Katie Fantaguzzi: Why Deworming is Crucial for Millions of Children
Summary:
In this episode, we speak with Katie Fantaguzzi. Katie lives in Texas and transitioned from work in private healthcare consulting to measurement and evaluation for global health nonprofits. She is now a senior advisor at the SCI Foundation (update: SCI was recently rebranded as Unlimit Health), which treats millions of people suffering from parasitic worm infections.
Some things we touch on in this episode…
Does a data-driven approach conflict with a faith-driven approach in doing good?
How SCI Foundation administered 1 billion deworming treatments.
How bad parasitic worms are and how deworming works.
Why deworming is so effective and how it will change in the future.
Being motivated in private sector jobs vs. nonprofit jobs.
Whether Christians should work in Christian vs. secular charities.
Living with the monastic community of St. Anselm in London.
Articles, organizations, and other media discussed in this episode
Unlimit Health (formerly SCI Foundation) is a leader in delivering impactful public health programs, focusing especially on eliminating schistosomiasis.
Global Burden of Disease studies are an invaluable resource in understanding the changing health challenges.
The American Society of Tropical Medicine and Hygiene (ASTMH) is one of the the largest international scientific organizations of experts promoting global health initiatives to prevent infectious diseases.
GiveWell is a charity evaluator identifying the most cost-effective opportunities to save lives through donations.
Miguel and Kremer (2003) published a study on “Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities".
St. Anselm Community in London provides a one-year experience of monastic life for people aged 20-35.
Episode Highlights:
Does data conflict with faith?
[01:02:46] “I don't see them as directly in conflict with each other. I see it as a way that we can calibrate what we're doing in real-time to make sure that we're having a positive impact. Right. If we're not measuring it, then we can act in the world and have no idea whether we're doing something well or not well, like people who are careless with their speech. Are you hurting other people's feelings? Are you considering it from another point of view? And to me, Data is asking that question. Am I looking at this from another viewpoint? Am I considering all of the things that could be playing a role in this so that I can make sure that I'm acting wisely in a way?”
The Community of St. Anselm in London
[01:07:10]“It was a fantastic experience. It was a limited one year kind of thing, and it's still ongoing for people who are based in the UK. I'm also aware that they're starting one in the US that calls the City at the Crossing, New York City there, and are lots of other communities that are kind of I think it seems like there's a movement towards monasticism a little bit [...] I was doing what I do now when I did that experience, but it didn't make me change my job or anything like that. But I think that it, for me at least, solidified this feeling that I had that what I think matters is what I should spend my time doing.”
How parasitic worms (specifically Schistosimiasis) harms people
[00:08:05] “So when a person is infected with schistosomiasis, there's a burden that's associated with it. It's not just a single worm that causes problems. It's that you kind of get a build up of worms, and they mate and they release eggs. And the eggs that are floating around your body cause morbidity or disease. They can do lots of different things depending on where the eggs are being released and kind of which type it is. But some of the things I think that are more severe are that it can make people more prone to HIV. It can cause infertility. It can cause organ damage, can even cause, I believe, cancer and anemia. It can affect the way that children's minds are developing.”
Why deworming is especially effective
[00:13:57]“Specifically, I think deworming is a really interesting intervention because it relies on sort of interrelated organizations working together in concert, and I think it's a really great success story about public private partnerships and how those can be maximized to do some real world good. So one of the reasons why deworming is so cost effective is because the drugs are donated by pharmaceutical companies, and the donation program is organized by the WHO so that countries can apply to the WHO for drugs. The drug companies make them available, and then they're shipped to the countries.”
Giving tools besides GiveWell?
[01:17:14]“I don't know what those tools would be, very honestly, because I think you're right. I think we come back to you. You're trying to compare disparate things, things that are not similar. We've kind of acknowledged that there really isn't a gold standard for comparing them. We have some tools for comparing them, but not fantastic ones. And so how do people who don't spend every day focusing on these areas kind of suss it out and figure out what's best to do? And unfortunately, I think that it is kind of a little bit of a crapshoot and it's very hard to figure out where your investment, where your donation can do the most good.”
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[00:00:02.890] - JD
Today, I'm speaking with Katie Fantaguzi on neglected tropical diseases and deworming 1 billion people. Katie is An MER Advisor for Operational Excellence at the Sci Foundation. She is Catholic, has an Episcopal background, and is part of the founding cohort of the Community of St. Anselm. It's an ecumenical community in London that was established by the Archbishop of Canterbury. Katie has a Masters in Public Health and worked as a consultant before working at a nonprofit at Sci. In her day job, she uses data to inform cost effective deworming programs. Her treats hundreds of millions of people who are at risk of being infected by parasitic worms. We talk about that and how to think about uncertainty in health interventions, how to think about improving lives versus saving lives, and what listeners can do to help be a part of this exciting movement to end parasitic worms so that nobody has to deal with these awful, awful diseases. I hope you enjoyed the show. All right, Katie, thank you so much for joining us.
[00:01:28.010]
Great to be here.
[00:01:30.410] - JD
Could you take a moment to share a bit about your background, your studies, and what it is you do now?
[00:01:35.390] - Katie
Sure. So, my name is Katie Fantaguzi, and I am a senior monitoring and evaluation advisor at the Schistosomiasis Control Initiative Foundation, SBI Foundation, and we're a charity that focuses on deworming programs in sub Saharan Africa. A little bit about me. I am from the US. Originally. I grew up with an Episcopal background as an adult, kind of moved more into the Roman Catholic Church. I spent some time at Boston College, a Jesuit institution. I think that was formative in that transition in my life. And I've always really been interested in international studies, international issues, and health issues. And so the role that I currently play kind of brings back my interest in international issues with focus on health. It's kind of an amazing opportunity to be able to really, I think, advocate for a population of people that sometimes is overlooked. So I feel very privileged to do what I do professionally because it kind of combines some things that I value and that I think are very important.
[00:02:47.650] - JD
Thanks for that. And what is it exactly that you do? You do emine. What does that stand for and what does that look like day to day?
[00:02:54.300] - Katie
Sure. Eminential hear variations of that. Mer mel. Basically, it's a shorthand for monitoring and evaluation, and it's the collection of data in order to figure out what programs are doing on the ground, if they're having the impact that we think they are, and also focusing on research and getting more information to find out how we can do things better. And so it's a combination of those things and different organizations kind of look at it slightly differently, but overall it's using data to inform decision making.
[00:03:30.130] - JD
Got it. So have you always been a data person? Has that always been your wheelhouse? Or was this something you picked up along the way because you cared about global health?
[00:03:40.230] - Katie
So it actually is not. I would not describe myself ever as a data walk, even today. I would say I'm probably more interested in policy and decision making and how do we make the right decision. And I think that that led me to a focus on data. And I kind of like this shorthand, that in an ideal world, we would have the right information in the right hands to inform the right decision at the right time. And I think that my focus on how do we get things to happen in the real world, but we need the right information. And I think that that's what led me to really focusing on data. And monitoring and evaluation seems crucially important.
[00:04:22.900] - JD
When there's so much data out there and so many different ways to spend money and to run programs, whether that's in the government or for nonprofit. But you've ended up in the nonprofit sector working with neglected tropical diseases. So why this cause area? Why this problem? And why not some other?
[00:04:41.050] - Katie
Sure. I think sometimes our careers end up being a little bit opportunistic and it's just the right opportunity kind of presents itself at the right time. And that's how I ended up working in neglected tropical diseases. I think this particular area interests me because it's very cost effective and it's a big global problem. So neglected tropical diseases, for those who might not be familiar with that term, are generally diseases of poverty, and they affect the world's poorest people. Often they're because there's poor sanitation, and so they're often in populations that are disconnected from maybe a more urban kind of infrastructure and they don't have access to clean water. And as a result, there are lots of diseases that kind of crop up and affect those populations. We estimate for worms, which is the particular area that I focus in, that there are over a billion people who are affected by those. So it's a massive global problem. And kind of growing up where I did and with my own background, it wasn't something that I thought was still an ongoing issue. And to realize the scope and scale of what is still going on in the world today when it's easily preventable, is a little bit disheartening.
[00:06:01.240] - Katie
And so I feel very privileged that I can work on that because it is a massive need.
[00:06:09.430] - JD
So you mentioned that a billion people have been infected by worms. Is that at any given time, or is that every year we have a billion new cases of new worms and there's many different kinds of parasitic worm infections. Right. So can you give us a better sense of the issue as a whole? And what parts of the pie of this issue are the worst? I suppose I think you work with SEI Foundation, so SEI, or for Schizosomiasis, maybe that's a big focus of your work, but yeah, I'd love to hear more.
[00:06:39.460] - Katie
Yeah. So when we talk about deworming, we're focused on parasitic worms, and there are really two different types of categories that are often kind of thrown around interchangeably. The first is schistosomiasis, a much harder word to say. That is, you say it three times as fast. Exactly. It's an infection that happens when people enter into fresh water, and there are basically parasites floating in the water that can break through unbroken skin, and then they cause an infection. The other type, soil transmitted helmets, are the ones that we might be more familiar with, like hook worm, roundworm, whipworm. And those have a variety of infection pathways. Sometimes it's from walking with no shoes in infected soil. It can be from eating unwashed fruits and vegetables, things like that. But those are two different types of worms that both are what deworming programs try and tackle. I think it's well understood that schistosomiasis is the more acute infection, and there are different types of schistosomiasis, but that is more acute than Sth, the other worms.
[00:07:57.010] - JD
What would it mean to get infected with schistosomiasis? How is someone's quality of life or health damaged?
[00:08:05.450] - Katie
So when a person is infected with schistosomiasis, there's a burden that's associated with it. It's not just a single worm that causes problems. It's that you kind of get a build up of worms, and they mate and they release eggs. And the eggs that are floating around your body cause morbidity or disease. They can do lots of different things depending on where the eggs are being released and kind of which type it is. But some of the things I think that are more severe are that it can make people more prone to HIV. It can cause infertility. It can cause organ damage, can even cause, I believe, cancer and anemia. It can affect the way that children's minds are developing. So cognition, I think that those are more the cognition elements. Been a closer link with Sth, but it can have impacts on a wide range of things that affect mostly children, but also adults and very young children. I think that you were asking a question about what happens is it a billion new infections? The issue with these pathogens is that you can be easily reinfected. So there's medicine that's available that you can take that will clear you or mostly clear you of infection, but then you go right back into these same environments and become reinfected almost immediately.
[00:09:27.760] - Katie
And so that's kind of the cycle that deworming programs are trying to break.
[00:09:32.710] - JD
Can you give us a sense of where in the world this is mostly a problem? So we're not just talking about all of sub Saharan Africa. We're talking about rural parts of some countries. What are some regions in particular people groups that are most at risk?
[00:09:47.010] - Katie
Yes. So the subasian continent is a big problem with worms. There. Sub Saharan Africa. Clearly, these were infections that were very prevalent throughout the world earlier on. I would say, like, in the 17th, 18th centuries, 19th centuries even in some places. But in places where there are sanitation systems and other kind of better infrastructure, they've declined and been eliminated in most places. But there's still persistent problems in those.
[00:10:17.350] - JD
Geographies, and it's hard to get my it's hard to wrap my head around the problem as a whole. And I think about a billion people infected with worms. I, of course, would never wish this upon myself or someone I know or my family. It seems unthinkable that there are that many people who wrestle with something like this. Are these symptoms that you mentioned, whether that's decreased cognition or development in children or organ damage, are these universal symptoms? Or are there many people who live fine with some worm infection, like they might with a hangnail, maybe not the most severe symptoms they get. It's not pleasurable, but it's not the end of the world. How do we wrap our head around that? A billion cases, but maybe not all of them severe? Is there a metric or something we use to see how, I guess, expansive this issue is?
[00:11:14.680] - Katie
Yeah, so we call that intensity of infection, because, like I was mentioning, a single worm might not cause you a problem, but if you have a larger number of worms, does that indicate more severe disease? I think that where the lines are currently. We lump them into low intensity, moderate intensity, and high intensity. So high intensity, you have more worms. And we would, you know, just logically associate that with a worse kind of physical state.
[00:11:42.830] - JD
But really, just the more worms you have, the worse the worse it is. So if you have, like, a small.
[00:11:48.530] - Katie
If you have a small load that we would assume, you would have less disease. But I think that there's become more research recently about how even light infections can have cognition issues, can create cognition issues.
[00:12:01.560] - JD
Do we have a sense of what the median case is? So, like, the median person or the average person who has worms, how that affects them?
[00:12:09.930] - Katie
I don't think that we have, like, a clear link between this many worms, links to these kind of specific symptoms. I don't think that there's a good.
[00:12:19.020] - JD
Understanding of or even the average, like a typical case, as opposed to an extreme.
[00:12:26.750] - Katie
Yeah, I think that it depends. It depends on the age of the person at infection. Like, some of the infertility things that might be happening to a young girl, but that's not going to appear until she's older, and that's an issue for her. So I think that damage can also depend on not just the number of worms, the length of time they've been infected without kind of any treatment. So I think it's hard to identify, especially with the worm issues, what it looks like in physical forms, morbidities it causes. But I think having a sense of the breadth of things that can go wrong when you have these infections, it's important, and sometimes they can be irreversible, even if there is a cheap and effective treatment that's available.
[00:13:12.990] - JD
So Sci Foundation has been praised by many for being very cost effective in how they go about deworming. It's been estimated that something like a few thousand dollars is enough to save $30 or disability adjusted life years. Could you give us a sense of whether those metrics are most important to you or you're a metrics person? You're trying to evaluate the effectiveness of programs. Do you measure that in the way that many others measuring Dollies do? Or how do you think about that? Is it more holistic? And if any, are your critiques of Dollies as one kind of metric?
[00:13:57.510] - Katie
Yeah, I think maybe I'll start with why deworming is cost effective, and then we can look a little bit more at DALY. Specifically, I think deworming is a really interesting intervention because it relies on sort of interrelated organizations working together in concert, and I think it's a really great success story about public private partnerships and how those can be maximized to do some real world good. So one of the reasons why deworming is so cost effective is because the drugs are donated by pharmaceutical companies, and the donation program is organized by the WHO so that countries can apply to the WHO for drugs. The drug companies make them available, and then they're shipped to the countries. The deworming mousetrap kind of falls down in that the expensive fit is the implementation, getting the drugs from the countries to where they need to go, to these rural populations that are disconnected and very often, sometimes not even counted in national censuses. So we don't even know about them. Our governments don't know about them. And so that's a difficulty. And that, I think, is where sometimes the expense comes in. But that is one of the reasons why it's so extremely cost effective.
[00:15:16.460] - Katie
But it's leveraging the ministries of health and the government resources with pharmaceutical companies, with nonprofits to do the delivery itself. And so that's kind of an explanation of how deworming programs often run.
[00:15:30.920] - JD
I'm glad you picked up on that, because I think I jumped over this bit about how it is we, in most cases, address deworming. Could you share a bit about that?
[00:15:39.550] - Katie
Yeah, I think one of the really important things about this is the involvement of the governments themselves in these endemic countries. Working through a Ministry of health or a Ministry of Education in some cases is extremely important because programs are delivered to communities, and they're delivered to communities maybe at a health center, if there is one, or a school or a community center. But there is a massive community element that's involved in this. And so leveraging those relationships, local relationships, is essential. If not, you might run into a situation where you have foreign international entity going into a community telling everybody they need to take this magic pill. I don't know that that would go down as you would hope it would, but if you can leverage the community, explain why it's important and have some local actors who are on board, I think that that really helps build the consensus that you need in order to get participation. Because, of course, if you're only able to treat 50% of a community, well, you're just right back in the same cycle and you haven't really addressed any of the transmission that's going on and it's just going to continue.
[00:16:56.420] - Katie
So getting a whole community treated is extremely important and I think the best way to do that is through local partners.
[00:17:04.890] - JD
So the deworming treatments are done through tablets or small pills. What are in these tablets is some kind of antiviral or some kind of nutrients that boosts the immune system. How does that work?
[00:17:21.390] - Katie
Yeah, so the treatment for shiftosomyosis is a pill called Prozequantal. It's a big pill, it's bitter, it's not the best tasting. From what I've heard, the treatment for soil transmitted helmets is mebendazole or albendazole, sometimes ibarmectin, which we may be familiar with from the COVID period, is also a treatment for worms. Currently we're giving pills mostly focusing on school age children. It's usually five years old to 15 years old. We're asking them to swallow a big bitter pill in many cases. There currently is some research in the development of a pediatric proze, quantum, which will be for younger than five, because you can't ask a small child to take a pill. So addressing that population is really important as well. They're dewormers, so they don't have any kind of vitamin supplementation to them. But often we ask that the participants, the beneficiaries, have something to eat. Just because even if you take a vitamin on an empty stomach, sometimes that gives you the wobbles. So often they're having a snack before they're taking these medications.
[00:18:40.710] - JD
And this is also why the local partnerships are important, right? Because with the distribution, you'll hand out doses, what, once a year or once a season to millions of school children and others, is that right?
[00:18:55.200] - Katie
That's right. So the frequency of these campaigns, the treatment campaigns, which we often call MDA or Mass Drug Administration, sometimes you'll also hear it as preventive chemotherapy. They all mean the same thing, passing out medication. They're done dependent, the frequency is dependent on the prevalence in certain communities. So if 50% of people are infected, we would consider that high prevalence. That community would probably be treated annually or two times per year, depending if there's lower prevalence. And that's kind of in question. The who has just changed their recommendations for that. So we're all in this deworming community kind of going through some changes on the board, but that's typically how it goes.
[00:19:47.790] - JD
And through SCIF foundation, you have dewormed over 100 million people over the last few years. It's an astronomical amount. What does a project like that cost? Like, how much does it cost to deworm a child and how do you reach such scale? That's incredible.
[00:20:08.600] - Katie
Yeah, so I think we reach scale because we're working through ministries of health. I think that's the magic to it is that what we're doing is we're providing technical advice. We're providing funding, really, the know how to interpret data so that we can have the expertise to make sure these programs are going where they need to go. But to get that level of reach, you really need to have local partnerships and work through the ministries of health. I think throughout SCIF's whole history, we're up to our billionth treatment now, which is amazing as an organization that's only about 20 years old. So we're really proud of that.
[00:20:47.070] - JD
Yeah, that's incredible. And I've heard that the tablet treatments cost something like a dollar per marginal person treated. Is this just the cost of FCIF on your end? Or is this the cost, including those partners you mentioned, the governments and the pharmaceuticals who donate the drugs? Is this somehow taking an average cost of that supply chain? I'm assuming it's a marginal cost on your end, right?
[00:21:13.640] - Katie
Yeah, generally we take a marginal cost approach just because it's very hard to estimate the economic cost of doing everything. As a shorthand. We'll often do like, a $0.50 or 33 kind of range of the cost per treatment. But of course, that's going to depend on local context. Obviously, we're in inflationary times that has an impact too, and so it depends on the context completely. But that's often what we'll just use it as a back of the envelope kind of calculation.
[00:21:46.610] - JD
And you've had tremendous success with that, it seems. Over a billion treatments now, there are still children who go untreated. Where are they and why is that happening if it's such a low cost intervention?
[00:22:00.380] - Katie
Yeah, I'm glad you brought that up. So one of the big things that we're often concerned about is children that we call non attending children. If you're doing a treatment campaign through a school, what happens to the children who aren't able to attend school? And they can be reservoirs of infection? And so how do we reach the kids who aren't able to come to school? And that's a really big deal. Also very concerned about equity. So we want to know who we're actually reaching. Are we only reaching the wealthiest kids in these communities who are able to send their kids to school? What happens to the kids who aren't maybe they're at school, but they weren't able to have a snack before and so they declined treatment? We're really concerned about understanding who is being reached, who is being treated, because that's going to indicate whether or not these programs are successful at all.
[00:22:55.270] - JD
So there is some spillover effect where if you have a lot of kids being treated, then there's less worms in those kids but also less worms transmitted in the local environment. And so there's some spillover, positive spillover effect, right. Similar to a kind of herd immunity, although different mechanism, right. But in a similar way if children don't take these de worming tablets and they create greater risk for everyone around them. And it sounds like there are corners that are less reached by these public institutions and infrastructure and partnerships you have. And so how do you get to these corners when they are so difficult to reach? And I imagine the marginal cost to treat those children and those at risk people is much higher. Do you have an idea? I think you had estimates of something like 80 million people go untreated every year who get worms. Is that the case or something like that?
[00:23:54.090] - Katie
I don't know the exact number, but it's definitely a large number of people who are not receiving treatment, especially for Schistosomiasis, I would say globally focus is more on sth, hook worm with worm, round worm and there's first of all more of it, but second it's more widely distributed. Schistosomiasis on the other hand, is it requires a fresh water body and so it's more vocal. And so sometimes those are the harder communities to reach. Another thing that we contend with is that a lot of the places where we're working don't always have the most stable political or social environments. And so working sometimes in these places you can have delays because they're elections or it's a conflict zone or even seasonal variations can affect your ability to reach some of these communities. And of course that you're right. That adds to your cost. I think another thing that we're really focused on now, previously there's been a big, I think, push for control. And we talk about control as you'll remember from the COVID era, is how do we get disease down to what we consider an acceptable level. We're not going to be able to get rid of it completely, but how do we get it down to an acceptable level that it can be kind of dealt with with the public health or the medical infrastructure that's available?
[00:25:24.310] - Katie
I think the problem that we're realizing with worms is that you can bend prevalence, you can get it down to a low level. If you stop treatment, it bounces right back to where it was before you started treating very quickly. And so then, now how do you focus on this control thing? Does that change your interpretation of the problem if you realize that taking your foot off the gas at all kind of bounces you back to where you were before? Now there's this big question, I think out there of do we need to look beyond control and find some way to start working on elimination and getting rid of it or to such a low level that it will take a very long time for it to come back and we can catch it before it does. So I think that there's some soul searching a little bit at the moment about how to do that. I think the World Health Organization is kind of leading the way. As I mentioned before, there's a new strategy for treatment, but I think that it goes beyond that and now is focusing on maybe it's time to consider not just Mass Drug Administration, but now:
[00:26:31.570] - Katie
Do we really need to think about water, sanitation and hygiene issues as well? Do we need to have more infrastructure? Do we need to have a more holistic approach to this? And of course that's going to add to cost.
[00:26:44.690] - JD
What would it take? It would take treating water. It would take even more mass Drug Administration. Can you give us a sense of the scale of what's needed to create a control scenario where levels so low or even it's nonexistent, right. Where we've eliminated worms from the population?
[00:27:07.390] - Katie
Yeah, I think we're talking about vector ecology. How do you treat the vector sort of the host before it gets to humans? What do you do with the water bodies? And if you want to tackle the broader problems, then it really is water, sanitation and hygiene, which I don't know how much the audience is familiar with that, but that's massively expensive. First of all to just build the facilities that are required, then to maintain them. And then you need a behavior change component because people are so used to open defecation and sort of that's how they go about their business. Changing that culture to use these facilities and kind of make that change is actually very difficult and expensive and time consuming. And then measuring if you've done a good job, that's not a one week process, that's a longer term process to see if what you've built is working the way you think it's going to work. It doesn't always.
[00:28:09.070] - JD
So it sounds like the final frontier in deworming is building up this health and sanitation infrastructure. It would be necessary to rid it from the quarters where it's left. Right, and that sounds like a multi decade long course there. It doesn't sound like it's going to happen this year. Next year we would need just systemic changes in how places operate and even in culture itself. Right, yeah.
[00:28:36.010] - Katie
But until we get to that place, then I think we're kind of left with MDA, just continued treatment and so we're able to kind of build up what we need to see with that more sustainable, longer term infrastructure solution. Of course, the spillover effects of getting there would be not just fixing worms, but a whole host of other diseases that would be fixed if sanitation practices and facilities were available. You brought up Dallas a minute ago, and I think we didn't really jump on it, but I'd love to talk about that. If you want to loop back, we'd.
[00:29:13.890] - JD
Love to talk about Dallas, and then I'd love to talk about sustainability and this push recently for sustainable development and some of your takes on that. So first yeah, on Dallas, what do you think of this measurement? Maybe you can summarize it for those who are less familiar and then go a bit deeper for those of the.
[00:29:30.710] - Katie
Listeners who are yes, sure. So often we talk about Dallas. It's kind of a reference to the Global Burden of Disease study that's been done, I think, since the first year might have been 1996, mid ninety s and continues today. And what it's trying to do is to get a handle on the worldwide burden of disease and put it into perspective what, what is causing, first, most lives to be lost and second, most lives to be affected by disability or kind of not live up to their fullest potential in health terms. And so it's a massive estimation exercise that's conducted, I think, now mostly through the University of Washington and other partners. How do you compare different health states to each other? How do you estimate the number of lives lost to cancer? A lot of that is an estimation practice using the available literature and other sources, vital records, things like that. What the Global Burden of Disease Study does is they calculate, based on different diseases, the number of lives lost. And then for states of disease, they make an estimation of years lived with disability. And so they'll calculate the amount of time that somebody is disabled or not living in a full state of health.
[00:30:56.120] - Katie
And then they'll use a disability weight to kind of quantify how bad it is to be in that health state. And using those two things together for particular diseases, they can kind of compare them against each other.
[00:31:08.520] - JD
Could you give us an example of a Dolly for a particular disease?
[00:31:12.960] - Katie
Yeah, yeah. So, like, I'll use cancer. So if we take a particular type of cancer that on average might cause an individual's life expectancy to be reduced from whatever it was when they were born, maybe like 80 years old, let's say it might cause their life expectancy to shrink by X amount. So that would be sort of the years of life lost, the period of time yeah, say ten years that we would have expected them to live had they not had cancer. They had cancer and now they've lost ten years. So that's an easy calculation. The trigger calculation is when you're sort of in that in between state, you have cancer, you're in treatment, you're not living a fully healthy life because you have this condition. But how bad is it while you're in this state where you have cancer, you're not fully healthy? How bad. Is it, and how long are you in that state? And so that's what the years of life lived with disability are, and they bring those things together, and that's how they'll quantify the DALYs for that particular type of cancer with all the sequels. So those are all the kind of other symptoms that go along with having that type of cancer.
[00:32:24.990] - JD
And do we get dollies through surveying, or do we just ask people, how much would you trade, you know, ten years of healthy life between 70 to 84 against something else, or yeah, how does that work, and how do we know? We really have a sense of people's preferences.
[00:32:42.380] - Katie
Yeah. So that that's that disability weighting bit of it. So how bad is it to be in different states of health? And I think that the Global Disease Study has gone through a variety of iterations, and I think that they're still maybe working on perfecting it. I don't think that there's ever a perfect answer to that. I think they got a lot of criticism with some of the earlier work because it was a group of experts that were kind of figuring out what they thought was worse than something else. After that, they did trade offs where you kind of take this many people living in this state of health versus this many people living in that state of health. What would you choose which is better? That gets uncomfortable because now you're asking people to sort of do a walk around for evaluating or estimating the worth of a life. And that's difficult. I think there's also a component of if you're asking about infertility, maybe that affects men differently than women, and they might perceive those states of health very differently. There's also the element of the people who are affected by certain conditions often rate their health differently than people who don't have those states of health.
[00:34:01.310] - Katie
So blindness, for instance. So it's very tricky, and it's estimating something that's difficult to estimate, but then that has a very real consequence because we're producing some numbers. And I think if there's a lack of understanding about the nuance behind how those numbers were produced, we can draw some conclusions that we might not if we had a clear view of how that number was calculated.
[00:34:27.830] - JD
So it seems essential that we have some metrics, right? Like, if we tried to weigh how two different diseases or impairments sack against each other, we can't just say that all diseases equal because, of course, it'd be kind of silly to say, like, well, all the hangnails in the world add to as much suffering as all the cancer. I mean, that would just be terribly insensitive and just on its face. Not true, right? Dolly sound like one way that we try to make apples to apples comparisons, but of course it's very difficult when you're comparing very different kinds of things like impairment to vision versus impairment to some other sense or in some other way. And Dolly, of course, is limited by serving as well and how well we can actually get the preferences of the general public and the people, the beneficiaries of the program, and not just ourselves or the experts, let's say. Are there other metrics that you're familiar with that you would advocate for? And I guess I'm also curious what you would say to Dolly. Do you think the Dollies are helpful for the most part, but cover maybe a small part of the picture, or is it most of the picture?
[00:35:48.270] - JD
Yeah. So curious what your reaction is and what else you turn to.
[00:35:52.610] - Katie
Yeah, I do think that DALYs are important. I do think that the global burden of disease study is really important because I think we have limited resources with which to treat illness in the world. What do we do with them? Where do we put our resources so that we can have the most improvement in health? How do we do that? And we need something to use to compare dissimilar states of health. I think that it's important to have that grain of salt to go with it, to say, okay, we need to spread our resources across the board. Maybe we don't have these numbers exactly right, but what's something we can feel mostly comfortable with, I think is good. I think that there are other metrics that are available. I think qualities are great and qualities are quality adjusted life years. Those are more, I think, data intensive to generate, and they're not as easily kind of used across context as DALYs are. And that's why we don't see them as often for global issues. I think, unfortunately, there isn't a gold standard metric or we'd all be using it. I think that some people are working on that as a focus of their careers.
[00:37:11.590] - Katie
Very honestly, I think this is particularly important for diseases that are chronic and don't always result in death. I think it's very easy, at least on the surface, to have a comparison for conditions that cause mortality, because that's.
[00:37:26.690] - JD
A very what's the cost to save a life? Yeah, you can save a life for the cheapest, right?
[00:37:30.640] - Katie
Exactly. And there you go. There's your answer. I think it's harder when you're looking at chronic diseases that can last a lifetime, then it's a little bit squishier territory.
[00:37:41.830] - JD
I know that's been a huge focus lately of evidence based charity is finding the lowest cost to save a life. And I know Against Malaria Foundation often comes on top in that fight for being able to save someone's life on average for an estimated $4,000. There are, of course, others in this class that do it for a similar amount. I think maybe sometimes, and I'm curious what you think about this, but maybe sometimes we gravitate towards that because that is concrete. I have a sense of what death looks like. I don't have a sense of what worm infection looks like. So I might as well just optimize for what I can understand.
[00:38:19.260] - Katie
Yeah, I definitely think that that happens, that it's easiest sometimes to have that endpoint because it's clear cut, it's comparable. I think the problem that I have with that is that we're maybe dumping a lot of resources into those things that are easy. I think for me the deworming problem is interesting because it is massively prevalent and maybe it doesn't have the most severe endpoint, but because it's spread so widely across the world. Actually if we have metrics, it might be really an important problem to tackle, especially if we have an understanding that it's limiting individuals cognition and might be holding back some economic productivity that is creating a poverty trap. Then could solving that actually be a game changer in terms of global development? It's possible, but I think yeah, being limited by what's the easiest to digest metric is just an unfortunate reality that happens not just with disease considerations, but so many things.
[00:39:29.670] - JD
And one of the benefits of deworming that you alluded to earlier is that we also help children stay in school and to perform better at school. And we think this translates to higher earnings that we measure. I read once something like 9% expected higher earnings from those who are Dewormed, according to at least I think the study from Kramer in Kenya from the believe so. It seems though there's a lot of debates about the, about the certainty of these benefits. We know that worm treatments decrease worm loads. We know that very confidently. We don't know exactly what the longer term impacts of these are for those who are treated. If it does lead to like a 9% increase in income, that would be huge. Right? Because these are people who are living in extreme poverty. Any increase is a huge increase for them and 9% is no laughing matter. But it sounds like we're not sure if that's the median case. Maybe it was just from Kramer study and not from some follow up studies. Can you speak into this debate that's come out these so called worm wars where some people are arguing oh, Deanworming actually isn't that effective and others are saying well it is an expectation, it's just maybe a low certainty but high value gamble here.
[00:40:58.610] - Katie
Yeah, I think that that's the case. I think a lot of the questions are driven by the fact that there's not an understanding of the mechanism by which clearing worm loads would then increase brain function and cognition. And some of those I don't think that those pathways are very clearly understood and as a result there is some debate about whether it's really deworming or could be something else that's causing those changes. I will say I think that some of the further analysis that was done on that led a lot of researchers to actually be more confident in deworming when using different statistical methods. On the same set of data. And so I do think that there is confidence there, but I think there's a lot that is not well understood about worm infection. Why is that? Could it be that there's not as much research done on it? Is it that kind of seeing some of those longer term impacts are very expensive to measure and monitor over a 20 year horizon? There aren't very many organizations who are capable of running an experiment that long. There's a lack of data, I think, for measuring these longer term impacts.
[00:42:17.210] - Katie
I think that there are, because this is such a low cost intervention, I think that there's a case to be made for saying, give it a try, when our alternatives for funding might be things that have even less impact data available to them. Thinking about some of the long term causes that are sort of open to engaging in the speculative nature about what we're doing today and how that's going to play out into the future, perhaps there is an argument to be engaged with for deworming3 where there is some uncertainty there as well.
[00:42:52.950] - JD
I think that's a fascinating concept. And so many of us, myself included, became interested in effective charity because we wanted to be sure that our donation was having an impact. We wanted to know that each marginal dollar we give goes to not just a good cause, but a great cause and the best cause. And I think this complicates the picture when we say, okay, there's lots of evidence that this is on average Ridge or possibly a really good cause, but we don't know for sure. And I guess the world is just not always as black and white as we would like it to be.
[00:43:32.400] - Katie
Yeah, I totally agree. But then we're left in this ethical dilemma of, well, what do we do? Do we do nothing until we have the evidence that will convince us, or do we do something and track what we've done to see if we can measure that in real time? I have kind of come down on the let's do something side myself.
[00:43:56.250] - JD
Can you speak to the risk profile of deworming? Compared to other interventions in global health, it sounds like malaria nets and other treatments that we have a higher confidence in, but maybe the expected value of them is a bit lower, or maybe the expected impact is a bit lower for every dollar we invest. Do you have a sense that deworming, even given these risks, is much more impactful than other interventions in the neglected tropical disease space?
[00:44:28.710] - Katie
I find that maybe hard to say. I think sometimes, as we've kind of spoken about before, I'm sometimes troubled by the easiest answer, kind of being the one that we gravitate towards. And I think that there seems to be a lot of resources that are available for certain cause areas and then less resources that are available for other cause areas. And that might have to do like you were saying, with the certainty, the level of certainty. But I think neglected tropical diseases as an umbrella are neglected and there are a massive global problem. And I think that they need some attention and time because there are effective treatments for those things, but they just don't get, I think, on the global agenda in the same way that other causes do.
[00:45:19.910] - JD
What would you say to an argument that for the cost of providing one heart surgery, you could deworm tens of thousands, hundreds of thousands of children? Would you still say a comparison like this? Of course, if it was someone we knew, we might have a certain obligation to someone we know and a certain preference to help them. But if we're looking impartially at helping the most people through the most effective health treatments, it does, to me at least, seem like there's a good case for the deworming over a more expensive treatment.
[00:45:58.870] - Katie
Yeah, I think that's the case. And that's unfortunately, the responsibility of a public health viewpoint is that you're not focused on, unfortunately, a single life and the value of a single life. That is important, but it's maximizing health across a population. And when you take that view, then it is about kind of how do we do the most good with what we have? That's sort of the way it is. And when we talked early on in some public health courses, often they come down to the most effective intervention is vaccines, because you're preventing something that can happen at a very low cost. So I kind of come back to that. Small issues spread across a large scale can add up to a very big problem versus something very acute that's happening to a small number of people.
[00:46:52.530] - JD
So I have some questions about scaling up deworming and what that would look like on the margin. One thing that I was always fascinated by with discussions about malaria nets is that there's such low overhead for a lot of these organizations providing these malaria nets. The real bottleneck is just funds to buy more raw malaria nets that we can distribute among people who need them. And so there's a pretty high level of confidence that at least this is my understanding, please correct me if I'm wrong, that if we invest, say, $5,000 in their distribution or in their charity, that's going to be converted to malaria nets which will be distributed. I think $5,000 gives you something like a thousand malaria nets or something. Whereas with a lot of charities, the programs are much more complicated than this. It's not like at the end of the day, each additional donation is just buying more of the direct product to the beneficiary. You have everything under specific programs, and these programs have teams. And these teams might have things at the bottom of them that they serve, whether it's maybe, let's say, a food pantry that's serving goods in a local community.
[00:47:58.660] - JD
But if you donate $5,000 to a food pantry, it's normally not $5,000 more food in the hands of the local homeless, for instance. Maybe you have to spend some of that money on some manager and some of that on compliance and so forth in deworming. Is it more like the former in the case of malaria nets where more funding at the margin is translating to more pills being distributed pretty one for one? Or is it more like the latter where at the margin new programs is quite complicated and we have to find new ways to break into these more isolated areas that need new warming treatments?
[00:48:39.580] - Katie
Yeah, I think that's a great question. I think that for existing programs where you have the ministries of health involved and they know what they're doing and they kind of have a clear understanding of how to run these programs, I think the former is the case. More funding means that they can reach more people. I think that there are certain countries where there are not existing worm programs or those worm programs really need some investment in order to get to a level where they can scale up those. I think probably more of the latter where you're going to need to spend money to get the right things in place in order to be able to figure out who needs treatment, where treatment needs to happen and how to do it effectively. And so I think it can be sort of a mixed bag depending on where you're looking. I think because the actual medication for deworming is generally donated, it's not as easy to kind of break down. A cost element of this is how much this will buy in each country. Context is going to vary significantly. So it's harder to do a sort of top line metric, but I think that it can be depending on the situation.
[00:49:51.150] - Katie
I think you're right that marginal donations can have a big impact.
[00:50:01.630] - JD
So do you have a sense of the current funding gap that CIF has and other effective deworming orgs in the space have? What do we need to do to meet the needs of I'm looking here now 130,000,000 people who we think still need chistosomiasis treatment. How much money do we need to fill that funding gap and how much talent do we need?
[00:50:22.310] - Katie
Yeah, I think the first, the starting point is what are you trying to achieve? Because if you're trying to achieve control where what we talked about earlier, you're just trying to bring infections to sort of an acceptable level prevalence to this level and that's what we're hoping to do. We're just trying to kind of quash the high and moderate prevalence areas and bring them in line to some low ish level, that's your goal, then that's going to require one set of things. If your goal is that you want to eliminate and you want to bring that to a much lower level. You want more sustainable programs where it's reaching very little transmission, ongoing transmission, then that's a different set of things that are going to require a very different level of investment time and talent and even expertise.
[00:51:17.990] - JD
Why do you think it is that if this is such an important problem and the ways to solve it are pretty well understood, at least where we have existing partnerships and drug companies willing to donate these deepworming tablets. Why it is that some big players don't just step in and close this gap by dropping a lot of new funding or just raising a lot of new talent. Bill Gates. For instance, with Bill Melinda Gates foundation donated billions. Right. I wouldn't be surprised if they put some of that towards deworming. I know they're actually very focused on vaccines, which is another really effective intervention. But yeah, why aren't there more big players just coming in and filling these gaps?
[00:51:58.670] - Katie
Yeah, this is just my own personal viewpoint, but I think worms aren't a very fun topic to address. It doesn't get the attention and it's not headline grabbing stuff. I think also we're dealing with populations that are often overlooked and so they don't have a voice to speak for themselves. I think that it's such a big problem that often communities that are deeply affected by them kind of feel that it's normal. Like one of the symptoms of particular type of schistosomiasis can cause blood and urine. And in some communities it's understood as like a rite of passage, a sign of maturation to have red urine because the whole community has that issue. If that's where we are, then who's really speaking up on behalf of this being an issue?
[00:53:00.570] - JD
Are there any other examples of cultural barriers to progress here where maybe the status quo is just embedded in people's minds? You mentioned sanitation earlier and how people go about their business. Are there any other examples that come to mind?
[00:53:16.990] - Katie
Well, I'm not sure about other examples. I think part of the problem that I think about just structurally with this is that with schistosomiasis being a vocal disease that requires a fresh body of water. For me, you can't get around the water being a problem. If there's no alternative for people to get drinking water, to bathe, to fish, if there's no alternative, then you can't tell people you can't go in the water. Of course they're going to have to and they're going to get reinfected and that's going to keep going. It's going to be a cycle until something changes. And what is that something? I think sure, MDA is very important, mass Drug Administration is very important. But if we're only able to get to a certain level and then we can't make much progress with MDA alone, then I think it's about figuring out what's next. And I think maybe some of the slowdown in investment is because there's not a clear understanding at this moment about what is required? How specifically do we deploy other interventions to combine here to really fix this problem? And we know those things will be expensive and we know researching them is going to be hard and time consuming.
[00:54:33.670] - Katie
But again, are we going to undo all of the progress and investment we've made because we're kind of at this difficult moment? I hope not.
[00:54:42.970] - JD
Do you have a sense of what the most promising opportunities are with improving water infrastructure? Water incentivation? Yeah. Do you have a sense of what of course, a lot of this is context dependent. So what might work in Kenya is not going to work in Southern Asia and so forth. But any promising organizations working in the space?
[00:55:04.610] - Katie
Honestly, Wash is not really an area of focus that I have. But I know that there are a lot of great organizations who are doing fantastic work there. I think one of the things that FBI Foundation is working on is figuring out how to get communities involved in a Wash discussion because just doing a cookie cutter approach in community after community is probably not going to be very effective. But you are going to need to address the context specific realities. And so I think that that's something that's very important. But as far as who I would recommend for Wash, I'm not going to venture there.
[00:55:43.150] - JD
Sure. So I'd love to transition to the rest of this discussion, talking about careers, how Christians interested in impacting this space can do that maybe most effectively, or what seemed like the best ways to start a career in this space, the best organizations to internet or conferences to go to. And maybe a bit later we can talk about some options for mid career professionals as well. But yeah, I guess starting with studies, would you have any recommendations for good majors or grad programs for people interested in deworming and neglected tropical diseases?
[00:56:23.270] - Katie
Yeah, I love that question. What I love most about public health and global public health is that it is multidisciplinary. And I think often people kind of jump to clinical backgrounds as being sort of the easiest way to get in or statistics being the easiest way to get in. And those are critically important. But I think that there's a lot to say about expertise in other areas and other specialties. I think that, like we learned from COVID a political environment is incredibly important and has a big impact on how health policies play out in real time in the real world. What are we deciding to do and how are we going to do it? That matters. So having sort of a political science viewpoint is important. Engineering is super important, I think, like general consulting skills about how do we get people in a room and spur them to action and kind of get an agenda agreed on and then make progress on that is also a very big one. Education behavior change? How do we convince communities to change something about what they're doing that leads to disease? And I think that social sciences, economics, basically everything, every discipline has something to say about health.
[00:57:50.180] - Katie
And so I think that kind of gets to the mid career people. It doesn't matter what you've done, there's a way to parlay it right and spin it so that you can add to the conversation if you think that that's something that interests you. But it's all important and it all has a role.
[00:58:06.570] - JD
So you worked in consulting before you entered the nonprofit space. I think it was it healthcare consulting. You did that for several years at a high level before Pivoting. Can you share a bit about that experience and how that maybe prepared you in a way that maybe a traditional nonprofit career might have prepared you in a different way? Like, what skills did you learn from consulting that you maybe wouldn't have learned if you just started in a nonprofit right after college?
[00:58:35.350] - Katie
Yeah, I think one thing that's been really helpful for me professionally, I think sometimes people get into certain nonprofits with a focus on what cause area they're doing. They have a specialty that's directly tied to that cause area. So infrastructure, maybe you have like an engineering background, you're going to do wash and I think that that's critically important. But I think that there's also something about the people who can see the bigger picture, can step back and see all of the different components at play and figure out how to make them work together or how to capitalize on different elements to kind of change the trajectory in a slightly different way or bring new players on board or new ideas. And I think that consulting gave me at least a tool set to draw on where it's about having a clear endpoint, what are we trying to do and then working backwards and getting stakeholder engagement to get there. And I think that that skill set is really important in the nonprofit sector. It's really important across the board though, I would say.
[00:59:51.710] - JD
So this more generalized skill set or maybe bigger picture perspective and then also being able to communicate those ideas in a way they can organize a team is crucial, not just these technical aspects which are also very important. How do you communicate to Beneficiaries or program? How do you also I'm curious how much technical work you're doing with M&E. So when I think of M&E, I think oftentimes of people doing some pretty quantity type research, but it sounds like you're doing some of that, but not just that. You're doing a lot of big picture stuff and a lot of cross organization analysis.
[01:00:36.730] - Katie
I think one of the things is you can have the data, but if you can't explain the data in a way that makes sense to people who are not experts in that field, then the data isn't as convincing as it could be, it's not as usable as it could be. And so I think I spend a lot of time trying to synthesize data sets in order for them to make sense to an external audience and be able to sort of drive decision making in that way, whether it's for the Ministry of Health. If we're doing a country survey and we've gotten thousands of people to participate in the survey, what did the survey tell us and what are we going to do about it? That's kind of what I spend my time trying to do. And how do we bring the right people on board to talk about what we learned, what the data showed, and act on it? Because if we're not acting on it, then what was the point of it? At the end of the day, if it's not just driving decision making, then it's a research paper that sits in a journal somewhere or on a hard drive.
[01:01:38.560] - Katie
The data sits there but doesn't actually move the needle in the real world. And that's what I want to focus on. That's what I get excited about.
[01:01:47.570] - JD
So I have a question about Data, and also I would like to dig deeper into your Christian roots and faith, how that comes to bear in this. Oftentimes as Christians, we talk about the crucial importance of surrendering our talents and our efforts in our endeavors to God in prayer and asking God to be with us and work through us so that we can be the hands and feet of Christ in this world. Sometimes Data seems a bit far removed from that. It seems like we've got God on one hand and then we've got science on the other. Do you ever feel like those are two different things? Like trusting God to do good through a program and then using Data to measure what works and scale that up?
[01:02:46.950] - Katie
I don't see them as directly in conflict with each other. I see it as a way that we can calibrate what we're doing in real time to make sure that we're having a positive impact. Right. If we're not measuring it, then we can act in the world and have no idea whether we're doing something well or not well, like people who are careless with their speech. Are you hurting other people's feelings? Are you considering it from another point of view? And to me, Data is asking that question. Am I looking at this from another viewpoint? Am I considering all of the things that could be playing a role in this so that I can make sure that I'm acting wisely in a way?
[01:03:34.870] - JD
Do you have advice for conferences or other events that undergraduates or graduate students can go to to dip their toes in the neglected tropical diseases space? Is there a community here that people can get more engaged with or even just weekends where they can see what it's.
[01:03:57.070] - Katie
Like, yeah. I was just recently at the ASTMH Conference, the American Society of Medicine and Tropical Health, Medicine and Hygiene there it is Conference, which is kind of a global conference. It's obviously based in America, but it's a global conference where a lot of the players in neglected tropical diseases and other global diseases come together. It's a really interesting community in that you have people from the CDC, you have people from big funding bodies, you have nonprofits to kind of tackle these big problems and discuss what's going well, what's not going well, and how we address them. I think that's very interesting. It's more of a professional body, though, for undergraduates, I would say. I really think it's important, like mission trips and things like that, where you have an opportunity to see what life is like for people who are different than you. Maybe that's study abroad even. Maybe it's a mission trip, but something where you are able to really see what life is like without some of the things that a lot of us are very privileged to have. Because I think that's an eyeopening experience where something that is a quick trip to a doctor for a lot of us can be life threatening for somebody else.
[01:05:23.750] - Katie
And I think that is a really good experience. I think that that's in the Bible also, to be able to really consider life from somebody else's viewpoint.
[01:05:35.130] - JD
Can you share about other biblical passages that have motivated your work? And you also spend a lot of time in a monastic community. Could you share also a bit about that and maybe how that ties into your work and your thinking of vocation and calling?
[01:05:49.200] - Katie
Yeah, sure. I think that different people approach their professional lives for a variety of different ways. But for me, I always really wanted what I did to make a difference. And I personally am not that motivated by other considerations that sometimes are drivers. But for me, what I'm doing and having purpose in my career motivates me to do my best work, I think. And so kind of working in this space is a clear alignment there. I was part of this monastic community while I was living in London called the Community of St. Anthelms, and it's a monastic community that's built for people who are interested in vocations. Maybe they want to live a religious life, but also for me at least, it was calling to people who live and have professional lay lives that are wanting to invest deeply in their faith and maybe don't have the opportunity to go to seminary for fun if that's not going to be what they're going to do professionally. So it was kind of building on some of that that I felt personally was kind of missing. I don't know what your sort of childhood and upbringing was like, but for me, when I was younger, there were a lot of church activities that I could go to.
[01:07:10.960] - Katie
I had a really good friend group through my church, and then as I got into my professional life, my grown up life, those opportunities didn't really materialize in the same way. And so this community was kind of an opportunity to get back to that in some ways, but go deeper also with priests and nuns and other people who were professionals to really talk about some of those deeper theological issues. It was an ecumenical community as well. And so it wasn't just people who had the same kind of upbringing or viewpoints as I did. And I loved that. I thought that that was fantastic to kind of respect the diversity of different Christian viewpoints, but also recognize the richness and beauty that's out there. It was a fantastic experience. It was a limited one year kind of thing, and it's still ongoing for people who are based in the UK. I'm also aware that they're starting one in the US that calls the City at the Crossing, New York City there, and are lots of other communities that are kind of I think it seems like there's a movement towards monasticism a little bit. People are interested in that.
[01:08:30.930] - Katie
So I found it to be very enriching. But exploring if other people are interested yeah.
[01:08:38.620] - JD
Would you say that it gave you, of course, a sense of this shared Christian heritage and this shared body? We are as one global church, as many body parts, but one head, one Christ, and of course, very spiritually, intellectually enriching and a lot of fun, I'm sure. Do you think it helps with your vocation and getting a sense of how your day in, day out work is part of advancing the kingdom of God and putting that into context? I'm curious if you had any professional revelations from being there. I don't know where that fits in and your timeline exactly, but if that precipitated any shifts in how you worked.
[01:09:28.490] - Katie
Or where you worked yeah, I was doing what I do now when I did that experience, but it didn't make me change my job or anything like that. But I think that it, for me at least, solidified this feeling that I had that what I think matters is what I should spend my time doing. From my own experience, I did this consulting thing in the private sector and I loved it. It was a wonderful experience. I learned a lot, got a lot of great skills from it. But I think I always somehow felt a little bit uncomfortable about it because it was for profit. And at the end of the day, we're trying to make some money, and I felt like specifically what we were doing to make money was something that I sometimes had trouble reconciling. Now that I'm working in the nonprofit sector in a cause that I believe in, that I think really matters and helps people who are vulnerable and who are excluded from society, I think for me, it's very helpful to say maybe I'm not going to reach the same status that I would have had if I pursued another career path.
[01:10:44.850] - Katie
But to me I'm okay with that because I love what I do and I think that I can be a powerful advocate for these people that don't have the same platform that I do. And so I think for me that was a really helpful experience because it kind of reminded me that it was okay and that was a valid way to approach my career, I guess.
[01:11:12.390] - JD
As we come to a close, I'm curious if you have any recommendations for how M&E can be done best. So especially looking at a lot of Christian orgs, and many Christians are committed to only giving or working with Christian organizations, do you think that there's a distinctive way that Christian orgs do emine that the secular development space doesn't do? And what are some lessons you think both can learn from each other?
[01:11:41.310] - Katie
Yeah, I would say I think obviously monitoring evaluation is critically important. I would also say I think the easiest answer isn't always the best answer. And I think sometimes there unfortunately can be so much push to have impressive metrics or good metrics or interesting metrics that we sometimes lose sight of what we're actually incentivizing people to do. And I think that making sure that what we're measuring, we're actually measuring what we think we're measuring and that those measurements are leading to good decision making. We kind of talked about cost per bed net, which is a great metric to have, but is the focus on this metric leading to the right decision making? Are we using it as like a key performance indicator so that we can then jump on to do the next right thing? Or are we using this as a competitive edge against somebody else? And I think that gets tricky for me because some of the things that really matter are hard to measure. Are we building capacity, are we sustainable? And if we're focusing on the wrong metrics, then maybe we're cutting corners where it matters in pursuit of a better metric than somebody else.
[01:13:07.930] - Katie
And then that becomes we're actually working against ourselves if we care about the long game.
[01:13:13.710] - JD
So with a malaria net example, one way we might because we love malaria nets, we think they're extremely effective. But one reasonable criticism somebody could have if they're first learning about this is that oh, you're just trying to minimize the cost for the malaria nets, but you're not actually trying to maximize the lives you save. If people don't use the malaria nets, well then you're focusing on the wrong metric and the reality is much more difficult to measure.
[01:13:41.260] - Katie
Or if you don't teach them how to use the bed net, or what to do in the case of a tear, or there's not that education element to it, why it's important if those things aren't in place. You can hand somebody a bed net, but have you saved a life? And I think that those are kind of the deeper questions that I think Eminem should focus on, so that we're actually getting the information we think we need, rather than I can present a page of very shiny things. That I've done this number of people trained or you choose your metric, whatever it is. But if it's not giving a sense of what the improvement has been in terms of the input and the outputs we care about, then it's not really meaningful.
[01:14:34.070] - JD
Do you think that this marginal approach is the right approach? Because one beautiful thing that GiveWell allows givers to do is to say, okay, I have $5,000 I can give this year. I want to know what real world impact that's going to have, what change is this amount of money going to bring? Or a donor who's giving $5 million. Right. They want to know what the world looks like if they give it to charity A, and what the world looks like if they give it to charity B. Right. And that's part of good stewardship for them. Do you think that that kind of marginal consideration, of course, give all this more than just looking at marginal things. They have other considerations, like we mentioned earlier. But do you think looking at this marginal consideration is a key part of M&E? Or is it much more complicated than that?
[01:15:25.830] - Katie
Maybe because I spend my time focusing on the data, I'm a little more focused on kind of where it can go wrong. But then I think if that's the case, then oftentimes people who are not digging into what the inputs are might just go with the easiest to interpret. And I think that if you're looking.
[01:15:49.730] - JD
At neglectedness, for instance, sorry, the connection broke up. So you're saying if you don't have the time to do the research to see how all the inputs are related to the outputs of what you really want right. Like not just outputs, but outcomes. Right. If you don't have that time, then maybe this kind of marginal measurement of X inputs to Y outputs optimizing that, maybe that's good then. But if you have the time, you want to look into how all the inputs relate to the outputs and how the outputs relate to the outcomes, the states of the world you care about.
[01:16:23.360] - Katie
Yeah, but I also think hopefully my connection has improved. But hopefully people are also able to consider the neglectedness of certain causes because funneling a million dollars into cancer research versus a million dollars into some more neglected cause area is going to make a bigger difference in the neglected cause area than another million dollars. You could measure your marginal impact there, but that's going to make a much bigger difference, I think, for causes that are not receiving as much attention as others.
[01:17:00.070] - JD
Yeah. Do you think that there are tools besides GiveWell? There are other tools that givers in the health and development space could look at to help them give more wisely?
[01:17:14.730] - Katie
I don't know what those tools would be, very honestly, because I think you're right. I think we come back to you. You're trying to compare disparate things, things that are not similar. We've kind of acknowledged that there really isn't a gold standard for comparing them. We have some tools for comparing them, but not fantastic ones. And so how do people who don't spend every day focusing on these areas kind of suss it out and figure out what's best to do? And unfortunately, I think that it is kind of a little bit of a crapshoot and it's very hard to figure out where your investment, where your donation can do the most good. I think it's an important consideration and I think that there are tools out there. I think it's kind of putting them together and figuring it out because I don't think there's one that we can always rely on.
[01:18:07.310] - JD
Right. And of course it helps to be an expert in this space or to have experience looking at these data sets. Most of us don't have the time or the interest for this. So it can be very helpful to have these outside recommenders or raiders. But it can also be a bit misleading if we have the time to go into the weeds to see how complicated the picture can be.
[01:18:30.980] - Katie
I think the other thing is knowing that no thing operates independently. I think that that's another thing that is important to me. Like poverty causes a lot of health conditions. Same thing with wash. Poor sanitation causes a lot of health conditions. These things all go together. If you could solve any piece of this puzzle, you might have a big impact on other pieces of the pie, I guess is a better metaphor. But you could maybe impact other areas. And so figuring out and understanding that anything that you do in one area isn't wholly disconnected from others and we're never going to be able to track and monitor all of those spillover effects because it's very difficult to measure long term impact, especially over a many long horizon. So I think, yeah, unfortunately there is no black and white answer. It's going to be gray to figure out what the right thing to do is.
[01:19:33.530] - JD
I think that's very, I guess, comforting for some, but also discouraging for others who want to plan a career that will have impact in the coming decades. Like, let's say quote unquote, the right sector in the development space and hearing that all these aspects are important, the wash, the water, sanitation space, that's important. And also the direct administration of medication, that's important. But all these are interdependent in ways that are just incredibly complicated. That being said, this huge stroke of ambiguity being made clear. Do you think that in the coming decades, neglected tropical diseases will be among the most impactful paths for those who want to want to serve the sick and the poor. Or are there even others that you would recommend? You mentioned wash, you mentioned extreme poverty and poverty traps.
[01:20:32.870] - Katie
Yes, I mean, I get back to the neglectedness of it all. I think that what an individual's contribution can be in cancer or malaria, where there's tons of resource, tons of attention, I think is very different than the impact, the outsized impact, I think, potential that exists in neglected diseases, the other less kind of focal areas that don't have the same place in the global agenda. I think that now is a very interesting time for malaria and other diseases because we're seeing some new technologies come on board and sort of new focus on doing different things, doing things differently. And so I think it's a really interesting time. If people are interested in global public health, you got like new vaccines kind of in the pipeline. I think also the COVID pandemic has really changed people's perception about how important these issues are. And so I think that it is a very interesting time and I think that the whole sector is going through a lot of transition. So I would encourage it. But again, we don't all need to be MDS in order to have a contribution to public health. I think all disciplines can have something important except maybe like aerospace engineers.
[01:21:52.350] - Katie
Probably not. I've got a lot to do, but I think mostly there's a lot of room in the conversation for a variety of expertise.
[01:22:01.350] - JD
It's really incredible, I think, for public health and extreme poverty in particular, that these do have so many ways that we can contribute, whether that's, as you mentioned, as MDS or even as someone who is a successful entrepreneur or business person who can give that money away effectively, or a manager or marketer or an economist. There are just so many routes for M&E in particular, are there any ways people can scale up for doing particularly what you're doing? Are there any degree programs or early career or mid career experiences people can have to learn what Emine is like and see if it's a good fit?
[01:22:40.900] - Katie
Yeah, I think emine kind of unless you have a I think generally people who early on know that they want to be focused on monitoring evaluation, will do some kind of mathematical degree or a hard science kind of thing. I think that their early career experiences, I don't know, I think analysis of any type and I think a focus on the actions that should come from analysis I think is a key thing. But I'm not sure exactly if there are training programs about that. But I think the question to ask yourself is so what? I have information. So what? What does that mean in the real world? And I think it's sort of a frame of mind and a question and trying to see the bigger pieces at play. But I'm not sure that there's anything that specifically teaches that. I think it's sort of an inquisitive mind, maybe.
[01:23:44.890] - JD
Do you hope to be working in deworming for the rest of your career or are you open to working on other causes within public health?
[01:23:52.600] - Katie
Yeah, no, I'm not a parasitologist. I really was attracted to deworming because of its neglectedness, the fact that it's working with vulnerable populations and that it's cost effective. I think for me, what drives me is kind of some combination of those things that what I'm doing. There aren't a lot of people who have a similar skill set to me, maybe so that I can have some unique skills to bring to the table. I think cost effectiveness is super important to me too. I think that being able to say there's an opportunity here to do some real good, that makes me feel good versus being another drop in the bucket. And so I think that maybe not deworming for the rest of my life. Maybe, but maybe not. I think for me, what's interesting is the pursuit of what's going to matter and what can we do about it? And if we can find something to do about it, then how do we kind of build momentum to make it happen? That motivates me.
[01:24:58.670] - JD
And I have a final thought or two. They're a bit disconnected from each other, but one is this challenge for or challenge from Christians who would say as Christians, we're called to help the poor, but not just the material poor and sick, but also those who are suffering spiritually. And we should only be focusing on development efforts that remind them of the gospel. So healing people's bodies that this is an important thing to do, but we must also share the gospel at the same time. What would you say to this kind of approach? I think it tends to it leads to programs right, that are much more holistic but maybe don't scale as well. Do you have any additional thoughts or have you ever encountered anyone with this sort of approach?
[01:25:46.870] - Katie
Yeah, I mean, just a personal belief. But I think what worries me sometimes when we bring these two things together is then we make helping people conditional on their spiritual engagement. And that concerns me because then I'm wondering about what we're actually trying to achieve. Are we only trying to help people who give us something back? Because now it seems reciprocal in a way that I'm hoping it doesn't need to be. Why can't we just help people and give them the immediate help they need? And then as disconnected from that, maybe we kind of talk about the spiritual components of it. From my own experience, I found that I'm much more effective as an evangelist, if you like. When I'm not trying to be an evangelist, when I talk to people about what motivates me and why I am the way I do. I am or I do the things I do. It's much more convincing, I've found, if I'm able to describe that to them in a way of just living my life rather than trying to open the Bible and have a come to Jesus meeting with them, that hasn't ever been very successful for me.
[01:27:02.420] - Katie
So I think trying to think about the world at large, I'm focused on helping people who need help now to meet their material needs that can be addressed here and now. And then I think when people are in a better place, then they're able to kind of consider their other things in a different way, their religious viewpoints in a different way. But I think providing the help is, to me, the immediate concern. I don't know if that's the right answer, but that's just my own viewpoint.
[01:27:29.510] - JD
Yeah. And then also, of course, you can only speak personally here from your own personal opinion, but have you ever wondered what the right trade off is between saving lives and saving souls? To put it crudely? Right. Like, we can help people here and now in their material bodies. And of course, there is an eternal aspect to our material bodies. Right. We know with the resurrection in the new earth that the life to come is not so disconnected from the life here and now. But at the same time, Jesus says the body is more than closed, and your Heavenly Father knows you need these things. And we're maybe warned against putting too much focus on our physical health. So how do you deal with this dichotomy of serving the body and serving the soul?
[01:28:21.170] - Katie
I mean, for myself personally, I kind of I disassociate them. I have sort of the work that I do professionally, which is to help people who need help. And then for myself and my personal sphere, that's kind of the space where I focus on my life as a Christian and sort of the impact I have in the community where I live and work, that aspect of it. For me, professionally, this is what I do. And then, you know, I I live the life of go to church. I'm in that kind of community over there.
[01:28:56.490] - JD
I think although you would consider the work you do as part of your Christian calling and part yeah, part of.
[01:29:02.900] - Katie
100%, what I'm doing absolutely aligns with that. But I don't feel like it's necessarily the best way for me to exercise my Christian life in order in talking to people or making that conditional. What I'm doing conditional on a religious viewpoint, it aligns. It motivates me to do what I do. But I think that I see this sometimes with family planning services that then you get a little bit more of a muddle, and then sometimes it's problematic. And I think with deworming it's less so. But you certainly can get into trouble with those kind of things, with vaccines as well. I think from a global standpoint, because viewpoints are going to differ, I think for me it's best to delineate those things very clearly and sort of provide health services in one bucket and then kind of tackle our spiritual needs in another bucket.
[01:30:02.850] - JD
Great. So thank you for all this. Any final thoughts about how we can encourage the next generation of Christians who want to solve the worming, who want to treat the sick and make this a thing for the history books? Right? You mentioned that in the 1617 hundreds we struggled with it here in the west, but how are we going to make it so that by 2050 nobody is getting these parasitic worms? Any final careers or career advice for Christians who are discerning this path, praying for God's guidance?
[01:30:36.110] - Katie
Yeah, I think we're at a place here where what we've always done, maybe doing more of it, we need to think differently, we need to do it to a greater extent or we need to do something different. But I think people who can see these global problems that have been stuck around for a really long time, I think we need a new viewpoint maybe on some of these things and creative energy about how to approach some of these big problems. I don't think it will come as a surprise to anyone that the world is not always an easy place to live and there's a lot of things that we could focus on to do better. I think kind of keeping that spirit of finding the problems and finding a practical solution to problems. I want people to hold on to that for all time throughout their entire lives and not get sucked into what I think is sometimes a trap of the career progression and sort of losing sight about the wonder of it all and that we can do something about it. If we get behind it and we get build momentum and we do something about it, there are solutions to big problems.
[01:31:51.970] - Katie
But I think if we kind of get into our own tunnel vision about things, we lose sight of our own importance and how we can have make a contribution in a real way and that our example of doing that might inspire other people to do the same. But I think accepting the world as it is and saying, well, it's always been that way and so we should just play the game that's been dealt. I would encourage people kind of early on and throughout their lives to not stop asking what can we do better and what can we do to help others? Not just myself, but what can we do to help others? Because I think that that regardless of what you do, is indicative sort of what you think ethically is important.
[01:32:38.530] - JD
Katie, thank you so much. If people want to read more about your work, is there any place they can go, or do you want to shout out any URLs or any other resources out there?
[01:32:50.620] - Katie
Yeah, so definitely check out our website. And also you can contact me if you have any questions. I'd be very happy to talk about the work that I do or my experience with the monastic community or really anything. Really happy that you guys are interested in the work that we're doing. And, of course, thank you for all the support.
