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

This episode discusses the high neonatal mortality rates in Uttar Pradesh, India, and explores solutions, particularly focusing on the low-cost, low-tech intervention known as Kangaroo Mother Care (KMC).

1. Uttar Pradesh has one of the highest neonatal mortality rates globally, primarily due to the high prevalence of underweight mothers and babies.
2. Kangaroo Mother Care (KMC) is a cost-effective intervention that significantly reduces neonatal mortality by providing essential warmth and nutrition through close contact and breastfeeding.
3. The success of KMC in Uttar Pradesh demonstrates the potential for low-tech, high-impact interventions in resource-limited settings.
4. Scaling up KMC could save numerous lives across Uttar Pradesh and similar regions with high neonatal mortality rates.
5. Economic and social dynamics, like gender inequality and poor sanitation, play a crucial role in maternal and infant health outcomes.

1: Introduction to the Issue

Luisa Rodriguez introduces the episode's focus on neonatal mortality in Uttar Pradesh and the potential of Kangaroo Mother Care. Dean Spears: "Uttar Pradesh could be a country with the highest neonatal mortality rate globally."

2: Understanding Kangaroo Mother Care

Dean Spears explains how Kangaroo Mother Care works and its benefits, particularly in low-resource settings. Dean Spears: "KMC is simple yet revolutionary, leveraging maternal warmth and breast milk to sustain newborns."

3: Challenges and Opportunities

Discussion on the challenges of implementing KMC widely and the potential for scaling the intervention. Dean Spears: "Expanding KMC could transform neonatal care across regions with similar challenges."

4: Broader Implications

The episode explores broader social issues impacting neonatal health, such as gender inequality and nutrition. Dean Spears: "Socio-economic factors like gender inequality exacerbate health disparities in regions like Uttar Pradesh."

1. Advocate for and implement low-cost healthcare solutions like KMC in regions with high neonatal mortality.
2. Support and educate communities about the benefits of maternal health interventions.
3. Encourage local health systems to adopt and scale effective interventions like KMC.
4. Promote gender equality and improve sanitation to address underlying causes of neonatal and maternal health issues.
5. Engage with local and international organizations to fund and support scalable health interventions.

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

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

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

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Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste

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Dean Spears
A plausible bound for saving lives is one in ten, you know, a ten percentage point difference in nun and immortality, like, on the order of one in ten lives are being saved. I actually think it's better than that, but that's going to make the math easier. Okay. Right. And a plausible bound for the cost is, you know, in the hundreds of dollars per baby.

So hundreds of dollars of cost per baby times, you know, one in ten lives saved gets you a cost in the low thousands, like in the thousands of dollars per life saved. And, you know, that's basically the whole story of the cost effectiveness.

Luisa Rodriguez
Hi, listeners. This is Luisa Rodriguez, one of the hosts of the 80,000 hours podcast. In today's episode, I speak with economist Dean Spears about the surprisingly low tech and low cost intervention kangaroo mother care, or KMC, which is currently saving the life of at least one newborn infant every week in Uttar Pradesh, India. We talk about the shockingly high neonatal mortality rates in Uttar Pradesh and how social inequality and gender dynamics plays a role, how teaching new moms about skin to skin contact and offering breastfeeding support can be such a game changer for babies who are born small and vulnerable, how kangaroo mother care compares to giving cash directly to poor households, and how the currently small program might be scaled up to save many more newborns lives in other parts of Uttar Pradesh. At the end of the interview, I also asked Dean about his work on the looming global population peak, which he expects to be around 2080, and why we should start a conversation now about the global depopulation that will follow.

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

Today I'm speaking with Dean Spears. Dean is an associate professor of economics at the University of Texas at Austin. Hes also the founding director of Rice, a non profit research organization focused on early life, health and wellbeing in India, and the director of the population well being initiative, a global priorities research center interested in children, parenting, and the future of population growth and social well being. Among other things. He is also the co author of the award winning book where India abandoned toilets, stunted development, and the costs of caste.

Thanks for coming on the podcast, Dean. Thanks so much for having me. I'm looking forward to it. I hope to talk more about what KMC is and the evidence behind it. But first, why is low birth weight such a big problem in Uttar Pradesh?

Dean Spears
So my work is about babies in India and health and survival at the start of life. So I work in a place called Uttar Pradesh, which is a state in India with 240 million people. One in every 33 people in the whole world lives in Uttar Pradesh, fifth largest country. If it were its own country, and if it were its own country, you'd probably know about its human development challenges, because it would have the highest neonatal mortality rate of any country. Except for South Sudan and Pakistan.

40% of children there were stunted. Only two thirds of women are illiterate. So Uttar Pradesh is a place where there are lots of health challenges. And then even within that, we're working in a district called Bharaj, where about 4 million people live. So even that district of Uttar Pradesh is the size of a country.

And if it were its own country, it would have a higher neonatal mortality rate than any other country. In other words, babies born in Bareich district are more likely to die in their first month of life than babies born in any country around the world. So it's a place where there's a lot of good that could be done. That's really, really horrible. And I actually found it extremely, I don't know, useful, enlightening for you to compare it to other countries, because I guess there's this annoying thing happening where I know India has human development problems, but, like, I think of it as middle income and.

Exactly. I don't assume it has the worst neonatal outcomes in the world, but if you get more granular, there are still places big enough to be huge and important and kind of large enough in scale that we might want to really think about how to direct resources to them effectively. That's right. Nobody's the ambassador to Uttar Pradesh, let alone the ambassador to Bharat district. There's no, you know, World bank mission or UNICEF mission in Baraich district.

But it's a place with a country sized population of people, and a lot of them are babies that face threats and challenges at the beginning of life? Okay. Yeah, that is, again, just really helpful. And, yeah. Can you talk about why neonatal mortality is so high in Uttar Pradesh?

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

Luisa Rodriguez
Right. Okay. And can you explain the mechanism there? Why is it that being underweight can cause neonatal mortality. There are a few reasons why being underweight is dangerous for a baby.

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

Luisa Rodriguez
Okay, I'm interested in zooming out and understanding why neonatal mortality is so disproportionately concentrated in India. Again, I think of India as being middle income and doing, like, reasonably well on lots of these things. And I'm really, really taken aback that it's actually, yeah, I guess, one of the worst in the world on neonatal mortality. Do we understand why that is? Yeah, it is surprising that there's so much neonatal mortality in India.

Dean Spears
And the thing to keep in mind is that it's not just India, but there's a lot of differences within India. And it's in particular in this northern India area where, for example, Uttar Pradesh and Bihar, where there is a lot more neonatal mortality than you would expect. So neonatal mortality comes from largely being low birth weight, and underweight babies largely come from underweight moms. And in this district where we work, about a third of the moms are underweight, in the sense of having a body mass index below 18.5. And so why are moms underweight?

Well, some of the reasons that moms in Uttar Pradesh are underweight are the reasons that sort of everybody in Uttar Pradesh has worse net nutrition than they might, such as the disease environment and poor sanitation. So moms and babies and dads all sort of live in a place where sanitation, and, yes, there's still open defecation here, mean that people are exposed to germs that use up their nutrition, that SAP their nutrition and their energy through diarrheal disease or just fighting infections. But it's not just the poor sanitation and disease environment that's causing so many moms to be underweight. Very importantly, it's also social forces like gender inequality and the moms being socially low ranking people. Can you say more about that?

Yeah. So mothers in India tend to have their babies at younger ages, unlike in, for example, sub saharan Africa, where childbearing careers are more spread out in age. A lot of the babies in India are born to moms in their early twenties. And that's a time where women in India tend to be particularly likely to be underweight. You might just be thinking, it's a poor country.

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

So India has this double challenge where mothers tend to have babies young, and that's when they tend to be underweight. Right. Right. And why is it that this is happening in India and not in countries in sub saharan Africa, for example? I think a very big reason is social status and women's status and the sort of hierarchy that you find, especially in traditional households.

Not all households are like this, but let's zoom in on a special case that it's easy to learn from, which is joint households. And so Diane Coffey and Ritika Kara and I wrote a statistical paper about learning from joint households where you have two brothers. They grew up together into adults. They got married, and they all lived together. And so in a household like this, the wife of the older brother is socially higher ranking than the wife of the younger brother.

And the wife of the younger brother, the lower ranking daughter in law, is expected to do more work for the family and is later in line for getting the food she needs to eat, even during pregnancy. And so that's a situation where we can see an effect of a difference in women's social status, even comparing, you know, cousins, their kids who live in the same family, live in the same house, live in the same village. And so a lot of things would be held constant. So what do we see? Well, we do see that the lower ranking daughters in law are thinner, and that's even though they have the same height.

And so it's not about their early life nutrition, it's about what happens to them in adulthood. Interesting. Yeah. It's like we have a little experiment here. We can look in these families as petri dishes to see holding these other things constant.

What's the effect of mom being underweight for these social reasons? Yeah. So what is the effect well, we see that the children of the lower ranking daughter in law are more likely to die neonatal deaths and we see that they're more likely to be stunted and so small in other ways. And so in a situation where we're pretty sure that the difference in maternal nutrition is coming from these social forces, we're seeing it all the way through into neonatal mortality. That is fascinating and depressing.

Well, I mean, I'm optimistic that in the long run it won't always be like this, that we're going to, you know, it is the case, especially in other parts of India, you know, maternal undernutrition has gone down. These things are changing over time. A few years ago, 35% of women in Baraich were underweight. In the most recent survey, only 30% of women in Baraich are underweight. So it's moving in that direction.

And, you know, hopefully, you know, in coming decades this will not be such a challenge anymore. In the meanwhile, there's going to be a lot of low birth weight babies in Uttar Pradesh who need this sort of professional nursing care. Yeah, yeah, makes sense. But you're part of this project, Rice, that is addressing this, at least in the district that you're working in. What exactly is this project doing?

That's right. I'm part of a group, Rice, that's partnered with a government medical college in this district to do a program of low cost neonatal healthcare. And that's what the good news is. Medical science knows what to do about this challenge of low birth weight. A lot of people come here on the 80,000 hours podcast and tell you about some amazing new technology.

But I'm here to tell you about an amazing old technology which is professional nursing care and lactation consulting and helping moms keep babies warm and clean and fed so that they get what they need to grow. Can you make that a bit more concrete? What specifically are these nurses helping with that has such a big impact on neonatal mortality? The centerpiece of this care is a set of techniques called kangaroo mother care. And so kangaroo mother care combines two things.

One thing is skin to skin contact between the mom and the baby, where the baby is right on the mom's chest and maybe only wearing a hat. And so the mom's body is keeping it warm, the mom's heartbeat is helping it breathe and the baby is right there for breastfeeding. And the other part of kangaroo mother care is breastfeeding and lactation consulting, helping moms breastfeed, encouraging them and troubleshooting the breastfeeding when they get going, so that the baby can grow and eat and stay warm and have what it needs. Yeah. I'm just.

Luisa Rodriguez
I guess it's not that surprising that the babies can't stay warm. I'm kind of surprised that the solution is, like, put the baby on the mom's chest. Well, so when you're cold, what do you do? I bet you put on a coat or. Yeah, I put on a jumper.

Dean Spears
Wrap yourself in a blanket. Right? Sure. So, you know, people have this idea if they have a little bitty baby that maybe they should wrap it in a blanket. Right.

But, you know, the reason that what, putting on a coat keeps you warm is that you're generating heat from your body, and the coat's keeping it there. Right. An underweight baby isn't generating the heat it needs, but the mom's body is. And so putting the baby right on the mom's body relieves the baby of that little bit of work and uses the mom to regulate the baby's temperature. Yeah.

Luisa Rodriguez
Okay. The other thing you said that piqued my interest was the mom's heartbeat helps regulate the baby's breathing. Does that work? That's right. Especially a premature baby that isn't as neurologically developed might not breathe, might have gaps in its breathing.

Dean Spears
Neonatal apneas when there's spaces in a baby's breathing. So one of the challenges of caring for an underweight or premature baby is making sure it's breathing. So the rhythm of the mom's chest and mom's heartbeat supports the baby breathing. Wow. Yeah.

Luisa Rodriguez
That's just. It does seem too simple to work. But I guess that is one of the things that is so cool about this program is that it's. It is very low tech. Yeah.

Dean Spears
It's stunning. It's surprising. Right. You. YoU wouldn't think that you could save so many lives with an intervention like this.

But the thing to understand is that, you know, these low birth weight babies do face a real challenge of death. So if you can. If you can help them, if you can get them what they need, there's an opportunity to do a lot of good. Yep. Okay.

Luisa Rodriguez
Okay. Makes sense. Yeah. Is there any more to the program worth pulling out? One exciting part about this program is that it's not just care in the hospital, but also follow up care at home.

Dean Spears
And so some of the nurses call the moms on the phone, some of the nurses go out and visit the moms in the village. So after the baby is out of the hospital, there's still support to make sure that the family can keep up. Kangaroo mother care can keep up what they need to do to keep the baby safe and growing. What is kind of the counterfactual in hospitals like these? Because it seems like these things are.

Luisa Rodriguez
You're not providing like a machine. That's rigHt. It's like a nurse giving concrete advice, keep the baby on your chest and have skin to skin contact. Here's a bit of support with breastfeeding, especially young babies have trouble early on. Why do you need to kind of provide a program?

Dean Spears
EXACTLY. That's, you know, what's surprising here isn't ThAT ThAT sort of thing helps. What's surprising here is what would happen otherwise. And, you kNow, what would happen otherwise is unfortunately that a lot of these babies would just, you kNow, and their families would just leave the hospital and go home to their, you KNow, houses, maybe in a village somewhere. There just wouldn't be an interaction where the baby is flagged for needing special care.

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

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

Dean Spears
Right. How happy should we be with this sort of outcome? Right. And I think what's amazing is that kangaroo mother care and the sort of support that goes along with it seems to stack up very well even against, you know, conventional, resource intensive neo. So there was a 2021 study in the New England Journal of Medicine that was the IKMC program or the immediate KMC program.

And basically what they were studying was the benefits of doing kangaroo mother care even sooner than it might otherwise happen. And so it's not like, you know, kangaroo mother care versus nothing. It's kangaroo mother care versus conventional care in a radiant warmer machine. So the control group in this study was still in a hospital, still under medical supervision, and was in a radiant warmer. And then the treatment in this IKMC study was KMC, skin to skin contact on the mother's chest and all of that.

And it's in poor countries. They did it in five hospitals, four in Africa, and one, what I would consider to be a relatively privileged public hospital in India. Cause it's in Delhi. It isn't this context. And you know, what they found is that there was less neonatal death amongst the babies who got immediate KMC than amongst the babies who got conventional care.

Even with radiant warmers and machines and medical care. That is wild. That's wild, right? So this is so good that it's at least holding its own against, you know, conventional care with a radiant warmer. In fact, they stopped the trial.

They decided that we couldn't ethically continue doing this experiment because the KMC was so good. And even in developed countries where there are lots of resources, a lot of the conversation right now is about, let's at least for a little bit, take the baby out of the incubator or the radiant warmer and put it on mom's chest for a little while. Now, I'm not a medical professor. I'm an economics professor. I'm a social scientist.

And what I think is interesting and what an economics professor can talk about is why wasn't this thing happening before? And how do we understand the social science of making it happen and getting families involved? But if you look at what the medical literature says is they wouldn't be surprised that this is helping because that's what they find when they look at experiments for this. And the frontier that they're asking about is, is this maybe even better than conventional care in some cases. So amongst the babies in this program, 11% of them die neonatal deaths.

It is possible to do better than that. And 11% is a lot better than what would have been likely to happen otherwise. This doesn't mean that the project of neonatal healthcare is done forever, but it means that we have something wonderful available if it can be organized and brought to the babies who need it. Yeah, I guess digging into what we know about the evidence in a bit more depth, I think KMC has been studied in over 20 randomized control trials. So has, yeah.

Luisa Rodriguez
This very rich evidence based. What exactly is the evidence about the impact of KMC? I guess both on mortality and on morbidity. So things like hypothermia and severe infections and maybe start out with mortality. Great.

Dean Spears
Yeah. So when we're thinking about the evidence base for KMC, we can think about what the randomized controlled trials tell us. And there's also something interesting to think about, about what we're not going to learn from randomized controlled trials. So starting from what the randomized controlled trials can tell us, you're right. In 2017, there was a Cochrane review that reviewed 21 RCT's with more than 3000 infants in them, all told from places around the world.

And they were looking at low birth weight babies and they were comparing babies that were in a place where they would either get conventional neonatal care, that was the control group, or kangaroo mother care as the treatment group. And they found that mortality was improved, that babies were about a third less likely to die or had a relative risk of two thirds as much if they were getting the kangaroo mother care, the treatment, instead of conventional neonatal care, the control group. So that's amazing. That's life saving. And in a place where there is a lot of neonatal mortality, then, or infant mortality, these studies had different endpoints.

That's going to be a lot of lives saved, and that's amazing already. But something to notice is that the control group there is conventional neonatal care. And so in our setting, the counterfactual what would have happened without this program, and what probably is happening in other districts is that there just isn't the space or the staff to provide conventional neonatal care. Many of the babies who need it to, these low birth weight babies, remember, this is a hospital where there are a lot of births each day. And so because this program increased the staffing and the management and the space that was available to the pediatricians and available to these babies, it would probably have had an even larger effect than in the places that would be in the Cochrane review, where they were able to compare kangaroo mother care straight to conventional neonatal care.

It's also the case that studies like this happen in places that can do studies like this, which is probably going to be a little bit more advantaged of a population. Yeah. Yeah. So is it the case that we just don't have evidence where the control is what you'd see in Uttar Pradesh otherwise, or at least in this kind of underprivileged hospital where maybe these babies aren't even getting special attention despite being so small. We have evidence.

We have evidence. We know how many babies with these properties die. There's a study in who journal of low birth weight babies in DACA looking at ones that would have been comparable and would have been the same weight range. They're finding that more than a quarter of babies die that would have been in a comparable weight range in. That study happened in Mozambique when they were implementing a kangaroo mother care program in 2000 and they were able to do it in some ways and yes.

In some ways, no. And the babies who ended up getting this kangaroo mother care in Mozambique were 50 percentage points, half more likely to survive and 70% of the ones who didn't get it died. You can look at demographic and health surveys and just observational studies and see that there is a lot of neonatal mortality amongst babies who don't get this care in poor country settings and are low birth weight. And you can see that, you know, the survival rates in our program that are a lot better. The way that we think about it is that it could be a third of these babies dying in the absence of the program and it's a lot less with it.

Luisa Rodriguez
Right, right. Okay. So I'm curious, what is our kind of best guess at the ballpark number of lives that your program is able to save given kind of like, I don't know, we don't have perfect information, but we have pretty good information about what this intervention can do and how bad the problem is in this area. Yeah. So we know that the neonatal death rate for the babies in the program is 11% and we think there's good reason to think it would be in the ballpark of a third without the program, if you look at data from before or data from demographic surveys.

Dean Spears
And so I sort of like to think that a floor is ten percentage points of survival, that this program probably has a ten percentage point effect on. Survival and how many babies are in the program. Yeah. So when we first did our Cospin benefit calculations, we were averaging eleven and a half babies a week coming in. And then a few months ago when we redid them it was up to 16 babies a week.

More people are coming to the program, more people are hearing about it, we're doing a better job of getting families to stay. And so we think there's a pretty good chance that the program is preventing a neonatal death per week on average and maybe more than that. It's just a really, it's very moving. It is moving. I feel grateful to get to be part of it and to get to, in a small way, support these moms who put a lot of effort into staying in this ward day in, day out.

It's hard, it's boring, it's scary. The nurses who show up and do it, and not just in the hospital, but on the phone calls to the families after they leave and the visits out to the village, it's a great team of nurses with great pediatricians behind them, and it is moving. Sometimes we get a picture from the graduations. And so a graduation is when, as part of the home visit program, a nurse goes out to the baBy's house in the village to take the baby's weight one last time and collect the stuff, get the kangaroo mother care wrap back, maybe get the scale back, whatever. We've sort of let them borrow, do the final entry into the statistics and take a picture.

And sometimes these pictures, the mom is pretty stoic in the picture because taking a lot of pictures from nurses from a government hospital is not an everyday occurrence for them. But sometimes you really see a smile and you can see how grateful the mom is for this baby who started out looking so little and by the time of her graduation would finally have a little bit of chubbiness to it. It is really moving to see these pictures from the graduations as they come in from the nurses. Nice. Yeah, that sounds really special, I guess talking a bit more about the concrete evidence that we do have.

Luisa Rodriguez
So there are these benefits that we have on the mortality front, but then there are also benefits on the morbidity front. And I think probably we should really acknowledge that those are real and important benefits, too. So what do we know about that? What is the impact of KMC on morbidity? Right.

Dean Spears
So pediatricians who work with low birth weight babies know the sorts of things that low birth weight babies die of. And, you know, hypothermia being too cold is an important predictor. Infection, sepsis is an important predictor. And so when the Cochrane review was studying the benefits of kangaroo mother care for survival, you know, it would only be credible that there's an effect on survival if you're also seeing an effect on the sorts of steps along the way, the things that we know are the real signs of a risk for a baby. And so, yes, they find the overall one third reduction in mortality, but they also see the steps along the way that an average baby in the Cochrane review studies was only half as likely to have one of these severe infections.

They were a lot more likely to avoid that really big threat. And they were only about a quarter as likely to be hypothermic to be too cold. And so that's a really big reduction. 28% is likely to be dangerously cold. After experiencing kangaroo mother care, we see the sorts of benefits along the way that make it plausible that there's a mortality benefit.

Luisa Rodriguez
Yeah. Okay. Okay. So it's the kind of evidence that, again, contributes to this overall evidential picture that is like, yes, it's pretty clear that this has big impacts. And like, we're not just seeing magical reduction in mortality, we're also seeing the kinds of things that could have caused that mortality going down.

I'm curious if studies find any impacts on longer term outcomes. So cognitive development in childhood or even income later in life. Yeah, that's a great question. I often hear this question of if you prevent a neonatal death amongst a premature underweight baby, is it going to go on to have challenges or irregularities later in life? I was born at 29 weeks.

Dean Spears
I was born ten weeks prematurely. As listeners, you might wonder whether this guy has irregularities later in life, but I'm actually pretty grateful to be alive. And the evidence is that so far as we know, that people do what's called non inferiority studies of whether babies who are getting this sort of intervention end up worse on other dimensions, like neurological dimensions later on. And there doesn't seem to be any evidence that getting kangaroo mother care is bad for you in the sense that you end up worse than another baby as a developing child. Okay, now that's about kangaroo mother care, about low birth weight.

You're absolutely right that one of the reasons that an economist like me thinks and cares so much about the size of babies is because the size of babies is a very important predictor of, you know, not just health, but human capital accumulation, being able to go to school and learn from it, being able to be a productive adult all through life. So I like to say that my favorite economic development statistic isn't GDP per capita. It's the average height of children, because a place where the children are taller is a place where we know that good things are happening in terms of early life health and where we can look forward to see them growing up to being healthy, productive adults with higher human capital. So birth weight in particular and the size of children in general is enormously important for economic development and human development. But there doesn't seem to be any evidence that by keeping these babies alive, we're causing harm or slating them for bad lives.

Luisa Rodriguez
Right? Right. Okay, so the not causing harm thing makes sense to me. But, yeah, I'm interested in this overall question of whether not only are you saving this baby's life, but are you also potentially giving them longer term benefits, like, maybe because they were really hungry or really cold as a baby, their cognitive development suffered, or maybe they would have had some slightly worse overall, I don't know, cognitive development trajectory that would have made them worse off in the long term. And there's kind of maybe a hint at evidence in that direction, from the fact that you're saying height is an important predictor of how well a particular child or adult is doing.

But it also seems totally possible that the actual reason that height is such a good predictor is because it goes along with other things, like the income of the family that the child is born into. So the thing I'm really curious about is, like, if you make it less likely that this infant starts out life really underweight, really cold, more likely to have infections, are they likely to have these lifelong benefits? Or is it the case that, like, they're more likely to be healthy when they're babies, and that is wonderful, but they'll still have difficult lives because the kind of underlying circumstances that led to them being low birth weight, those things are all still present? Does that make sense? I'm glad you asked about that, because that's the sort of question that got me thinking about children in developing countries.

Dean Spears
I was interested in. I was interested in the effects on the survivors of being exposed to things that might harm a kid's health in early life. I got into this because I was wondering about the average height of children in India compared to other developing countries. Children in India are shorter. And, you know, that has to be a story about survivors, because you're only measuring the height of the survivors.

And so it really is a really important area in the nutritional literature and the development economics literature in the public health literature, just how important these early life markers of growth and development are for subsequent outcomes like learning and productivity. Now, if we think in our case, where this project in a government medical college is doing this intervention to prevent neonatal deaths, we can divide the babies who they're helping into three groups. There's the group who, unfortunately, would have died without the program, and unfortunately still die with the program. So the ones who still end up dying, that's a smaller group than it otherwise would have been. There's the middle group who would have died without the program and who now survive.

And that's, you know, the great and most important benefit of the program. But there's also going to be some babies who get the kangaroo mother care treatment who, you know, would have survived without the program and survive with the program. And those babies are going to be, you know, healthier and stronger. They. They won't have been exposed to as much infection.

They probably do have faster and better weight gain than they would have had without the program. And, you know, there's no, you know, it would be a very long term and very expensive study to track those all the way into adulthood. But from everything we know from the public health and demographic and economic and nutritional literature, a baby that's getting less infection in neonatancy and better nutrition in neonatancy is going to grow up to be healthier and achieve a little bit more of its height potential and a little bit more of its cognitive and learning potential and, you know, maybe even live longer in older adulthood. And so for that third group of babies, you know, when we do our cost effectiveness computations, we're not counting them as a benefit. We're just counting the survivors, but it probably is helping those babies who would have survived otherwise have better, healthier, richer, and more productive lives.

Luisa Rodriguez
Yeah, yeah, yeah. I guess, as you said, it would take an incredibly expensive and long term study, and we probably won't actually ever know this with certainty, at least not anytime soon. But it sounds like there's at least some theoretical reason to think that those babies who might have survived but are getting extra care might lead them to be stronger and healthier, and those of effects might last. But it also seems really hard to tease that apart from something else, like babies who get more, better nutrition and other kind of general support that leads them to be taller, it might just be that they get that kind of better nutrition and support throughout their lives, and that long term effect is what causes them to be taller and better off. Right.

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

Luisa Rodriguez
Okay. That makes sense to me, and I agree. Seems at least like a totally reasonable possibility, and I hope it's true. Yeah. Are there any benefits we haven't covered yet?

We've talked already about hypothermia, sepsis. Obviously, the huge one is reducing the risk of death and then potentially these longer term benefits that are a bit hard to know whether they're happening or not, but hopefully. Are. Are there any others? Well, when we think about the cost effectiveness of this program, we're basically valuing the neonatal survival.

Dean Spears
But, you know, I have to think that there are important benefits for the moms and the families of their babies being more likely to be alive. And, you know, having this experience, having this supportive experience where, you know, after you give birth, there are nurses and ward assistants who are there to help you and make sure that you eat and make sure that you're taken care of. And. And, you know, if the counterfactual is not as good of an experience for the moms, then, you know, that's a. That's a benefit that counts, too.

Luisa Rodriguez
Mm hmm. Nice. Okay. So based on the program's costs, GiveWell found that your program is able to save a baby's life for just $2,500 per life saved, which is. Yeah, incredibly cost effective.

How did this happen? How did GiveWell end up evaluating you? How'd you get put in touch with them? This is really amazingly cost effective. And GiveWell had a suspicion that kangaroo mother care could be, you know, before they had heard of us and before this project had even started, Givewell had done a deep investigation of Kangaroo mother care and had concluded that it really looks like it could be very cost effective.

Dean Spears
But the problem is, just like with so many things in policymaking in developing countries, it looked like it just wasn't going to actually happen and be implemented. This is a well known challenge. Some of the first randomized controlled trials in development economics were about getting teachers to show up for school and government schools in India or getting nurses to show up for work. And so it's a well known challenge, and this is one case of it that Givewell had concluded. Kangaroo mother Care looks life saving, and it wouldn't be surprising that if somebody implemented it, it would be amazing.

But it looks like there are really serious implementation challenges, and just announcing a program or drawing up the guidelines might not be enough to make it happen. They wrote up a review to that effect on the Internet and put it out there, and a little while later, they got an email or a call from another contact in the philanthropic world that said, hey, we hear about this government medical college in Uttar Pradesh where there's a project, and they claim that they're implementing this and doing it cost effectively and saving lives. And to the credit of the folks at Givewell. They were eager to change their mind and learn that, you know, it could be happen. They wanted to be right.

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

And we sent them a spreadsheet. And it sort of all made sense that it was having a big effect because, you know, the program was being implemented. And so what we had been able to do that might have been hard or challenging in other circumstances, was to build this professional culture amongst the nurses and the pediatricians who were leading it, and get everybody on the same page of providing and managing and staffing professional nursing care and getting the parents to come and be involved, too. And so when Givewell saw that, they wouldn't have been surprised, given all of the medical evidence out there that that's saving lives. And so, you know, we were delighted they made the decision to fund the program.

And, you know, that meant that we were able to keep going and continue to meet payroll. You know, most of the expenses is just the nurses and, you know, make some other investments and, you know, a refrigerator and a car to drive out to the villages and things like that. Yeah. What exactly was the kind of implementation challenge that Cavell was worried about? And how specifically does your program get around it?

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

Now it's flipped. It's more than 80%. And so a lot more babies are being delivered in institutions, and that's really good. The mom gets obstetric care, the baby gets early life vaccinations, vitamin K injections, maybe some slight encouragement to breastfeed, and that's a lot better. That's one of the ways in which the world is getting better.

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

Luisa Rodriguez
So are the hospital staff, do they not know what the guidelines say? Do they not have time to implement the guidelines? Because it's. It takes time to explain KMC to explain or to give lactation support or is it something else? You know, there are just a couple, just a few pediatricians who work there, and they had just a few nurses working with them, and that's just not going to be enough for this many babies.

Dean Spears
Now, you know, the government of Uttar Pradesh recognizes this. The department of medical education is working hard to open more new medical colleges and new nursing colleges. And hopefully one day that'll happen, or one day when all of that happens, that'll be a lot better for these babies. But there wouldn't have been enough staff and there aren't in other places to make this happen. Okay, that makes sense.

Luisa Rodriguez
So that is kind of the problem that this program, through rice, is trying to solve. It's a good problem to have. When a lot more babies are being born in facilities, most of them are getting what they need, but the ones in this birth weight range aren't. Yep. Yep.

Okay, so that's the kind of concrete problem that rice is trying to solve. What's the more conceptual one that you alluded to? Yeah, I mean, the more conceptual problem is that there are well known market failures and incentive problems in healthcare. That's something that sort of every health economics class starts with. And that's why a really positive development in development economics has been investigating when it would be better to just give families cash instead of paying for programs and why we think this isn't one of those cases, because you're not just going to be able to go out and buy this sort of health care, and that's because of these market failures.

Dean Spears
And so part of that is, is what economists call information asymmetries, where families might not know that their baby faces a threat, and they might not know the threat that it faces. And so a huge part of the work that the nurses in this program do is helping families understand the challenge and that it can be helped and motivating them to participate. So that's one reason why it might not have happened independently, because people wouldn't be clamoring for this to happen, because they wouldn't know that their babies had a problem that needed solved. Another reason, sort of more broadly, for why this doesn't exist. It wouldn't have to be in the government clinic.

Why wouldn't this have already existed? From a private provider, for example, you might ask. But the challenge there, too, is getting right back to these market failures in health economics, that what a private provider has incentive to do is get customers and provide sort, sort of the appearance of medical care. But if there isn't the right culture or regulation, then they might not actually be doing that much good. And a stunning fact about the statistics of early life death in Uttar Pradesh is that babies born in private facilities are more likely to die at the start of life.

Luisa Rodriguez
Oh, my gosh. Than babies born in public facilities, even though it's richer families, healthier families paying money for it. So something's really going wrong at the care of these private facilities in Uttar Pradesh. So that's not going to solve the problem. So that wasn't going to be there either, for the same basic reason of market failures in health economics.

Dean Spears
The third reason that I think about why this wouldn't have otherwise been happening, and I think it tells us something that could be important to anyone who's trying to do something like this, is that microeconomics would call a coordination equilibrium. Where I might want to do good, you might want to do good. The good can only happen if we both do it together. And so if we're not on the same page of both doing it on the same time, then there's no opportunity for me to solve the problem by myself. There's no opportunity for you to solve the problem by yourself.

The way that this is a coordination equilibrium is that I think the pediatricians there wanted to be providing better care, but it doesn't make sense for them to do it if they're not going to have the nursing staff and not going to have the patients. I think families want their babies to survive, but they just might not understand that they're going to be able to get this medical care. And if one family just shows up all by themselves, nothing's going to change. And these great nurses who the program employs, who went to nursing school and want to do good things, they want to be able to have a job where they can do good work. All of these things need to happen at the same time in a context where the leadership of the medical college is excited and the state government is excited.

So putting together all of these pieces creates what economic theory calls a coordination equilibrium, where it's reinforcing to everyone that it's all happening. So why did this program happen? Because it got coordinated into happening, and once it started going, it reinforces one another. I think that happens a lot in international development where situations stay worse than they could, because that's a coordination equilibrium, and they could be a lot better if there could be another coordination equilibrium. Yeah.

Luisa Rodriguez
Okay. Yep. That makes sense and is a sad thing, but I guess also an opportunity. Okay. So getting back a bit to the kind of cost effectiveness of this program and to Givewell support for it.

So, as I understand it, Givewell's $2.5 million grant was intended to cover the program for five years, including an evaluation of the program, which is very cool and exciting, but it sounds like you have room for more funding than you expected. How is that? Great. Yeah. Let's talk about that cost effectiveness number.

Dean Spears
The sort of highly cost effective things that you might be familiar with include maybe giving out insecticide treated bed nets to save lives against malaria. And so one of those nets, I think, costs on the order of $5. But if you give out a lot of them, then sort of the low probability of saving a life for each one all works out that you can save a life for something in the low thousands, right? Yep. This is a different way of getting to a cost effectiveness number.

In that ballpark, it costs our program about $5,000 a week to run, and that's sort of a cost of staffing and management and some supplies. And so when we did our cost effectiveness computations, we at that time were able to have about eleven and a half babies a week passing through the program. So that works out to $430 per baby of average cost. So the average cost of the program when we did the cost effectiveness calculation is $430 per baby. Now, how you get from that number to a cost per life save depends on how many lives the program is saving.

And so here's one sort of really basic way to think about it. A plausible bound for saving lives is that is one in ten, you know, a ten percentage point difference in neonatal mortality, like on the order of one in ten lives are being saved. I actually think it's better than that, but that's going to make the math easier. Okay. Right.

And a plausible bound for the cost is, you know, in the hundreds of dollars per base. So hundreds of dollars of cost per baby times one in ten lives saved gets you a cost in the low thousands, like in the thousands of dollars per life saved. And that's basically the whole story of the cost effectiveness. But going forward, the program is helping more babies than eleven and a half per week. And so that means a few things.

One, it means that there's an opportunity to put more funding to good use. You know, you know, in order to really reach all of the babies who are, you know, appearing, we're attracting babies from the smaller clinics are coming. Instead we're, we're catching more of them that pass through where we're persuading more families to stay instead of leaving. For all of these reasons, more babies are coming. And so, you know, that means we need more nurses.

Now, you know, the good news is, in economics, we have average costs and marginal costs, and the average cost is the average cost per baby. That's like that $430 number that I said before. The marginal cost is the extra cost of reaching another baby. And this is a program where there are lots of scale effects, where, you know, once we have a manager who is organizing the shifts of which nurse is on home visits and which nurse is on the overnight shift, and believe me, this is a big and thankless task. But once we have that nurse doing it, that is done.

And so the marginal cost of helping another baby, we don't have to hire another person to do the scheduling. And so chances are the marginal cost of helping more babies is even lower than that $430 average cost. And so we're in a situation where, where, on the one hand, because the program is successful in attracting more demand and doing a better job of finding the babies that can be helped, we're able to help more babies than we thought would be the case. On the other hand, we're probably helping the or treating the marginal baby for less expensively than the average baby. And so that means there's a real opportunity here to cost effectively save lives.

Lives. So if a listener out there is eager to find a way to make a cost effective life saving donation in a place where there is an opportunity to absorb the funding and put it to good use. Riceinstitute.org and we think we have that right here. That is really exciting. Okay, so pushing on a bit.

Luisa Rodriguez
You're also doing this evaluation that give well funded. So how's that going? Do you have any results yet? We don't have any results yet. Some excellent medical professors in Lucknow, along with the staff of this government college and the leadership of it, are excited about putting together a team that's going to do a matching based impact evaluation of going to government medical colleges in nearby districts and looking at babies that have the same observable properties, so the same gestational age at birth, the same birth weight, moms that are observably comparable, the same birth order and things.

Dean Spears
And these variables explain a lot of the variation in early life survival. And so if we can match on these variables, we won't have a randomized controlled trial, but we will have a pretty good idea of what's going on with comparable babies in neighboring places, which, you know, of course we already have from big picture demographic data sources. And so once we get all of that data collection machine going and running for a year or however long to see what happens, then this collaboration with medical university in Lucknow and this government medical college and sort of all the people involved, we'll be able to take this situation where we have really great reason to believe that there's a positive effect and be more quantitatively precise about it. Nice. Cool.

Luisa Rodriguez
Well, that sounds really exciting. But just to be clear, as long as the life saving effect is at least as good as one in ten, then the cost effectiveness numbers are going to be in that ballpark. So we interviewed Paul Niehaus last year about the organization he co founded, give directly. And he made the case that in many cases, kind of global health and development is better served by people just directly giving people cash rather than trying to figure out how to deliver a specific program to them. Why do you think that is not the case here?

Dean Spears
Well, first off, I think he's right that that is probably often the case. So I don't disagree with him in any sort of big picture way. In this case, it goes back to the fact that healthcare involves a lot of market failures. The idea behind giving someone cash is that then they're going to be the customers who can go out and make sure they're getting a good product and getting the product that's actually valuable for them. But there's no real way, you could take the $430 that, on average, this program is spending per baby and buy something like this in the market.

The private providers here aren't providing this quality of care, or even a very high quality of care at all. Babies born in private facilities in Uttar Pradesh are actually more likely to die than babies born in public facilities in Uttar Pradesh, even though their families are better off. And then there's just the well known market failures of do the parents know that they need this? Right? So, yes, it probably is true that in a lot of cases, giving cash is a good idea, but it's not going to provide this outcome of neonatal survival.

This is a case where there's a special opportunity of these moderately underweight babies, not the very most underweight babies, but these moderately underweight babies, where this sort of intervention of low cost neonatal care can save their lives. But it's not going to happen if it doesn't happen in an organized way. Yeah, I actually, Paul did talk about exceptions where it does seem possible for organizations wanting to do good, to beat cash and where they do, he's excited for people to fund those directly rather than give cash. And so I wouldn't be that surprised at all, actually, if in the end you two agree on this being a case where you can be cash, and so you should. Yeah.

Luisa Rodriguez
So I know that givewa was excited about funding even more of this type of program, but there just aren't many good opportunities, good kind of versions of it being implemented. Can you imagine expanding the program further? Yes, I think this is something that could happen in a lot of different places, either within this district, there are a district like this is a home for millions of people. It's the size of many central american or sub saharan african countries. And nobody would think that in a country you would want only one program like this.

Dean Spears
And so there are community health centers and there are other places within the district where you could expand this program, too. And this is only one of many districts in Uttar Pradesh, to say nothing of the districts in Bihar and Madhya Pradesh and other places. And so there are lots of babies in north India who could benefit from this sort of program. And is that something that you hope to do? Do you want others to come fill that space?

I think the most important thing is for hospitals and doctors to be excited about doing it. We're partners with this government medical clinic and they're really the leaders here in wanting to do something exciting and improve the care they're offering. If there were another place in Uttar Pradesh or Bihar, for that matter, where the doctors and the leaders of a district hospital or a government medical college were excited about doing this, then, yeah, that would be a place where something like this could happen. Nice. Okay, so if there were kind of hospitals excited about that opportunity, and in theory, one of our listeners were excited about kind of playing the role that you've been playing, where should they start?

Luisa Rodriguez
What would they need to know? How could they even begin to think about whether they could be helpful here? It would have to start with the hospital. And the thing that could make it happen is an organization that would provide the management to hire nurses and the support staff for them and make them happen. So it's a lot of management at Rice.

Dean Spears
We are not nurses. We're not doctors. We help the nurses and doctors do the great work that they do. And, you know, that is pretty nitty gritty, you know, make, you know, doing the hiring, making sure there are the resources, doing the scheduling and the staffing. And so it have to be somebody who had an aptitude for that sort of management and for doing something like that while letting the hospital take the leadership of the program and the development of the program and the pace of the program.

Luisa Rodriguez
Yeah. Okay. So it's something like a lot of kind of natural ability to get a bunch of operations y types tasks done. And also, ideally, a way to connect a hospital like this with the resources to support these hires. So one of the people who we work with, Nikhil, is just one of these natural leaders of operations tasks.

Dean Spears
And we happenstantially met him, you know, more than a decade ago on a. You know, we were driving from one place to another, and we stopped in to see a nutrition program about double fortified salt. And we saw such a great job Nikhil was doing on that. And the rice team has been collaborating with Nikhil ever since. And he's been making wonderful things happen.

And, you know, the. You know, the first most important people making this program happen are the, you know, the moms and the nurses. The second most important people making this program happen are the doctors and leaders of this government college. But Nikhil, if you're listening, he's the next most important ingredient in making this happen. And he has amazing management and operational skills.

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

Luisa Rodriguez
Yeah. Is there anything else you'd want to flag to someone who is interested in, in trying to expand something like what you're doing? Well, you know, this isn't exciting in the same way that some of the things you might hear about on the 80,000 hours podcast are exciting. This isn't about, you know, AI risk or new forms of currency. This is about, you know, hiring nurses, planning their shifts, planning who's going to go on leave for which religious holiday or wedding at which time, and who has the night shifts and who has the village shifts and.

Dean Spears
And who's happy about that. And who isn't happy about that. And making sure that they have their food and making sure that they have their supplies. And doing that all again next week. And doing that all again the next week.

And so if you think that you can do that, if that's the skill for you, then find a way to contribute that management skills to making something amazing happening. Either KMC or one of the other things. Were coordinating a great new program and overcoming these coordination constraints, rates can really cause something wonderful to happen. Turning to a completely different topic, you're co authoring a book on fertility and population decline. And the basic idea of the book is that population growth is going to continue until around 2080, at which point it'll peak, and then it's apparently going to shrink.

Luisa Rodriguez
And supposedly it's not going to plateau. It's going to keep shrinking, which I find really weird and counterintuitive and hard to believe. Why is that? So, at the beginning of this podcast, I told you that Uttar Pradesh is a place with some of the highest neonatal mortality rates in the world. And so you might think that birth rates would also be very high there.

Dean Spears
But in fact, the total fertility rate in the most recent demographic survey for muttar Pradesh was only 2.4 births per woman on average. And since the amount that is required to hold the population size stable is a little bit more than two, that means even Uttar Pradesh, a place where neonatal mortality is high, is getting close to that stabilizing birth rate. Is it going to stop at two? Well, probably not, because it hasn't stopped at two anywhere else. Two thirds of people around the world live in a country where the birth rate is now below that level.

That would stabilize the population. And if you look in these demographic surveys from India, even young women in Uttar Pradesh say on average, they want 1.9 children. And so the world is moving towards low birth rates and even Uttar Pradesh is no exception. Yeah, I guess I can still just imagine people finding it really counterintuitive that even if you get below two, why wouldn't you expect it to plateau at some point? Like how small could the population get?

Luisa Rodriguez
Realistically, I think when I first kind of read this article, I had the reaction, surely there must be some bottom, some plateau. Well, you know, humans reproduce sexually and so, you know, as long as that's the case, it's going to take two grown ups to make, you know, one kid. And so if two grownups aren't on average having two kids, or each grown up isn't on average having one kid, then the size of the population is going to get smaller. So as long as you think it's plausible that the world could, you know, converge towards a situation where on average, the whole world is having less than one kid per grown up, and as long as you think it could stay that way, then the size of the world population could fall. That might be surprising because you're used to the idea that the size of the world population is growing fast now.

Dean Spears
It's growing more slowly now than it was last decade and growing more slowly last decade than it was the decade before that. But even during that whole time when the size of the world population has been increasing, birth rates haven't, over any long period, been going up. The reason that the world's been getting more populous is because mortality rates have been falling. We've all been doing a better job of keeping one another and our babies alive because of programs like neonatal health care. And so it shouldn't be that surprising that the population size could fall once birth rates get low enough that the number of human deaths per year is greater than the number of human births per year.

Luisa Rodriguez
Okay. Okay. Yeah. That doesn't make sense. How small could the population get?

Dean Spears
Nobody knows. And one of the reasons why I think it's important to be having a conversation about birth rates and population size is exactly because could be an unprecedented future. If we do have a future where birth rates are below two and no other future looks more likely, then that would cause exponential population decline. And so what I think is important is to start a conversation now about these questions so that we can all be part of understanding what to expect and what to think. Okay, so I guess to make this more concrete, the population peak is meant to be around 2080.

Luisa Rodriguez
And then after that, how quickly does this decline happen? Well, it depends on exactly what happens to birth rates. So the UN projects a peak in the 2000 eighties, but other demography groups predict an earlier peak. In fact, what will happen after that depends on exactly where birth rates go. You know, the size of the world population quadrupled over the past hundred years.

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

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

Luisa Rodriguez
Right. Okay, nice. I like that. I guess I can actually hear other people who might be listening to this conversation and deciding kind of what they think about it. Yeah.

Thinking that depopulation could be good. Maybe it'll help with climate, maybe it'll help with other problems in the world. Do you buy that? I don't think it's right to think that it's gonna. That population change is gonna save us from our environmental challenges.

Dean Spears
Challenges. I think that climate change is not merely a potential crisis. Climate change is an actual urgency, and we need to be working on it right now. Nothing that's going to happen with population size is going to happen quickly enough to be a solution to our environmental challenges. And so for people out there who are thinking depopulation will, in some sense, you know, buy us out of having to decarbonize quickly.

No, we need to be decarbonizing long before we're going to be hitting these population peaks. Let's do that now. And while we're working on decarbonizing, start a forward looking conversation about the future of population. Okay. I guess regardless of whether depopulation is going to solve our problems now, I don't think it's obvious to lots of people that major depopulation is necessarily negative, but is there a reason to think that it might be?

I think that's right. That it's not obvious. And so, in writing this book, we've thought about a lot of different perspectives and a lot of different things. It's going to impact. One very important question is gender inequality and the fact that there's a sad history of coercion where governments around the world have tried to control people's most private decisions.

And so if changing birth rates turns out to be a situation where people call for more of that coercive control, and it's not just an if. We already hear people saying things like that, that sort of attempt to coerce people's private decisions would be a crisis and would be a tragedy. And so one reason to start talking about it now is to not leave the conversation to the people who would be advocating those sorts of things more broadly. There's a lot to think about. There's the consequences for the environment.

There's the consequences for gender inequality. There's the consequences for global health and poverty, there's the consequences for the economy, the fact that when we all work together, we can do great things. And I think amongst all of those, one consequence to think about is the value in getting to live a life. And if we think it's better when more people get to be alive and enjoy a good future, those are hard questions. And in this book, we don't pretend to have all the answers, but we do think that those are questions that more people should be engaging with, so that as we go towards a world of lower birth rates, all of those perspectives on all of those questions are part of the conversation.

Luisa Rodriguez
Okay, we will leave this here for now and hopefully come back to it when your book comes out in 2025. For now, a final question. What is a piece of advice that you wish you could give to your younger self? My younger self didn't really know how things were going to go for me, and my present day self looks back and sees a lot of surprise. And so I think the situations where my friends and collaborators and I have managed to sometimes accomplish something, it's often been pretty surprising and serendipitous.

Dean Spears
So I think one piece of advice is to be looking for that serendipity and sort of have openness to the randomness. And, you know, when you have a success, don't take it too seriously. Another piece of advice is to have the friends and collaborators who are going to be able to take advantage of that with you if that's, you know, I told you about meeting Nikhil randomly at a program, or Mike, my collaborator on the book about birth rates, who happened to be my cubicle mate in grad school, or just so many of the collaborators in the rice family. And all of it are people who I've met happenstantially, or we've taken advantage of something randomly together. So I think Pablo Picasso said something like, yes, inspiration strikes, but it should find you at work or something like that.

I would say, say, yes, inspiration and randomness happens. And when it comes, be sure that you have the friends and the teammates that you can take advantage of it with because I know that if I didn't, I wouldn't have been able to do such useful things. Nice. Okay. I like that.

Luisa Rodriguez
My guest today has been Dean Spears. Thank you so much for coming on, Dean. Thank you.

If you want to learn more about other Givewell recommended interventions, I strongly recommend Rob's interview with Ellie Hassenfeld on two big picture critiques of Givewell's approach and six lessons from their recent work. All right, the 80,000 Hours podcast is produced and edited by Kieran Harris. The audio engineering team is led by Ben Cordell, with mastering and technical editing by Milo McGuire, Simon Monsoor, 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 Katie Moore. Thanks for joining and talk to you again soon.