpartum is still great, maybe we’ll keep running postpartum, maybe we will pivot to something else, or maybe we’ll shut down the organisation.

And in retrospect, it probably would have been ideal to fully resolve the postpartum question and then move on to the second question. What ended up happening was we did some work on it, we felt like we’d resolved it, and then I started having second doubts and going back into it again and looking into it again. So we basically kind of parallel processed these two investigations.

But we wanted to make sure that we were both doing the research and looking into the kind of science questions, and that we were doing the reflection to say, are we still bought into this? Because we could imagine a world where postpartum seems useful, but we don’t feel like we want to run this organisation anymore — and we wanted to make sure that we were fully bought in, because I think that you can only do a good job if you are fully bought in.

Luisa Rodriguez: Totally. Yeah. OK, so you’ve got these two questions. You’re working on them in parallel. What were you turning up?

Sarah Eustis-Guthrie: Let’s start with the scientific question about how cost effective postpartum is. We talked a bit earlier about this question of programmes that increase uptake and how does that translate into reduced unintended pregnancies? And back when we’d started, we weren’t aware of any programmes that had actually measured changes to pregnancy rate. But we said, let’s check again, let’s do a dive, let’s see if there’s any studies. And we ended up finding that there were three studies that actually looked into this, and that two of them found no changes to pregnancy rate and one of them found only a very small change.

Luisa Rodriguez: Oh my god.

Sarah Eustis-Guthrie: This was so fascinating to find. And it was just surprising, because I think my assumption was if these studies existed, a lot of people would be talking about them and there would be discussion about them. But what we found is that, A, these studies existed; B, there wasn’t a lot of discussion about them; and C, even within the studies themselves, there wasn’t a lot of discussion about them, or the discussion that was about them was never in the direction of, “Maybe this programme is less useful.” The discussion was always like, “Maybe if we do this programme slightly differently, it’ll work better,” or just like, “This still seems great, please continue.” So that was a quite surprising finding for us.

Luisa Rodriguez: I mean, is there a way to square that…? Yeah, I can’t tell a story where it improves contraceptive takeup, but it doesn’t decrease unintended pregnancy, and it’s still good.

Sarah Eustis-Guthrie: Right. Well, I think there’s two aspects of what you were saying right there. Number one is that on priors, it’s really surprising that you would have a programme that would increase contraceptive uptake, but that wouldn’t decrease pregnancies — because it’s just, you know, you think it’s obvious, right? That’s what contraceptive uptake does: it makes it harder to get pregnant. So that’s a question that we dug into a lot.

But then there’s the second part of your question, which is maybe it seems obvious to you that if there was a programme that wasn’t that useful at decreasing pregnancies, that doesn’t seem like a very useful programme — and that’s what Ben and I believe — but that is not what basically everyone else in the space believes. So we dug into that question a bit as well.

Luisa Rodriguez: OK, so let’s tease those apart then. So the first one: did you feel like you were able to make sense of this disconnect between maybe successfully increasing contraceptive use, but not successfully decreasing pregnancy rates?

Sarah Eustis-Guthrie: Yeah. So our hypothesis on this is that it comes back to another thing that we alluded to earlier, this question of postpartum abstinence and then this related factor of postpartum breastfeeding.

So if you look at a lot of these models, including our own model, of how uptake translates to reduced pregnancies, they always kind of assume that the postpartum period is similar to any other period, where there’s a reliable way that using contraception translates to reduced pregnancies. But we’ve come to believe that it’s not accurate to model the postpartum period in the same way that you model other periods.

What this comes down to is two factors. So we talked about postpartum abstinence: there’s this cultural norm where a lot of women don’t have sex soon after a birth. This might even entail that they moved to their mother-in-law’s house for a while. So quite unlikely that they’re having sex. And there’s some argument about this, where a lot of people will say, “I don’t trust women’s responses to surveys because there’s desirability bias. They say that they’re not having sex, but maybe they’re really having sex.” So I think that’s one of the reasons experts don’t take it as seriously.

But for us, actually, a much bigger factor than postpartum abstinence was this factor of postpartum amenorrhea. So long word, tough to spell. What postpartum amenorrhea means is not having a period after you give birth. This is usually due to breastfeeding. Especially in sub-Saharan Africa, very high rates of women breastfeed soon after giving birth. It’s super common.

And breastfeeding on its own is not considered to be a reliable form of contraception. The World Health Organization says breastfeeding on its own isn’t reliable. What you have to do is what’s known as LAM: the “lactational amenorrhea method.” So I’m warning you, this is going to get a little technical. But they have this very narrow definition for LAM, where in order for breastfeeding to count as LAM, it has to be:

• Exclusive breastfeeding — so the baby can’t get any food or water aside from their mother’s milk.
• It has to be frequent — so under their definition, every several hours, including sleeping. So you have to fall asleep and then wake up and feed the baby and then fall asleep again.
• The woman has to be amenorrheic, so her period hasn’t returned yet.
• And it has to be in the first six months after birth.

As I say this, I’m flashing back to when I was writing the trainings for healthcare providers, and you’re trying to explain LAM, and it’s immensely complicated and it’s very annoying.

Luisa Rodriguez: Yep, horrible.

Sarah Eustis-Guthrie: So the WHO recommends you should teach women how to do LAM precisely as LAM, because when you do it precisely as LAM, it has this really high effectiveness rate — like 98.5% protection against pregnancy.

What happens in practice is that a lot of women are breastfeeding, but they’re not doing LAM. So maybe when their brother gives the baby a bath, they give the baby a little bit of water. This is the kind of thing that people talk about. So when the WHO or whomever is going around and surveying women, with that woman it would be like, “You’re breastfeeding, but you’re not doing LAM.” So they would say that this woman is at complete risk of getting pregnant. And this is what I had always heard.

And when we started MHI, we focused on LAM as one of the methods: you have to make sure women know all the criteria. I guess my assumption had been something like, if a woman is not doing LAM, she’s totally vulnerable. But after having months of getting these WhatsApp messages from nurses saying, “Well, she says that she’s protected,” I got kind of curious about this. I was wondering, maybe it’s somewhat effective. Maybe it’s kind of effective.

So this, to me, is one of the most interesting parts. I found a bunch of studies that where they looked at women who weren’t doing LAM precisely — so maybe it was 12 months after she’d given birth, but they were still amenorrheic, so they didn’t have a period, but they were still breastfeeding — and a number of studies found that it was still pretty effective at preventing pregnancy. So I’d say on average like 94% effective at preventing pregnancy.

Luisa Rodriguez: Oh my gosh, that’s really high. That is actually much higher than I expected you to say.

Sarah Eustis-Guthrie: Yeah, it’s really high. That was higher than I expected to find. I’ve had many conversations where I was talking to someone in the space and they would say, “That’s not high enough. We want women to be totally protected, and that’s not high enough. It shouldn’t count.”

Luisa Rodriguez: It’s not high enough for whatever the bar is for full contraception, but it is high enough to massively impact the counterfactual of how many pregnancies you’d expect.

Sarah Eustis-Guthrie: Absolutely, yeah.

Luisa Rodriguez: Oh, how frustrating.

Sarah Eustis-Guthrie: So I think there’s several interesting parts of this. I think one part of this is, we were coming at this from both a pragmatic approach and from a kind of systems approach. One, I can tell you from a pragmatic approach that it’s hard to get women to do LAM precisely. It involves a lot of work, and also, I don’t think they totally want to.

So I’ve noticed this tendency in both papers that people publish and in these overall official recommendations where they’ll focus on the ideal. They’ll say, it would be ideal if all women had the most protective things. But then when you go on the ground, you find that women often don’t actually want those methods.

So you might ask, why don’t all women just use IUDs all the time? And it’s like, there are reasons women don’t like to use IUDs. And that’s totally fair.

To me, respecting women’s choice means respecting that some women don’t want to use an IUD. It means respecting that some women don’t want to do full LAM. And it means making sure that those women have that full information. It doesn’t mean that you’re going to pressure them to use certain methods.

And one thing that I’ll just throw in here is, I was kind of curious, so I was talking to a friend who’s an OB/GYN here in California, and I said, “What do you say to postpartum women about their family planning options?” And she said, “I say to women, ‘If you’re breastfeeding and you don’t have your period, it’s pretty unlikely that you’ll get pregnant. But there is a real chance. So if it’s really important to you to not get pregnant, you should use another method. But if it’s not really important to you, that has you pretty covered.'”

And I thought that basically aligns with what I see in the literature, but it does not align with the official recommendations, especially for low- and middle-income countries. And it is true that it’s riskier to have a short-spaced pregnancy in a low- and middle-income country, but that’s because of all of these terrible structural inequalities. So I think to some extent, I look at this evidence and I say we should be investing more in making it safer for women to give birth than in trying to give women this information that actually isn’t as useful to them.

Luisa Rodriguez: Totally. Yeah. You just mentioned IUDs. Is that something you considered including in your programme?

Sarah Eustis-Guthrie: So one thing that ended up being a big question mark when we were looking at the studies and deciding how to design the programme was this question of how much to focus on particular contraceptive methods. One thing we found was that a lot of the studies had a big focus on postpartum IUDs, and what’s known as “long-acting reversible contraception” — so that could be things like implants.

What we found is that a lot of the studies, and especially a lot of the studies that showed really big increases in contraceptive uptake, had a big focus on IUDs. And one interesting technical note here is that you can actually get an IUD inserted immediately after you give birth. And the pro of this is you’re kind of already up in there, you might be under anaesthesia or, anaesthetic of some kind, so it’s actually relatively straightforward to insert that IUD. So some experts, they’re like, this is one of the biggest, best things about doing postpartum family planning is that you can insert these IUDs immediately post birth.

But there’s also some issues about this, especially as related to consent and coercion. So I had this really surprising experience: I was talking to the authors of one of the big papers about postpartum IUDs. This paper was like, “Postpartum IUDs are great. And we ran this great programme.” And then I had this call with one of the authors, and he said, basically, “I do not love postpartum IUDs, and I do not recommend including them in your programme.” So that was really surprising.

Basically he raised this concern about coercion, where, especially in low- and middle-income countries, healthcare providers are seen as real authority figures, and folks maybe feel like they have less latitude to disagree with what a healthcare provider is suggesting. And then with IUDs, one thing that is true, but you might not reflect on, is that you can’t get an IUD taken out unless you have a health provider involved.

So there have been some recent studies — and in fact, with these studies, they were so concerned about backlash that there’s this study where they actually anonymise the name of the country that it’s in, which is wild.

Luisa Rodriguez: Whoa.

Sarah Eustis-Guthrie: I’d never seen that before. But in this study, they interviewed a bunch of people at clinics who would talk about their experiences. Like, they got an IUD. Maybe they didn’t super want it. Or maybe they did want it, but then they changed their mind. And then they went in and they said, “I would like this IUD taken out.” And the healthcare provider said, “No, I won’t take out that IUD.”

Luisa Rodriguez: Oh my god.

Sarah Eustis-Guthrie: So this is terrible. Total violation of people’s rights. And this is an issue where it’s really hard to say how prevalent it is, because people are hesitant about raising this as an issue. But when we spoke to experts, it seemed like this was a real concern, especially with some of these programmes.

And I had noticed this when I read it in the studies: they would recruit people to the programme by going to women who were currently in labour, although not in active labour, and then they would say, “Do you want to get this IUD?” What you can easily imagine is a woman who, you know, she’s in labour, probably not 100% at maximum intellectual capacity, and it might not be clear to her, like, is this medically necessary? Is the doctor telling me that I have to do this?

So they’re recruiting women in these labour wards, and then they’re inserting this postpartum IUD, and then there’s this added concern of maybe they won’t be able to get it out. And this is a big problem. And we were just like, wow, we do not want our programme to look anything like this.

Luisa Rodriguez: That seems incredibly reasonable and very good.

Sarah Eustis-Guthrie: And I think there’s this tragic irony here, because autonomy is such a big reason to promote these types of programmes. But I honestly have this concern — and my cofounder did a great job of raising this as a concern — of there’s sometimes programmes that couch themselves in terms of autonomy, but it sometimes feels like they’re actually more about pressuring women to use family planning. And I think, given some of the ugly histories here, it’s particularly important for development organisations to be really careful about this.

So what this ended up looking like for us is we said that IUDs can be part of the mix, but we’re not going to do immediate postpartum IUDs except where they’re already happening. We want to develop a programme that’s about centering clients’ preferences, and what they want.

Is family planning still a promising intervention? [01:22:59]

Luisa Rodriguez: OK. So you’ve talked a lot about how your thinking changed on postpartum family planning in particular. Did your take on family planning broadly shift at all?

Sarah Eustis-Guthrie: It did shift. I think I’m less wildly optimistic about the space in general. I remain convinced that there are areas where there’s really cost-effective opportunities, but I think that space is a lot narrower than I thought it was before, and I’m really aware of how careful you need to be to avoid buying into the hype, I suppose.

And I think this goes back to one thing I mentioned earlier, which was there’s a lot to be excited about in terms of autonomy and saying we can go beyond the health benefits. But I think digging into this deeper gave me a sense of part of why EA foregrounds the health benefits, which is that they’re harder to fake. If you look at “this disease leads to this mortality burden, you prevent this disease, bam”: those are hard numbers.

But when you’re looking at autonomy benefits, I had been enthused because I said you can have these numbers for how many new users of contraception, how many pregnancies are averted — but it turns out that those numbers are actually much more complicated than you might initially think.

When you think, for example, about adding new users of contraception, when we were doing our geographic analysis and then going to visit clinics, I got the sense of there’s a big difference between running a programme that adds new contraceptive users in a context where their baseline access to contraception is really terrible, and in an area where their baseline access is actually half decent. So it’s not just a matter of all new contraceptive users mean an equal level of agency. It’s something like, if you’re working in urban Ghana in areas where there’s already a lot of access, that’s just less useful.

But it’s really hard to capture that spreadsheet, so it’s too easy to end up in a world where you say, “We have 10,000 new users! We fixed everything! Please fund us forever” — and you don’t want to end up in that world.

There’s one more thing I just want to add, because it’s really interesting to me. Initially I’d heard about these numbers, about the rates of unintended and unwanted pregnancies in low- and middle-income countries, and I’d been shocked and appalled. And wow, we need to take action on this, and maybe relatively light-touch action can make a big difference.

But I was surprised when I looked at stats from countries like the US at how the numbers are also not great there. So here’s a stat for you: in the US, 42% of pregnancies are unintended or unwanted. That’s a lot: 27% of pregnancies are “wanted later,” and 18% of them are actively unwanted. To me, that’s just horrifying that that number is so high, despite how much infrastructure we have here. So to me, this doesn’t suggest that the problem is less urgent; it just suggests that maybe the solutions are much harder than you might think at first glance.

Luisa Rodriguez: Yeah, yeah. Just to check I understand “wanted later”: is that something like you got pregnant, you didn’t want to get pregnant, but over time you become happy that you got pregnant and had that baby?

Sarah Eustis-Guthrie: So what they do is they survey women and they said, when you got pregnant, did you want to get pregnant at that time; did you want to get pregnant, but not at that time in particular; or did you not want the pregnancy at all? These are really complicated questions, and I think women also feel internally complicated — so these numbers do fluctuate, and there’s a lot that’s hard to pin down. But I do think these point to a general picture of a lot of women don’t feel like they’re currently having the tools that they would like to have to make these choices fully. So I think it underlines the urgency of the problem, but also how tough of a problem it is to solve.

Luisa Rodriguez: Yeah. Did you dig in at all to why it’s 42% in the US?

Sarah Eustis-Guthrie: Well, I can tell you that is higher than a lot of other high-income countries — and especially right now, people have a lot of takes on specific policies that could be different — but I think that there are not a lot of countries where this rate is zero, for example. I think there’s a lot of challenges around this. I know some people are excited about maybe developing new tools that make it easier for women to control their reproductive futures, even new tools so that men can be more involved with the process, like contraception for men.

But this is a really big topic, where there’s a lot of women — in both high-income countries and low- and middle-income countries — where they look at the set of contraceptives available, and they say, “This doesn’t really work that well for me.”

So I think if you have a naive look at those “unmet need” numbers that I referenced at the very beginning — one in 10 women with an unmet need — a naive look says that we should just run a bunch more programming and tell women about the options and then they’ll all take them up.

But what I realised over the course of the programme is often women aren’t taking up options not because they don’t know about them, but because it doesn’t work for them. For example, some forms of contraception, like the implant, might cause bleeding irregularities in more than half of women who use them. And for some women, maybe in some Islamic countries, for example, they don’t feel comfortable praying when their bleeding is irregular. So maybe they say, “That’s actually a no-go for me.”

But there hasn’t been a tonne of research into this. All of the side effects research tends to be focused on “medical” side effects, and it’s taken less seriously that this might affect women’s quality of life or their religious practice.

So all of this is to say that this is an immensely complex area, and we have to be careful to not be naive about simple solutions to really complex problems.

Luisa Rodriguez: Yeah, we could easily spend the next hour talking about this.

Sarah Eustis-Guthrie: But thank you for letting me talk about that a little more because it’s so fascinating.

Luisa Rodriguez: It is fascinating, and I genuinely feel shocked at what my family planning options are. They all suck, and it feels completely unacceptable. And yet here we are. Oh, man. OK, so you’re finding this and you’re… I think I’d be feeling stressed, frustrated, demoralised. What were you feeling at this point?

Sarah Eustis-Guthrie: I think I was feeling all of those things, but also confused. I just kept coming back to this factor of “this is a complex situation.” I’m sure it sounds complicated when I’m talking about it. It felt even more complicated to me when I’m trying to dig into these studies. And I kept consistently running into that I had this different take than the standard take, and I personally like to defer to experts a certain amount, but I just thought that the experts had this one wrong.

It goes back to what we were talking about before, about what’s the chance that I’ve picked up on something that people haven’t picked up on, versus that I’m wrong? And I think as I was working through this, I kept wrestling this question of, maybe I’m just completely off base, and maybe I’m missing something really obvious about why this is actually fine.

So I think for me, it was just feeling uncertain, feeling confused, not knowing how much to trust myself… Plus feeling like, man, I kind of bet on the wrong horse here.

Luisa Rodriguez: Sounds really, really tough. So that at least sounds to me like a very solid hypothesis for why there was this empirical disconnect between contraception and pregnancies.

Where did you come out on this question of whether, at the end of the day, you should care about pregnancies as your outcome and not just contraception use for its own sake?

Sarah Eustis-Guthrie: I think that family planning is valuable insofar as it empowers women to have more control over their reproductive lives. But I think if you have a programme, and it’s showing that it’s not changing pregnancy rate at all, that suggests to me that you might be living in the world where the programme actually just isn’t providing a lot that’s of value to women. So I don’t think that changing pregnancy rate is the only useful part of increasing family planning uptake, but I think that it’s suggestive that maybe you’re running a programme that’s not that useful.

And for us, we started with this prior of the programme has to prove that it’s above the bar. We can easily imagine — especially in the family planning space, where what the programme looks like is talking to women, giving them information — a programme that’s not that useful, that’s not giving information to women that they want. And I think we felt like we were quite solidly in that world.

Luisa Rodriguez: At this point, is it obvious what you want to do next, or is there still a lot you’re wrestling with thinking about where to go from here?

Sarah Eustis-Guthrie: We also spent a lot of time thinking about our personal considerations on the matter. What this looked like is it was some amount of personal reflection and some amount of discussion together. So we spent a lot of time doing individual reflection on these questions and reflecting on both do we want to do postpartum family planning regardless of how good it looks, and then this question of, maybe we should pivot. We spent a decent amount of time thinking about this, because I think there is often a very plausible case there. And I don’t think my broader message is that all organisations, when things look at all bad, should immediately shut down. You have to think about what comparative advantage does the org have.

So we thought about what’s our comparative advantage? And after talking to a lot of people, we figured part of it was we had this specific knowledge and expertise of working in Ghana; part of it was we had this knowledge and expertise of working on family planning programmes, especially programmes in health facilities; and also that we were a strong team. We worked really well together. Despite the year and a half having a lot that was immensely painful, I think the harder things got, the more confident I felt in my choice to work with Ben, just because he was so great to work with. We had a really high level of trust and I think we could handle that conflict about the programme well.

Luisa Rodriguez: That’s so wonderful.

Sarah Eustis-Guthrie: Yeah, that part of it is great. So we were thinking about these comparative advantages, and we didn’t feel like there was an obvious, yeah, we should definitely pivot from doing postpartum family planning in Ghana to doing this other health intervention in Ghana, or to doing a different facility-based family planning organisation in a different country.

Luisa Rodriguez: Makes sense.

Deciding to shut down MHI [01:34:10]

Luisa Rodriguez: Where did you land? What happened when you and Ben came back together?

Sarah Eustis-Guthrie: We had a couple different moments of like, we’re going to make the provisional decision, then we’re going to go off for Christmas and see how we feel after. Then we’re going to circle back. And at every one of those points, we were both independently like, “We don’t feel like this makes sense anymore. We don’t feel like we want to keep doing it.”

Luisa Rodriguez: How long had you been working on this at that point?

Sarah Eustis-Guthrie: It was about a year and a half total.

Luisa Rodriguez: That’s such a long time.

Sarah Eustis-Guthrie: Yeah, it’s a long time. I felt pretty bad. I think I just kind of felt like a loser. I just felt like this is such a reflection on me. And I would talk to people, and they’d be like, “No, it’s not a reflection on you. It’s just this thing in the world, and you couldn’t control it.” And I don’t fully endorse that take, to be clear. I think it was a lot of factors out in the world, and it’s overestimating your own agency over the world to be like, “This is all about me.” But I think it just felt so intensely personal, and it felt so much like we had made this bet, and this was on us, and it just felt like we totally messed up.

What if we’d started this other thing and it had been phenomenally good? Is it my fault? Should I feel guilty about the fact that we didn’t help that many people? But if we had started this other programme, we could have helped a lot more people. Should I feel personally responsible for those people? So yeah, it was not a great mental space to be in. That was a pretty depressing time, to be honest.

Luisa Rodriguez: Yeah, it sounds awful. I mean, from my perspective, I think it’s easy to have the outside view of like, this is just the most laudable thing I can imagine in this space. You founded this charity that you thought was among the most cost-effective charities you could found; you had a bunch of check-in points as you gathered more information about how well it was going to work in the actual world; when you got to a check-in point that showed more definitively that it wasn’t going to do as much good as you hoped, you decided not to keep at it because you were afraid of disappointing everyone or disappointing yourselves or sunk cost fallacy. And I think that’s incredible.

Sarah Eustis-Guthrie: I would not go that far. But no, I do appreciate it, and I think when I’m thinking about other people in this situation, I think it’s easier for me to say this is a laudable course of events. But I think the simplest possible thing is I felt like it was my job to create a highly effective charity. I had not created a highly effective charity, and therefore it was a failure.

But I definitely do — in a broad sense, but not as applying to me [laughs] — no, I do endorse the more positive take these days. Yeah, we should be honest about when things are going wrong, and we should shut them down rather than keeping going.

Luisa Rodriguez: Did you have the sense that some of the Charity Entrepreneurship charities had shut down, and that there were “failures” to come out of the incubation programme, and that that was a possible outcome?

Sarah Eustis-Guthrie: Yeah. So there have been organisations that have shut down. And since we shut down, another organisation from our cohort actually also shut down. But before we had shut down, it was generally because things had gone wrong quite early on, and there wasn’t a clear-cut example of someone saying, “This just doesn’t work as well as we’d hoped, and so we’re going to shut down and just leave it at that.”

I do think the folks at Charity Entrepreneurship wanted this to be more of a thing, because I think they do have this genuine bets-based mindset. I don’t want to put words in their mouth, but my sense of it is that the ideal is you start a bunch of charities, they test stuff out, and then some of them turn out to be phenomenally effective, and you want to scale those up as fast as possible; some of them turn out to not work out at all, and you want to shut those down as quickly as possible; and then there’s a lot of disagreement about what you do in the middle cases. So some people would say, if it’s not going to be the most effective thing, then you should shut it down. Some people would say it depends on where you get your funding from.

But I think one of the reasons I took this so hard is because entrepreneurship is all about this bets-based mindset. So you say, “I’m going to take a bunch of bets. I’m going to take some risky bets that have really high upside.” And this is a winning strategy in life, but maybe it’s not a winning strategy for any given hand. So the fact of the matter is that I believe that intellectually, but l do not believe that emotionally.

And I have now met a bunch of people who are really good at doing that emotionally, and I’ve realised I’m just not one of those people. I think I’m more entrepreneurial than your average person; I don’t think I’m the maximally entrepreneurial person. And I also think it’s just human nature to not like failing.

Luisa Rodriguez: Yeah, it feels like it’s one of these cases where the optimal thing might be to have a bunch of people make these bets, and have some massively pay off and some not pay off and fail. And on the whole, that’s a great strategy. And everyone participating should get some credit for the wins, because they’re participating in the system that overall has this really valuable high payoff strategy.

But individually, the people who make the really successful charities with high cost effectiveness get to feel that win very viscerally, and the people who don’t feel like they’ve lost, despite it being a thing that was maybe the best thing for the world. And it just feels incredibly unfair and really difficult and painful. And yeah, I’m both grateful to you for participating. I’m also not quite outraged, but I do feel indignant that there are cases where this strategy is optimal and people have to…

I mean, I think it is really applicable for careers, and the thing 80,000 Hours is about: we’re telling a bunch of people to be really ambitious with their careers. And it does make me feel really pained that, for some, despite it being the optimal thing that they took a really big career bet, they will feel like they failed. But that’s still part of the portfolio we want to have.

So just a massive thank you, and well done. But obviously it felt really painful.

The surprising community response to news of the shutdown [01:41:12]

Luisa Rodriguez: So again, this is about 18 months in. At this point, a bunch of people know that you’re doing this. Probably your family and friends know that you’re doing this. People in your professional network, as well as everyone at Charity Entrepreneurship. How worried were you about announcing the fact that you were shutting down?

Sarah Eustis-Guthrie: I was not looking forward to it. I guess I was kind of torn on how much I genuinely believed the “I’m a total failure, everyone will think horribly of me” mindset. Probably part of me genuinely believed this, and part of me was like, “People will think that it doesn’t reflect great on you, but that it’s kind of OK.” But I think my overall take was that people would be disappointed in us shutting down, but also that they wouldn’t be super interested in it as a topic.

So Ben was working on this post for the EA Forum about our shutdown. And he was really invested in this post. He was working on it, and there was a part of me that wanted to say, “I really don’t think that many people will read the post. Maybe you should work on other stuff.” But I felt like, well, it’s the end of the project, we don’t need to optimise as much. If it makes him feel better, he can work on it.

And then we posted it, and it got this incredible response. I was so surprised. I was like, “We’re this tiny org that no one cares about. Why does anyone find this interesting?” Then I think I was surprised that people thought that it demonstrated integrity rather than kind of loserness to be shutting down. And I was also really excited about the fact that people thought that this was an opportunity to think about the lessons.

Luisa Rodriguez: Yeah. I guess kind of building off of what we’ve just said, it feels like a nice almost solution to this problem where we’re asking people to make big bets. Some of the people’s bets won’t pay off, and we can still give them hopefully this big reward and appreciation and thank you. So I’m really glad people were interested.

Sarah Eustis-Guthrie: Yeah. I think part of the reason I was surprised that people responded the way that they did is because I think to us, shutting down, though it was very painful, it felt quite natural. And it actually in some ways felt like the choice that maximised our own wellbeing.

For example, people would say things like, “It’s admirable that you shut down because I can easily imagine you continuing going for months or years.” I mean, with those postnatal care results, we could have said, “In this one facility, we saw this really big uptake. We’re going to keep going.”

And I think Ben and I just didn’t feel that way at all. To us, the stress of running a programme the way it felt for like the first year, where we were uncertain about how successful it was and we had these nagging doubts, that was not a great feeling. And then the feeling we had once we were like, “This probably isn’t great,” that was such a terrible feeling. I think to us, we just couldn’t conceive of what it would look like to run a programme you weren’t totally bought into.

Luisa Rodriguez: Right, right. You weren’t that actually tempted to just like stick with it out of the desire to not quit.

Sarah Eustis-Guthrie: Yeah, absolutely.

Luisa Rodriguez: You were like, “No, I actually just don’t want to keep doing this.”

Sarah Eustis-Guthrie: I mean, if you think about how exhausting it is to run a new programme, then that’s assuming that it’s going to potentially be really good. Now it’s like, imagine running a new programme, but you think it’s actually not helping people that much. And assuming that you’re living in a world where there is counterfactual funding, and you really believe in that — and I do really believe in that — where people funded our project and they could have instead funded our friends’ projects, which also looked really exciting.

So I’m living in this world where I have this burden of, I feel like we have to be constantly living up to running a programme that’s good enough for that money. And if that programme is worse off, then maybe instead of sacrificing a bunch to make the world better, I am sacrificing a bunch and then actively making the world worse, because we’re not spending this money well.

I think that just to us, was such an ick factor that we were not at all tempted to continue operating if we thought it didn’t work. The main question was, maybe it does work. But we didn’t want to run a programme that didn’t work. And I think that felt so natural to us that it was surprising to us that people would think differently.

Luisa Rodriguez: Yeah, yeah. In general, how have you felt about the decision since making it? Was that kind of late 2023, early 2024?

Sarah Eustis-Guthrie: So we formally decided in the end of January to shut down. And after we made the decision, it wasn’t like, bam, we have immediately closed our doors. There was a lot of work we had to do in terms of shutting down the ops, but then also working to publish our results. So we’re trying to publish multiple papers about the work. We wrote this article in Asterisk about it. But just like the nuts and bolts of what happens to this money now, what happens to these parts of the organisation. So there were two or three months where we were still working on shutting it down.

Then I took a bit of a break, and I think early on it felt like this anvil dragging me down of I still have to keep working on this thing, and I feel embarrassed and ashamed about how it turned out. Once I was able to actually shut the laptop and go take a bit of a break, I started feeling a little bit better.

And when I think back on the eight months since we fully shut down, there have been times when I’ve second guessed my exact take on postpartum family planning. So I feel confident that it doesn’t meet the bar for being among the most cost-effective charities, but I’m still uncertain about exactly how good or bad it is. There’s these hard judgement calls about postpartum abstinence, all this.

So I’ve thought about that a bit and wrestled with that a bit, but there hasn’t been a single moment where I’ve thought that we should have kept going with MHI, we should have kept running postpartum family planning programming. And that’s honestly a surprise to me. I thought that I would feel more doubt about it.

Luisa Rodriguez: More ambivalent. Yeah, yeah. So you had these kind of social worries. Did you also have professional ones? Were you worried this would kind of hurt your career?

Sarah Eustis-Guthrie: Yeah, I figured that it would be somewhat bad. I mean, in general, you would rather be associated with a good project than a bad project. So I assumed it would be somewhat bad, but people might be like, “Well, you seem vaguely competent in that you could run some of this. It seems kind of bad that you shut it down and couldn’t make it work well enough, but whatever.” So I definitely had professional concerns, but it seemed wrong to think of that as at all a factor in deciding to shut down. So I was just like, I have to bite this bullet.

And then I think kind of the opposite played out. I’m on this podcast, for example, which probably wouldn’t have happened even if the project had been really successful. So it’s been really unexpected to me the way that people have responded to it and interpreted it.

Luisa Rodriguez: Yeah, I love that. I think that’s great. I also think it would be good if you got recognition, obviously, if the thing had succeeded. But I feel good about the community around you for recognising the bravery, integrity, self-awareness, judgement to make the decision you did — and still be a badass human.

Mistakes and what Sarah could have done differently [01:48:54]

Luisa Rodriguez: OK, so if you’re open to it, I’m interested in talking a bit about whether you think you made any mistakes worth learning from during this experience. Obviously you know so much now that you didn’t know then, but do you think that you and Ben made mistakes that you reasonably could have avoided at the time?

Sarah Eustis-Guthrie: We made a tonne of mistakes. It’s harder to figure out for any given mistake, could we reasonably have avoided it to stop thinking about hindsight? But when we were shutting down, we ran this process of trying to think about what were our biggest mistakes, kind of rank-prioritise our mistakes: can we learn from this? I think there were some consistent themes that emerged, where we were making similar classes of mistakes repeatedly.

I think probably the biggest consistent mistake that we made was insufficient prioritisation. So the EA approach is all about prioritisation, so you might think we’ve got prioritisation down pat — but I think there’s a lot of ways that prioritisation plays out on a concrete, day-to-day basis. I think one difficulty was that when we were starting, and we had newly become charity directors, we were trying to figure out what does it look like to run a nonprofit?

I think one way that I thought about this was, “What do I imagine might be the tasks that that kind of person would do?” So we made these objectives and key results for different areas of the organisation. We’d say, what should we be doing in fundraising this quarter? What should we be doing in communications this quarter? So we had all these ideas for things that seemed pretty useful: it would be pretty useful to have a nice-looking website rather than the absolute bare bones; it would be pretty useful to start doing some applications for funding.

And part of it was I didn’t know exactly what I was supposed to be doing, and I lived in fear of waking up six months from now and thinking, “Oh my gosh, we haven’t applied for funding! We should have obviously applied for funding!” But what we came to realise is that your time is so limited, and that the class of things that it’s incredibly important to get right is at the core of what you’re doing. We realised that you have zero time to spend on tasks that seem “kind of” useful: you have to ruthlessly prioritise, and only spend your time on the activities that are going to cash out in making the most important parts of the organisation work.

For example, I wish in hindsight that I’d said, “We have enough funding for the next year and a half. I’m going to spend 0% of my brain thinking about funding for at least the next six months, probably the next year” — and we would have been totally fine.

Luisa Rodriguez: What would you have done instead?

Sarah Eustis-Guthrie: Well, for us the most urgent thing was, can we make this intervention work? And we found that there was so much that we could do either regarding desk research, looking into what had made previous interventions work, or being on the ground and talking to folks.

I would categorise this as another one of our big mistakes: not focusing on learning more on the ground at the outset. Because in that fall we had a big discussion about how much time should we be spending on the ground? Because there’s one model of this in which you say, “We’re running a charity in Ghana. Therefore both cofounders should go immediately, move to Ghana, and just be in Ghana into the future.” And then there’s another model of this where you say, “We have an implementation partner. They’ll mainly be on the ground, and we’ll go occasionally.”

We tried to do our best to make this decision. We talked to people who’d run similar organisations, and we found a broad range of what people were saying. So I think at the time, if we had thought it’s essential to make the charity do better to be on the ground, we would have done it.

But I think we made the wrong call in saying that we didn’t think it was essential. I think it would have been really helpful just to spend more time in clinics, more time understanding exactly what was going on on the ground, because that is so essential. Because in order to design a programme, I think it’s easy to get stuck in like, “I’ll read a lot of studies” — but ultimately you are designing a programme for a specific context, and the best thing you can do to make that programme better is to combine the stuff from the studies with actual on-the-ground information.

Luisa Rodriguez: Yeah. This is something I’ve wondered about for Charity Entrepreneurship charities. I think sometimes people do have ties to the places where they’re founding the charity, but it seems like often they don’t. Does this seem like, in a patterned way, it could cause problems? I guess you’re less familiar at the outset with the place, but also people don’t necessarily want to completely uproot their lives and move to a country often with more dire health or economic problems than their own.

Sarah Eustis-Guthrie: Right. I think you’re pointing at a real difference in how different groups of people think about this. One critique that Charity Entrepreneurship has received is from some folks who say that you shouldn’t have foreign founders; you should have a founder who’s from that country, who speaks the language, who has deep ties to that country.

And I know actually there’s a number of funders who will only fund local groups, or if you’re of a particular gender identity, national identity. I think actually I would disagree with that exact approach to it, because I think, for example, if you look at a country like Ghana, there is so much diversity within the country. You could easily have someone who’s from Ghana, but maybe they’re from the coastal regions and speak one language, and actually they’re going to be running a programme that’s in the northern regions where there’s an entirely different language.

I think the important thing here isn’t if you come from that country, but if you spend a lot of time in the context. And it’s not just about the context of the country, but the context of the environment you’re working in.

So I wish I’d just spent a lot of time there, and parked myself in a hospital, and learned as much as I could, spent time in maternity wards. And part of this is like, it’s tough to do that; it’s tough to get permission. You show up at the hospital and they say, “Who are you?” You need permission; you can only come on certain days. But I think that this kind of learning helps you make a programme that’s more rooted in the actual realities of what’s going on.

This points to other decisions that we made, which is, over the course of our time in Ghana, we actually worked at 18 different facilities — which to us felt quite natural, because we were always thinking about scaling up. We were like, “We want a diverse mix of facilities; we want to make sure we’re not over-updating.” But in retrospect, I wish that we’d picked one facility and kind of embedded ourselves at that facility and iterated with making the programme work, getting to know people there really closely. I think that would have given us a lot more information than the approach that we took.

One thing I realised is that one essential trait is figuring out how much to update on different experts’ advice. Because what you find is that experts tell you a bunch of different stuff, and then you say, “How much should I trust this expert on this versus on that?” I think for us, we updated too much on charities that were doing very different types of interventions. So there were some charities that had had a lot of success with not being on the ground, and when they spent time on the ground, they felt like sometimes that was even detracting. So I think this is really tough.

Luisa Rodriguez: Yeah, yeah. That makes sense. So, not prioritising spending more time on the ground and in the facilities in particular; in general, not prioritising harder. Any other categories of mistakes that you think might have been mistakes, looking back now?

Sarah Eustis-Guthrie: I think those are the biggest ones. I mean, a lot of mistakes, but maybe just less-interesting-to-learn-from mistakes.

Luisa Rodriguez: You chose the wrong webcams.

Sarah Eustis-Guthrie: Yeah, exactly.

Luisa Rodriguez: On prioritising: I hate having to ruthlessly prioritise. It’s not fun to be like, there are a bunch of really good things we can do, but they’re just not good enough. And you have to say no to literally everything that isn’t the best thing you could do.

Sarah Eustis-Guthrie: Absolutely. I think sometimes there’s this idea that part of being an entrepreneur is about iterating and being creative and doing all these different exciting and new things. Sometimes I felt like we were doing what we were supposed to do, in doing these creative and innovative and interesting things. But one thing that I learned is that if you’re looking at a long to-do list, the single best thing you can do to achieve that to-do list is to cross a bunch of things off the to-do list without doing them, and say, “This is not the best use of my time.”

Because you have to remain focused on what you’re there to do. And often what you’re there to do is really, really hard, and you’re better served taking the top four most important things from your to-do list and spending 80% of your energy there — and then either delegating the rest of it, or just crossing it off the to-do list and saying, “We can figure this out later.”

Luisa Rodriguez: Were there any points where… I guess you’ve described these moments of yellow flags, where you learned about postnatal abstinence, or you started hearing from people in the facilities that women already had the contraception they wanted. Looking back at those, do you have any feeling of like, “I really just should have pivoted then”? Or do you feel like, “I can kick myself all day for it, but actually, with the knowledge I had at the time, I made sensible choices”?

Sarah Eustis-Guthrie: I continue to be genuinely uncertain about this question. I think back to the decisions we made about having those bad gut feelings in Ghana, having these bad gut feelings about aspects such as postpartum abstinence… and I don’t know.

I do think that persistently we didn’t have the best approach for responding to these kinds of anxieties. I think often what happened is there would be an anxiety, and I would kind of freak out about it. I would let it dominate my thinking. Or maybe I’d try to push it aside, but it was making me stressed all the time. So I’d be in these other meetings, but I’d really be thinking about this thing, and then I’d be also doubting myself for trying to shelve it.

And then we would spend time working on it, but I think the time we spent working on it we didn’t spend as efficiently as we could have. So we spent too much time in desk research and discussion, and not enough time in talking to experts in a way in which we were willing to sound silly or be asking things that might be considered dumb questions.

So, in retrospect, I mainly wish I’d changed the process. I wish that I’d started from the beginning, because we started doing this later: just having a document of miscellaneous concerns. And then something happens, we just kind of file it in that document, say, “This thing happened. It’s related to this overall ongoing concern we have.” And maybe I’m in the middle of a meeting, and I’m just going to throw it in that document, and then I’m going to go and focus on what’s right in front of me.

Then have a time that was preset — but not all of the time; like once a quarter — where we’re going to look at these concerns. And as time went on, I think we were better about saying, after the pilot, we’re going to come back to these questions. But I think I don’t love our process.

And when it comes to whether we should have responded differently to those red flags at the beginning… I still don’t know, man. If anyone has takes on this, feel free to tell me, and maybe I can feel better or worse in retrospect. But I think ultimately, I just come back to this framework of we were trying to do something that’s tough and complicated, and I think we were making a reasonable effort. We were definitely making mistakes along the way, but I think you have to give yourself a bit of grace when you’re doing something that’s really tough and complicated.

Luisa Rodriguez: 100%.

Sharing results in the space of postpartum family planning [02:00:54]

Luisa Rodriguez: Have you shared any of your results with organisations still working on postpartum family planning?

Sarah Eustis-Guthrie: We have. When we came to this conclusion that we had changed our mind on the intervention, we were immediately thinking, what can we do that’s useful with these results? We don’t want to just shut down, say nothing about it, and then things continue on in the world unchanged. We wanted the chance to share our results and maybe potentially affect how some folks think about it, maybe change how some folks direct funding.

So we worked on writing up our results, making some reports. By the way, if you’re interested, we have more information on our website if you want to dig into the weeds on this. But we approached a couple of the major funders of postpartum family planning and met with some of them to share some of our results to say that we think that the field is missing some aspects of what makes these interventions have an effect on people’s lives; we have some concerns about these interventions. We just wanted to start the process of sharing this information.

Luisa Rodriguez: I was going to ask how they’ve responded, and I’m also just curious: is this a big part of some funders’ portfolios? How common is it that funders are trying to fund postpartum family planning in particular?

Sarah Eustis-Guthrie: That’s a great question. So it’s a pretty well-regarded intervention, and it’s considered one of the priority focus areas for global family planning funders. I can’t give you an exact number, but if I had to guess, somewhere in the neighbourhood of tens of millions of dollars per year. So definitely real money going there.

In terms of how folks have responded, a lot of these discussions are still in progress, somewhat TBD. I would say there’s a lot of scepticism, and I think folks often come at this from such a different perspective that they’re just thinking about it in very different terms.

For example, I had one call with someone who is really committed to evidence-based approaches, is embedded at one of these funders, and was giving me advice on how to talk to them. I talked her through our beliefs on this, the evidence base, why we think it’s less effective, and she said to me, point blank, “You can’t frame it like this to the funders. You can’t say, ‘We don’t think this intervention works very well.’ That’s just not how they think about things. There’s not a world in which they can spend less funding on this and instead direct the money to something else.”

And I was kind of confused by this. I was like, what do you mean “there isn’t a world”? Is there no control over where the funding goes? She was like, “It just doesn’t work like that. You can’t move the money around like that.” And I honestly was just not super convinced by this, but it was such a fascinating perspective.

Luisa Rodriguez: Huh. So in theory, the money could have been moved, but in practice, there was no one who was going to be open to hearing this thing doesn’t work, the studies actually say there’s no effect on unwanted pregnancies, and so let’s fund something else? That just wasn’t going to happen?

Sarah Eustis-Guthrie: That’s my best guess on it. It’s just really interesting, because I think a lot comes down to what is your fundamental perspective on the development space.

Do you have this perspective where you’re saying, “Our funding is limited; we need to be in triage mode. If we’re spending more on intervention A, we have to spend less on intervention B, so therefore we should prioritise between them”?

Or do you have this perspective of, “There’s a lot of different ways of doing good in the world; the world is really messy and complex, so we can’t really compare between them. Studies don’t tell us a lot. Therefore, let’s just kind of keep funding the stuff that seems vaguely good, and let’s not spend less on some areas”?

I’m obviously extremely bought into that first mindset, so I’m not the best person to provide a defence of the second mindset. But I do think a lot of the resistance that we’ve encountered just comes from people seeing the world in a fundamentally different way.

And it’s kind of a bummer to me. It feels really frustrating, and it feels like letting down the beneficiaries. If there are these better ways of helping them, which I genuinely believe is true, then I think we owe it to them to invest in those better ways. But there’s a disconnect in approaches.

Luisa Rodriguez: So after you had this conversation with this person, did you then try to convince anyone, or did you try a different framing, or are you accepting that you might not be able to move any of the people who are going to make these decisions?

Sarah Eustis-Guthrie: We’ve thought a lot about framing, and we want to frame it in the way that’s most likely to be effective, rather than necessarily the way that we most believe in, because that’s just how things work. I think that there is fundamental value in trying to create more of a conversation about these studies. Despite the fact that there is a disconnect in attitudes, I think people do care a lot about actually making things happen in the world.

So I don’t think that tomorrow, big orgs are going to turn around and say, “We’re going to stop funding postpartum family planning,” but I think having these conversations is worthwhile. It’s a long journey. I feel optimistic that some changes will happen, pessimistic that radical changes will happen, and we’re just going to do our best.

Luisa Rodriguez: What sorts of framings are you trying that you hope might be effective for this audience?

Sarah Eustis-Guthrie: I think there’s several different framings. One approach is to really foreground the autonomy side of this, and to not talk about unintended pregnancies in and of themselves, but talk about the feedback that we’ve gotten from beneficiaries where they say, “We don’t feel like this is the best use of our time.” Maybe they’re hungry for information at different touchpoints, and really focusing on how we can shift money to more effective areas that are doing similar things in family planning, but maybe not at this exact touchpoint.

One thing I’ll just throw in here, that is a rabbit hole of its own, is that we have seen some preliminary evidence that approaches to preventing short-spaced pregnancies that are focused on community-based programmes — so programmes involving community health workers going into women’s homes; programmes that are heavier touch, where maybe they’re visiting six times in the first year post birth, rather than just having this light-touch interaction at a health facility — there’s a couple of studies on this that have shown robust decreases in short-spaced pregnancies.

And that’s really exciting. I don’t feel like there’s enough evidence to say, like, this is the solution. And frankly, this is a tiny fraction of the current funding that goes into postpartum family planning, because I think a lot of funders really love this idea of light touch, just adding it into existing touchpoints. But one thing we’ve talked about with funders is that some of these community programmes look promising.

And I’m very sceptical that they’re cost competitive with the most effective health charities, but they do show evidence of actually being effective in an endline way, which is not true of facility-based family planning. So comparatively, I do think that they are a better bet.

Luisa Rodriguez: Yeah. So if someone is committed to putting their funding into family planning to avert short-spaced pregnancies —

Sarah Eustis-Guthrie: This is the best short-spaced pregnancies bet, in my opinion.

Should more charities scale back or shut down? [02:08:33]

Luisa Rodriguez: It strikes me that charities seem to scale back or shut down at potentially a much lower rate than businesses — and that seems bad. It seems like businesses have some incentives that don’t always lead to incredible outcomes, but they are probably tracking something like whether they provide value. And if charities aren’t shutting down nearly as often, that might suggest something about too many existing that aren’t providing much value. Does that seem true to you?

Sarah Eustis-Guthrie: I think you’re pointing to the most important factor here, which is that structurally charities are built in such a way that your expectation on priors would be that a lot of them would just be doing stuff that’s not very useful. Because the difference in the way a business works is, at least in an ideal case, a business provides a product or a service to their consumers. If that product or service isn’t very good, then unless there’s a monopoly or something wonky going on, consumers stop purchasing that product and that business goes out of business.

But what happens is that instead of it being dual when it comes to charities, it’s actually this triangle: one point you have the charity, one point you have its beneficiaries, but then on another point you have the donor. And in some ways, the donor ends up having most of the power — because if the donor is the one that’s giving the money to make this programme happen, and you’re the charity, and you’re looking at your beneficiaries and you’re looking at your donor, you’re saying, “If the donor doesn’t like what we’re doing, the programme can’t happen. But if the beneficiaries don’t like what’s going on, as long as the donor keeps liking this, this can keep happening.”

And to be clear, I’m not saying that charity founders are sitting there saying, “Bwahahaha, I’m going to do bad things for my beneficiaries.” I think nearly all charity founders are really well intentioned and are trying to make the world better. But you end up in this structural space where you are structurally incentivised to make your donors as happy as possible — and then you’re only really incentivised to make sure you’re helping the beneficiaries insofar as the donor cares about it.

So maybe the donor wants to see photos of happy-seeming beneficiaries; maybe they want to see studies of this programme is really effective; maybe they want to see ongoing monitoring and evaluation data — but depending on what they demand, things could look very different on the ground. And of course, organisations can also demand these things, but in general, I think funders are often the ones who have the most leverage.

Trust-based philanthropy [02:11:15]

Luisa Rodriguez: So it seems like one solution is focusing more on outcomes for beneficiaries, and really trying to figure out some incentive structure that means that the actual thing that you’re measuring and holding yourself accountable to as an organisation is beneficiaries getting the thing that you think is valuable for them, and that they hopefully say is valuable for them.

But there’s been this huge backlash against the randomista movement, which tries to kind of forefront outcomes — so conducting randomised control trials to better measure the actual impacts of global health and development programmes. And you pointed out in the article that you cowrote with Ben — which is in Asterisk and which we’ll link to — that there’s this kind of new move toward what’s called “trust-based philanthropy,” which is a term I actually hadn’t heard before. Can you talk about what trust-based philanthropy is, and maybe what the best case for it is?

Sarah Eustis-Guthrie: Absolutely. I’m really glad you brought this up, because in some ways, I think that trust-based philanthropy emerged in response to this really important, really urgent problem in the nonprofit sector. And it’s part of this problem that I’m talking about, but I actually don’t think that it fully goes all the way in trying to fix that problem. So my relationship with it is like, “I’m really excited you’re pointing to this problem, but I don’t totally agree with all the ways that you’re trying to fix the problem.”

So trust-based philanthropy is one of the biggest forces in philanthropy right now. If you go to a conference on philanthropy, people will use trust-based philanthropy language. It’s gotten a lot of acclaim, and I think it’s very much in the philanthropy water in a way that I did not fully understand until I both started talking to some donors and also doing some research on this.

Trust-based philanthropy burst into wider awareness in the US around some of the racial justice protests a couple years ago. And it’s very much rooted in this idea of how we need to equalise the balance of power between donors and nonprofits and the communities they serve.

And it points to this really important thing, which is that it seems wrong for donors to have a disproportionate amount of power, and if they’re trying to improve things in the communities that they serve, that’s only going to happen when there’s this partnership of equals among donors and nonprofits and their beneficiaries.

So what does that actually mean in practice? Well, that’s a trillion-dollar question, and I will say I get the sense that in practice sometimes this just means using different words to describe the same thing happening as it was before.

But a lot of the shift that you see in practice is about reducing these burdensome reporting requirements that charities have to do for their donors. The fact of the matter is that a lot of donors — especially if it’s money from government development agencies rather than from private donors — will require this ridiculously long list of reporting requirements. So they want you to report on, “This is exactly how we used the budget, and this is like exactly what we did for this programme.”

And obviously, like maybe your listeners and you are thinking that that makes sense. But somehow, many organisations managed to do this in the most aggravating and time-consuming possible way. So I remember talking to another charity about a big grant that they’d gotten, and they said, “Maybe you should apply for this grant. But just heads up, we had to hire a part-time operational person for a full year solely to do the reporting requirements for this one grant.”

Luisa Rodriguez: Wow.

Sarah Eustis-Guthrie: Because they would make them fill out all these forms, and if you didn’t do it in exactly the right way, they would take away your money.

So reporting requirements are a huge headache for a lot of nonprofits. And I think this is actually less known in many effective altruist charities because actually many EA donors actually operate in a way that’s very much like the trust-based philanthropy approach — which I suppose I haven’t even gotten to; it’s just saying that maybe we should make these reporting requirements less onerous.

And I fully endorse many aspects of that, because I think there’s a lot of ridiculous time that’s spent on reporting that ultimately just makes the funders feel better. Like, “We’re doing our due diligence to get you to do it in this detailed way.” But really, for years nonprofits have been saying, “Oh my gosh, can you just make this easier for me?” — but maybe not even saying that to donors, because they’re afraid to say that to donors, because then maybe the donors will take away their money.

So lessening reporting requirements is a big part of this. And some donors have gone very far in that direction. So MacKenzie Scott has become one of the biggest philanthropists in the world. I don’t even think many people are aware of the full extent of her grantmaking. But over the last four years, she has given I think more than $17 billion to nonprofits. Probably that number will be outdated by the time that you release this podcast, because she’s just dispersing ginormous amounts of money.

And she doesn’t have a huge staff. I don’t know actually how many staff she has, but if you would do that under the normal reporting requirements, you would require the world’s most ginormous foundation. But what she’s done is she has been giving this money out with absolutely zero strings attached, at least to my knowledge. And often she doesn’t even talk to the nonprofits ahead of time. I don’t know how this actually works, but I think it’s something along the lines of like the head of the Boys and Girls Club in Boston gets an email that says, “Hey, MacKenzie Scott wants to give you a million dollars, no strings attached. It’ll be in your bank account next Tuesday.”

So in some ways, this is a big win, because charities have to spend less time on these reporting requirements; they have to spend less time trying to figure out exactly what does this donor want from me, cultivating these relationships.

But I also have worries about this, because I think in some ways, this approach conflates the nonprofits with the beneficiaries themselves. Because trust-based philanthropy in some ways boils down to trusting nonprofits to do what’s best for the beneficiaries. And you can think that people who run nonprofits are really well intentioned and great, and you should be friendly and make their lives easier, but also think that maybe it’s better for everyone involved if we have some ways of making sure that that money is actually helping the beneficiaries lead better lives.

Luisa Rodriguez: Yeah, it does sound really nice in theory.

Empowering the beneficiaries of charities’ work [02:18:04]

Luisa Rodriguez: What is your best guess at how to solve this? How to give power to beneficiaries in particular?

Sarah Eustis-Guthrie: So I don’t have a five-point plan to fix philanthropy.

Luisa Rodriguez: Yeah, it’s a tall order.

Sarah Eustis-Guthrie: But I do think there’s a couple ways of going about this. First of all, if you’re really focused on, “I just want to empower beneficiaries as much as possible,” if that’s your biggest priority, I think the best thing you can do is direct cash transfers. And I think that organisations like GiveDirectly have set it up in a way that mostly gets rid of concerns about corruption, that makes sure it’s going to folks who are the neediest around the world.

I am eagerly waiting for the moment in which people who are really focused on empowering beneficiaries start adopting cash as one really promising approach, because I think it’s such an exciting approach.

When I think about ways to empower beneficiaries, one approach is maybe they’re on a committee that helps decide where some of these charities’ funds go, and they have these long discussions. That seems maybe vaguely useful, but it also seems really easy for that to end up in a failure mode where it doesn’t actually make that much of a difference. On the other hand, if you just send people money, they can do whatever they want with that money. And a lot of studies have shown that people in extreme poverty tend to really reliably use that money on stuff that meaningfully improves their lives.

But I think that if you care about how we can empower people to do what they want to improve their own lives, then just giving it to them directly and bypassing the nonprofits entirely — not to put myself out of a job — but that is maybe just the simplest, best possible way. Give them the money directly.

Luisa Rodriguez: Yeah. I mean, I’m a huge fan of GiveDirectly and of that intervention. I guess you’ve pointed at one of the potential ramifications, which is putting a bunch of charities out of the job. Do you have an idea for how this happens? If you actually follow this to the logical conclusion, you’d probably see a bunch of charities shut down. And what does that actually look like that doesn’t feel horrible to a bunch of people actually at charities working and hoping to do good work?

Sarah Eustis-Guthrie: I think in my ideal world, there would be a lot more money that’s directly going to cash. And what that means is not that everyone who works at a charity is out of a job, but that instead they can be working on the interventions that are most impactful to help improve those people’s lives.

So I think in my world, what that looks like is not that there are zero charities — I mean, unless we’re living in our ideal world — but that there’s charities that have different focus areas, and that maybe have a different approach to monitoring and evaluation. And I think that that’s a really exciting future for both beneficiaries and the people working at charities — because 99.9% of people who are working at charities are there because they want to help people. So to me, this idea that we can help more people better, that is in fact a win-win.

The tough ask of getting nonprofits to act when a programme isn’t working [02:21:18]

Luisa Rodriguez: Totally, yeah. I guess when I try to imagine how this ends up happening in a way that isn’t kind of devastating, it’s like there is some kind of cultural shift where people working on nonprofits look really critically at the intervention they’re implementing — as you have — and some of them realise that the thing that they’re doing is not as good as other things that they could be doing, or that another charity is already doing. And they make this decision that you’ve made — to either shut down a programme or shut down themselves.

But that just seems like such an incredibly difficult ask. And it seems like MHI was, in some ways, kind of one of the easier cases of shutdown: you had three employees; you had people around you who celebrated the decision to shut down as a wise one, rather than considering it just a complete failure or disappointment — which is just less true in much of the world, unfortunately.

How realistic is it to think that nonprofits will shut down programmes with 30+ employees that don’t have that culture, or even entirely shut down their organisation?

Sarah Eustis-Guthrie: I absolutely agree with the premise that this is a tough challenge, and one that is not going to be solved in a day. I think that reframing it from shutting down to shifting programme focus areas, or shifting people from one programme to another programme, is a really helpful way of thinking about this.

One interesting example for this is New Incentives, which provides conditional cash transfers to help incentivise immunisations. You may have heard of New Incentives because right now it’s doing really well: it’s one of GiveWell’s top charities; it’s widely recommended.

But what you might not know is that when New Incentives originally started, they were doing a very different programme. Their founder was really excited about conditional cash transfers to help reduce poverty. She was originally focused on, I think, cash transfers to prevent mother-to-child HIV transmission. So she was working in Nigeria, and they were working in a bunch of clinics. And it was going decently, but they realised things looked different than they originally thought, and they were really not going to be able to scale up with this programme.

So they’d been operating for a couple of years, it had been going kind of well. I wasn’t involved at all, but my sense is they faced this fork in the road of: should we keep going with this programme that we think is decent, or should we try to pivot to something else? I can imagine them sitting in the room trying to figure it out, like, “Wow, this is a really tough decision. We have a lot of staff who might be affected. What’s going to happen?”

What they ended up saying is, “We are here to make a cost-effective, impactful charity and we want to focus on the most useful thing.” So they ended up pivoting to these cash transfers for immunisation. They ran an RCT, it turned out really well, and then they massively scaled. So they went from a small number of employees to I think they now have more than 3,000 employees in Nigeria.

Luisa Rodriguez: Holy crap! I did not know that.

Sarah Eustis-Guthrie: So pivoting is what allowed them to unlock their potential as an organisation.

Luisa Rodriguez: Nice.

Sarah Eustis-Guthrie: So I think that this is a lot about how we frame this conversation. Are we framing this as, “More people should do the painful and unpleasant thing of shutting down,” or do we frame this as, “More people should look at the exciting opportunities of pivoting their programmes to things that can help more people”?

I think there are tough calls, especially when it comes to are people going to lose their jobs. Speaking as someone who kind of fired myself recently, especially when I was like four months into job searching, I was like, “This sucks more than I realised. Man, I can’t believe I fired myself.”

Luisa Rodriguez: Job searching is the worst.

Sarah Eustis-Guthrie: Yeah. I think if you make it easier for people to pivot jobs, that really helps. Or if you provide them a different job within the organisation. And I think this is an area where it actually makes a big difference how you think about hiring people.

So I can tell you, when I was job searching, I was looking at a bunch of different organisations. Some of them were more EA-impact focused, some of them less so. And I can tell you that there’s a lot of organisations where I’d see an organisation, I’d be like, “This job looks cool. I think I could be good at it.” And then I’d look and the requirement would be like you have to have worked for the last five years in this specific focus area. So you have to have worked in nutrition or you have to have worked in malaria, or it might say you have to have a master’s degree in this specific focus area.

There is value in trying to select people based on their domain expertise, but I think that makes it a lot harder for people to move around. I think that makes it a lot harder for people to implicitly question the value of that domain area of expertise.

So I think this is one thing that effective altruism does well, although maybe sometimes does too much, is saying, “We want to hire exciting, competent generalists — and we don’t care about their backgrounds.” I think sometimes EA goes too far with this, but it makes it possible for people to move around, for people to fundamentally question if this domain area is the best way of helping people.

So I think that’s something that every organisation should think about, the tradeoffs of that when they’re thinking about how to hire folks.

Luisa Rodriguez: Yeah, yeah. I agree it’s hard to find the balance, but I do think there is something about not having everyone in your organisation have their identity staked in exactly that particular intervention that you’re implementing.

Sarah Eustis-Guthrie: Absolutely.

Exploring and pivoting in careers [02:27:01]

Luisa Rodriguez: I think thinking about your career can also have some parallels here. So 80,000 Hours recommends lots of people try out a particular career path, and then lots of those people have to figure out, is this the right thing? Should I keep investing in this thing and making this bet? And sometimes they have to decide that actually, no, I shouldn’t continue down that career path.

So I think this question of how to decide whether to double down or pivot is really important and really broadly applicable. How do you think that organisations, but also individuals, should think about how and whether to continue on their bet or pivot and do something else?

Sarah Eustis-Guthrie: I think that’s a great question. It’s certainly something I think about all the time. I think the most important part is to think clearly about what path you’re on, what the different assumptions are that would suggest that that’s a really good path, and try to dig into: Are there ways that you could try and test those assumptions? What is the balance of the evidence in one direction or the other that suggests that maybe this is a really good path or maybe this is a bad path?

Thinking really clearly about this, for me, usually looks like a spreadsheet. So for postpartum, I made this big spreadsheet that was: What are the biggest concerns about it as an intervention? How certain am I in each of these concerns? How much does this concern affect the bottom line impact of the intervention? And then talking to a bunch of different people and getting their input into it.

What ended up happening for postpartum was saying, I have a bunch of different uncertainties. And I think it’s important to remember as a baseline that you are going to be uncertain on every decision to some extent. You have to say, what’s the level of uncertainty that I’m comfortable with? I have these uncertainties, but the fact that I have so many uncertainties that are of sufficient size and affect the bottom line so much that that’s just greater than the amount of uncertainties that I’m comfortable with, or comparing it to comparable options.

So I think that if you can be as clear as possible in articulating what you believe, and creating opportunities for yourself where you can maybe test the ground-level truth of that assumption, is really important. And that’s extra tough when you’re working in really speculative areas. Maybe you’re thinking about something that’s far off in the future or that’s really speculative, but if you can at least concretely articulate, “This is exactly how speculative it is,” that makes a big difference in how well you can think about it.

Reevaluation points [02:29:55]

Luisa Rodriguez: Yeah, yeah, yeah. A kind of related idea that has helped me is: assessing how speculative a project is and estimating the chances of success or failure. If the project seems worth doing given those odds, I give it my best shot, and aim to think of it as a good and worthwhile bet even if it doesn’t work out. Then, I set a timeframe (like three months) to gather more information. If I reach a point where things look promising, I continue, which is a success. If not, deciding to stop is also a success! Regardless of the outcome, I’ve followed my plan and made good choices with the information I have.

Sarah Eustis-Guthrie: Right. I am the world’s biggest advocate of reevaluation points. I think that everyone should have reevaluation points both personally and organisationally, where you’re going to sit down and you’re going to say, “We have this strategy. Our whole approach rests on these assumptions. A, should we have these assumptions in the first place? And B, how well are we actually doing in achieving this thing? Maybe there’s different approaches to achieving our goal in a better way that’s more effective.”

I think that the genius of reevaluation points is that it both ensures that you have a time when you’re going to be reflecting on your approach, and it also gives you permission to set aside your concerns on a day-to-day basis. So you write down that concern in your reevaluation doc, and then you go back to regular life — and you know that you’re going to have a moment where you come back and say, “Wait a minute, is this actually a good idea?”

And I think that it’s really easy for organisations to not do this. Someone from a very large charity came up to me after a talk I gave on this topic and said, “We totally don’t do this at all.” I was really surprised, because I guess I just kind of figured that everyone did this. But the fact of the matter is I think that this kind of big-picture strategic thinking just isn’t often incentivised. So maybe if your funder isn’t going to pay for you to spend some time doing this thing, I mean, that’s where you get all your money, so you’re not going to spend time doing this thing.

So I think it’s really important as individuals and as organisations to be intentional about having this reevaluation point — because if it turns out that you were doing a suboptimal thing all along, that’s a big problem.

Luisa Rodriguez: Are there any other lessons you’re taking from all this?

Sarah Eustis-Guthrie: Yeah. One aspect we haven’t talked about much is this question of why aren’t charities doing more of this thinking and this kind of reflection? I think it gets at what I was just saying about how they often don’t have the money or the staff time or the resources to do this kind of reflection. And I think that everyone involved needs to acknowledge that if we’re going to take evaluating our programmes more seriously, if we’re going to take monitoring our programmes more seriously, that that will cost money.

And we’re going to have to incorporate this into how we fund programmes, how we think about programmes. Because if it’s not getting prioritised — and when I say “getting prioritised,” I mean “getting money” — then it is not going to happen.

Luisa Rodriguez: That makes sense.

PlayPumps were even worse than you might’ve heard [02:33:25]

Sarah Eustis-Guthrie: One thing I’d love to briefly talk about is PlayPumps, because it’s such an EA bugbear, but also really perfectly encapsulates a lot of what we’ve been talking about. So for people who aren’t familiar, PlayPumps is this charity where they had this really exciting idea. You need to draw water from wells in many low- and middle-income countries, and often this involves a lot of laborious pumping that women especially have to do. So they designed this play structure, where the idea was kids play on the play structure, and that automatically pumps the water. And this was a really exciting idea. It just has this kind of intuitive appeal.

Luisa Rodriguez: Super wholesome.

Sarah Eustis-Guthrie: Yeah, yeah. It got huge amounts of money. And then it turned out, whoops, it actually doesn’t work very well. EAs love to hold this up as an example of, look, things in development often don’t work.

But when I started digging into this example, I was like, wow, this is even worse than I thought it was — because it wasn’t just that this was something popular that was kind of like in magazine ads and people on the street started funding it; it got this big grant in 2000 and then grew in momentum over the next couple of years. And you got to this point where Laura Bush announced a $16 million USAID contribution to PlayPumps, and big celebrities were doing these benefit concerts.

And it was actually only once they had built like hundreds, maybe even over 1,000 of these PlayPumps that some of these reports were commissioned or started seriously circulating, which actually went and figured out how well it worked. And it seemed from the reports that it was pretty easy to figure out that it didn’t work that well.

And I don’t know exactly what had happened in the process, but clearly before making these big donations, organisations — including orgs like USAID that require a ridiculous amount of reporting — were apparently not requiring reporting on the most important thing, which is like, that this thing actually works.

So it turns out that there’s actually a bunch of different problems with PlayPumps. And just for context, a PlayPump costs about four times as much as a regular hand pump, and sometimes they replaced the regular pump with the PlayPump. And then the PlayPumps were really complex, they had a lot of parts, so when they broke down, it was tough to repair them. So not only are PlayPumps less effective, but I think you could argue that they were actually a net loss for communities. So that I think is a really damning part of this.

And the guy who founded PlayPumps, as far as I know, previously I think had been an advertising salesman. I think this speaks to what we were talking about the incentives — where in order to make this programme happen and to make this big change happen to the lives of these people in low- and middle-income countries, in many communities, they weren’t at all consulted. This thing just happened that made their lives worse because some salesman was able to sell something — not only to people on the street, but to some of the people making big decisions at the US’s biggest development agency.

So to me, that speaks to the problems with current philanthropy. And I think trust-based philanthropy is in part responding to these problems, but I don’t think it goes far enough. I think what charities have to do to be more accountable is to take more seriously this monitoring and evaluation: to, for any intervention that they’re doing, actually do some sort of proof-of-concept test where they can go out in the field and consult with potential beneficiaries to see if it’s really helping them.

But you can’t just ask them, “Is this helping you?” because they might feel pressured to say yes — but see, is it really connecting to aspects of their life where it’s meaningfully improving them? So that doesn’t mean giving textbooks written in a language that the kids can’t read. That doesn’t mean giving laptops to kids where there isn’t electricity, or where their reading isn’t very good either. It means trying to focus on the interventions that are meaningfully improving people’s lives, and taking a serious look at even some interventions that sound really good, even interventions that look good in initial randomised control trials but don’t always scale.

So you have to have this consistent, sceptical perspective, where you’re running an organisation and you’re saying, “We’re so enthused to be running this organisation, and we trust that we all have great intentions here. But we also are going to be dedicating a meaningful part of our resources to checking up on, is this intervention a good idea? Is it still improving people’s lives meaningfully?”

Luisa Rodriguez: Yeah. OK, if you want to learn more about Sarah’s lessons learned, I highly recommend the Asterisk article she coauthored with Ben, “Why we shut down.” It’s so, so good. And there are also some juicy quotes from people in the field who refused to even be named because they were so controversial. So it’s just a really good read.

Charity Entrepreneurship [02:38:30]

Luisa Rodriguez: OK, let’s move on. You founded Maternal Health Initiative as a result of doing Charity Entrepreneurship’s Incubation Program, which we’ve pointed at a few times. But can you talk about the programme a little bit more?

Sarah Eustis-Guthrie: Yeah. The programme is really cool. I’m a big fan of it. I encourage people to check it out if you’re interested. Basically, how it works is Charity Entrepreneurship has a research team that researches some interventions that we think could be phenomenally cost effective, but there aren’t currently a lot of organisations implementing it, or there’s big gaps where nothing is being implemented. They do this research, and then they recruit folks who are interested in starting charities.

And they have a programme where during the programme you do a lot of projects with other people who are interested in founding a charity. Throughout the programme, you are both figuring out which of the ideas that they’ve researched you want to found, and you’re trying to figure out which of the other potential founders you want to work with and maybe found a charity through. So throughout the programme, you do these projects, you do a provisional pairing, and then at the end of the programme you do a project proposal where you pitch for funding from their funding network.

Luisa Rodriguez: Cool. And what exactly was the process like of narrowing down your options and choosing a specific intervention to found a charity around?

Sarah Eustis-Guthrie: The safe answer is always, “It involved a lot of spreadsheets.” But it involved a lot of thinking from the highest theoretical level to the lowest practical level of these questions, like: How do I weigh different intervention effects? Maybe I only care about saving lives. Charity Entrepreneurship also does a lot of work in the animal space. I think ours was the rare all-human-interventions programme, but for a lot of programmes, people are thinking, “Would I rather do a programme that supports animals or that supports humans?” — which involves a lot of complicated philosophy and personal reflection to also thinking about these more pragmatic considerations.

For me personally, my top charity choices I was considering during the programme were doing postpartum family planning, and doing a charity related to road traffic safety. Because deaths in traffic accidents are one of the biggest causes of preventable deaths in the world, and there’s been a bunch of charities that have found that if you make policy changes in some countries related to speed limits or seatbelts, you can save a lot of lives. And the other one I was considering was more of a research-focused intervention: doing research on different potential interventions that other organisations would then work on.

And so comparing these three different options involved a lot of questions. For example, on a day-to-day basis, do I want to be advocating governments? Do I want to be sitting at more spreadsheets? Do I want to be out in the field? So, trying to think through those questions, trying to think through what would I enjoy, what am I good at? A lot of really tough questions.

Luisa Rodriguez: Yeah, yeah. Was it those personal fit considerations that pushed you toward postpartum family planning?

Sarah Eustis-Guthrie: I think the biggest piece of it was the impact piece. It’s kind of awkward to say this now, but I felt convinced that it was the most effective way to help the most people, which was really exciting to me. I think also, as a feminist, I was really excited about an organisation at the intersection of EA and feminism.

But I was really excited about the other interventions. It’s this funny thing; I’m bummed because when an intervention isn’t started in a particular cohort, it gets moved to the next cohort and usually it’s eventually founded, but somehow still no one has founded the road traffic safety charity. So I’m thinking, should we have founded it? What would be going on with this charity right now? But yeah, it was a really interesting but tough process, for sure.

Luisa Rodriguez: How do you feel about it now? My impression, and maybe we’ll talk about this more in a minute, is that you didn’t try to found something else. You’ve decided to do something different. But do you still recommend it to other people?

Sarah Eustis-Guthrie: I absolutely recommend it. I didn’t realise, going into it, how much I would learn, what a phenomenal network and community I would become a part of. I genuinely think that compared to my previous job — where I was working in government in what I thought was a very decent first job after college sort of thing — I genuinely think that I learned 10 times more in this job than I did at my previous job.

I would say it’s a big commitment, and I don’t think you should underestimate how big of a commitment it is. But I think that it’s a phenomenal programme, because, for me, I not only learned about how to start a charity, but I learned a lot of great stuff about how to solve problems, how to approach difficult questions, how to navigate uncertainty that I think will be phenomenally useful with every other job, and even beyond professional aspects of my life moving forward.

Luisa Rodriguez: Wow. It sounds like it really isn’t a normal job. It really sounds like, more than most jobs, including jobs where people work really hard, that it really dominated your life. Is that just the requirement? Is founding a charity just going to be probably that intense? And so people should go into it knowing that it’s going to be really the biggest thing in their life for quite a long time?

Sarah Eustis-Guthrie: I’m wary of making sweeping conclusions on this, because I am but one human. I think if I had to guess, I probably found it more intense and dominating than the average person. And I don’t want people to think that everyone has my exact experience with it. I will say, when I look at a lot of my friends and colleagues, I can see how this sense of personal responsibility takes a real mental and physical toll on a lot of people. And I think there’s a real cost there. I think even in a community that’s as warm and positive as CE, I still think we could do better to say, “Hey, this is taking a really big toll on people. How can we do a better job of supporting folks?”

I think this is true in effective altruism more broadly, where people take these questions really seriously, they feel like what they’re doing really matters, and so they put a tonne of pressure on themselves. I know I’ve certainly put too much pressure on myself.

But I would say that I think for many people it’s really big and dominating in their lives. I’m sure for some people it’s less big and dominating in their lives. There have been a number of people who are doing the programme and running a charity even though they have kids, or even though they have substantial other obligations. So you don’t have to sign up and give up everything else in your life.

And just for context, for example, I tried to avoid working on weekends. I would sometimes say that I can’t do this work trip on these dates because I have family commitments. So absolutely, you don’t have to sign everything away — but I think you should take seriously that it is a serious commitment.

Luisa Rodriguez: Yeah. Are there other kinds of traits of a person that might make them a better fit for the Incubation Program?

Sarah Eustis-Guthrie: Yeah. I think part of it is being hungry to meaningfully change the world, and being bought into this evidence-based mindset. Probably the biggest differential factor is this question of how comfortable you are in a fast-moving, uncertain context — where you both have to take a lot of responsibility and you need to be self-motivated. Startups are their own beast, and you have to be willing to wake up in the morning and you don’t have a boss: it’s up to you to make the decisions on what you work on that day.

One thing I remember reading is they say if you’re the kind of person who can take a self-directed online course and complete all the stuff despite having no one haranguing you, that’s a good indicator.

Frankly, I think most people, myself included, tend to underrate their ability to do this kind of thing. So at some point they did some sort of survey and they asked people who were charity founders through the programme, “Did you think you’d get into the programme?” and most people were like, “No, I didn’t think that I’d get into the programme.”

So I think if you’re excited about this sort of thing, and it sounds like it might be a good fit, then it’s worth applying for and figuring out whether it’s a good fit along the way. But I do think more people than realise it have this kind of entrepreneur-y mindset.

Luisa Rodriguez: Was it obvious to you all along that you were the kind of entrepreneurial person who would thrive in a charity incubation programme like Charity Entrepreneurship?

Sarah Eustis-Guthrie: Absolutely not. I don’t think I had ever once thought that the word “entrepreneurial” applied to me before I applied to CE. I think I’d always thought of entrepreneurship in terms of tech and business, like pitching your cool new app idea. And I don’t think of myself as particularly techie or business-y.

But what happened is I was just kind of aimlessly scrolling through the EA Forum. I saw a post about Charity Entrepreneurship. It feels kind of silly to say, but they had this quiz you could take where you could say what different personality traits that you have, things you’ve done with your past. And I am the kind of person who, when I was in high school, I liked to start a lot of clubs, or run a lot of clubs, or do these projects on my own.

And it wasn’t for me that I looked at that title of “charity founder” and I was like, “Wow, that is absolutely me!” But I took this quiz and it was like, “Maybe you’re a good fit for this.” And as I started thinking about it, I was like, “Huh. Yeah, maybe entrepreneurial is a decent description of myself.” I do like things that are fast moving.

So I think that’s a pointer that it’s not always that you first hear about an opportunity and you’re immediately like, “This is my life’s quest. I’m going to absolutely be this person.” Sometimes it’s just helpful to investigate a little, keep an open mind, and you might realise that you’re actually a really good fit for something that you’d never considered.

Luisa Rodriguez: Any advice for someone considering founding a charity, given everything you’ve learned?

Sarah Eustis-Guthrie: I think that a programme like Charity Entrepreneurship helps a lot in helping you get these networks, helping you get the support. But if you’re the kind of person who wants to found something, and has that drive to found something, and feel like you can do it outside of that network, that absolutely also is phenomenal. More organisations is great, assuming that they have perspectives where it’s going to be a net positive.

If you’re doing the programme specifically, it’s really helpful to have an open mind about other founders and interventions, while also realising that this is a person that you’re going to have to be working with for years, potentially, that this is an intervention that you’re going to be owning for years, potentially.

I think early on in the programme, I felt nervous about asking questions that might sound dumb to people who’d written the research reports, or talking about things that might make me sound dumb to other potential cofounders. But this is a big thing, and it’s a quick research process — and as we’ve learned, sometimes they miss important aspects of the intervention. So you can come in, and take yourself seriously, and ask really critical questions about, is this intervention actually a good idea?

Because I do think that some of the interventions that CE recommends are incredibly, phenomenally cost effective and blow other even top charities out of the water. And then I think some of them are less exciting and less promising. So if you go in and you have strong feelings of this intervention looks a lot better, you might be right. Trust yourself.

Then when it comes to your cofounder, I think I initially was very focused on these questions of professional compatibility. So with my cofounder and me, I was like, “Well, we have similar strengths. We’re both generalists; we’re communication/research-y kind of people. Maybe we’re just not a good fit.” But we realised that mattered less than these questions of: How well do you work with this person? Can you handle conflict well? And I’d say most importantly: Is this a person you can trust?

So I think when you’re imagining — and this extends to not just starting a charity, but doing a close professional or otherwise collaboration with someone — you have to ask yourself this question of: If I imagine the two of us in this difficult scenario where we have to make a really tough call, do I trust this person to be on my team? Do I trust that we can work together in both the moments when things are going really well and the moments when everything seems like it’s falling apart? I think there’s a lot of fancy ways you can think about compatibility, but that is the most important question at the end of the day.

And I feel so lucky to have worked with Ben. He’s just such a phenomenally competent person, such a phenomenally smart person — but also just someone who I really trust, and made it not only doable, but fun and exciting to run this sort of charity with. So I encourage you to think seriously about the kind of person that you work with.

Luisa Rodriguez: Nice. OK. So yeah, you went through this whole experience and then you entered the job search. And as many job searches are, it sounds like it probably had some ups and downs. But you now know what you’re doing next. What are you doing next?

Sarah Eustis-Guthrie: I recently joined GiveWell on their malaria team. And I am super excited about this, because I’ve been a big fan of GiveWell for a long time, and I think it’s a good fit. But it’s been really cool to join the team, and I’m really excited about what the next couple of years are going to bring.

Luisa Rodriguez: That’s so exciting! Congratulations.

Sarah Eustis-Guthrie: Thank you.

The mistake of counting yourself out too early [02:52:37]

Luisa Rodriguez: OK, we’ve got time for one more question. What is one of the most valuable mistakes you’ve ever made, and how can our listeners learn from it?

Sarah Eustis-Guthrie: I’m not going to say starting MHI, if that’s what you were digging for. I think for me, I look back on my career, such as it is, and I think back to when I was 17, and I first learned about EA. I read about it on the internet; a friend introduced me, and I just thought, “This seems just true. This seems like a great way of thinking about the world. I want to be an EA. How can I become maximally part of the movement?”

And I feel weird saying this on the 80K podcast. Maybe I’m not allowed to say this, but I went on the 80K website and I said, hey, what should I do? And I was reading through all these opportunities and I had this sense that you need to be like a really exceptional person to do these really important things. And I was like, statistically it’s unlikely that I’m that kind of person. I don’t feel like I’m that kind of person. And I think maybe there was also this element of some of the specific things that were described. I was like, I don’t look at any of these and think I should definitely do this thing.

So I kind of just left it there. I went through college. I was like, “I’m going to be a vegetarian. I’m going to donate my money to these effective charities, but maybe the career stuff isn’t really going to work out for me.” And then after I graduated college, I applied to a bunch of EA orgs — not that many in retrospect, but what felt like a lot to me — and I was rejected from all of them. I said, “OK, this isn’t going to work out. I’ll just work in government or whatever.” And eventually I learned about CE and I went through the programme.

But there have been so many moments when I kind of counted myself out, and where I said, “I don’t think I’m good enough to do useful things in the world.” And I think the fact that I’ve been able to do things that are hopefully useful for the world shows that I was wrong.

And then I think also kind of being on the inside… You know, having friends who run orgs and they’ll say, “We’re hiring and we just can’t find the right person for this job that is really useful for making this organisation run” — I think I could probably think of like five different things like this right now. And those jobs, it’s not always the really exciting jazzy thing, like running the org. I don’t want to overemphasise that everyone should go found an org, because I think founders and people who run orgs get too much of the credit and too much of the social status. But practically, the org works because it has all the different parts, right? And all the different parts is the person who makes sure that the website works and the person who processes the donations.

Also, there’s so many phenomenally impactful opportunities that are outside of the direct EA sphere. I don’t think that if you want to help the world, you need to say, “I need to fit into this exact mould,” or, “I need to be exactly like who someone else says I need to be.” I think that there’s so many different ways that you can help — whether that means working at a job where you make a lot of money and donating a lot of that money; whether that means working in some government position, where there’s a lot of leverage and there really are lives at stake, and being the person in the room who says, like, “Hey, maybe we should use more data to inform this decision.” Or maybe it means working at a super impactful organisation and helping make it be even more impactful.

I think I’ve made the mistake of counting myself out too early, and of thinking I had to be one exact thing. And I just really encourage people to trust themselves and to know that you’ll get rejected from a lot of things. It was like two months ago, and I was sitting there feeling not great because I kept getting rejected from things. And then I ended up getting the job offer that I was most thrilled about, and the job that I most wanted. So sometimes you just gotta give it a little time.

Luisa Rodriguez: Yeah. I do feel like it is this brutal ask, that I think at 80,000 Hours we make a lot: it’s like, “Be brave, and try not to rule yourself out of opportunities because you think you might not be good enough, and because the rejection would be really painful.” And it’s true that it would be really painful. And it’s true that probably if you’re applying to the right number of jobs, you will get rejected much, much more often than you get job offers. And I hate that we ask people to do this — because you’ve been through it, and I’ve been through it and it sucks.

But yeah, I think it is the approach that for many people is important, if you can stand it, for trying to figure out how to do the most good with your career.

Sarah Eustis-Guthrie: Right. Absolutely.

Luisa Rodriguez: Well, thank you for that. And thank you for continuing to apply for jobs despite it being demoralising and rough. And congratulations again! GiveWell are lucky to have you. That is all the time we have. My guest today has been Sarah Eustis-Guthrie. Thank you so much for coming on. It’s been such a pleasure.

Sarah Eustis-Guthrie: Thanks for having me. This has been surprisingly fun.

Luisa Rodriguez: Nice. I’m so glad to hear it.

Luisa’s outro [02:57:50]

Luisa Rodriguez: All right, The 80,000 Hours Podcast is produced by Keiran Harris.

Content editing by me, Katy Moore, and Keiran Harris.

Audio engineering by Ben Cordell, 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.