Nicolas Laing: Tackling Healthcare “Black Holes” in Rural Uganda

Summary:

We speak to Nicolas Laing, a doctor from New Zealand. Nick has managed rural health centers for 10 years in Northern Uganda through his charity, OneDay Health. He first became passionate about unreached areas after seeing the huge numbers of rural citizens in Northern Uganda not covered by either the private or public healthcare system. Nicolas initiated and managed the first 15 Oneday Health centers launched, which have grown to 40+.

Some things we touch on in this episode:

• Healthcare black holes — what they are, how Nick finds them and supports those living in them.

• OneDay Health and cost-effectiveness estimates (see here for Nick’s excellent EA forum BOTEC calculations on this).

• Nick’s dream for Oneday Health.

• How Nick’s faith has influenced Nick’s decision to pursue medicine.

• Radical stewardship of money and how Nick lives that out.

• Effective Altruism and what both Christianity and Effective Altruism can learn from each other.

• Nick’s career advice for young Christians who want to have an impact.

Articles, organizations, and other media discussed in this episode

• OneDay Health maps and selects healthcare “black holes.” They train local nursse to treat patients accurately and consistently and equip them with 50 essential medications to treat 30 common conditions.

• CMS New Zealand is an evangelical mission community, seeking to mobilize the church in New Zealand for God’s mission in the world.

• JPAL supports randomized evaluations measuring interventions against poverty on topics ranging from agriculture and health to governance and education. Its mission is to reduce poverty by ensuring that policy is informed by scientific evidence. It does this through research, policy outreach, and training.

• Happier Lives Institute connects donors, researchers, and policymakers with the most cost-effective ways to increase global wellbeing.

• GiveWell is an independent non-profit focused on helping people do as much good as possible with their donations by evaluating the most effective charities.

• EA Forum is a platform for research, discussion, and updates on the world's most pressing problems. Including global health and development, animal welfare, AI safety, long-term future and global catastrophic risks.

• Christian Association for Medicine of Malawi (CHAM) is the largest non-governmental healthcare provider and the largest trainer of healthcare practitioners in Malawi. CHAM provides 30% of Malawi’s healthcare services and trains up to 80% of Malawi’s healthcare providers in rural and hard to reach areas.

• 80,000 Hours Podcast which has in-depth conversations about the world's most pressing problems and what you can do to solve them.

• New Incentives provides small cash incentives to caregivers in order to increase childhood vaccination rates in northern Nigeria.

• 80,000 Hours is a London-based nonprofit organization that conducts research on which careers have the largest positive social impact and provides career advice based on that research.

• Doing Good Better A book about how to really make a difference, from a co-founder of the effective altruism movement, William MacAskill.

• Call Me Brother is a book on the inspiring story of Edric Baker, a Kiwi doctor who lived in remote, rural Bangladesh and dedicated his life to providing medical care to those in need.

• Read for Life is an education NGO based in Gulu in Northern Uganda. Through a variety of tools, they work with teachers to improve literacy instruction in Ugandan classrooms.

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Episode Highlights:

Healthcare Black Holes: A Matter of Life and Death

“In Uganda, there's actually 10 million people in these remote rural healthcare black holes. When they get sick, they have no good option. They can either spend a crippling amount of money to reach a distant health facility or wait and hope the illness gets better. And it can be the difference between life and death.”

Managing over 95% of the disease burden at under $2 a patient.

“So these health centers, these one day health centers can manage over 95% of the disease burden at under $2 a patient. So it's a super efficient way of providing health care in places which have this enormous need.”

The Two-Fold Benefit of health clinics.

“Basically, the benefit of one-day health kind of comes in two things, potential benefit. One is, is if people get treatment faster. So it sounds a bit silly, but it's been studied if you get treatment for malaria faster or pneumonia faster, then you're less likely to die, which seems obvious, but there's evidence that that's true. So the second thing is quality of care. So people getting better quality of care at a one-day health center. So more likely to get diagnosed faster.”

Innovation outside the government.

And in Uganda, we're filling an enormous gap. And the other thing, just harking back to what I say, is if it's a really good idea and it really works, then there's a good chance the government can end up taking it over. And innovation often happens outside the government. In fact, I mean, I don't think anyone would disagree that innovation usually happens outside the government and then the government can pick it up.

Do not worry about tomorrow — Focus on God in the present.

“And just this idea that when I had this humility towards God and when I could see all the issues with my own life, just that there was so much blessing in that. And so that was the first thing. And then the big one for me is, which is just, I think it's brilliant and not talked about enough, is the worrying about tomorrow.”

The Value of Getting Boots on the Ground

“If you want to work in a field and do really effective work, I think get your boots on the ground for a period of time. So what I mean by this, if you want to start a teaching charity, maybe spend six and you want to do leadership, maybe spend six months, you know, teacher aiding or something in the kind of place that you want to work in. If you want to be a doctor, you know, work in those places…The first six months, the first one year, really understand the context, understand the problem. And the best way to do that is to be working on it.”

Move towards the way of Jesus and away from what the world is telling you.

“Try and find a way of moving towards the way of Jesus and away from what the world is telling you. Like the world is telling you, you need to save up a lot of money, you need to have this career, you need to do all these things to make your life secure and safe. And there's some truth in that, but there's also a lot of lies. So like when you're making your decisions about what to do, like turn to your Christian mentors and turn to the Bible.”

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• Full Transcript (expandable)

  JD (00:03.114)

  Nick, thanks so much for coming on.

  Nick (00:05.62)

  Thanks JD, so excited to be here. Love this podcast.

  JD (00:09.73)

  Really happy to have you here. Could you take a second to share a little bit about yourself, how you stay busy, and how it is you aim to impact the world?

  Nick (00:19.328)

  Sure, so I'm Nick. I'm a doctor from New Zealand, and I've lived and worked now in Northern Uganda for the last 10 years. It's quite funny, I actually wanted to be an engineer at school, but I failed math so badly in like when I was 16 that I changed my mind and was really fortunate that I got into medicine. And I mean, people often ask like, how did you get into medicine? And the first thing I always say is that, like I was very, very fortunate. I mean, I was born into an incredible, loving, curious middle-class family that valued education a lot. And I like to say that I kind of won the geographic and socioeconomic lottery, you know, and that's what allowed me to get here. And I became a Christian when I was 15 through this incredible, loving youth group, but I never actually became part of a church until I went to university. And it's amazing, like people ask, why did you want to become a doctor? And I call it luck or fate or the hand of God but I'm super grateful I'm here because I love people and thinking about how to care for people so medicine's a great place to be yeah.

  JD (01:28.246)

  That's incredible. So what is it exactly you do now as a doctor? And you're also from New Zealand. You went to medical school there, I suppose. And you're not there now. So walk me down that road a bit.

  Nick (01:37.033)

  Yep.

  Nick (01:41.832)

  Yeah, so how did I get there? Well, in my first year of university I had tutorials every day of the week. Monday, Tuesday, Wednesday, Friday, and it just happened I didn't have one on Thursday. And there was a Justice Bible Study group on that Thursday. And I'll never forget, I went to the group and the first question that the leader asked me was, look, asked the group of us, was she said, look, I'm just trying to raise money at the moment for World Vision. And my friend's a really heavy smoker. And I just gave him two packs of cigarettes. So he’d join the donation to World Vision. What do we all think of that? Discuss. And that's like the first hour of justice conversations involving the trade-offs and the stuff. So that's kind of how I got into it. But more important than that, as part of that group, every Friday, we would go to a dinner, which was set up by a local church in a poorer neighborhood. And we would just help out, we'd talk to people. I was from a middle-class family. That was the first time that I saw people who were poor and struggling and a whole different side of life. I connected that with the Bible and justice. I think in my second year of medical school, I kind of came up with the idea that, hey, maybe I should be thinking of working in a place where maybe I could do more good or where I'm needed a little bit more than in New Zealand where there's already a lot of doctors

  Nick (03:09.34)

  Very naive. They're a mix of faith and ego and compassion and white saviorism, but also a lot of love and energy and kind of mixed in with all that. And I suppose to cut a really long story short, my wife was also really passionate about similar things. She's a community organizer and an activist. And we joined CMS, which is the church mission organization, which I can talk a bit about because I'm really passionate about it as well.

  And we came to Uganda 10 years ago and I've been working as a doctor and managing health centers and then launching this organization One Day Health, which I'm super excited about as well.

  JD (03:50.002)

  And sort of the one day health in a nutshell is that you train local nurses and local healthcare providers to identify really common, really deadly diseases like malaria or pneumonia and some others, and you equip them with the essential medications to treat the most common conditions. And you've done this across what, like 40 clinics in rural Uganda, is that right?

  Nick (04:12.572)

  Yeah, so I'd say it's that and it's even more. So when I first went to Uganda, I started working as a doctor. And then I was asked by the Anglican church to run some of their health centers. I mean, all around the world, the church was often the first people to launch health centers and hospitals. And that was the same in Uganda. But in Uganda still, about a quarter of healthcare is provided by the Catholic Church, the Anglican Church, the Orthodox Church, Pentecostal Churches. And so I was asked to join that system. But as I was moving, me and my co-founder Emma, we were moving between these bigger health centers. We'd encounter communities, you know, we'd eat a chapati on the side of the road and they'd ask, “what about us? Like you're moving between this health center and this health center, but those health centers are 10 kilometers away. So what about us?”

  And we kept getting these questions, these challenges from these communities that were in what we now call healthcare black holes, places which don't have access to healthcare. In Uganda, there's actually 10 million people in these remote rural healthcare black holes. When they get sick, they have no good option. They can either spend a crippling amount of money to reach a distant health facility or wait and hope the illness gets better. I always say the human body is an incredible thing, it has an amazing ability to heal itself, but without medical care, sometimes it doesn't, it loses. And so we asked ourselves, how do we solve this problem? And we came up with this idea of launching really basic health centers and rented buildings operated by nurses. So how this thing works, we identify these healthcare black holes. We don't just go there along the road anymore because we're too big for that. We've got a jet.

  JD (05:58.126)

  You don't just throw darts at a map. You have a system. You have a process. How do you find those? Is there a threshold for what's a healthcare black hole or not? That's such a jarring phrase who really caught my attention when I read it. It's really a foreign concept to me. I guess in the US you do have areas where healthcare is less secure, less safe or immediately available, but it's not a black hole. Such a powerful, dark idea.

  Nick (06:02.181)

  Yeah, yeah, exactly.

  Nick (06:11.936)

  Mmm.

  Nick (06:25.628)

  Yeah, and the thing is it's only a black hole because of the extreme poverty. Like if you're five kilometers from a health center in America, you know, you jump in the car and you get there in 15 minutes, 10 minutes, it's a piece of cake. But if all you have is walking, you know, and your five-year-old kid is a bad fever with malaria, then five kilometers can just be too far, too difficult. And it's pouring with rain. And it can be the difference between life and death. But how we find them?

  Now we actually have a really cool app where we can just put a circle on, we've mapped all of the health centers in Uganda and we can just put a circle on the map between those health centers and it estimates the population for us. And we look for areas of between 3,000 and 8,000 people in a healthcare black hole and then we go and visit it. We talk to the community, we ask them, look, is this a place where you really need us? Could you pay the small amount of money that is needed for the health center? And then once the community is really on board and it looks like a good place, then we train the nurse.

  So we get a solar unit which can charge the phone and light the facility for at night. And then the place is equipped with over 50 medications. So this ranges from tablets to antenatal care, to injections and fluids to treat more severe diseases. So these health centers, these one day health centers can manage over 95% of the disease burden at under $2 a patient. So it's a super efficient way of providing health care in places which have this enormous need. And I love talking about launch day because on the launch day we load the health center into a truck so we get all the furniture, all the medication, the solar unit, we throw it in a truck, we get out there and on everything fits in a pickup. On the website is a really fun photo of one of our nurses with thumbs up in front of the health center truck and then on the very same day we arrive we treat our first patients with malaria or pneumonia or a skin infection

  JD (08:06.702)

  Everything fits in a truck.

  Nick (08:22.652)

  Yeah.

  JD (08:24.11)

  And so when you say you can treat 95% of the burden, so you mean like common diseases, 95% of everything that can come up, you can provide some really low cost medication with one of these makeshift health clinics.

  Nick (08:39.76)

  Yeah, exactly. I mean, it's pretty incredible. We can do not so different from what a family medicine clinic can in the States. So we treat the acute conditions like malaria, pneumonia, typhoid, urine infections. We can treat high blood pressure and diabetes. We have about eight tests. These new rapid tests have completely changed medicine. We would not be able to do one day health without them. Now you can just, yeah, exactly. You can get a drop of blood and see where the malaria.

  JD (09:01.338)

  Mm. Like the COVID rapid tests, but like for other diseases as well.

  Nick (09:10.276)

  HIV, hepatitis B, syphilis. Obviously, we know about urine pregnancy tests and urine tests. So even without a power system, a good power system, without a fridge, we can now diagnose all these diseases with just a drop of blood. And we also, like we said, we do antenatal care and then in pre-referral injections as well. So we call it like the MVP, which can be both minimum viable product or most valuable player either of kind of primary healthcare. So like what's the simplest way to provide a comprehensive package of primary health care? And I think that's kind of what One Day Health does.

  JD (09:46.622)

  Yeah, that's incredible. So I was reading some analyses of the estimated impact of one day health and in those analyses, there was a lot of emphasis on malaria and pneumonia. Could you share about why? Because it sounds like you're treating a lot of different kinds of health burdens. Why all this focus on malaria and pneumonia?

  Nick (10:06.716)

  Yeah, there's a really interesting situation in global health, which is a little bit hard to reconcile at the moment. And that is that a huge percentage of the mortality and the morbidity is actually children under five with just a handful of conditions. So you can take the whole population and all their health issues, and I don't know what the numbers are, but maybe half of the issues come from malaria, pneumonia, diarrhea, and kids under five. And so we do treat that, but we also treat everything else.

  So there's a concept called universal healthcare, which you might have heard of. And what that is like kind of what we do, the minimum viable product of healthcare for everyone. So I think there's sometimes too much focus on just those few diseases, because yeah, we can find a solution for just them maybe, but then what do we do about everyone else when they get sick as well? So when we talk about cost effectiveness, usually we focus on just a few diseases, and usually mostly children under five, because that's where kind of the really big impact is.

  But in terms of what the community cares about, in terms of the community's wellbeing and the community's kind of saving money, the community's wellbeing, the community saving money, the future of the community, they really care about having a health centre that can treat everything, because then they don't worry when their kid gets sick, or if they have blood pressure, they have a place to go. So there's this interesting balance between, yeah, kind of just focusing on the most cost-effective impact, but also providing the service which is really helping the whole community.

  JD (11:37.698)

  That's really interesting because I've often heard it said that, and I've read a lot of analyses about how cost effective it is to treat diseases like malaria or parasitic stomach worms like schistosomiasis or pneumonia, right? So but you're saying that in a community, people have this felt need for universal health care coverage, whatever that minimum, like that minimum universally available health care coverage is, that's what people are looking for.

  Nick (12:05.268)

  Yeah.

  JD (12:05.747)

  Even if dollar by dollar by the public health experts estimate that's maybe not on average most effective compared to specializing on malaria.

  Nick (12:14.96)

  Yeah, and I think when you look at kind of utilitarians and the effect of altruism community, that's the big focus. But to be honest, when it comes to the WHO and public health experts, they're also very concerned with universal health care and the whole community care. So I'd say it's not just the community, but in general, the public health community is very, very interested with universal health care, as well as kind of the community itself. But even putting that aside, like I think it is, one day health is still super, super could be super cost effective. Just to be really, really clear, we haven't had an RCT done on one day health get. And that's a huge gap. And we're actually trying to work with J-PAL at the moment, which is really cool. J-PAL is a big organization which does RCTs. That's a randomized control trial. So the idea is basically that we'd choose 40 black holes, health care black holes. We'd randomly put health centers in 20 of them, and then see if the health care was better with the RCT.

  if the health outcomes were better, where the one-day health centers were, compared to where they weren't put. And that's kind of the next step. But based on our calculations, we think that one-day health might save a life for somewhere between kind of 1,000 and 3,000 US dollars, which is really good compared to a lot of other interventions. And that's only taken into account a few diseases as well. So obviously that looks a little bit better, at least, if you take into account the whole population and all those other diseases, which we were talking about there.

  JD (13:40.746)

  Right, and that's because I was looking at those estimates from Monday Health and you're looking at, I think you said you treated something like 150,000 patients overall, including 70,000 from malaria.

  Nick (13:54.896)

  Yeah, it's actually, we've just ticked over. Sorry, I'm interrupting, but I'm excited because I just looked at our 2023 data and we've just treated our 200,000th patient, which is like, yeah, let's go. And that's over 90,000 patients with malaria. And we now have 40 of these, I think 41, 42. We actually launched one on the 2nd of January, which I felt bad about. We should have, the manager and the nurse should have been on holiday, but we launched one three days ago, which was pretty cool.

  JD (13:58.879)

  No, it's great.

  JD (14:05.462)

  That's so exciting. Yeah.

  JD (14:23.21)

  It's also my birthday, which is a great day to launch a clinic like this. And looking at those estimates, that cost effectiveness estimate is based mostly on just the malaria and pneumonia impacts, right? It's not even looking at almost all the other impacts we're doing, including this really hard to measure one, the psychosocial benefits of knowing, hey, you are someone who's living in a rural village. You didn't have a hospital nearby.

  Now you have a health clinic nearby that can treat basic diseases and you have that peace of mind knowing if something did happen, you could go. I mean, I don't even know how J-PAL is thinking of measuring that or if they want to measure that aspect at all, but I'm curious what you think. How valuable is that for the people you see?

  Nick (14:58.82)

  Oh.

  Nick (15:03.976)

  That actually might be the easiest thing to measure. So you can, well-being is a big new feature. There's actually, I mean, even with an effect of altruism, they're more and more interested in well-being now. And just the simple thing of asking people before and after, you know, how was your life before? How was your life after the one day health center? So I'm hoping we can actually measure that fairly easily. The health outcomes are actually the really hard things to measure. Because like,

  JD (15:07.761)

  Mm.

  Nick (15:30.484)

  Think about how do you measure the malaria prevalence in a community? You have to go out there and test thousands of people and check. And the number of health centers and patients treated you need to look at child mortality is huge, because health care is improving everywhere. So finding things which do improve child mortality and really nailing that down is difficult. So I'm actually hoping that looking at community well-being might actually be one of the easier things to measure in the RCT. Yeah.

  JD (15:58.738)

  Is Happier Lives Institute and those people measuring well-bees, are they interested in working with you? Maybe with this J-PAL study, you could do it on the side, some kind of well-be analysis as well.

  Nick (16:07.42)

  Yeah, I mean, I think it might not even be on the side. I mean, wellbeing is a fairly mainstream kind of topic now. I've had a bit of a talk to Happier Lives Institute people and hopefully they can help support us with questions and that kind of thing. But yeah, I think it's great just to ask people, I mean, it's validated and it's just to ask people, has your life improved? Has your life not improved? And it's amazing, I mean, who would have thought people are really good at talking about whether their lives improve or not. And that actually seems to correlate with other disease and life expectancy measures. It's an interesting one anyway. It's a big discussion.

  JD (16:45.162)

  Yeah, to be clear, by on the side, I meant like as part of the program design, not like as some kind of secondary marginal concern. Speaking of which, if there are any Christians at J-PAL who are listening in who would like to come on the podcast, please let me know. We're really appreciative of what you do there. And that's really exciting. We'll definitely stay in touch to hear how that develops. I want to ask a question about the impact here because, and if somebody wants to take a deeper look at one day health's impact.

  Nick (16:51.581)

  Yeah.

  JD (17:14.13)

  one resource I came across, Nick you can correct me if this isn't the best place to look, is this EA forum post that you wrote in February of 2023, Remote Health Centers in Uganda, a cost effective intervention where you basically broke it down and said, hey, look, if you go through the numbers like I do, and you look at how many patients we treat for malaria, how many of these are counterfactually significant by these criteria, here's how much it costs to treat people for malaria. And it's plausibly within the same estimates as GiveWell or better actually on your numbers. But one of the issues here is actually measuring that counterfactual, right? Counterfactual is what would have happened otherwise.

  And there's a lot of good discussion happening about like, well, without an RCT, how do you really know? And it sounds like you're very sympathetic to that, but yeah, what do you think are maybe some of the bigger uncertainties about knowing how effective one day health is?

  Nick (18:09.36)

  I mean, there's this huge uncertainty. Basically, the benefit of one-day health kind of comes in two things, potential benefit. One is, is if people get treatment faster. So it sounds a bit silly, but it's been studied if you get treatment for malaria faster or pneumonia faster, then you're less likely to die, which seems obvious, but there's evidence that that's true. So the second thing is quality of care. So people getting better quality of care at a one-day health center. So more likely to get diagnosed faster.

  There's actually a big problem with overdiagnosis of malaria in Uganda, a huge problem. Like a lot of people don't give the test because they don't have it or because it's too expensive. And that's actually a really major, major problem. So those are the two things. And of course, we're doing a lot of guesswork and figuring out, well, if they didn't come to us, you know, they'd then get a vehicle and they'd... So how long would that take and how much worse would that be for them? So the counterfactual is so, so hard to estimate. And that's probably the biggest uncertainty, is how much better is it for people to get the quick, to get the cheap care at One Day Health compared to having to go a very long way. Yeah.

  JD (19:19.118)

  in your defense, one day health has been operating, what, in the last five years, a $300,000 total budget over those five years. So that's below the cost of some high-powered academic RCTs, right? So with what you have, I mean, I don't think anyone could discredit what you're producing here.

  Nick (19:39.1)

  And this is one of the ethical concerns, right? Cause as we're looking to get an RCT and the RCT will cost probably the same or more than, you know, than all of the money we've spent on treating these, these people in these remote rural areas. The other thing I think is that, like, which I like to say is that the cost effectiveness, it sounds fairly plausible. So if each one health center, you know, costs $4,000 to start and operate for the first year, and then if patients are bringing money, even if it's cost neutral for the patients, it's quite easy to.

  Consider, well, if it costs $4,000, and if it saves two or three lives, just that's all you kind of need to get to a really cost-effective level. So it is very plausible, if the health center's only costing $4,000, you don't need to save very many lives for it to become very cost effective, if that makes sense.

  JD (20:29.598)

  Yeah, so I want to dig just a little bit deeper here before moving on to some of the faith components of this work as well.

  JD (20:41.65)

  This matters, right, because it's not just about proving whether one-day health at its current size is effective and impactful. There's really a huge amount of room for growth and for doing this across the rest of Uganda, I imagine, and in other countries as well. Let's say J-PAL does a study and it does come out really promising. What does that mean for the expansion of one-day health? What are your big dreams for one-day health in the next five, 10 years? And, you know, it's 40 clinics now.

  Could it be 400? Could it be 4,000?

  Nick (21:13.692)

  Wow, big numbers scare me, JD. I'm more of a step by step kind of person. I mean, my board and my co-founders are like, Nick, you know, think big, think huge, go for the... I'm always one step at a time. But so we've got 40 already. We think in Uganda that the scope of these populations between 3000 and 8000 people, there might only be 100 or 120 total in Uganda. So our scope for growth in Uganda is there, but I don't think we could launch 400 in Uganda. So we've actually just visited Malawi.

  We did a big analysis of different countries where we might be able to help. I mean, the only reason we started in northern Uganda is because that's where I was, right? That's where we started. So there's no reason to think that a similar model or a version of One Day Health couldn't be just as effective or more effective somewhere else. And so we're hoping to have a partnership in Malawi as well. There's a big organization called CHAM, which is I think it's the Christian Association for Medical, and they provide an even higher percentage of healthcare in Malawi than happens in Uganda. So we're hoping to maybe partnership with them to move into Malawi and other countries as well. But I mean, the big thing that could help us to really, really scale is government. So what I'm really hoping is to convince the government that this is a really efficient way of providing healthcare. And then if the government could come in and really we could work together, then all of a sudden you have the ability to move into hundreds of health centers and scale much faster. That's actually the way a lot of organizations have grown. If you look at the community health worker movement, which is a famous movement all around the world, that was pioneered in a number of places in India and Liberia through NGOs and social enterprises. Then governments were like, this is working, and it was passed over partly to governments.

  I mean, I even say going back to the start of hospitals, like back into the year kind of 300 or 400 when the Christians started opening the first public hospitals, like, hey, we're opening hospitals not just for ourselves, but for people outside of the Christian faith as well. And then over time that got picked up by other organizations and then governments took over healthcare. I mean, it's easy to forget even in places like the US, most of the hospitals originally started through Christian organizations and then they became private, you know, all the government.

  Nick (23:37.62)

  took them over. So that's actually been the pattern in a lot of the world. And so I think that's as a mode for growth to kind of say, hey, we've got this idea, we've got this thing which is working and then governments can come on board. That'll be our dream. It's not easy to get to that point, but that's the dream.

  JD (23:56.01)

  Yeah, because there is this common critique as well, right, that when NGOs operate in low-income countries, they might actually disincentivize the creation of government infrastructure if they're just basically taking the job off the government's shoulders. I have mixed feelings about this. I mean, I think we, I mean, there's a great episode on the 80,000 Hours podcast with, I think her name was Claire. I think she actually worked at J-PAL. And she was talking, I think she was saying, hey,look, these governments are pretty burdened as it is. It's not like the Kenyan government or the Ugandan government draws a ton of tax income anyways. And so they might not even have the margin to do this. So it's not always clear that we're just like, that we're just crowding out the government's responsibility in operations here. How do you think about it with your role? Do you think if one day health didn't exist that in these 40 villages, there wouldn't really be some substitute.

  Nick (24:56.008)

  Yeah, I mean, in Uganda, that's easy. And that's part of the reason we're doing it. Because 15 years ago, the Ugandan government said, well, we're not building any new health centers. We're just going to upgrade the current ones, which is different in different countries. For example, Ethiopia has a health post system, which they're expanding. Rwanda is building more health centers in different places. So it depends where you're working. And in Uganda, we're filling an enormous gap. And the other thing, just harking back to what I say, is if it's a really good idea and it really works, then there's a good chance the government can end up taking it over. And innovation often happens outside the government. In fact, I mean, I don't think anyone would disagree that innovation usually happens outside the government and then the government can pick it up. I think there is risk of crowding out, of crowding out. Another great example of that, I think, is bridge schools in Liberia. I don't know if you've heard of bridge schools, but it's a kind of, it's a social enterprise school system, which is based off a tablet and they can have kind of

  JD (25:27.035)

  the government will take it over, right?

  JD (25:48.525)

  No.

  Nick (25:54.916)

  less educated teachers teaching the students and there's good feedback. And basically they showed the outcomes were really good in Liberia and the Liberian government said, hey, we'll just we'll take over the schools. And they said, that's great. And I think that can be a really, a really, a really good way of working together. I think there are cases, there are things where definitely it's not a good idea to, for NGOs to work there where the government is already working.

  And I think the examples of that, I think, are often health camps, like within medicine. So there's a lot of health camps which come into like a health center and they provide services which the health center is kind of already providing, but maybe they didn't have enough medication. So why didn't you just give the medications to the health center rather than doing a health camp? So I'm pretty, usually pretty anti-health camps as a system. So there's plenty of interventions, I think, which can crowd out government services. So it's an important question.

  JD (26:48.63)

  Yeah, for some other discussion on this, we have an episode with Liz Hickson from New Incentives about their incentivizing vaccines in Nigeria, northern Nigeria. And I know partnerships with the government there are crucial for their success, as well as for deworming campaigns. We talked to Katie Fantaguzi from, I think it's Unlimited Health now, used to be SCIF Foundation, and just to provide millions of deworming tablets every single year, you really have to be partnered with the government and with schools to do that efficiently and effectively. So I think sometimes this is pitched as like a, outside actors versus local governments kind of situation when really it's more like, in the best case, some kind of partnership.

  Nick (27:37.508)

  Exactly. I've got nothing to add there JD. You said it well. Love it. Love it.

  JD (27:42.506)

  Well, and I love what you were saying about Christians starting the first hospitals back around 300 AD. And I'd love to, I guess, going back to your story, ask how much was your faith a motivation for your work in medicine? And you mentioned you became a Christian at 15. Was it clear that you wanted to really model your career after certain Christian role models or examples you saw in scripture? Or I guess this is a big way of I guess a broad way of me asking, how does your faith fit into the work you're doing right now, especially in medicine?

  Nick (28:18.62)

  Yeah, I mean, it's, this is, it's, I don't want to know what I'd be doing if I wasn't a Christian. It kind of scares me sometimes. I think that's one of almost my most scary counterfactors when I look back and I'm like, wow, where would I be? And what would I be? What would I be doing? Because, you know, as a 16 year old, and even as an immature Christian, I was just going along doing my own thing. You know, how can I kind of get a job and get a career and buy a house and be happy? And then...

  And then really this justice group in the first year of university that I mentioned kind of turned all that around. And the passage, I mean, the passage for me, which just has blown my life apart is the Sermon on the Mount. And I just keep coming back to it again and again. I mean, it was over 2000 years ago and almost everything in it, you're like, this is so insightful and this rings true to reality. And for me, like, the deeper I get into the Bible, into my faith, the more what Jesus says really reflects the way the world works, if that makes sense, which is kind of a reverse thing. Many people are like, well, I came to faith because I had this moment and I was touched. It was an emotional experience, or maybe like the brain ticked over, oh, this makes sense. But for me, it was almost more like the Sermon on the Mount just describes how the world works with incredible accuracy. And also like, When I try and be the kind of person, sermon on the mountain kind of person, then I'm so much happier and integrated and better person as well.

  JD (29:51.53)

  Yeah, can you share a bit more about what in particular the Sermon on the Mount affected you? And this is quite personal for me as well. My wife, she wasn't always a Christian before she became a Christian. She read the Sermon on the Mount and was just so shocked that was in the Bible. She thought the Bible was about lots of other things, lots of esoteric sacraments and like.

  To be clear, I don't think sacraments are esoteric, but I could understand and sympathize with someone who's reading from a modern Western lens, who's like, what's all this spiritual ritual practice? But when you read Jesus in the Sermon on the Mount, it is so insightful into our everyday experience. And were there any particular verses or aspects of the Sermon on the Mount that changed your life?

  Nick (30:38.396)

  Yeah, I mean the first one is actually probably the most esoteric part of the whole sermon on the mount, ironically, which is the start of it, which just described myself like blessed is the poor in spirit, for theirs is the kingdom of God, blessed are the meek, for they will inherit the earth, blessed are those who mourn, for they will be comforted. And when I was 16, I was like trying to be all that. I'm like, oh, I'm trying to win the sports games and do well at school. And I mean, I was just a mess inside, you know, I had this big ego and everyone could see it and people didn't like me very much and that was fair enough. I was a pretty bad 16 year old. And just this idea that when I had this humility towards God and when I could see all the issues with my own life, just that there was so much blessing in that. And so that was the first thing. And then the big one for me is, which is just, I think it's brilliant and not talked about enough, is the worrying about tomorrow.

  Which is just really, really fascinating thing. Like I was always worried about what people would think of me tomorrow and whether I'd pass the exam tomorrow. All our worries and our fears are in the future. And obviously there's lots of modern practices like mindfulness. I mean, it's not ancient practices, but it's becoming mindfulness and meditation. But just that idea that do not worry about tomorrow because today has enough troubles of its own and really like focusing on what God's doing now in the present, that was huge. And then some of the money stuff as well, like about opening up, yeah, the do not store up treasures on earth is just a huge verse. We can talk about that a little bit more maybe in a little while. But yeah.

  JD (32:24.758)

  Yeah, I'd love to. Why don't we jump into that? And why don't we pull up the verse itself? I'll do that here in a second. But how does your stewardship of money play into your understanding of impact and also with your understanding of faith and what it means to follow Jesus and radically live out your Christian faith?

  Nick (32:45.168)

  Yeah, I mean, I love talking about this, JD. I'm trying to figure out where to start. I'm actually gonna start with, I'll start with kind of a couple of things. So first, my favorite kind of Bible verses around this, one is this amazing story where someone comes to Jesus and they're like, should we give taxes to Caesar? And Jesus responds, well, yeah, give to Caesar what is Caesar, but give to God what is God's.

  And it's this crazy thing like, yeah, you know, pay your taxes, but give to God what is God's. And I interpret that as well. Well, everything's God's. I am, you are, Caesar is God's. Like, what is this little coin tax that we're paying when? And so this idea that when we think about what resources, what money we have in our hands at any one point in time, especially for those of us who might have more than enough, that they're not ours, they're just passing through. So how do we think, you know, God would have us use these things which are in our hands, which are not really ours. And kind of following on from that, I think we have the super, even Christians, most Christians have the super individualistic idea about money. And I think we kind of put money, we kind of think about doing two things with money, which I think is weird. We think we should spend and saving. You hear people talk about, are we spending money or are we saving money, you know?

  On one hand, we've got this capitalistic world flooding in, like, buy everything for yourself, food and stuff and experiences. And then on the other hand, we're told like, oh, your future is uncertain and clear, so you need to save all of this money for your future, comforted security. So you've got kind of these weird two things going on, spending and saving. But I think like with that verse in mind, everything is God. I kind of like to think about using money. So we have these resources in our hands. So instead of thinking, what are we spending or what are we saving?

  How do we use this to bring, sure to bring restoration and goodness to ourselves and our families, but also to people who are struggling and to the environment and to future people? Like, how do we think about using God's resources, which are in our hand now, rather than kind of getting boxed into what are we spending and what are we saving? Anyway, that's kind of my little take on that for a start.

  JD (35:00.266)

  Yeah, and I'm pretty astounded sometimes when I come across, I don't want to pick on any one particular group or person or saying in particular, but when I come across like this normie Christian understanding of how to use money and it goes something like this, in my context at least, use your money to take care of yourself and to take care of your family and tithe the bit to your local church, but the rest of it is really yours to do with as you please.

  That once you pay your first fruits to God, you can really, you know, barring any like extravagant or really directly harmful uses of money, you can use the rest of the money however you want. It's not a more, it's not a spiritual issue. It's not a moral issue. I think that comes into huge classroom with the kind of vision you're painting here, really discerning from scripture. And I'm gonna read Matthew 6, 19 to 21, which I think is a relevant passage you were citing.

  Where Jesus says, do not store up for yourselves treasures on earth, where moth and rust consume, where thieves break in and steal. But store up for yourselves treasures in heaven, where neither moth nor rust consumes, where thieves do not break in and steal, for where your treasure is, there your heart will be also. And I think for many people, including myself, like I think where I put my money is quite convicting in terms of showing me that at the end of the day, my heart isn't fully with the poor and it's not fully with God. And that's something that I'm continually repenting of and like striving to be more Christ-like in and asking for God's grace and help with.

  Nick (36:35.98)

  Yeah, I think it's so hard because every the whole world and everything is just telling us, you know, like I said Like like you said keep the money like spend it on yourself. Save it for yourself Compartmentalize this you know, but when you read the gospel, it's nothing I mean, it's just nothing like that at all and one thing i'm wrestling with at the moment is the idea of saving because like Just from a biblical perspective. I really struggle to find verses which talk about I mean, it's just the verses don't you know store up treasure on earth instead have open hands and see what's happening in the kingdom and let it flow with the hands. So that's something I struggle with personally. I mean, obviously there's good reasons to save and be smart, but I find it hard to see any real New Testament biblical mandate to saving large amounts of money, which is something I think we don't talk about a whole lot as Christians.

  JD (37:34.296)

  Yeah, it's difficult, especially when in Christian circles, we also emphasize responsibility and caring for your own, especially for your own family. And there is this sense that to take care of, to be a responsible father, for instance, that does involve having savings and having provisions. And even in average life in the West, in the US or in New Zealand, it's not cheap, right? Like even in average, in our podcast with Paul Niehaus, we were talking about how in an average church, not even an extravagant church.

  It's going to cost hundreds of thousands of dollars, right, just to pay the pastor and to get the guitar and the drums for the worship band. And this is before all the bells and whistles. And let alone the smoke screen that you have. The smoke machine, you have in a lot of modern city churches right now. You have to have the smoke machine. Right, that's a, I mean, that's, I don't know, maybe very effective, actually. But yeah, definitely not the bread and butter. But.

  Nick (38:27.197)

  You have to have that. I mean, you've got to have the smoke machine.

  JD (38:39.902)

  Yeah, there is a huge challenge here, and I'm wrestling with it as well myself as I think about how much to save for a future family and for my own retirement. But I think you're right, at the end of the day, we don't see Jesus talking about retiring in a nice earthly home, but we see Jesus talking about our heavenly home in storing up treasures in heaven. So I don't have a whole lot to add, but I just think this is really on point.

  Nick (39:03.548)

  Yeah, and I think this is also one thing.

  It's also something I've been challenged by the effect of altruism community, actually, is that I've seen people commit to generosity, the kind of generosity that sometimes I haven't seen within the church. And I almost found that a little bit shameful. I was like, why are we seeing people giving away all this money? Christians have done that for years. And there's loads of Christians that have given away 90% of their income. I mean, think about heroes like John Wesley, who made millions of dollars, effectively, and said like...

  JD (39:11.776)

  Mm.

  Nick (39:37.128)

  gave it all to ministry to keep churches growing and spreading and lots of other people who are very quiet and diligently, you know, so I'm not saying Christians don't do that, but seeing the conviction from people, effective altruists, to give away money to help the poor is actually really convicted and shocked me a bit in some cases.

  JD (39:57.93)

  Yeah, how did you get involved with effective altruism? And for those who are listening who don't know, effective altruism is this idea, use your, use reason and evidence to find the very best ways to do good and then take action on that basis. It really emphasizes effective giving as a really powerful way we can have an impact or an effective altruistic impact in this world. But then it's also a movement that Nick, you and I have been a part of. But how did you get involved? How did you hear about it as well?

  Nick (40:25.172)

  I mean, I've got an interesting story and that I actually came into effective altruism kind of from the other side. So I was here in Uganda for three years and I was becoming a bit disillusioned with a lot of big NGOs and just how inefficient they were. I live in communities and the NGOs would come into the communities I was living in and do these programs and spend a lot of money and do trainings and the community would look exactly the same after it than it did beforehand.

  Millions of dollars in Northern Uganda spent on agricultural training and development. And if you go to the village, people are still farming mostly the same way they did 100 years ago. And so I was becoming quite disillusioned with aid. And then someone recommended this book, Doing Good Better by Wil Macaskill. And basically I read it. And as I was reading it, I felt like I was reading my experience in Northern Uganda. And I was like, wow, this makes so much sense that these NGOs are not like really optimized for efficiency. And they're not based on evidence. They're based on what they think will do good. And there's a lot of good intentions there, but good intentions aren't enough. And so that was my first kind of encounter with it. And that actually helped me to think about my own life as well, like as I was working managing these larger health centers. But then to help me think about how can I, even more effectively help even more people than maybe I am right now.

  That pushed me towards spending more time and energy in one day health rather than managing the bigger health centers and just working as a doctor. And then I went to, I follow my wife everywhere. That's how my life works. My wife got a PhD scholarship to Cambridge, so I followed her there and I joined the Effective Altruism group there for 10 months. And it was my two groups, I was at the church and I was at the Effective Altruism group and they were a really interesting group of people and they helped me.

  Yeah, understand the whole thing better. And then, yeah, actually, and then I got into the Effective Altruism Forum about a year and a half ago, and that kind of reconnected me. I mean, I live in this semi-rural kind of Northern Uganda, and sometimes, to be honest, like I have my wife, but real intellectual stimulation and fast moving discussions are quite hard to find sometimes, honestly, because a lot of people living around me are kind of struggling to make the everyday lives work, you know, so the...

  Nick (42:50.072)

  They don't have this luxury and this privilege I have to spend a lot of time thinking about a whole lot of other stuff. So I've found that really useful to help me think about development and even to help me reflect on my faith and stuff around money as well.

  JD (43:08.5)

  What do you think that Christians can learn from the effect of altruism movement and ideas and vice versa as well? What do you think the EA movement can learn from Christianity and from the life of Jesus?

  Nick (43:20.284)

  Yeah, I find this story, this one Bible story, which I think is really interesting to come in here, and that's, there's a woman who comes to Jesus and just pours this perfume on his head. And I was looking it up, it's about maybe $50,000 of perfume. And basically his disciples say like, you know, why didn't you give the 50,000 to One Day Health, you know, and save 20 lives kind of thing, you know, literally like, why didn't you give it?

  Why don't you sell it and give it to the poor?" And Jesus was like, what this woman's done is beautiful. She loves me. She understands the significance of this moment and she lavished this love. And so, yeah, I find it's a really interesting kind of dichotomy, challenge in my own life between loving the people around you really well and also being really, really efficient and effective in your work and trying to save lives. And for my own life, like in terms of what, when I came to Northern Uganda, I wasn't thinking about being the most effective. I was thinking about living in the community and learning about them. And that's kind of what opened up this OneDay health opportunity, was being part of the community and understanding the language and the culture and moving around and seeing this enormous gap that was there.

  I mean, I couldn't have found that, going on the internet, looking through a list of maybe effective causes. And so I think that living here in solidarity with the community is part of what, for me, it means to live as a Christian here is hugely valuable. But I also think that, like I said, the NGOs, and especially Christian NGOs, can be very, very inefficient. And actually, they want to be helping people, right?

  As Christians, we want to see lives transformed. That's what we want to see. And if you're not doing that, then I think, I don't think that's the best. I don't think Jesus is particularly happy with that. So I think the effect of altruism movement can learn that there's a lot to be learned from local, from local knowledge and local understanding. And I think a lot of causes and ideas can kind of come out of that.

  Nick (45:45.2)

  And the other thing I think is that I just believe as a Christian, I don't think that, you know, development and just having the perfect policy and the perfect idea solves all the problems. You know, I think people have deep spiritual needs, which we just... The idea that we can solve all the world's problems just by putting all the money in the right direction, you know, I just don't... that's just not going to happen. And I think even in Western countries, we've seen big issues with that over the last, you know, 10, 15 years that a lot of places things haven't become the kind of utopia that we hoped, you know, with political division and conflict and dissatisfaction. And I think there's a faith gap there. There's a spiritual gap that people have in their lives. And it doesn't matter how much we work on our work-life balance, you know, or consume the right content. That's never going to be met. So yeah, that's a bit scattergun, but I hope that helps.

  JD (46:41.934)

  So I'd like to transition to talk a little bit about working in global health as a Christian and also Christian charity. And one thing that comes up a lot of times when I chat with people who are planning their careers is Christians feel called to work for a Christian organization. Or if they start something, there is this question of, oh, do I start a Christian organization or non-Christian organization doing Christian things?

  I know Vida Plena has had some, Joy Vida Plena has had some thoughts about this. I'm curious if you do as well and feel free to talk a bit more about, I think you said it was the AMS, I don't know if that's like the Anglican Mission Society that you kind of sprung out of, but to my knowledge One Day Health is not a Christian organization, but you yourself are a believer and it motivates your day to day life. Do you think there's a reason for health charities to be explicitly Christian or is what matters that you're actually serving the needs of the poor first and foremost? Can you talk a bit about those themes?

  Nick (47:46.668)

  Yeah, I think it's a really hard question and I don't think there's any right answers here. I mean, for One Day Health, what happened is I went to the head of our organization and I was like, look, I think there's this big opportunity here. You know, I want to start like a charity and what should I do? And here's a Kenyan guy, actually. He's a brilliant guy. So the head of New Zealand CMS is a Kenyan because someone worked with him in Kenya. They're like, this guy's brilliant. So they brought him to New Zealand. He's actually now become a bishop, which is super cool in New Zealand he said now look, I think what you should do is start an independent NGO, you know, which is not faith-based, because that's going to give it the most opportunity to grow and do good. I mean, obviously, if you're thinking about, you know, like church planting or obvious things like that, then it's going to be completely different. I think it's very, very situational, I think, and it depends on the nature of what you're doing. But I think it's very hard if you are thinking about really, like if you're thinking about the possibility of big scale and getting really, really big. I think there's a lot of, you can get a lot more buy-in, a lot more people involved. If we want to work explicitly with government and tie in with that, that becomes more difficult if we have specific faith-based ways of working. So I think when it comes to scale for a health organization in the current environment, I think there's arguments for it not being faith-based. But I think it really depends on the situation. Yeah.

  JD (49:16.374)

  Yeah. And for people considering a role like yours, a nonprofit founder, working in the medical field, I guess there's a couple ways we could look at your role, right? You are a doctor, you are a nonprofit entrepreneur, you're a researcher. What does your day-to-day life look like? You know, if I'm 16 year old Nick, and I'm considering like one day making the jump that you made.

  Help me get a sense of what your day to day looks like from when you wake up to when you go to bed.

  Nick (49:50.972)

  Yeah, I mean, at the moment, we walk out of our hut. We live in these two beautiful huts. I mean, we live in a little piece of paradise, is how I put it. I literally was in my garden today, and I'm like, I don't think I'm ever gonna live in a more beautiful place than this. Like, we have a path from our hut to the outside toilet, and it's covered with bougainvillea leaves, the road to the toilet. And it's almost like something out of Lord of the Rings or something, you know, as you walk out, and the golden light is gleaming through the bougainvillea onto the path. But no, so we get up, often we might heat water on our charcoal stove and we throw it in flasks. Good quality flasks are an absolute, absolute godsend when you try to keep water warm. And then we jump on my bike, head off to work. And the office here is like an office anywhere in a Western country. You know, we have computers and pretty stable power. I mean, we need to use the generator sometimes. It's a very normal office workplace.

  And then we might go and visit a one-day health center in the village, which is about as different from a Western office as you could possibly imagine and 50 times poorer than where I live. I mean, I live in this beautiful grass-stached hut and I'm one of the richest people in the neighborhood, and that makes me feel uncomfortable. So when Western people come and visit us, they're like, oh no, you live without water inside and you don't have a fridge.

  And I'm living here thinking, my goodness, how do I justify living with all this stuff and then this luxury when everyone around? So it's really interesting getting different perspectives on that. But so you're continually moving between worlds of extreme poverty and kind of not at home and not on the office. And sometimes you get used to it and it's just natural. And other times you reach a potential one day health care black hole and you just feel this compassion in this heart. And even if it doesn't make sense to start a One Day health center, you just want to start one. You know, we can help people here. And yeah, it's an interesting mix between trying to remain compassionate and alert to what's going on and not being overwhelmed all the time.

  JD (52:06.942)

  And who, that's, that's so fascinating. And who would you recommend go directly versus maybe stay at home? And we didn't, what we didn't talk about is like paths for impact and how you would compare, you know, Oh no, I didn't ask this question earlier. I just think we should bring it up now. Right. Like there's a version where Nick, you stayed in New Zealand and you did the earning to give path. Right. And a great example of a doctor doing this is Jason Dykstra, who we had on in another episode.

  Uh He's living in Michigan, he's living very modestly, I mean very much within his means, and giving a large amount away to support global health charities like One Day Health to prevent malaria and save lives. And he'll tell you he has much greater impact by giving to effective global health charities than he ever does directly in West Michigan. Now you could have more impact if you go to Uganda, right? And your boots on the ground and you scale up some effective charity. But did you ever kind of do that calculation or sit and pray about, you know, should I go back to New Zealand and earn a lot of money and just fund organizations or should I go directly? And how would you recommend somebody who's kind of still a medical school or someone who's kind of early career kind of weighing those trade-offs.

  Nick (53:29.052)

  Yeah. So firstly, for me, it was straightforward because I only got into effective altruism kind of seven years ago, you know, well after I was already embedded in life here. So it's I didn't have that question to ask, which is a really difficult question. One thing I'll say is if people are not sure, I think go out and go to you come to Uganda come live in this hut here where I'm sitting for come for three.

  JD (53:52.374)

  Is that an invitation?

  Nick (53:59.292)

  Yeah, it's a huge invitation. I mean, we have people come here a lot with actually one of the doctors that works with One Day Health. Kristen's American, she's I think in her 50s, and she's actually just bought a piece of land 500 meters from where I'm living now. And she's going to split her time between the US and coming here, because she came here. And so I think a really good amount of time is between three months and six months. I think that's good. I think one or two weeks is not enough. I think if you've got it on your heart, you're like, and I don't mind the Christian idea of calling. It's kind of cheesy, but I think there is like, I think you can get more confidence.

  ‘Okay, I'm getting drawn to this and then you go and you try it for three to six months.” And then I mean, that's what I did originally. We came on a medical elective here, I think 15 years ago to Western Uganda for three months. And after that, I was like, yes, this is you know, this is what this is what my heart is in. This is where I want to go. I mean, I personally I don't think I could manage to give my heart is very fickle. I mean, I mentioned what I said, if I wasn't a Christian, I don't want to know. I think if I was earning a lot of money, I think my values would change. I think I'd really struggle. Other people, I think some of the strongest people, other people who can earn a lot of money and give a lot of it away. I mean, I have so much respect for that. I think it's really, really difficult thing to do. But my big advice is if you're not sure, come and try. And some people come and they work and they're like, that was fine, but there's no way I can work again. I'd say the majority of people who come and volunteer for short periods are like, I don't think this is how I wanna spend my life. But I really think there's a lot of value in spending three to six months in a place like here or anywhere which you're connected to. That's my one real piece of advice I always give.

  JD (55:37.066)

  people ever come and you think, ah, there's no way they're going to last like three weeks here. They're going to want to go home. I'm sure you wouldn't want to tell them.

  Nick (55:43.784)

  I mean, there was only one experience, which was not one of my volunteers. This is actually when I was working at a big hospital. And it's just fascinating because there was 60 patients and she was supposed to see 60 patients in a day. But the first five of them were sicker than patients she would ever encounter in America. So she just couldn't get past the first five patients. And the local doctors were looking at their watch. If the tests aren't ordered for these 55 patients, they're not going to get the test for the day. And after a few weeks, she was like, I just can't do this. I can't not give my best to every person because often that's what you are left doing. There are people whose lives you could be saving if you spent three hours, but then what about the other 30 people? So I think personality is really, really important. I think for extreme perfectionists, I don't think this is the place to be. And a lot of doctors are extreme perfectionists, to be honest. But I do want to say that it's really sad that more people are not living and working in these places.

  JD (56:33.059)

  Mm.

  Nick (56:42.768)

  I think in terms of doctors working overseas, the numbers have been dropping and they've been dropping for some time, in terms of there's very few people who stay for five or 10 years. And I think there's a lot of reasons for that. Part of it is because perceived financial pressures of youth in America and that security thing I was talking about, which I actually think churches should be able to solve that problem. The church should be able to be like, look, you go there, you don't earn any money.

  If anything goes wrong, come back and we'll just sort you out. You know, like we'll sort you out when you come back. That's what I think churches should be like with people who are keen, but I don't know.

  JD (57:21.774)

  Are there any organizations you would recommend if someone is in the medical path, like going to try to, you mentioned very generously that you'd be interested in inviting people to stay with you, but are there other organizations or other programs that maybe are like, I don't wanna say like, cookie cutter options for like two months abroad, because it's not a trivial thing, like it really needs to fit your interests and your sense of calling and.

  Nick (57:33.267)

  Yeah.

  Nick (57:44.613)

  No, this-

  Nick (57:48.668)

  There's hardly any actually. Amazingly at the moment, we're getting volunteers for our bigger health center through a British government program. So if you're a training doctor in England, there is opportunities, partly funded by the British government, to come and work here or in a lot of other places. So if you're in England, there's a good option. In America, I think mainly it's facilitated by churches. And it is a role that churches can play, is to give people, like, even moving outside, obviously, strict faith stuff, give people the opportunity to have much bigger impact in their lives. So I think churches should be supporting and paying for people and encouraging people to come for three to six months. But the simple answer is there aren't many cookie cutter options. It's actually really difficult for people. And there are big sacrifices. I mean, I don't love the word sacrifice. Maybe I shouldn't use that word. But what I mean by that is that if people come here for two to five years, often, they can lose their medical license or it's harder to specialize. So there's a lot of trade-offs to be had. So I'm not like, I'm encouraging you to come. That's why three to six months I think is good because you don't lose much in a trade-off for three to six months really. And then you can decide, okay, is this a five-year thing for me or is this or a 10-year or is this not? But the simple answer is cookie cutter options are not usually there.

  JD (58:52.537)

  Mm.

  JD (59:15.406)

  This is exactly why we recommend, here's a shameless plug, our Christian Impact Mentorship, which is a way that people who are still discerning their career path can get connected with mentors, people like Nick who have walked the walk and can help you really pray with you in your individual situation, get a sense of where God might be calling you to really live the life you're mentally, but also have a huge impact doing that within your individual circumstances. So big plug for that. And Nick, did you have any mentors in your life who were especially influential? Putting you on the spot here, it didn't prep you with this question.

  Nick (59:49.904)

  Yeah, I mean, no, there's mentors which I knew and mentors which I didn't know. But the one really big one was there was this guy at church who was a really simple guy. He went to Uganda for, I think, 15 years and started up a carpentry vocational institute under a church diocese in eastern Uganda. He hardly talked about it. You know, real And then my wife actually went and visited and she was like, oh my goodness, it's 15 years after he left and there's this kind of flourishing trade school that's connected to the local. And she was like, this is amazing. And this guy used to come to the young people's church services when he was like 65, you know, and he was a real inspiration to us and part of the connection, you know, our connection with Uganda. And there's, I think there's so much value in older people and younger people connecting like that, even if it's not the most straightforward of relationships.

  There's also a doctor from New Zealand called Edric Baker. There's actually a book about him called Doctor Brother, which I'd recommend for any kind of budding doctors. And he went to Bangladesh and started up, classic kind of thing, a couple of hospitals in the bush that were so efficient, like so incredibly. And I actually encountered his work before Effective Altruism, and it had a lot of Effective Altruism-y kind of ideas.

  And he innovated in a lot of ways. Like when he treated diabetes, he used people's urine and chemicals rather than using the expensive electronic machines to treat diabetes and stuff like that. And he was treating patients for, cheaper even than one day health was treating patients. And so, Edric Baker was a real inspiration. I met him once in New Zealand and it was amazing. He came to church to do a speech and the church was full of Bangladeshis and there were hardly anyone else. This is in New Zealand.

  And it turns out this guy's like a hero in Bangladesh and no one's ever heard of him in New Zealand, which is really funny. And these were Bangladeshis, they were mostly Bangladeshi Muslims who were there and they were like, oh, this guy's amazing, you know, he's got this hospital and he's working here. And I was like, what's going on? So yeah, that's Edric Baker and a really interesting book, Dr. Brother. So a bit of a plug for that one as well.

  JD (01:02:06.702)

  That's incredible. And any advice for leaders, people who want to start something? You're not just a doctor. You're not just a researcher. You're a nonprofit entrepreneur, really. And you manage, you oversee a lot of people, and you envision new projects, and you pitch that dream to other people. Any advice for people who are thinking of starting their own charity or own organization?

  Nick (01:02:29.852)

  Yeah, I mean, I've kind of got almost anti-leadership advice, which is, I think if you want to work in a field and do really effective work, I think get your boots on the ground for a period of time. So what I mean by this, if you want to start a teaching charity, maybe spend six and you want to do leadership, maybe spend six months, you know, teacher aiding or something in the kind of place that you want to work in. If you want to be a doctor, you know, work in those places. I think

  These days, often leaders want to shoot for the top very quickly. And I think there's risk in that. I've actually, people can really disagree with me here, but I think there's a lot of worth in going slowly at the start. The first six months, the first one year, really understand the context, understand the problem. And the best way to do that is to be working on it. My favourite charity, education charity here, there was co-founded by a Ugandan and Australian woman and she worked teaching in a Ugandan primary school with 120 kids in her class for a year. And then she's like, okay, these are the things that need to happen. And it's matched so closely with, it's called Read for Life, that it's matched so closely with the values of actually an effective altruism charity that they last year actually gave them a bunch of money to continue their work, which was super cool. So I think there's a lot of value in being humble and working in the area that you're thinking of leading, whatever that is. Yeah, that's my advice.

  JD (01:04:05.454)

  Nice, nice. I know you've also talked at other times about testing things out, like trying new things, finding others who've tried the idea that you're interested in, talking to them, really trying out a bunch of things, seeing what sticks, seeing how it works, and what can scale. Anything you would add to that or?

  Nick (01:04:20.956)

  Yeah. Yeah, I mean, this is the thing. Most things have kind of been done before. So we love thinking about innovation and we love thinking about being the first person to do things, but I don't think it matters being the first thing. I mean, like Ethiopia, for example, they've launched these health posts that are similar in some ways to One Day Health. And we got some inspiration from, okay, that's working there. Maybe similar things could work here. Like in such an interconnected world, a lot of things have been tried. Like find the people who have tried them before talk to them. There will be someone out there who's tried or done the thing you're thinking of. And I'd say this especially actually for Christians who are thinking of doing it, because Christians are often very trigger happy and like starting NGOs or funding something or doing something. And I think there's a great impulse there, but there's enormous value in talking to a bunch of people, like the local people in the country you're helping and maybe people who've funded or done that stuff before.

  JD (01:05:03.917)

  Mm.

  Nick (01:05:18.268)

  People have probably done what you're doing. I hate to break it to you, but it's probably the situation. So talk to them. Yeah.

  JD (01:05:24.714)

  Another plug for Impact Mentorship, talk to Christians who are three years ahead of you on your very similar career path, who might have some insights and wisdom to share. Yes. Well, we're wrapping up here just on this point of career advice. Any final parting career advice you would give to any listeners who are still discerning, what is this radical calling God might have for their life and a way that they can use their career to advance God's kingdom.

  Nick (01:05:50.632)

  Yeah, like try and find a way of moving towards the way of Jesus and away from what the world is telling you. Like the world is telling you, you need to save up a lot of money, you need to have this career, you need to do all these things to make your life secure and safe. And there's some truth in that, but there's also a lot of lies. So like when you're making your decisions about what to do, like turn to your Christian mentors and turn to the Bible and the Sermon on the Mount rather than what everything else is screaming at you. I think the biggest issue is people just not doing things, people just going on with their career and their life and not making a decision to maybe do things a bit differently.

  JD (01:06:46.003)

  Awesome. Nick, is there any way we could be praying for you or supporting you in what you're doing at One Day Health?

  Nick (01:06:52.2)

  Yeah, I mean, really thoughts about Malawi and whether that's going to be a goer or not. We want to make good decisions. We really want to use donor money well. Obviously, if we start there, it could fail, but we want to give it the best chance of success. So that's the thing which is really kind of on my heart at the moment. And also about this trial, like if we can get a trial going and that would be great. And also this, like the question obviously, it's going to cost a lot of money and thinking through both the ethics of that and raising that as well, I suppose. I think the trial and that are those are two things I think to pray for. Thanks.

  JD (01:07:37.642)

  And we'll include any links to One Day Health or any of the resources mentioned in this episode on the podcast page on our website at christiansforimpact.org Nick, thanks so much for joining me. It was really a pleasure and I'm sure this won't be the last conversation, but just really love what you're doing and so inspired by your heart for God and for the poor and vulnerable.

  Nick (01:07:59.08)

  Thanks so much, JD. Honored to be on this podcast. You've interviewed so many awesome people and it's so cool to be here.

  JD (00:03.114)

  Nick, thanks so much for coming on.

  Nick (00:05.62)

  Thanks JD, so excited to be here. Love this podcast.

  JD (00:09.73)

  Really happy to have you here. Could you take a second to share a little bit about yourself, how you stay busy, and how it is you aim to impact the world?

  Nick (00:19.328)

  Sure, so I'm Nick. I'm a doctor from New Zealand, and I've lived and worked now in Northern Uganda for the last 10 years. It's quite funny, I actually wanted to be an engineer at school, but I failed math so badly in like when I was 16 that I changed my mind and was really fortunate that I got into medicine. And I mean, people often ask like, how did you get into medicine? And the first thing I always say is that, like I was very, very fortunate. I mean, I was born into an incredible, loving, curious middle-class family that valued education a lot. And I like to say that I kind of won the geographic and socioeconomic lottery, you know, and that's what allowed me to get here. And I became a Christian when I was 15 through this incredible, loving youth group, but I never actually became part of a church until I went to university. And it's amazing, like people ask, why did you want to become a doctor? And I call it luck or fate or the hand of God but I'm super grateful I'm here because I love people and thinking about how to care for people so medicine's a great place to be yeah.

  JD (01:28.246)

  That's incredible. So what is it exactly you do now as a doctor? And you're also from New Zealand. You went to medical school there, I suppose. And you're not there now. So walk me down that road a bit.

  Nick (01:37.033)

  Yep.

  Nick (01:41.832)

  Yeah, so how did I get there? Well, in my first year of university I had tutorials every day of the week. Monday, Tuesday, Wednesday, Friday, and it just happened I didn't have one on Thursday. And there was a Justice Bible Study group on that Thursday. And I'll never forget, I went to the group and the first question that the leader asked me was, look, asked the group of us, was she said, look, I'm just trying to raise money at the moment for World Vision. And my friend's a really heavy smoker. And I just gave him two packs of cigarettes. So he’d join the donation to World Vision. What do we all think of that? Discuss. And that's like the first hour of justice conversations involving the trade-offs and the stuff. So that's kind of how I got into it. But more important than that, as part of that group, every Friday, we would go to a dinner, which was set up by a local church in a poorer neighborhood. And we would just help out, we'd talk to people. I was from a middle-class family. That was the first time that I saw people who were poor and struggling and a whole different side of life. I connected that with the Bible and justice. I think in my second year of medical school, I kind of came up with the idea that, hey, maybe I should be thinking of working in a place where maybe I could do more good or where I'm needed a little bit more than in New Zealand where there's already a lot of doctors

  Nick (03:09.34)

  Very naive. They're a mix of faith and ego and compassion and white saviorism, but also a lot of love and energy and kind of mixed in with all that. And I suppose to cut a really long story short, my wife was also really passionate about similar things. She's a community organizer and an activist. And we joined CMS, which is the church mission organization, which I can talk a bit about because I'm really passionate about it as well.

  And we came to Uganda 10 years ago and I've been working as a doctor and managing health centers and then launching this organization One Day Health, which I'm super excited about as well.

  JD (03:50.002)

  And sort of the one day health in a nutshell is that you train local nurses and local healthcare providers to identify really common, really deadly diseases like malaria or pneumonia and some others, and you equip them with the essential medications to treat the most common conditions. And you've done this across what, like 40 clinics in rural Uganda, is that right?

  Nick (04:12.572)

  Yeah, so I'd say it's that and it's even more. So when I first went to Uganda, I started working as a doctor. And then I was asked by the Anglican church to run some of their health centers. I mean, all around the world, the church was often the first people to launch health centers and hospitals. And that was the same in Uganda. But in Uganda still, about a quarter of healthcare is provided by the Catholic Church, the Anglican Church, the Orthodox Church, Pentecostal Churches. And so I was asked to join that system. But as I was moving, me and my co-founder Emma, we were moving between these bigger health centers. We'd encounter communities, you know, we'd eat a chapati on the side of the road and they'd ask, “what about us? Like you're moving between this health center and this health center, but those health centers are 10 kilometers away. So what about us?”

  And we kept getting these questions, these challenges from these communities that were in what we now call healthcare black holes, places which don't have access to healthcare. In Uganda, there's actually 10 million people in these remote rural healthcare black holes. When they get sick, they have no good option. They can either spend a crippling amount of money to reach a distant health facility or wait and hope the illness gets better. I always say the human body is an incredible thing, it has an amazing ability to heal itself, but without medical care, sometimes it doesn't, it loses. And so we asked ourselves, how do we solve this problem? And we came up with this idea of launching really basic health centers and rented buildings operated by nurses. So how this thing works, we identify these healthcare black holes. We don't just go there along the road anymore because we're too big for that. We've got a jet.

  JD (05:58.126)

  You don't just throw darts at a map. You have a system. You have a process. How do you find those? Is there a threshold for what's a healthcare black hole or not? That's such a jarring phrase who really caught my attention when I read it. It's really a foreign concept to me. I guess in the US you do have areas where healthcare is less secure, less safe or immediately available, but it's not a black hole. Such a powerful, dark idea.

  Nick (06:02.181)

  Yeah, yeah, exactly.

  Nick (06:11.936)

  Mmm.

  Nick (06:25.628)

  Yeah, and the thing is it's only a black hole because of the extreme poverty. Like if you're five kilometers from a health center in America, you know, you jump in the car and you get there in 15 minutes, 10 minutes, it's a piece of cake. But if all you have is walking, you know, and your five-year-old kid is a bad fever with malaria, then five kilometers can just be too far, too difficult. And it's pouring with rain. And it can be the difference between life and death. But how we find them?

  Now we actually have a really cool app where we can just put a circle on, we've mapped all of the health centers in Uganda and we can just put a circle on the map between those health centers and it estimates the population for us. And we look for areas of between 3,000 and 8,000 people in a healthcare black hole and then we go and visit it. We talk to the community, we ask them, look, is this a place where you really need us? Could you pay the small amount of money that is needed for the health center? And then once the community is really on board and it looks like a good place, then we train the nurse.

  So we get a solar unit which can charge the phone and light the facility for at night. And then the place is equipped with over 50 medications. So this ranges from tablets to antenatal care, to injections and fluids to treat more severe diseases. So these health centers, these one day health centers can manage over 95% of the disease burden at under $2 a patient. So it's a super efficient way of providing health care in places which have this enormous need. And I love talking about launch day because on the launch day we load the health center into a truck so we get all the furniture, all the medication, the solar unit, we throw it in a truck, we get out there and on everything fits in a pickup. On the website is a really fun photo of one of our nurses with thumbs up in front of the health center truck and then on the very same day we arrive we treat our first patients with malaria or pneumonia or a skin infection

  JD (08:06.702)

  Everything fits in a truck.

  Nick (08:22.652)

  Yeah.

  JD (08:24.11)

  And so when you say you can treat 95% of the burden, so you mean like common diseases, 95% of everything that can come up, you can provide some really low cost medication with one of these makeshift health clinics.

  Nick (08:39.76)

  Yeah, exactly. I mean, it's pretty incredible. We can do not so different from what a family medicine clinic can in the States. So we treat the acute conditions like malaria, pneumonia, typhoid, urine infections. We can treat high blood pressure and diabetes. We have about eight tests. These new rapid tests have completely changed medicine. We would not be able to do one day health without them. Now you can just, yeah, exactly. You can get a drop of blood and see where the malaria.

  JD (09:01.338)

  Mm. Like the COVID rapid tests, but like for other diseases as well.

  Nick (09:10.276)

  HIV, hepatitis B, syphilis. Obviously, we know about urine pregnancy tests and urine tests. So even without a power system, a good power system, without a fridge, we can now diagnose all these diseases with just a drop of blood. And we also, like we said, we do antenatal care and then in pre-referral injections as well. So we call it like the MVP, which can be both minimum viable product or most valuable player either of kind of primary healthcare. So like what's the simplest way to provide a comprehensive package of primary health care? And I think that's kind of what One Day Health does.

  JD (09:46.622)

  Yeah, that's incredible. So I was reading some analyses of the estimated impact of one day health and in those analyses, there was a lot of emphasis on malaria and pneumonia. Could you share about why? Because it sounds like you're treating a lot of different kinds of health burdens. Why all this focus on malaria and pneumonia?

  Nick (10:06.716)

  Yeah, there's a really interesting situation in global health, which is a little bit hard to reconcile at the moment. And that is that a huge percentage of the mortality and the morbidity is actually children under five with just a handful of conditions. So you can take the whole population and all their health issues, and I don't know what the numbers are, but maybe half of the issues come from malaria, pneumonia, diarrhea, and kids under five. And so we do treat that, but we also treat everything else.

  So there's a concept called universal healthcare, which you might have heard of. And what that is like kind of what we do, the minimum viable product of healthcare for everyone. So I think there's sometimes too much focus on just those few diseases, because yeah, we can find a solution for just them maybe, but then what do we do about everyone else when they get sick as well? So when we talk about cost effectiveness, usually we focus on just a few diseases, and usually mostly children under five, because that's where kind of the really big impact is.

  But in terms of what the community cares about, in terms of the community's wellbeing and the community's kind of saving money, the community's wellbeing, the community saving money, the future of the community, they really care about having a health centre that can treat everything, because then they don't worry when their kid gets sick, or if they have blood pressure, they have a place to go. So there's this interesting balance between, yeah, kind of just focusing on the most cost-effective impact, but also providing the service which is really helping the whole community.

  JD (11:37.698)

  That's really interesting because I've often heard it said that, and I've read a lot of analyses about how cost effective it is to treat diseases like malaria or parasitic stomach worms like schistosomiasis or pneumonia, right? So but you're saying that in a community, people have this felt need for universal health care coverage, whatever that minimum, like that minimum universally available health care coverage is, that's what people are looking for.

  Nick (12:05.268)

  Yeah.

  JD (12:05.747)

  Even if dollar by dollar by the public health experts estimate that's maybe not on average most effective compared to specializing on malaria.

  Nick (12:14.96)

  Yeah, and I think when you look at kind of utilitarians and the effect of altruism community, that's the big focus. But to be honest, when it comes to the WHO and public health experts, they're also very concerned with universal health care and the whole community care. So I'd say it's not just the community, but in general, the public health community is very, very interested with universal health care, as well as kind of the community itself. But even putting that aside, like I think it is, one day health is still super, super could be super cost effective. Just to be really, really clear, we haven't had an RCT done on one day health get. And that's a huge gap. And we're actually trying to work with J-PAL at the moment, which is really cool. J-PAL is a big organization which does RCTs. That's a randomized control trial. So the idea is basically that we'd choose 40 black holes, health care black holes. We'd randomly put health centers in 20 of them, and then see if the health care was better with the RCT.

  if the health outcomes were better, where the one-day health centers were, compared to where they weren't put. And that's kind of the next step. But based on our calculations, we think that one-day health might save a life for somewhere between kind of 1,000 and 3,000 US dollars, which is really good compared to a lot of other interventions. And that's only taken into account a few diseases as well. So obviously that looks a little bit better, at least, if you take into account the whole population and all those other diseases, which we were talking about there.

  JD (13:40.746)

  Right, and that's because I was looking at those estimates from Monday Health and you're looking at, I think you said you treated something like 150,000 patients overall, including 70,000 from malaria.

  Nick (13:54.896)

  Yeah, it's actually, we've just ticked over. Sorry, I'm interrupting, but I'm excited because I just looked at our 2023 data and we've just treated our 200,000th patient, which is like, yeah, let's go. And that's over 90,000 patients with malaria. And we now have 40 of these, I think 41, 42. We actually launched one on the 2nd of January, which I felt bad about. We should have, the manager and the nurse should have been on holiday, but we launched one three days ago, which was pretty cool.

  JD (13:58.879)

  No, it's great.

  JD (14:05.462)

  That's so exciting. Yeah.

  JD (14:23.21)

  It's also my birthday, which is a great day to launch a clinic like this. And looking at those estimates, that cost effectiveness estimate is based mostly on just the malaria and pneumonia impacts, right? It's not even looking at almost all the other impacts we're doing, including this really hard to measure one, the psychosocial benefits of knowing, hey, you are someone who's living in a rural village. You didn't have a hospital nearby.

  Now you have a health clinic nearby that can treat basic diseases and you have that peace of mind knowing if something did happen, you could go. I mean, I don't even know how J-PAL is thinking of measuring that or if they want to measure that aspect at all, but I'm curious what you think. How valuable is that for the people you see?

  Nick (14:58.82)

  Oh.

  Nick (15:03.976)

  That actually might be the easiest thing to measure. So you can, well-being is a big new feature. There's actually, I mean, even with an effect of altruism, they're more and more interested in well-being now. And just the simple thing of asking people before and after, you know, how was your life before? How was your life after the one day health center? So I'm hoping we can actually measure that fairly easily. The health outcomes are actually the really hard things to measure. Because like,

  JD (15:07.761)

  Mm.

  Nick (15:30.484)

  Think about how do you measure the malaria prevalence in a community? You have to go out there and test thousands of people and check. And the number of health centers and patients treated you need to look at child mortality is huge, because health care is improving everywhere. So finding things which do improve child mortality and really nailing that down is difficult. So I'm actually hoping that looking at community well-being might actually be one of the easier things to measure in the RCT. Yeah.

  JD (15:58.738)

  Is Happier Lives Institute and those people measuring well-bees, are they interested in working with you? Maybe with this J-PAL study, you could do it on the side, some kind of well-be analysis as well.

  Nick (16:07.42)

  Yeah, I mean, I think it might not even be on the side. I mean, wellbeing is a fairly mainstream kind of topic now. I've had a bit of a talk to Happier Lives Institute people and hopefully they can help support us with questions and that kind of thing. But yeah, I think it's great just to ask people, I mean, it's validated and it's just to ask people, has your life improved? Has your life not improved? And it's amazing, I mean, who would have thought people are really good at talking about whether their lives improve or not. And that actually seems to correlate with other disease and life expectancy measures. It's an interesting one anyway. It's a big discussion.

  JD (16:45.162)

  Yeah, to be clear, by on the side, I meant like as part of the program design, not like as some kind of secondary marginal concern. Speaking of which, if there are any Christians at J-PAL who are listening in who would like to come on the podcast, please let me know. We're really appreciative of what you do there. And that's really exciting. We'll definitely stay in touch to hear how that develops. I want to ask a question about the impact here because, and if somebody wants to take a deeper look at one day health's impact.

  Nick (16:51.581)

  Yeah.

  JD (17:14.13)

  one resource I came across, Nick you can correct me if this isn't the best place to look, is this EA forum post that you wrote in February of 2023, Remote Health Centers in Uganda, a cost effective intervention where you basically broke it down and said, hey, look, if you go through the numbers like I do, and you look at how many patients we treat for malaria, how many of these are counterfactually significant by these criteria, here's how much it costs to treat people for malaria. And it's plausibly within the same estimates as GiveWell or better actually on your numbers. But one of the issues here is actually measuring that counterfactual, right? Counterfactual is what would have happened otherwise.

  And there's a lot of good discussion happening about like, well, without an RCT, how do you really know? And it sounds like you're very sympathetic to that, but yeah, what do you think are maybe some of the bigger uncertainties about knowing how effective one day health is?

  Nick (18:09.36)

  I mean, there's this huge uncertainty. Basically, the benefit of one-day health kind of comes in two things, potential benefit. One is, is if people get treatment faster. So it sounds a bit silly, but it's been studied if you get treatment for malaria faster or pneumonia faster, then you're less likely to die, which seems obvious, but there's evidence that that's true. So the second thing is quality of care. So people getting better quality of care at a one-day health center. So more likely to get diagnosed faster.

  There's actually a big problem with overdiagnosis of malaria in Uganda, a huge problem. Like a lot of people don't give the test because they don't have it or because it's too expensive. And that's actually a really major, major problem. So those are the two things. And of course, we're doing a lot of guesswork and figuring out, well, if they didn't come to us, you know, they'd then get a vehicle and they'd... So how long would that take and how much worse would that be for them? So the counterfactual is so, so hard to estimate. And that's probably the biggest uncertainty, is how much better is it for people to get the quick, to get the cheap care at One Day Health compared to having to go a very long way. Yeah.

  JD (19:19.118)

  in your defense, one day health has been operating, what, in the last five years, a $300,000 total budget over those five years. So that's below the cost of some high-powered academic RCTs, right? So with what you have, I mean, I don't think anyone could discredit what you're producing here.

  Nick (19:39.1)

  And this is one of the ethical concerns, right? Cause as we're looking to get an RCT and the RCT will cost probably the same or more than, you know, than all of the money we've spent on treating these, these people in these remote rural areas. The other thing I think is that, like, which I like to say is that the cost effectiveness, it sounds fairly plausible. So if each one health center, you know, costs $4,000 to start and operate for the first year, and then if patients are bringing money, even if it's cost neutral for the patients, it's quite easy to.

  Consider, well, if it costs $4,000, and if it saves two or three lives, just that's all you kind of need to get to a really cost-effective level. So it is very plausible, if the health center's only costing $4,000, you don't need to save very many lives for it to become very cost effective, if that makes sense.

  JD (20:29.598)

  Yeah, so I want to dig just a little bit deeper here before moving on to some of the faith components of this work as well.

  JD (20:41.65)

  This matters, right, because it's not just about proving whether one-day health at its current size is effective and impactful. There's really a huge amount of room for growth and for doing this across the rest of Uganda, I imagine, and in other countries as well. Let's say J-PAL does a study and it does come out really promising. What does that mean for the expansion of one-day health? What are your big dreams for one-day health in the next five, 10 years? And, you know, it's 40 clinics now.

  Could it be 400? Could it be 4,000?

  Nick (21:13.692)

  Wow, big numbers scare me, JD. I'm more of a step by step kind of person. I mean, my board and my co-founders are like, Nick, you know, think big, think huge, go for the... I'm always one step at a time. But so we've got 40 already. We think in Uganda that the scope of these populations between 3000 and 8000 people, there might only be 100 or 120 total in Uganda. So our scope for growth in Uganda is there, but I don't think we could launch 400 in Uganda. So we've actually just visited Malawi.

  We did a big analysis of different countries where we might be able to help. I mean, the only reason we started in northern Uganda is because that's where I was, right? That's where we started. So there's no reason to think that a similar model or a version of One Day Health couldn't be just as effective or more effective somewhere else. And so we're hoping to have a partnership in Malawi as well. There's a big organization called CHAM, which is I think it's the Christian Association for Medical, and they provide an even higher percentage of healthcare in Malawi than happens in Uganda. So we're hoping to maybe partnership with them to move into Malawi and other countries as well. But I mean, the big thing that could help us to really, really scale is government. So what I'm really hoping is to convince the government that this is a really efficient way of providing healthcare. And then if the government could come in and really we could work together, then all of a sudden you have the ability to move into hundreds of health centers and scale much faster. That's actually the way a lot of organizations have grown. If you look at the community health worker movement, which is a famous movement all around the world, that was pioneered in a number of places in India and Liberia through NGOs and social enterprises. Then governments were like, this is working, and it was passed over partly to governments.

  I mean, I even say going back to the start of hospitals, like back into the year kind of 300 or 400 when the Christians started opening the first public hospitals, like, hey, we're opening hospitals not just for ourselves, but for people outside of the Christian faith as well. And then over time that got picked up by other organizations and then governments took over healthcare. I mean, it's easy to forget even in places like the US, most of the hospitals originally started through Christian organizations and then they became private, you know, all the government.

  Nick (23:37.62)

  took them over. So that's actually been the pattern in a lot of the world. And so I think that's as a mode for growth to kind of say, hey, we've got this idea, we've got this thing which is working and then governments can come on board. That'll be our dream. It's not easy to get to that point, but that's the dream.

  JD (23:56.01)

  Yeah, because there is this common critique as well, right, that when NGOs operate in low-income countries, they might actually disincentivize the creation of government infrastructure if they're just basically taking the job off the government's shoulders. I have mixed feelings about this. I mean, I think we, I mean, there's a great episode on the 80,000 Hours podcast with, I think her name was Claire. I think she actually worked at J-PAL. And she was talking, I think she was saying, hey,look, these governments are pretty burdened as it is. It's not like the Kenyan government or the Ugandan government draws a ton of tax income anyways. And so they might not even have the margin to do this. So it's not always clear that we're just like, that we're just crowding out the government's responsibility in operations here. How do you think about it with your role? Do you think if one day health didn't exist that in these 40 villages, there wouldn't really be some substitute.

  Nick (24:56.008)

  Yeah, I mean, in Uganda, that's easy. And that's part of the reason we're doing it. Because 15 years ago, the Ugandan government said, well, we're not building any new health centers. We're just going to upgrade the current ones, which is different in different countries. For example, Ethiopia has a health post system, which they're expanding. Rwanda is building more health centers in different places. So it depends where you're working. And in Uganda, we're filling an enormous gap. And the other thing, just harking back to what I say, is if it's a really good idea and it really works, then there's a good chance the government can end up taking it over. And innovation often happens outside the government. In fact, I mean, I don't think anyone would disagree that innovation usually happens outside the government and then the government can pick it up. I think there is risk of crowding out, of crowding out. Another great example of that, I think, is bridge schools in Liberia. I don't know if you've heard of bridge schools, but it's a kind of, it's a social enterprise school system, which is based off a tablet and they can have kind of

  JD (25:27.035)

  the government will take it over, right?

  JD (25:48.525)

  No.

  Nick (25:54.916)

  less educated teachers teaching the students and there's good feedback. And basically they showed the outcomes were really good in Liberia and the Liberian government said, hey, we'll just we'll take over the schools. And they said, that's great. And I think that can be a really, a really, a really good way of working together. I think there are cases, there are things where definitely it's not a good idea to, for NGOs to work there where the government is already working.

  And I think the examples of that, I think, are often health camps, like within medicine. So there's a lot of health camps which come into like a health center and they provide services which the health center is kind of already providing, but maybe they didn't have enough medication. So why didn't you just give the medications to the health center rather than doing a health camp? So I'm pretty, usually pretty anti-health camps as a system. So there's plenty of interventions, I think, which can crowd out government services. So it's an important question.

  JD (26:48.63)

  Yeah, for some other discussion on this, we have an episode with Liz Hickson from New Incentives about their incentivizing vaccines in Nigeria, northern Nigeria. And I know partnerships with the government there are crucial for their success, as well as for deworming campaigns. We talked to Katie Fantaguzi from, I think it's Unlimited Health now, used to be SCIF Foundation, and just to provide millions of deworming tablets every single year, you really have to be partnered with the government and with schools to do that efficiently and effectively. So I think sometimes this is pitched as like a, outside actors versus local governments kind of situation when really it's more like, in the best case, some kind of partnership.

  Nick (27:37.508)

  Exactly. I've got nothing to add there JD. You said it well. Love it. Love it.

  JD (27:42.506)

  Well, and I love what you were saying about Christians starting the first hospitals back around 300 AD. And I'd love to, I guess, going back to your story, ask how much was your faith a motivation for your work in medicine? And you mentioned you became a Christian at 15. Was it clear that you wanted to really model your career after certain Christian role models or examples you saw in scripture? Or I guess this is a big way of I guess a broad way of me asking, how does your faith fit into the work you're doing right now, especially in medicine?

  Nick (28:18.62)

  Yeah, I mean, it's, this is, it's, I don't want to know what I'd be doing if I wasn't a Christian. It kind of scares me sometimes. I think that's one of almost my most scary counterfactors when I look back and I'm like, wow, where would I be? And what would I be? What would I be doing? Because, you know, as a 16 year old, and even as an immature Christian, I was just going along doing my own thing. You know, how can I kind of get a job and get a career and buy a house and be happy? And then...

  And then really this justice group in the first year of university that I mentioned kind of turned all that around. And the passage, I mean, the passage for me, which just has blown my life apart is the Sermon on the Mount. And I just keep coming back to it again and again. I mean, it was over 2000 years ago and almost everything in it, you're like, this is so insightful and this rings true to reality. And for me, like, the deeper I get into the Bible, into my faith, the more what Jesus says really reflects the way the world works, if that makes sense, which is kind of a reverse thing. Many people are like, well, I came to faith because I had this moment and I was touched. It was an emotional experience, or maybe like the brain ticked over, oh, this makes sense. But for me, it was almost more like the Sermon on the Mount just describes how the world works with incredible accuracy. And also like, When I try and be the kind of person, sermon on the mountain kind of person, then I'm so much happier and integrated and better person as well.

  JD (29:51.53)

  Yeah, can you share a bit more about what in particular the Sermon on the Mount affected you? And this is quite personal for me as well. My wife, she wasn't always a Christian before she became a Christian. She read the Sermon on the Mount and was just so shocked that was in the Bible. She thought the Bible was about lots of other things, lots of esoteric sacraments and like.

  To be clear, I don't think sacraments are esoteric, but I could understand and sympathize with someone who's reading from a modern Western lens, who's like, what's all this spiritual ritual practice? But when you read Jesus in the Sermon on the Mount, it is so insightful into our everyday experience. And were there any particular verses or aspects of the Sermon on the Mount that changed your life?

  Nick (30:38.396)

  Yeah, I mean the first one is actually probably the most esoteric part of the whole sermon on the mount, ironically, which is the start of it, which just described myself like blessed is the poor in spirit, for theirs is the kingdom of God, blessed are the meek, for they will inherit the earth, blessed are those who mourn, for they will be comforted. And when I was 16, I was like trying to be all that. I'm like, oh, I'm trying to win the sports games and do well at school. And I mean, I was just a mess inside, you know, I had this big ego and everyone could see it and people didn't like me very much and that was fair enough. I was a pretty bad 16 year old. And just this idea that when I had this humility towards God and when I could see all the issues with my own life, just that there was so much blessing in that. And so that was the first thing. And then the big one for me is, which is just, I think it's brilliant and not talked about enough, is the worrying about tomorrow.

  Which is just really, really fascinating thing. Like I was always worried about what people would think of me tomorrow and whether I'd pass the exam tomorrow. All our worries and our fears are in the future. And obviously there's lots of modern practices like mindfulness. I mean, it's not ancient practices, but it's becoming mindfulness and meditation. But just that idea that do not worry about tomorrow because today has enough troubles of its own and really like focusing on what God's doing now in the present, that was huge. And then some of the money stuff as well, like about opening up, yeah, the do not store up treasures on earth is just a huge verse. We can talk about that a little bit more maybe in a little while. But yeah.

  JD (32:24.758)

  Yeah, I'd love to. Why don't we jump into that? And why don't we pull up the verse itself? I'll do that here in a second. But how does your stewardship of money play into your understanding of impact and also with your understanding of faith and what it means to follow Jesus and radically live out your Christian faith?

  Nick (32:45.168)

  Yeah, I mean, I love talking about this, JD. I'm trying to figure out where to start. I'm actually gonna start with, I'll start with kind of a couple of things. So first, my favorite kind of Bible verses around this, one is this amazing story where someone comes to Jesus and they're like, should we give taxes to Caesar? And Jesus responds, well, yeah, give to Caesar what is Caesar, but give to God what is God's.

  And it's this crazy thing like, yeah, you know, pay your taxes, but give to God what is God's. And I interpret that as well. Well, everything's God's. I am, you are, Caesar is God's. Like, what is this little coin tax that we're paying when? And so this idea that when we think about what resources, what money we have in our hands at any one point in time, especially for those of us who might have more than enough, that they're not ours, they're just passing through. So how do we think, you know, God would have us use these things which are in our hands, which are not really ours. And kind of following on from that, I think we have the super, even Christians, most Christians have the super individualistic idea about money. And I think we kind of put money, we kind of think about doing two things with money, which I think is weird. We think we should spend and saving. You hear people talk about, are we spending money or are we saving money, you know?

  On one hand, we've got this capitalistic world flooding in, like, buy everything for yourself, food and stuff and experiences. And then on the other hand, we're told like, oh, your future is uncertain and clear, so you need to save all of this money for your future, comforted security. So you've got kind of these weird two things going on, spending and saving. But I think like with that verse in mind, everything is God. I kind of like to think about using money. So we have these resources in our hands. So instead of thinking, what are we spending or what are we saving?

  How do we use this to bring, sure to bring restoration and goodness to ourselves and our families, but also to people who are struggling and to the environment and to future people? Like, how do we think about using God's resources, which are in our hand now, rather than kind of getting boxed into what are we spending and what are we saving? Anyway, that's kind of my little take on that for a start.

  JD (35:00.266)

  Yeah, and I'm pretty astounded sometimes when I come across, I don't want to pick on any one particular group or person or saying in particular, but when I come across like this normie Christian understanding of how to use money and it goes something like this, in my context at least, use your money to take care of yourself and to take care of your family and tithe the bit to your local church, but the rest of it is really yours to do with as you please.

  That once you pay your first fruits to God, you can really, you know, barring any like extravagant or really directly harmful uses of money, you can use the rest of the money however you want. It's not a more, it's not a spiritual issue. It's not a moral issue. I think that comes into huge classroom with the kind of vision you're painting here, really discerning from scripture. And I'm gonna read Matthew 6, 19 to 21, which I think is a relevant passage you were citing.

  Where Jesus says, do not store up for yourselves treasures on earth, where moth and rust consume, where thieves break in and steal. But store up for yourselves treasures in heaven, where neither moth nor rust consumes, where thieves do not break in and steal, for where your treasure is, there your heart will be also. And I think for many people, including myself, like I think where I put my money is quite convicting in terms of showing me that at the end of the day, my heart isn't fully with the poor and it's not fully with God. And that's something that I'm continually repenting of and like striving to be more Christ-like in and asking for God's grace and help with.

  Nick (36:35.98)

  Yeah, I think it's so hard because every the whole world and everything is just telling us, you know, like I said Like like you said keep the money like spend it on yourself. Save it for yourself Compartmentalize this you know, but when you read the gospel, it's nothing I mean, it's just nothing like that at all and one thing i'm wrestling with at the moment is the idea of saving because like Just from a biblical perspective. I really struggle to find verses which talk about I mean, it's just the verses don't you know store up treasure on earth instead have open hands and see what's happening in the kingdom and let it flow with the hands. So that's something I struggle with personally. I mean, obviously there's good reasons to save and be smart, but I find it hard to see any real New Testament biblical mandate to saving large amounts of money, which is something I think we don't talk about a whole lot as Christians.

  JD (37:34.296)

  Yeah, it's difficult, especially when in Christian circles, we also emphasize responsibility and caring for your own, especially for your own family. And there is this sense that to take care of, to be a responsible father, for instance, that does involve having savings and having provisions. And even in average life in the West, in the US or in New Zealand, it's not cheap, right? Like even in average, in our podcast with Paul Niehaus, we were talking about how in an average church, not even an extravagant church.

  It's going to cost hundreds of thousands of dollars, right, just to pay the pastor and to get the guitar and the drums for the worship band. And this is before all the bells and whistles. And let alone the smoke screen that you have. The smoke machine, you have in a lot of modern city churches right now. You have to have the smoke machine. Right, that's a, I mean, that's, I don't know, maybe very effective, actually. But yeah, definitely not the bread and butter. But.

  Nick (38:27.197)

  You have to have that. I mean, you've got to have the smoke machine.

  JD (38:39.902)

  Yeah, there is a huge challenge here, and I'm wrestling with it as well myself as I think about how much to save for a future family and for my own retirement. But I think you're right, at the end of the day, we don't see Jesus talking about retiring in a nice earthly home, but we see Jesus talking about our heavenly home in storing up treasures in heaven. So I don't have a whole lot to add, but I just think this is really on point.

  Nick (39:03.548)

  Yeah, and I think this is also one thing.

  It's also something I've been challenged by the effect of altruism community, actually, is that I've seen people commit to generosity, the kind of generosity that sometimes I haven't seen within the church. And I almost found that a little bit shameful. I was like, why are we seeing people giving away all this money? Christians have done that for years. And there's loads of Christians that have given away 90% of their income. I mean, think about heroes like John Wesley, who made millions of dollars, effectively, and said like...

  JD (39:11.776)

  Mm.

  Nick (39:37.128)

  gave it all to ministry to keep churches growing and spreading and lots of other people who are very quiet and diligently, you know, so I'm not saying Christians don't do that, but seeing the conviction from people, effective altruists, to give away money to help the poor is actually really convicted and shocked me a bit in some cases.

  JD (39:57.93)

  Yeah, how did you get involved with effective altruism? And for those who are listening who don't know, effective altruism is this idea, use your, use reason and evidence to find the very best ways to do good and then take action on that basis. It really emphasizes effective giving as a really powerful way we can have an impact or an effective altruistic impact in this world. But then it's also a movement that Nick, you and I have been a part of. But how did you get involved? How did you hear about it as well?

  Nick (40:25.172)

  I mean, I've got an interesting story and that I actually came into effective altruism kind of from the other side. So I was here in Uganda for three years and I was becoming a bit disillusioned with a lot of big NGOs and just how inefficient they were. I live in communities and the NGOs would come into the communities I was living in and do these programs and spend a lot of money and do trainings and the community would look exactly the same after it than it did beforehand.

  Millions of dollars in Northern Uganda spent on agricultural training and development. And if you go to the village, people are still farming mostly the same way they did 100 years ago. And so I was becoming quite disillusioned with aid. And then someone recommended this book, Doing Good Better by Wil Macaskill. And basically I read it. And as I was reading it, I felt like I was reading my experience in Northern Uganda. And I was like, wow, this makes so much sense that these NGOs are not like really optimized for efficiency. And they're not based on evidence. They're based on what they think will do good. And there's a lot of good intentions there, but good intentions aren't enough. And so that was my first kind of encounter with it. And that actually helped me to think about my own life as well, like as I was working managing these larger health centers. But then to help me think about how can I, even more effectively help even more people than maybe I am right now.

  That pushed me towards spending more time and energy in one day health rather than managing the bigger health centers and just working as a doctor. And then I went to, I follow my wife everywhere. That's how my life works. My wife got a PhD scholarship to Cambridge, so I followed her there and I joined the Effective Altruism group there for 10 months. And it was my two groups, I was at the church and I was at the Effective Altruism group and they were a really interesting group of people and they helped me.

  Yeah, understand the whole thing better. And then, yeah, actually, and then I got into the Effective Altruism Forum about a year and a half ago, and that kind of reconnected me. I mean, I live in this semi-rural kind of Northern Uganda, and sometimes, to be honest, like I have my wife, but real intellectual stimulation and fast moving discussions are quite hard to find sometimes, honestly, because a lot of people living around me are kind of struggling to make the everyday lives work, you know, so the...

  Nick (42:50.072)

  They don't have this luxury and this privilege I have to spend a lot of time thinking about a whole lot of other stuff. So I've found that really useful to help me think about development and even to help me reflect on my faith and stuff around money as well.

  JD (43:08.5)

  What do you think that Christians can learn from the effect of altruism movement and ideas and vice versa as well? What do you think the EA movement can learn from Christianity and from the life of Jesus?

  Nick (43:20.284)

  Yeah, I find this story, this one Bible story, which I think is really interesting to come in here, and that's, there's a woman who comes to Jesus and just pours this perfume on his head. And I was looking it up, it's about maybe $50,000 of perfume. And basically his disciples say like, you know, why didn't you give the 50,000 to One Day Health, you know, and save 20 lives kind of thing, you know, literally like, why didn't you give it?

  Why don't you sell it and give it to the poor?" And Jesus was like, what this woman's done is beautiful. She loves me. She understands the significance of this moment and she lavished this love. And so, yeah, I find it's a really interesting kind of dichotomy, challenge in my own life between loving the people around you really well and also being really, really efficient and effective in your work and trying to save lives. And for my own life, like in terms of what, when I came to Northern Uganda, I wasn't thinking about being the most effective. I was thinking about living in the community and learning about them. And that's kind of what opened up this OneDay health opportunity, was being part of the community and understanding the language and the culture and moving around and seeing this enormous gap that was there.

  I mean, I couldn't have found that, going on the internet, looking through a list of maybe effective causes. And so I think that living here in solidarity with the community is part of what, for me, it means to live as a Christian here is hugely valuable. But I also think that, like I said, the NGOs, and especially Christian NGOs, can be very, very inefficient. And actually, they want to be helping people, right?

  As Christians, we want to see lives transformed. That's what we want to see. And if you're not doing that, then I think, I don't think that's the best. I don't think Jesus is particularly happy with that. So I think the effect of altruism movement can learn that there's a lot to be learned from local, from local knowledge and local understanding. And I think a lot of causes and ideas can kind of come out of that.

  Nick (45:45.2)

  And the other thing I think is that I just believe as a Christian, I don't think that, you know, development and just having the perfect policy and the perfect idea solves all the problems. You know, I think people have deep spiritual needs, which we just... The idea that we can solve all the world's problems just by putting all the money in the right direction, you know, I just don't... that's just not going to happen. And I think even in Western countries, we've seen big issues with that over the last, you know, 10, 15 years that a lot of places things haven't become the kind of utopia that we hoped, you know, with political division and conflict and dissatisfaction. And I think there's a faith gap there. There's a spiritual gap that people have in their lives. And it doesn't matter how much we work on our work-life balance, you know, or consume the right content. That's never going to be met. So yeah, that's a bit scattergun, but I hope that helps.

  JD (46:41.934)

  So I'd like to transition to talk a little bit about working in global health as a Christian and also Christian charity. And one thing that comes up a lot of times when I chat with people who are planning their careers is Christians feel called to work for a Christian organization. Or if they start something, there is this question of, oh, do I start a Christian organization or non-Christian organization doing Christian things?

  I know Vida Plena has had some, Joy Vida Plena has had some thoughts about this. I'm curious if you do as well and feel free to talk a bit more about, I think you said it was the AMS, I don't know if that's like the Anglican Mission Society that you kind of sprung out of, but to my knowledge One Day Health is not a Christian organization, but you yourself are a believer and it motivates your day to day life. Do you think there's a reason for health charities to be explicitly Christian or is what matters that you're actually serving the needs of the poor first and foremost? Can you talk a bit about those themes?

  Nick (47:46.668)

  Yeah, I think it's a really hard question and I don't think there's any right answers here. I mean, for One Day Health, what happened is I went to the head of our organization and I was like, look, I think there's this big opportunity here. You know, I want to start like a charity and what should I do? And here's a Kenyan guy, actually. He's a brilliant guy. So the head of New Zealand CMS is a Kenyan because someone worked with him in Kenya. They're like, this guy's brilliant. So they brought him to New Zealand. He's actually now become a bishop, which is super cool in New Zealand he said now look, I think what you should do is start an independent NGO, you know, which is not faith-based, because that's going to give it the most opportunity to grow and do good. I mean, obviously, if you're thinking about, you know, like church planting or obvious things like that, then it's going to be completely different. I think it's very, very situational, I think, and it depends on the nature of what you're doing. But I think it's very hard if you are thinking about really, like if you're thinking about the possibility of big scale and getting really, really big. I think there's a lot of, you can get a lot more buy-in, a lot more people involved. If we want to work explicitly with government and tie in with that, that becomes more difficult if we have specific faith-based ways of working. So I think when it comes to scale for a health organization in the current environment, I think there's arguments for it not being faith-based. But I think it really depends on the situation. Yeah.

  JD (49:16.374)

  Yeah. And for people considering a role like yours, a nonprofit founder, working in the medical field, I guess there's a couple ways we could look at your role, right? You are a doctor, you are a nonprofit entrepreneur, you're a researcher. What does your day-to-day life look like? You know, if I'm 16 year old Nick, and I'm considering like one day making the jump that you made.

  Help me get a sense of what your day to day looks like from when you wake up to when you go to bed.

  Nick (49:50.972)

  Yeah, I mean, at the moment, we walk out of our hut. We live in these two beautiful huts. I mean, we live in a little piece of paradise, is how I put it. I literally was in my garden today, and I'm like, I don't think I'm ever gonna live in a more beautiful place than this. Like, we have a path from our hut to the outside toilet, and it's covered with bougainvillea leaves, the road to the toilet. And it's almost like something out of Lord of the Rings or something, you know, as you walk out, and the golden light is gleaming through the bougainvillea onto the path. But no, so we get up, often we might heat water on our charcoal stove and we throw it in flasks. Good quality flasks are an absolute, absolute godsend when you try to keep water warm. And then we jump on my bike, head off to work. And the office here is like an office anywhere in a Western country. You know, we have computers and pretty stable power. I mean, we need to use the generator sometimes. It's a very normal office workplace.

  And then we might go and visit a one-day health center in the village, which is about as different from a Western office as you could possibly imagine and 50 times poorer than where I live. I mean, I live in this beautiful grass-stached hut and I'm one of the richest people in the neighborhood, and that makes me feel uncomfortable. So when Western people come and visit us, they're like, oh no, you live without water inside and you don't have a fridge.

  And I'm living here thinking, my goodness, how do I justify living with all this stuff and then this luxury when everyone around? So it's really interesting getting different perspectives on that. But so you're continually moving between worlds of extreme poverty and kind of not at home and not on the office. And sometimes you get used to it and it's just natural. And other times you reach a potential one day health care black hole and you just feel this compassion in this heart. And even if it doesn't make sense to start a One Day health center, you just want to start one. You know, we can help people here. And yeah, it's an interesting mix between trying to remain compassionate and alert to what's going on and not being overwhelmed all the time.

  JD (52:06.942)

  And who, that's, that's so fascinating. And who would you recommend go directly versus maybe stay at home? And we didn't, what we didn't talk about is like paths for impact and how you would compare, you know, Oh no, I didn't ask this question earlier. I just think we should bring it up now. Right. Like there's a version where Nick, you stayed in New Zealand and you did the earning to give path. Right. And a great example of a doctor doing this is Jason Dykstra, who we had on in another episode.

  Uh He's living in Michigan, he's living very modestly, I mean very much within his means, and giving a large amount away to support global health charities like One Day Health to prevent malaria and save lives. And he'll tell you he has much greater impact by giving to effective global health charities than he ever does directly in West Michigan. Now you could have more impact if you go to Uganda, right? And your boots on the ground and you scale up some effective charity. But did you ever kind of do that calculation or sit and pray about, you know, should I go back to New Zealand and earn a lot of money and just fund organizations or should I go directly? And how would you recommend somebody who's kind of still a medical school or someone who's kind of early career kind of weighing those trade-offs.

  Nick (53:29.052)

  Yeah. So firstly, for me, it was straightforward because I only got into effective altruism kind of seven years ago, you know, well after I was already embedded in life here. So it's I didn't have that question to ask, which is a really difficult question. One thing I'll say is if people are not sure, I think go out and go to you come to Uganda come live in this hut here where I'm sitting for come for three.

  JD (53:52.374)

  Is that an invitation?

  Nick (53:59.292)

  Yeah, it's a huge invitation. I mean, we have people come here a lot with actually one of the doctors that works with One Day Health. Kristen's American, she's I think in her 50s, and she's actually just bought a piece of land 500 meters from where I'm living now. And she's going to split her time between the US and coming here, because she came here. And so I think a really good amount of time is between three months and six months. I think that's good. I think one or two weeks is not enough. I think if you've got it on your heart, you're like, and I don't mind the Christian idea of calling. It's kind of cheesy, but I think there is like, I think you can get more confidence.

  ‘Okay, I'm getting drawn to this and then you go and you try it for three to six months.” And then I mean, that's what I did originally. We came on a medical elective here, I think 15 years ago to Western Uganda for three months. And after that, I was like, yes, this is you know, this is what this is what my heart is in. This is where I want to go. I mean, I personally I don't think I could manage to give my heart is very fickle. I mean, I mentioned what I said, if I wasn't a Christian, I don't want to know. I think if I was earning a lot of money, I think my values would change. I think I'd really struggle. Other people, I think some of the strongest people, other people who can earn a lot of money and give a lot of it away. I mean, I have so much respect for that. I think it's really, really difficult thing to do. But my big advice is if you're not sure, come and try. And some people come and they work and they're like, that was fine, but there's no way I can work again. I'd say the majority of people who come and volunteer for short periods are like, I don't think this is how I wanna spend my life. But I really think there's a lot of value in spending three to six months in a place like here or anywhere which you're connected to. That's my one real piece of advice I always give.

  JD (55:37.066)

  people ever come and you think, ah, there's no way they're going to last like three weeks here. They're going to want to go home. I'm sure you wouldn't want to tell them.

  Nick (55:43.784)

  I mean, there was only one experience, which was not one of my volunteers. This is actually when I was working at a big hospital. And it's just fascinating because there was 60 patients and she was supposed to see 60 patients in a day. But the first five of them were sicker than patients she would ever encounter in America. So she just couldn't get past the first five patients. And the local doctors were looking at their watch. If the tests aren't ordered for these 55 patients, they're not going to get the test for the day. And after a few weeks, she was like, I just can't do this. I can't not give my best to every person because often that's what you are left doing. There are people whose lives you could be saving if you spent three hours, but then what about the other 30 people? So I think personality is really, really important. I think for extreme perfectionists, I don't think this is the place to be. And a lot of doctors are extreme perfectionists, to be honest. But I do want to say that it's really sad that more people are not living and working in these places.

  JD (56:33.059)

  Mm.

  Nick (56:42.768)

  I think in terms of doctors working overseas, the numbers have been dropping and they've been dropping for some time, in terms of there's very few people who stay for five or 10 years. And I think there's a lot of reasons for that. Part of it is because perceived financial pressures of youth in America and that security thing I was talking about, which I actually think churches should be able to solve that problem. The church should be able to be like, look, you go there, you don't earn any money.

  If anything goes wrong, come back and we'll just sort you out. You know, like we'll sort you out when you come back. That's what I think churches should be like with people who are keen, but I don't know.

  JD (57:21.774)

  Are there any organizations you would recommend if someone is in the medical path, like going to try to, you mentioned very generously that you'd be interested in inviting people to stay with you, but are there other organizations or other programs that maybe are like, I don't wanna say like, cookie cutter options for like two months abroad, because it's not a trivial thing, like it really needs to fit your interests and your sense of calling and.

  Nick (57:33.267)

  Yeah.

  Nick (57:44.613)

  No, this-

  Nick (57:48.668)

  There's hardly any actually. Amazingly at the moment, we're getting volunteers for our bigger health center through a British government program. So if you're a training doctor in England, there is opportunities, partly funded by the British government, to come and work here or in a lot of other places. So if you're in England, there's a good option. In America, I think mainly it's facilitated by churches. And it is a role that churches can play, is to give people, like, even moving outside, obviously, strict faith stuff, give people the opportunity to have much bigger impact in their lives. So I think churches should be supporting and paying for people and encouraging people to come for three to six months. But the simple answer is there aren't many cookie cutter options. It's actually really difficult for people. And there are big sacrifices. I mean, I don't love the word sacrifice. Maybe I shouldn't use that word. But what I mean by that is that if people come here for two to five years, often, they can lose their medical license or it's harder to specialize. So there's a lot of trade-offs to be had. So I'm not like, I'm encouraging you to come. That's why three to six months I think is good because you don't lose much in a trade-off for three to six months really. And then you can decide, okay, is this a five-year thing for me or is this or a 10-year or is this not? But the simple answer is cookie cutter options are not usually there.

  JD (58:52.537)

  Mm.

  JD (59:15.406)

  This is exactly why we recommend, here's a shameless plug, our Christian Impact Mentorship, which is a way that people who are still discerning their career path can get connected with mentors, people like Nick who have walked the walk and can help you really pray with you in your individual situation, get a sense of where God might be calling you to really live the life you're mentally, but also have a huge impact doing that within your individual circumstances. So big plug for that. And Nick, did you have any mentors in your life who were especially influential? Putting you on the spot here, it didn't prep you with this question.

  Nick (59:49.904)

  Yeah, I mean, no, there's mentors which I knew and mentors which I didn't know. But the one really big one was there was this guy at church who was a really simple guy. He went to Uganda for, I think, 15 years and started up a carpentry vocational institute under a church diocese in eastern Uganda. He hardly talked about it. You know, real And then my wife actually went and visited and she was like, oh my goodness, it's 15 years after he left and there's this kind of flourishing trade school that's connected to the local. And she was like, this is amazing. And this guy used to come to the young people's church services when he was like 65, you know, and he was a real inspiration to us and part of the connection, you know, our connection with Uganda. And there's, I think there's so much value in older people and younger people connecting like that, even if it's not the most straightforward of relationships.

  There's also a doctor from New Zealand called Edric Baker. There's actually a book about him called Doctor Brother, which I'd recommend for any kind of budding doctors. And he went to Bangladesh and started up, classic kind of thing, a couple of hospitals in the bush that were so efficient, like so incredibly. And I actually encountered his work before Effective Altruism, and it had a lot of Effective Altruism-y kind of ideas.

  And he innovated in a lot of ways. Like when he treated diabetes, he used people's urine and chemicals rather than using the expensive electronic machines to treat diabetes and stuff like that. And he was treating patients for, cheaper even than one day health was treating patients. And so, Edric Baker was a real inspiration. I met him once in New Zealand and it was amazing. He came to church to do a speech and the church was full of Bangladeshis and there were hardly anyone else. This is in New Zealand.

  And it turns out this guy's like a hero in Bangladesh and no one's ever heard of him in New Zealand, which is really funny. And these were Bangladeshis, they were mostly Bangladeshi Muslims who were there and they were like, oh, this guy's amazing, you know, he's got this hospital and he's working here. And I was like, what's going on? So yeah, that's Edric Baker and a really interesting book, Dr. Brother. So a bit of a plug for that one as well.

  JD (01:02:06.702)

  That's incredible. And any advice for leaders, people who want to start something? You're not just a doctor. You're not just a researcher. You're a nonprofit entrepreneur, really. And you manage, you oversee a lot of people, and you envision new projects, and you pitch that dream to other people. Any advice for people who are thinking of starting their own charity or own organization?

  Nick (01:02:29.852)

  Yeah, I mean, I've kind of got almost anti-leadership advice, which is, I think if you want to work in a field and do really effective work, I think get your boots on the ground for a period of time. So what I mean by this, if you want to start a teaching charity, maybe spend six and you want to do leadership, maybe spend six months, you know, teacher aiding or something in the kind of place that you want to work in. If you want to be a doctor, you know, work in those places. I think

  These days, often leaders want to shoot for the top very quickly. And I think there's risk in that. I've actually, people can really disagree with me here, but I think there's a lot of worth in going slowly at the start. The first six months, the first one year, really understand the context, understand the problem. And the best way to do that is to be working on it. My favourite charity, education charity here, there was co-founded by a Ugandan and Australian woman and she worked teaching in a Ugandan primary school with 120 kids in her class for a year. And then she's like, okay, these are the things that need to happen. And it's matched so closely with, it's called Read for Life, that it's matched so closely with the values of actually an effective altruism charity that they last year actually gave them a bunch of money to continue their work, which was super cool. So I think there's a lot of value in being humble and working in the area that you're thinking of leading, whatever that is. Yeah, that's my advice.

  JD (01:04:05.454)

  Nice, nice. I know you've also talked at other times about testing things out, like trying new things, finding others who've tried the idea that you're interested in, talking to them, really trying out a bunch of things, seeing what sticks, seeing how it works, and what can scale. Anything you would add to that or?

  Nick (01:04:20.956)

  Yeah. Yeah, I mean, this is the thing. Most things have kind of been done before. So we love thinking about innovation and we love thinking about being the first person to do things, but I don't think it matters being the first thing. I mean, like Ethiopia, for example, they've launched these health posts that are similar in some ways to One Day Health. And we got some inspiration from, okay, that's working there. Maybe similar things could work here. Like in such an interconnected world, a lot of things have been tried. Like find the people who have tried them before talk to them. There will be someone out there who's tried or done the thing you're thinking of. And I'd say this especially actually for Christians who are thinking of doing it, because Christians are often very trigger happy and like starting NGOs or funding something or doing something. And I think there's a great impulse there, but there's enormous value in talking to a bunch of people, like the local people in the country you're helping and maybe people who've funded or done that stuff before.

  JD (01:05:03.917)

  Mm.

  Nick (01:05:18.268)

  People have probably done what you're doing. I hate to break it to you, but it's probably the situation. So talk to them. Yeah.

  JD (01:05:24.714)

  Another plug for Impact Mentorship, talk to Christians who are three years ahead of you on your very similar career path, who might have some insights and wisdom to share. Yes. Well, we're wrapping up here just on this point of career advice. Any final parting career advice you would give to any listeners who are still discerning, what is this radical calling God might have for their life and a way that they can use their career to advance God's kingdom.

  Nick (01:05:50.632)

  Yeah, like try and find a way of moving towards the way of Jesus and away from what the world is telling you. Like the world is telling you, you need to save up a lot of money, you need to have this career, you need to do all these things to make your life secure and safe. And there's some truth in that, but there's also a lot of lies. So like when you're making your decisions about what to do, like turn to your Christian mentors and turn to the Bible and the Sermon on the Mount rather than what everything else is screaming at you. I think the biggest issue is people just not doing things, people just going on with their career and their life and not making a decision to maybe do things a bit differently.

  JD (01:06:46.003)

  Awesome. Nick, is there any way we could be praying for you or supporting you in what you're doing at One Day Health?

  Nick (01:06:52.2)

  Yeah, I mean, really thoughts about Malawi and whether that's going to be a goer or not. We want to make good decisions. We really want to use donor money well. Obviously, if we start there, it could fail, but we want to give it the best chance of success. So that's the thing which is really kind of on my heart at the moment. And also about this trial, like if we can get a trial going and that would be great. And also this, like the question obviously, it's going to cost a lot of money and thinking through both the ethics of that and raising that as well, I suppose. I think the trial and that are those are two things I think to pray for. Thanks.

  JD (01:07:37.642)

  And we'll include any links to One Day Health or any of the resources mentioned in this episode on the podcast page on our website at christiansforimpact.org Nick, thanks so much for joining me. It was really a pleasure and I'm sure this won't be the last conversation, but just really love what you're doing and so inspired by your heart for God and for the poor and vulnerable.

  Nick (01:07:59.08)

  Thanks so much, JD. Honored to be on this podcast. You've interviewed so many awesome people and it's so cool to be here.

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