Global Poverty

There are hundreds of millions of people in the world living on less than $2/day (PPP-adjusted). It’s hard to wrap your head around that figure – could anyone survive on $2/day in the US? Surely $2 must go a lot further in the poorest countries in the world? But no – PPP-adjusted means living on what you could buy for $2 in the US. Hundreds of millions of people are living on less than a twentieth of US minimum wage.

Income inequality is a hot political topic these days, but global income inequality is not. It should be. Living on $2/day makes it hard to get enough to eat, hard to send your children to school. It is easy to get sick and die of a disease that doesn’t exist, or would easily be treated in the US. And because the income disparities are higher, questions of justice are even more forceful than domestically. Can it be just that I have so much, and they have so little? That where you are born determines so much about the course of your life?

How much less are the lives of the poor worth than our own? The question is shocking, but the answer is worse. GiveWell estimates they can save a life for a few thousand dollars; the US government is willing to spend a few *million* dollars to save an (American) life. So the world’s current answer is “1000x less” – a far cry from “all men are created equal”.

We can ask the same question on a personal scale. Almost all of us could spend a few thousand less a year, and save a life by giving it to the world’s poorest instead (and perhaps a few thousand more after that). Few do. Does that mean we value our own comfort more than the lives of others? Is that compatible with believing that everyone’s life has equal worth and value?

It’s tempting to immediately start poking holes in this logic. But instead, I want to hold here with the cognitive dissonance for a little while. There’s a tension between what is morally obvious and what almost all of us do – take some time to consider that, without judgment or rationalization. Take some time to practice the virtue of hypocrisy, of believing in something you don’t always live up to. As a wise man reminded us: “Do I contradict myself? Very well then I contradict myself; (I am large, I contain multitudes.)”.

An aside: the “virtue” of hypocrisy? Yes. It is right that we should not live up to our aspirations; if we do, we’ve set our sights too low. When our actions don’t match our beliefs, there are two roads to consistency: changing our actions, or changing our beliefs. But imposing self-consistency by lowering our ambitions is worse than doing nothing. A vision of how we could be better is the first step towards self-improvement. But hypocrisy is a private virtue; let others judge you by your actions, not your intentions.

I haven’t resolved this tension for myself, so I won’t try to tell you how to do it. But I do think it’s worth taking seriously. I’ve moved both my actions and beliefs closer to the middle. I give a lot more to people in global poverty. But I also think people have a right to spend a lot of their money on themselves (a shift from my previous more utilitarian view).

For more, I recommend this book on the same topic: https://www.thelifeyoucansave.org/the-book/

Hell is Other Universes

I died about a year ago, I think. That’s when the first miracle happened. The doctors can’t explain it. They waved off the first remission; sometimes people are just lucky. But then it happened again, and again. I just won’t die. They brought in specialists after the third time. And they concluded what I had already deduced; medicine can’t explain this.

But physics can. A century ago, we discovered a terrifying truth: the universe is fundamentally random. We used to think the world was made of tiny particles. But then we learned that you can’t quite pin them down – in some way, the particles are in many places at once. Until you look. And then the universe tidies up its room, and shows you a nice and orderly world. But that’s a lie. When we aren’t looking, there is only chaos.

How can this be? How does the universe know when we’re looking at it, when to clean up its act? It was a puzzle for many decades. Until Everett came up with the answer: we’re part of the mess. The probabilities don’t resolve into one thing happening and another not. They *both* happen. But we only see down one path in the road. Another me takes the other path. Time isn’t a line, one thing after another. It’s a tree, branching unbelievably quickly at every moment. Nature follows the old dictum: “When you come to a fork in the road, take it”.

Everything happens, but some things happen *more* than others. In day-to-day life, we don’t suddenly find ourselves teleported to Mars, sporting a tentacle instead of an arm, or knowing the winning numbers for tomorrow’s lottery. But why not? It’s all possible; it all happens. The answer: unlikely things happen, but they happen *less*. Time is a tree, but it has a trunk. And almost always, that’s where we find ourselves, not in one of the fantastically unlikely branches. These shadows of our world barely exist at all, burdened by the impossible coincidence of coming into being. You won’t find yourself in one of them unless you are impossibly lucky, or you have a good reason.

I have a good reason; I died. My most real self, the one in the trunk of the great tree of time, is no more. And so my soul is scattered among the branches where I survived. These barely real worlds, mere shadows of the main timeline, are all I have left. They saved me as I lay dying, but miracles have a price; their improbability diminishes their reality. The doctors marveling at my survival are equally insubstantial; their more real selves have already noted my death and moved on to the next patient. Their shades are the only ones who witness my miraculous survival.

But one miracle is not enough. I remain on the brink of death, and new improbabilities are needed to save me almost every day. Time continues to provide. Well, mostly it doesn’t. But when that happens I’m not around to find out. With every new miracle, my reality fades a little more. Compared to the trunk of the main timeline, I must be on an unimaginably tiny branch, an irrelevant speck in the ocean of probability that is our universe. But these specks are all I have left. Death is our slow erasure from the tree of life. But that erasure will never be fully complete. As long as there is some way I can survive, and there always will be, I will never be completely gone.

No one is, I suppose. No one ever really dies, not completely. They just sink into ever thinner branches of time, ever-amazing miraculous survivals. For years. Decades. Millenia. Somewhere on that great tree, alive today, you could find Hammurabi, Cleopatra, Jesus of Nazereth, Julius Casear. Everyone of us get our own private afterlives, filled with the ghosts of those we knew. At least for a while, until they die too. Our afterlives are only committed to keeping us alive; our attendants will age and die as mortals. I will live, I believe, to see my doctors die of old age. Will they, shades that they are, get their own afterlives? I suppose they must.

I wonder some days if I really will ever cease. Can a branch become so insubstantial that it just fades altogether? What if the simulationists are right, and we are just some unthinkably complicated computer simulation. And eventually, after too many miracles pile up, after my branch no longer commands enough substance, it simply gets rounded down to zero. But that’s probably just wishful thinking.

You see, immortality alone is a cruel blessing. Think of Tithonius, who Zeus granted immortality but not youth. My body knows it is dying. And it wants me to know too. That’s what the agonizing pain is for, a cruel attempt to motivate me to stave off the inevitable somehow, to pull off a miracle. It’s a cruel joke, since I know the miracles will always be forthcoming. But the pain will never cease. This fading shadow of a world, my personal afterlife, is also my personal hell. Forever and ever. Amen.

Remember to Multiply

Which is safer: flying or driving? This simple factual question is the subject of endless fascination, even though the data is very clear – planes are much safer (60x safer per mile; 4x safer per hour). But plane crashes are big news stories. And they have buried their way into our souls, much deeper than a simple factual error. Flying is also scarier than driving. Every flight starts with a safety lecture – this is the institutional manifestation of our collective fears. The *reason* that airplanes are safer than cars is because we fear them more. I wonder how much cheaper flying would be if we were willing to tolerate as much risk as we do driving.

Consider school shootings. Big news stories – vanishingly rare. But we worry. And we take action. Most schools now run “lockdown” drills to prepare students for the possibility of a mass shooting. We’re teaching our children to worry too, transmuting our exaggerated fears into childhood trauma. Is it really worth it?

Consider terrorism. The worst terrorist attack ever, 9/11, killed ~3000 people and cost billions of dollars. It was a horrific tragedy. But the material damage pales in comparison to the psychic damage. The most visible manifestation of that damage are the wars in Iraq and Afghanistan. They have cost hundreds of thousands of lives (mostly not American), and trillions of dollars [1]. There are also many harder-to-tally costs: Islamophobia, overzealous airport security, the “war on terror”, etc. And after all of it, are we really any safer?

For decades, nuclear power has been the safest and cleanest way to generate electricity (although never cheap [2], and renewables are now equally safe and clean). Public perception is exactly the opposite – that nuclear meltdowns are a terrifying threat and nuclear waste is a pressing unsolved problem. Why? Even though meltdowns are incredibly rare and cause few direct deaths [3], they are huge news stories. The opposition to nuclear power has made the climate crisis far worse.

The most important thing about nuclear waste is that it is solid. Air pollution is unbelievably bad – it kills millions of people every year (the total number of deaths per year is tens of millions). Once waste gets into the air, it is almost impossible to remove or avoid. Solid waste you can pretty much dump in a landfill and stay away.

The common thread in all of these examples is innumeracy. When you read the news, remember to multiply. Plane crashes, mass shootings, terrorism, and nuclear meltdowns make the news exactly because they are rare. Each individual event is horrible, but in aggregate, they just aren’t very important. And we should treat them that way.

[1]: Trillions of dollars to the US. I can’t find anyone who has tried to tally the costs for Afghanistan and Iraq, not to mention the rest of the world

[2]: I really want to know, but can find no data: how much cheaper would nuclear power be if it were allowed to be as dangerous as coal?

[3]: No one died during the Three Mile Island meltdown. The evacuation from Fukishima killed many more people than the meltdown (and the earthquake and tsunami killed many more, completely unrelated to nuclear power). Chernobyl directly killed only ~60 people. It is not known how to accurately measure the long-term indirect effects from radiation exposure from these incidents.

The Case for Kidney Donor Compensation

Hundreds of thousands of Americans suffer from end stage renal disease (ESRD) — essentially, kidney failure. Within 5 years, most of them will be dead. It doesn’t have to be this way.

There are two main treatments for ESRD – dialysis, and kidney transplant. Dialysis is rough – it involves visiting a clinic and being hooked up to a machine that pumps your blood outside your body and cleans it. This takes hours, and you have to do it three times a week. 20% of dialysis patients die within a year, and 65% die within five years. Even for the survivors, dialysis is exhausting [1].

It’s also expensive; about $88,000 per patient per year. The US government, through Medicare, picks up most of the tab, more than $30B per year. This is around 1% of the federal government budget, every year.

The other treatment is a kidney transplant. With a successful transplant, a patient doesn’t have to do dialysis at all. You do have to take immunosuppressant drugs (forever) to make sure your body doesn’t reject the new kidney — it’s not nothing, but it’s a lot better than dialysis. The five-year survival rate after a transplant is ~80%. Compared to dialysis, transplants offer recipients a much better and longer life.

Transplants are also cheaper than dialysis. The initial surgery is about $35,000, and the per-year costs of the immunosuppressant drugs and other care is about $25,000 per patient per year.

Transplants aren’t perfect, but they are better for the patient’s health and less expensive. So why are so many people on dialysis?

To do a kidney transplant, you need a kidney. The main source of kidneys for transplant in the US are deceased organ donors. They provide about 14,000 kidneys per year for transplant. Unfortunately, most people don’t die in a way that allows them to donate their organs. About 60% of Americans are signed up as organ donors. More would help, but it won’t be enough to close the gap. Around 80,000 Americans are currently on the waiting list for a kidney transplant. The average wait time is 5 years; by then there’s a good chance a dialysis patient will have died.

Luckily, there is another (better [3]) source of kidneys. Everyone is born with two functional kidneys, and you only need one. About 5,500 living people donate kidneys each year. Most Americans could be living kidney donors. But it isn’t as simple as giving blood. Removing a kidney is a major surgery; recovery takes days or weeks, and, like every major surgery, donors run a small risk of death. There are also some long-term health risks, including increased chance of future kidney failure.

Most people aren’t willing to undergo major surgery out of sheer altruism. Some wonderful people are, but we would need tens of thousands of additional donors every year to give a transplant to everyone who wants one.

That’s a shame, because the benefits to recipients are so large. Donors give up a few weeks to prepare for and recover from the surgery, and take on some small health risks; recipients are given lives free of dialysis, and *years* of additional life expectancy. Because dialysis is so expensive, the government even saves money with every transplant.

With such large benefits on one side, and substantial but much smaller costs on the other, I see an obvious solution: make a deal. We should compensate donors for their time and their risk. At almost any price, a kidney would be a bargain [2], so there’s plenty of room to make sure we compensate donors fairly. Everyone wins.

This is the biggest “free lunch” US policy I know of, by which I mean that the conclusions are relatively certain and ~everybody ends up better off. The gains are large – tens of thousands of years of extra life expectancy annually and billions of dollars saved annually.


[1] A year living on dialysis is estimated to be worth around 0.5 QALY. QALY stands for “quality adjusted life year”. It is meant to represent the value of living one year in good health. To say that a year on dialysis is worth 0.5 QALYs is to say that a typical dialysis patient would be willing to give up one year on dialysis to live for six months in good health.
[2] A low-end estimate for the value of a QALY in the US is $50,000. If a kidney donation takes a patient from 5 years of 0.5 QALY/year life expectancy to 10 years of 0.8 QALY/year life expectancy, it’s worth $275,000 in QALYs alone. The financial savings compared to dialysis are worth another $155,000, using the assumptions in this post. Even paying $100,000 per donor would be worth it.
[3] Kidneys from living donors work better than kidneys from deceased donors. “A living donor kidney functions, on average, 12 to 20 years, and a deceased donor kidney from 8 to 12 years. “