Transcript

Cold open [00:00:00]

Lucia Coulter: I think that from the perspective of a manufacturer, they’re only putting in a small amount of lead: 1% intuitively doesn’t feel like that much, right?

Rob Wiblin: It’s just a splash of lead. Just a little bit.

Lucia Coulter: Just a tad. So I think it’s not intuitive, how bad that could be. One way of communicating it is that if you had a little sugar sachet — the type that you would get at a cafe to put in your coffee — if that was filled with lead dust, and you sprinkled it across an area the size of an American football field, that level of lead loading would be sufficient to cause lead poisoning if a child spent time in that environment. So a very, very small amount of lead can have these really toxic effects. And that’s not intuitive; that’s pretty surprising.

So I think that’s probably how people think about it. But often manufacturers, in some of our experience, will move really quickly. Sometimes days after we show them the results, they’ve ordered their non-lead alternative ingredients.

Rob’s intro [00:01:00]

Rob Wiblin: Hey listeners, Rob Wiblin here, head of research at 80,000 Hours.

I know many of you subscribe for our more distinctive coverage of topics related to global catastrophic risks, but even if you only listen to the occasional episode on global health and development, this should be one of them.

The Lead Exposure Elimination Project (LEEP) has been one of the most successful organisations I’ve ever heard of being founded. Lead is astonishingly toxic to children, and is still an enormous problem in much of the world — and LEEP is making major headway on tackling it in many countries despite a very limited budget.

We speak with its cofounder Dr Lucia Coulter, who is just super knowledgeable about the impacts of lead, how people are still exposed, why LEEP has been managing to smash it out of the park so far, what alternative approaches they have considered and rejected, and what other opportunities to tackle lead could be even better than what they’re doing and why.

LEEP’s story and the lessons that come from it are something you really ought to know. Lucia talks both about how she managed to start this outrageously successful organisation despite having very limited relevant experience, because she got the support of the Charity Entrepreneurship Incubation Program. She also explains why she pledged to give away 10% of her income to highly effective charities as an undergraduate, and I push back a little on whether that’s a good idea.

Plus, we recorded in person in London and just have some great bants.

If you feel inspired by this conversation, give to global health and development causes, and haven’t done your holiday giving yet, you could do a lot worse than to head to leadelimination.org and give some lovely young babies the gift of not getting lead poisoning at an expected cost of $2 per child.

And note that LEEP is about to hire a few program managers — those job ads should go up on the 20th of December, but if you go to leadelimination.org/jobs you can join a mailing list now and get notified about them when they go up.

Without further ado, I bring you Lucia Coulter.

The interview begins [00:03:14]

Rob Wiblin: Today I’m speaking with Dr Lucia Coulter. Lucia studied medicine at Cambridge University and during her studies published some peer-reviewed research on public health, taught microbiology and parasitology, and gained clinical experience in Sierra Leone. After graduating, she worked as a medical doctor in the UK’s National Health Service.

But in 2020, Lucia made a big career change and went through Charity Entrepreneurship’s Incubation Program in London. This led her to found Lead Exposure Elimination Project (LEEP), a health policy nonprofit working to reduce childhood lead exposure in low- and middle-income countries. That’s because she believed lead exposure in low- and middle income countries was far more harmful than commonly appreciated, and extremely neglected by nonprofits and philanthropists. While it’s only been around for three years, as we’re about to hear, LEEP has already had a remarkable string of successes, and has a lot of big fans out there who I’m sure are going to be very excited to listen to this interview.

As if that story wasn’t badass enough, Lucia is also a member of Giving What We Can, having pledged to give 10% of her income to the most effective charities that she can find.

Thanks for coming on the podcast, Lucia.

Lucia Coulter: Hi, thanks so much. It’s really great to be here.

How bad lead is [00:04:22]

Rob Wiblin: I hope to talk about some thought bubbles I had about how to get more sweeping lead elimination, as well as the completely mad story of lead being put right into food in Bangladesh.

But first, most people probably have a reasonable sense that it’s not healthy to chow down on a handful of lead. But is it possible to give us an intuitive sense of just how bad lead is for your health?

Lucia Coulter: So lead is extremely toxic. One way to think about why is that basically, it mimics calcium and other metal ions that serve these essential functions in pretty much every part of the body. And we’ve evolved for the vast majority of our history in an environment where lead was buried in the earth, so our cells are just not well adapted to tolerate any of this interference. And it interrupts many different subcellular processes, and that affects pretty much every organ system.

So we could think about it in terms of what would the impact be on the average child in a low- or middle-income country? The average child in a low- or middle-income country has a blood lead level of around 5 micrograms per decilitre, and that’s high enough to cause health, educational, and economic impacts. So a child with that blood lead level would have a reduction in IQ anywhere from around one to six IQ points, depending on which analysis you take. That, in turn, will affect their future earning potential. They’ll also have reduced educational attainment. There was a recent analysis by the Center for Global Development that pretty conservatively concluded that would be equivalent to around one year of lost schooling.

And then it also causes an increased likelihood of cardiovascular disease and mortality from cardiovascular disease. And that could be as high as a relative risk of around 1.5 at the average level of lead exposure that children have in low- and middle-income countries. That’s according to a recent analysis of US data.

And then on top of all of that, it increases risk of kidney disease, anaemia, foetal health problems, behavioural disorders, ADHD, and possibly even mental health problems and dementia.

Rob Wiblin: So one thing is, because we evolved for so long in an environment where lead was not present, we don’t have any bodily process for removing lead. So it tends to just hang around in the body for a very long time, and it ends up in all kinds of different tissues. I think in adults, often it can end up in the bones, and it tends to hang around there a long time and then gradually leach out, over decades even. But it’s not something that you just consume and then pee out very quickly. It hangs around for a long time.

And as you’re saying, it mimics other metal ions that we do need to use, so it interferes with all kinds of different enzymes throughout the body that are doing just the basic work of a cell. It’s getting in there and just screwing them up constantly. It’s also mimicking calcium ions in the brain, so it gets into the brain and then it screws up the ability to send signals between neurons.

Lucia Coulter: And that’s particularly dangerous when children are very young and their brains are developing, because that’s such a complex and delicate process — which is why it has such a severe impact on young children, by impacting the way that their brains are forming and all those neurons are connecting in the very early years.

Rob Wiblin: Yeah. So just given that it can interfere with so many different bodily processes, in the places where we’ve checked and we’ve been able to see it, we can measure big damages that it’s causing. And you might guess that in other organs, maybe the damage to the spleen or to the kidneys or perhaps the liver is a serious issue. Maybe it’s not as severe in other organs, but you would just guess that it’s messing up enzymes there too, and probably just causing all kinds of micro damage throughout every cell, more or less, inasmuch as you have a reasonable amount inside you.

Lucia Coulter: Yeah. And what you said about how it’s deposited in the bones: it’s deposited in the bones, but then it also is released from the bones at a relatively constant rate. But then there are periods in your life, particularly in women… When women are pregnant, their bones will release more lead — because they’re releasing calcium for the baby to absorb — and then that is absorbed by the baby. So the mother can actually pass the lead that they’ve accumulated through their lifetime to a baby, which is pretty concerning.

And then, when women go through menopause, again, their bones change in their structure and the lead is again released into their blood, which can probably increase the harms of lead at that time. So there’s a lot of really scary stuff going on in there.

Rob Wiblin: OK, so we’ve got the effects on brain development at levels that are quite common even in the UK or US — and very common, I think, in poorer countries — of around 5 micrograms per decilitre. I’m just going to start using the numbers with this, because that’s a bit of a mouthful. So we’re talking about like 5, 10, 15 as different blood lead levels. Even at that level, it’s causing one to six IQ points loss. It’s causing as a result, or basically the same thing as to say that it’s causing people to do worse at school, and to be less able to be productive at work. It’s also increasing people’s risk of cardiovascular problems by 50% is what you’re saying. And that’s at pretty standard levels — not even exceptional levels of lead.

It’s also been accused of a bunch of other stuff as well. You’re saying there’s mental health [effects]. I’ve heard there’s a link between people being exposed to lead and committing crimes, and just generally engaged in uncontrolled impulsive behaviour. Do you know how strong the evidence is for that?

Lucia Coulter: There have been two recent meta-analyses looking at this. I think they identified some publication bias in the literature, but still identified that there’s probably a real link. I think it was something like maybe somewhere between 7% and 30% of the variance in crime in the US since the ’70s might be explained by changes in lead exposure. Quite substantial.

Rob Wiblin: Yeah. I guess all of this stuff is a little bit hard to prove and pin down very precisely, because lead is so clearly toxic that you could never run an experiment where you gave half the kids a bunch of lead and saw what happened. So we’re forced to use kind of natural experiments — where we see random variation that occurs in how much lead people are exposed to, and then look at the outcomes — or try to do controlled studies where we control for someone’s age and their socioeconomic status and then see whether lead has some additional effect. But none of it is super precise.

So in countries where lead is a more serious problem, where they haven’t really gotten on top of this in the way that the US or UK mostly have, how large could the effects be there on children who are currently getting exposed to alarming levels of lead?

Lucia Coulter: Do you mean like overall estimates for the burden in low- and middle-income countries?

Rob Wiblin: Yeah, I suppose. How much might it reduce someone’s healthy life expectancy might be one measure. I guess there’s so many different channels of harm here that it’s a little bit hard to know what. You could use dollars, you could use years of healthy life expectancy. You can also use school results or IQ measurements.

Lucia Coulter: Yeah, I think one way to kind of summarise some of that is to look at overall DALY burdens and that sort of thing. So it’s estimated that in low- and middle-income countries, around 20 million DALYs per year are caused by lead exposure — that’s by estimated by the Global Burden of Disease Study.

Estimates for cardiovascular disease mortality vary quite a lot. Estimates vary from around 1.6 million deaths a year to 5.5 million — the vast majority of those being in low- and middle-income countries. And then for the economic toll, again, the estimates vary. So from around $1 trillion of lost income a year to around $2.4 trillion (in international dollars).

Rob Wiblin: A DALY — just to remind everyone — is a disability-adjusted life year. So one DALY would represent someone’s healthy life being shortened by a year, or the quality of their health being halved for two years — for example, by having a severe chronic health problem for that time.

I think there’s some controversy in the public health world about just how bad lead is for you. I think there’s been some recent estimates that have pushed up the estimates for how much harm is being done quite substantially — by like 2x or 5x. What is the nature of the disagreement, inasmuch as there is one?

Lucia Coulter: So this upper estimate, the 5.5, is from a World Bank report that was released in The Lancet just a few weeks ago. I think it’s basically derived from regressions of blood lead levels on cardiovascular mortality in the US — trying to control for a bunch of things, and then applied to the global population. So I haven’t looked into this much yet; the paper only came out quite recently and I haven’t had a chance. But I guess that the biggest problem would be whether or not it was possible to control for things enough, to see if the controls are doing enough.

And then the other estimate, the lower estimate, 1.6, is from the Global Burden of Disease Study. And I think that’s more likely to be an underestimate. Basically, it only looks at the mechanism of lead exposure impacting cardiovascular disease through hypertension, so through increased blood pressure. And we know that there seem to be substantial effects on cardiovascular disease through other mechanisms as well, like more directly damaging arteries and that sort of thing.

Rob Wiblin: So something in that range.

Lucia Coulter: Something in that range. I mean, it hasn’t been particularly consequential for us. Even the lower number is extremely high, and it makes interventions addressing that exposure look really very cost effective if they work.

Rob Wiblin: These days, something like 600,000 children die of malaria every year. And malaria is a big deal, and it’s one of the most ridiculous things, that we haven’t managed to eliminate these deaths from a disease that is so straightforward to prevent. But in this case, you’re saying the lower estimate is that lead is causing three times that many deaths, exclusively via its effects on cardiovascular health. We’re talking really big numbers.

And in terms of underestimating the effect, a really interesting tidbit that I learned while doing background research for this is that in terms of the health literature, if exposure to lead reduces your IQ below 85, then that counts as an official health impact, because now you have a learning disability. If it reduces your IQ from 100 to 95, that doesn’t count as having any health impact at all, because 95 is still considered a normal IQ. And I think by any normal standard, any parent would not really want their kid to lose five IQ points. So it really systematically underestimates the impact that it’s having on people’s wellbeing.

Lucia Coulter: I think that’s right. And there are probably also other health impacts that aren’t included in these sorts of estimates. And there are very few estimates that actually try and aggregate all of the different types of harms that lead exposure does on health, education, society, crime, income. So it’s pretty huge.

Rob Wiblin: One estimate I heard was that the total damage done by lead each year across all of these different mechanisms was estimated to be 7% of global GDP. Do you understand where that estimate is coming from?

Lucia Coulter: I think that 7% comes from this World Bank paper that came out a few weeks ago, and it includes the impact of lead exposure on IQ — which then has an impact on earnings, so the total earnings lost from having a lower IQ. And then the other thing it would add to that is the impact of lead on cardiovascular disease mortality, and then converting that lost life into an economic value, and then taking that total economic loss and looking at what that is equivalent to in terms of a percentage of GDP. I think that’s probably what it is.

So even that doesn’t really incorporate necessarily all the other kinds of economic consequences or health consequences. But for the reasons that we talked about before, it might be an overestimate in some ways.

How many times more damage lead is doing in low- and middle-income countries [00:15:35]

Rob Wiblin: If I understand correctly, 40 years ago about 90% of people’s exposure to lead, in rich countries at least, was coming via leaded petrol, which has now been almost completely eliminated everywhere. Well, I guess except for avgas. This is one crazy thing that I learned: that we haven’t figured out a way to run planes safely without putting lead in the petrol there, which is one of the top reasons now that people still get exposed to lead in countries like the UK or the US. But anyway, as a result of getting rid of leaded gasoline, we’ve seen a massive decrease in lead levels in children in the US — by around 90% since the late ’70s, and probably something in that ballpark for the UK and Australia, although I think that the data on that is surprisingly rickety; it was a little bit hard to find any good systematic studies of that in recent years.

But an interesting thing is that the research suggests that most damage is done by the first bits of lead that you get exposed to: it’s actually the first milligram that’s doing the most damage per milligram, and then you get gradually declining damage, which is counterintuitive. I suppose the mechanism might be that, as you get exposed to more and more lead, all the damage that can be done by lead specifically has already been done; it kind of runs out of low-hanging fruit to harm you even more.

Anyway, if that’s the case, the damage that lead is doing to people’s health — even in rich countries, where the exposure levels have been reduced 90% — could still be really quite meaningful. It’s not necessarily enough to reduce it 90% — you really want to reduce it by more like 99% or 99.9% in order to feel comfortable that we’ve done enough.

One thing I’ll just note is that listeners might recall all of the news coverage of Flint, Michigan a couple of years ago where they screwed up something about their water supply and children were getting exposed to lead above the US’s permitted limits. But the blood lead levels that led to the declaration of a national emergency in the US are just completely standard in India: I think 5% of the children in that city had blood lead levels above 5, but I think two-thirds of children in India have that level of lead in their blood, and that’s just regarded as completely normal and a matter of course. It’s kind of crazy.

Anyway, that is a huge lead-in to this question: How many times more damage is lead doing in countries that LEEP operates in, as opposed to countries like the US or UK, where most listeners live?

Lucia Coulter: Yeah, it’s really crazy, that statistic. So LEEP operates in low- and middle-income countries, and 95% of the global burden of lead poisoning roughly is concentrated in low- and middle-income countries. In low- and middle-income countries, the average blood lead level is around 5 micrograms per decilitre, which is classified as lead poisoning — so on average, most children have lead poisoning. And in high-income countries, the average childhood blood lead level is around 1 microgram per decilitre. It’s a bit lower than that in the US. And like you say, the data is not amazing anywhere on this, but it’s about five times lower in high-income countries.

And the Flint, Michigan example is really stark. I think that was a huge crisis, having 5% of children in Flint, Michigan with lead poisoning. But the fact that just every single day, 50% of children in low- and middle-income countries have that level of lead poisoning is really concerning, really troubling.

Why hasn’t this problem already been solved? [00:18:35]

Rob Wiblin: We’ve known for at least 100 years that lead is poisonous. I guess we can see that because France banned leaded paint in 1909. I think they were one of the first countries to do it. But nonetheless, they thought it was sufficiently dodgy that there was lead going in paint in houses that they banned it 110 years ago. And apparently even the ancient Romans suspected that lead was bad for you. I guess they probably didn’t have gold standard randomised controlled trials, but they probably noticed that people who worked in lead mines ended up with extreme health problems, and figured out that lead was probably bad for you.

Is there a simple reason why this problem hasn’t already been solved? Why didn’t we know in the 19th century to stop adding lead to stuff that people were going to be eating?

Lucia Coulter: I think it’s a good question. It’s probably not that simple of an answer. I think to start with, lead is just a really useful metal: it’s abundant, it’s malleable, it’s durable, and its compounds make loads of really helpful things — like strong glazes, bright pigments, antiknocking fuels. I think in the ’20s the industry in the US described lead as “a gift from God” because it’s just such a great thing. So I think people will just keep using it unless they aren’t able to, unless they’re strongly incentivised not to.

I think another reason is that there is extremely low awareness of both the prevalence of lead poisoning and the harms of lead poisoning, and the sources of exposure. Low awareness generally, but also among important decision-makers, important institutions, and low- and middle-income country governments and funders. I guess that leads to the question: Why is the awareness so low?

Rob Wiblin: Yeah, maybe this is something that a historian should be looking into understanding. Maybe they could find some mentions in parliamentary records or something from the 19th century of people raising the question of whether lead was safe. There must have been some stuff written about it, if it was banned in France in 1909. But why is it that that didn’t win the day? Why is it that industry, that wanted to add lead to things, won out the debate?

Lucia Coulter: Yeah, I always wonder if one part of it is just the really invisible nature of lead as a poison. Of course impacts aren’t invisible: millions of deaths and trillions of dollars in lost income. But the fact that lead is the cause is not apparent. It’s not apparent when you’re being exposed to the lead. The paint just looks like any other paint; the cookware looks like any other cookware. And also, if you are suffering the effects of lead poisoning, if you have cognitive impairment and heart disease, you’re not going to think, “Oh, it was that lead exposure.” It’s just not going to be clear.

Rob Wiblin: I guess it’s an issue with how we tend to treat specific acute diseases and be very aware of that, but then everyone suffering some relatively small chronic impact just doesn’t really rise to the level of anyone’s notice and cause a public outcry.

Lucia Coulter: Yes, exactly. And the symptoms aren’t specifically characteristic of the cause. It’s not like malaria, where you get cyclical fevers and it’s like, obviously something going on here. I think that’s part of it as well.

Why everyone is paying attention to lead right now [00:21:24]

Rob Wiblin: I have this perception that lead is kind of having a moment. Or at least I hear a lot more about lead than I did five years ago. Is my perception correct, that people are talking more about lead than they used to? Maybe you’re the worst person to ask this.

Lucia Coulter: I mean, definitely in my circles.

Rob Wiblin: Yeah. People are just talking lead all the time.

Lucia Coulter: Yeah, what’s that about? No, I think there’s something to that. I was thinking about this recently, and also asking a couple of people who’ve been around in lead longer than me what the reason might be. I don’t really know. There’s a few reasons I could think of.

One is that the Global Burden of Disease Study started looking at risk factors. The Global Burden of Disease Study is really influential, and it started including lead as a risk factor, and communicating about the impacts of lead exposure globally. And in 2019, the Global Burden of Disease data reported that one in three children globally have lead poisoning. Then there was this Toxic Truth report, which was authored by UNICEF and Pure Earth, that used that statistic. And I think that was really powerful, so maybe that had something to do with it.

There’s also been a lot of pretty influential academic publications. There was a Lancet Commission on pollution and health which said that one in six deaths globally are due to pollution. There was this Ericson et al. meta-analysis that said that almost 50% of kids in low- and middle-income countries have lead poisoning. And then more recently, there was this World Bank report, which I think is making a splash as well. So maybe these things are contributing.

I think GiveWell has played a role. GiveWell’s recommended grants in the lead space, and there hasn’t really been much funding around historically for work on lead. The Center for Global Development is running a working group, which I think is a bit of a focus for actors in lead.

I don’t know if these things are causes or symptoms, but I think you’re right that there’s something.

Rob Wiblin: I guess a very simple answer would be that it’s a huge deal, so it’s no surprise that people are paying attention to it now. Maybe what we need to explain is more the question of why in the 2000s weren’t people talking about this much more.

What LEEP set out to attempt in Malawi [00:23:21]

Rob Wiblin: All right, that’s enough about lead as a problem at a high level. Let’s talk about the Lead Exposure Elimination Project. We’ll get to more recent events later, but can you start by telling us this amazing story of some of the very first things that you did early on? The story of what did LEEP set out to attempt in Malawi?

Lucia Coulter: So our goal in Malawi was to first find out, is lead paint a problem here? — there was no data to begin with — and then to find out, if it is, could we support the government to act on it? So we went to Malawi, we partnered with the University of Malawi, and we conducted some basic market analysis: we bought every brand of paint that we could find, three colours of each, and we dried them and sent them to a lab and got them analysed for lead. And we found that 57% of the samples that we tested had very high levels of lead, which was kind of surprising. I mean, we knew regionally this was likely, but we were like, wow, this is really a thing, and no one knows this is a thing.

Rob Wiblin: Was it high levels even by the standards of leaded paint, or just typical for paint that’s leaded a lot?

Lucia Coulter: Varying, but some over 1% lead. It’s not that untypical for leaded paint, but the limit is less than 90 parts per million, and we’re talking like 10,000 parts per million.

Rob Wiblin: It’s like 100x what would be the safe level?

Lucia Coulter: Yeah, exactly. So we brought that to the Ministry of Health and the Malawi Bureau of Standards, and they were really receptive. The Malawi Bureau of Standards basically said that they had thought that this practice had been phased out years ago. Understandably, they thought this was an outdated technology. And so although they had a standard in place, a mandatory standard, it wasn’t being monitored or enforced because it just wasn’t known to be a problem. This data was a real eye opener. And at that point, they immediately committed to implementing the regulation. So that was really a great start, and happened more quickly than we expected that it would.

Rob Wiblin: How much did it cost to do these tests, and how long did it take?

Lucia Coulter: It takes about a week or two to find all the paints, dry them, and then send them to the lab, and that takes another week for them to come back. It costs around $27 a sample. So a study overall will cost less than $5,000.

Rob Wiblin: OK, and then you let the government know this. Was it hard to find the right person to notify and get them to answer your emails?

Lucia Coulter: It was not too difficult. We just reached out to anyone we knew who might have a relevant connection and they’d put us in touch with the next person. We’d ask their advice about who we should speak to about this, who would be the relevant authority, and then they’d connect us to the next person. And it worked like that. Everyone was really helpful and really keen to help us get to the right place.

Rob Wiblin: So it was already illegal to be doing this. The paint companies were sticking lead in there anyway. Maybe they weren’t thinking about it that much. The government certainly wasn’t thinking about it, because they just didn’t realise that this was happening at all. And once they found out, was there a quick turnaround in actually removing lead from the paint?

Lucia Coulter: It’s a bit of a process to get enforcement going and to get the regulation implemented. It’s one thing to have it on the books; it’s another thing to have the processes set up to be collecting the right samples, to have testing capacity and that sort of thing.

So over the next year or two, we were helping the Malawi Bureau of Standards — supporting them with testing capacity, updating their regulation to make it more enforceable, and making sure that the right samples were being collected. It needs to be coloured paints, because they’re much more likely to be leaded than white paints. And the default globally for anyone doing monitoring of a paint industry would be to just collect white paints, so you’d naturally miss lead in that. So that’s a bit of a process. And then industry typically is unlikely to reformulate until they feel that there will be consequences.

Rob Wiblin: Did you call them up and say… ?

Lucia Coulter: Yeah. I mean, we spoke to them before we did the study, and we said, “You’re aware of lead as an issue in paint?” and that sort of thing. Broadly, they said that they were aware of it, but that maybe some other manufacturers were doing it, but not them. So then we come back with the results and we say, “There is a lot of lead in your paint.” And they’re like, “Ah, OK” — and at that point we offer our support.

So we can help in quite a few ways. We have a paint technologist who’s absolutely amazing, who can give really detailed technical support with the switch. We can help them find suppliers of the non-lead raw materials, which can sometimes be a barrier because their usual suppliers might not necessarily supply these non-lead alternatives. We also offer to retest their paints for them so they can be confident that they’re lead-free and that sort of thing.

Some of them engaged, some of them didn’t really. Some of them said to us, like, “I don’t really know. Does the Malawi Bureau of Standards really have testing capacity? Do we really have to do this?” And so we were like —

Rob Wiblin: Wow, that’s ballsy to be saying, “OK, sure, you busted us, but we don’t think that you have the testing capacity to check again, officially.”

Lucia Coulter: Yeah, exactly.

Rob Wiblin: Interesting. Were any of them mortified? Sounds like no.

Lucia Coulter: No, not that was apparent to me. I mean, I don’t know how they were feeling internally. In a professional context, you might not really let on your real feelings about it. I think that from the perspective of a manufacturer, they’re only putting in a small amount of lead: 1% intuitively doesn’t feel like that much, right?

Rob Wiblin: It’s just a splash of lead. Just a little bit.

Lucia Coulter: Just a tad. So I think it’s not intuitive, how bad that could be. One way of communicating it is that if you had a little sugar sachet — the type that you would get at a cafe to put in your coffee — if that was filled with lead dust, and you sprinkled it across an area the size of an American football field, that level of lead loading would be sufficient to cause lead poisoning if a child spent time in that environment. So a very, very small amount of lead can have these really toxic effects. And that’s not intuitive; that’s pretty surprising.

So I think that’s probably how people think about it. But often manufacturers, in some of our experience, will move really quickly. Sometimes days after we show them the results, they’ve ordered their non-lead alternative ingredients.

Rob Wiblin: Do you know what’s motivating those ones to move faster than the others?

Lucia Coulter: I think it could be that they think this is the right thing to do. And I think sometimes beforehand, it’s not always obvious to everyone in the company that lead is being used. The names of these pigments, they’re called things like “Lemon Chrome” or “PY34.” They’re not called, like, “lead.”

Rob Wiblin: Maybe some manager finds out, and that manager assumed they weren’t using lead, and then when they find out that they were, they’re like, “What are you doing?”

Lucia Coulter: Exactly. I think it can also be brand reputation. Sometimes if it’s a brand with a reputation for being high quality, then that could be really important for them. And sometimes it’s just that they want to get ahead of any incoming regulation.

Rob Wiblin: They see the writing on the wall.

Lucia Coulter: Yeah. There’s a really inspiring guy from the paint industry, he’s called Johnson Ongking. He is a VP of a big paint company in the Philippines. And when he found out about the use of lead in the paints in his company, they switched immediately. He’s been since advocating for regulation in the company and also more broadly. And he gave a talk for us to show manufacturers, and he speaks really inspiringly about the moral responsibility on industry. And the way he puts it is, “You have a choice to be the hero or the bad guy of this story.” And I think that’s really cool when it’s coming from industry to industry. It’s not really a type of messaging that would be helpful for us to say.

Rob Wiblin: We should maybe explain a little bit why it is that lead in paint is such an issue, because most of us are not in the habit of eating that much paint. But lead affects kids the most because it gets into their brains as they’re developing, and basically screws up the wiring as it’s developing, and then they have lifelong learning disability issues. And little children, unlike adults, tend to crawl along the floor where paint dust and paint chips can fall off. They tend to lick things; they tend to stick stuff in their mouth much more than adults do. So they end up potentially eating paint, basically, or consuming paint dust incidentally. And that’s how it can be quite a significant impact on children’s lead intake, even if it isn’t a very big one for adults.

Lucia Coulter: Yeah, and also children are smaller, so the same amount of lead consumed would result in a higher concentration. Also just biologically, they absorb it more readily as well. So it’s all of those reasons.

Rob Wiblin: Yeah. In adults it tends to go into bones, right? Whereas in children it tends to hang around in their tissues being able to do more damage?

Lucia Coulter: Yes.

Rob Wiblin: At least that’s what I read on Wikipedia earlier today. Fingers crossed that Wikipedia is correct on this one.

It’s very sad that houses are still being painted with lead paint now, because in the UK we have houses that still have lead paint on them from 100 years ago. We’ll talk about this later, but you brought in this x-ray gun that can check for lead in objects, and we were using it in the office here. And we found that some of the old railings in this office still have leaded paint. I think you were saying they probably have a non-leaded coating over the top, but there’s still leaded paint underneath. Anyway, the paint that is going onto houses in India with lead today is going to be there for decades, possibly 100 years, in some cases still poisoning children out into the future. Because it’s so difficult to remove leaded paint once it’s on a building, you normally don’t strip off all of the paint completely, you just paint over it.

Lucia Coulter: Yeah, exactly. And also a lot of these countries where the lead paint is still on the market, they’re going through periods of population growth, urbanisation, economic development. So there’s big growth in the paint market, and more and more paint is being put into new homes all the time, and it’s going to remain a source of exposure for decades to come. It reminds me that there’s a real urgency in stopping this from happening now, especially given these long-term impacts.

Rob Wiblin: Yeah. OK, let’s close the loop on the Malawi story a little bit. What has happened since then? Is lead out of the paint in Malawi more or less a couple years after you did this initial survey?

Lucia Coulter: So a few weeks ago I was back in Malawi, and we were doing a followup study together with the Malawi Bureau of Standards, and we found that there’s been a substantial reduction in the amount of lead paint on the market. The biggest brand, which makes up the majority of the lead paint market share, appears to have switched to lead-free, and one other brand has switched to lead-free in their driers. There are just a few remaining smaller brands that are still using lead pigments, but are in the process of reformulation mostly. They say that they will have their lead-free paints on the market by early to mid-2024. So most of the lead paint in Malawi looks to have gone now.

Rob Wiblin: And what remains is probably going to be gone within the next few years. And I guess you’ll follow up, or the government in Malawi is going to follow up and make sure that’s the case.

Lucia Coulter: Exactly. Yeah, they’re on it.

Rob Wiblin: OK, so this has cost LEEP tens of thousands of dollars, and it’s cost the Malawi government not very much, I imagine. It’s not a lot of staff time; there’s not a lot of resourcing that’s required here. And potentially you’re bringing forward by years, possibly decades, the removal of leaded paint in Malawi, which is going to reduce lead exposure for hundreds of thousands, millions of children over many years.

You tried to do a cost-effectiveness analysis, where you looked at what would be the total health gain, what would be the total economic gain from all of this for every dollar that you spent. What sort of results did you come up with?

Lucia Coulter: So we did an initial cost-effectiveness analysis in expectation towards the beginning of the project. We tried to compare two scenarios: one in which compliance with lead paint regulation starts to increase quite soon — that’s the LEEP-intervention scenario — and the other scenario is where LEEP doesn’t exist, and compliance with regulation starts to increase at some point in the future, which has got nothing to do with LEEP. In each scenario, we model out how many homes will be painted with lead paint, and how many children will be exposed as a result. And then we take the difference between those two scenarios, and look at the health and economic benefits from that averted lead exposure.

The results that we got a few weeks ago put us in line with what we modelled, which suggested that it would cost $14 for each disability-adjusted life year equivalent averted. So we’re converting economic benefits here into disability-adjusted life year equivalents, with one DALY is equivalent to 2.5 years of average income.

And of course, huge uncertainty, and loads of assumptions go into this, so lots of caveats. But we have also been working on a new model recently, which I think has got a bit of a better method and also incorporates most of our other countries that we’re working in, and the results are looking pretty similar. So that makes me feel a bit more confident in the results. And then also Founders Pledge has conducted a cost-effectiveness analysis on a bunch of our programmes, and it’s also in a similar range, so it looks pretty promising.

Rob Wiblin: OK, so the idea is you’ve managed to do the goodness equivalent of giving someone an extra year of healthy life in expectation, on average, across all the different scenarios, for $14 — which is extremely good value by the standards of health interventions in the developing world. I think that’s more effective than the classic charities that GiveWell recommends that reduce malaria, and maybe even the ones that do deworming and so on as well.

What are the biggest uncertainties that go into an analysis like that? I imagine there’s some things that seem fairly clear, and other things that you have to slightly guess a bit.

Lucia Coulter: One of the big uncertainties is how many years are we actually bringing forward regulation. It’s pretty hard to predict the future, so that’s always going to be an uncertainty. And we use different numbers of years for different countries, depending on what stage of progress they were in to begin with. For Malawi it was eight years.

Another uncertainty is how much is lead paint raising blood lead levels? So what is a blood lead level impact if a child grows up in a lead-painted home? There’s actually surprisingly very little data on that. So we try and work that out in a few different ways, mostly looking at data from the US.

Then another uncertainty is what number do we use for the health impacts? So we have these DALY estimates from the GBD, the Global Burden of Disease Study, which is from the Institute of Health Metrics and Evaluation. But the 2019 numbers from the GBD, which are the most recent numbers, refer to the DALYs experienced now by lead exposure, that was mainly experienced years ago by a cohort that was born decades ago. So it’s not necessarily equivalent to the DALYs that lead exposure now is responsible for.

So things like this. We try and take account of these things and try and be conservative, but there’s always a lot of uncertainty.

Rob Wiblin: Right. You estimate that you’re bringing forward regulation of lead paint in Malawi by eight years, is that right? It seems like a low number. This would be going on for decades. Couldn’t this have continued for a very long time without you?

Lucia Coulter: I think so, yeah. Talking to people, we try and calibrate that number by asking our government partners, “When do you think this would have happened? Did you have any plans to do this?” That sort of thing. And our understanding is that it really wasn’t on the radar, so it probably would have taken someone else to come and do a paint study for that to change.

Rob Wiblin: Yeah, needed some external impetus. But as I understand it, in your cost-benefit analysis of the Malawi programme, you estimated that 80% of the benefits came through higher incomes — because children weren’t having these terrible effects on their brain, which then allows them to do better in school, then to do better in the workplace later on in life — and only 20% of it came through better health, which felt like an odd way around to me. I would have thought that the ratio would be the other way around, because the effects on people’s incomes are coming effectively via harm to their health. And it’s a bit strange that you would have larger gains from the thing that’s further downstream — where, because you’re healthier, you can earn more money, and that benefits you so much, rather than just the direct harm to your body that’s occurring from this poison.

Lucia Coulter: Yeah, that is weird. It’s because the health benefits that we’re counting are the DALYs that don’t incorporate the health harms of having cognitive impairment, unless it comes below this very low level which constitutes intellectual disability. So we’re not really counting those health harms that just come from cognitive impairment generally.

Rob Wiblin: Yeah. Seeing that, I guess the effect on people’s incomes may be easier to quantify. You maybe have a better measurement of that, whereas the effects on people’s health might be quite diffuse across a very wide range of different possible health outcomes.

Seeing that the effect on people’s incomes was bringing 80% of the juice here, and only 20% was the other health stuff, made me think that that health bucket is probably getting underestimated quite a lot — and in fact, maybe that could be two, three, four, five times larger than what you’re estimating in reality. And the problem is we just can’t measure it very well currently with the research that we have.

Lucia Coulter: Yeah, that sounds right.

Rob Wiblin: OK, so you have this crazy outcome of potentially giving someone a year of healthy life of $14. It’s insane. If we could accomplish that in the UK, people’s heads would explode. When that happened, did you think that this was likely to be a fluke? Or did you think that this was probably something that you could more or less replicate in a whole lot of other countries, because the situation is more or less the same across 100 different countries in the developing world?

Lucia Coulter: I think we weren’t sure, but we were pretty optimistic. We weren’t really expecting the regulatory authority to be so receptive and to immediately take this data so seriously and want to act on it. And we didn’t know if we’d find that elsewhere, but then we did. That’s been a really common finding across the countries that we’re working in.

Another difference is that Malawi already had a legal mechanism on the books, whereas not all countries do. So that means it will take longer in some other countries, because you have to go through the process of getting the regulation in place before you can enforce it.

Rob Wiblin: I see. So in some countries it’s already illegal, and you just have to go in and tell the regulator — and then, fingers crossed, they’ll have some initiative and they’ll start testing and they’ll contact these companies and tell them to lay off. Whereas in other ones, you might have to have a two-stage process where you point this out, and then you have to advocate to the government that this is a really important issue that they’ve been underestimating, and they’ve got to get laws on the books so that they can crack down on leaded paint. And then you can go through this second stage of then approaching the regulator or doing these tests in order to make sure that there’s follow-through.

Lucia Coulter: Yeah, exactly.

Lead paint vs other sources of lead [00:41:22]

Rob Wiblin: We’ve been talking almost exclusively about lead paint so far. Why do you focus on lead paint, as opposed to other sources of lead? And what are the other main sources of lead?

Lucia Coulter: There are many different sources of lead exposure in low- and middle-income countries. Paint we’ve talked about. Others include aluminium cookware, lead-glazed ceramics, cosmetics, lead-adulterated spices, water systems, lead-acid battery recycling, mining, and recycling. There are probably others too that we don’t even really know about yet. And we don’t really know which exposures are most significant in which countries, or the relative contribution of different sources in different areas: there’s a big lack of data. It does look like it varies a lot geographically, but there’s enough to make some educated guesses.

As to why we’re focused on paint, it’s because it seems like a widespread, important source of exposure that’s also unusually tractable and also very neglected. I think the tractability is probably a really important factor, and possibly more differentiating than those others. We know that with a little bit of support, low- and middle-income country governments can get lead paint off the market, which is a big reason why it’s so cost effective to work on.

Rob Wiblin: Let’s just pause again on what those other sources are. So there’s lead-acid batteries from cars: there’s people who are doing informal recycling of those, I assume in pretty poor areas. And of course, if you’re involved in that, that’s a massive exposure of lead for you.

Lucia Coulter: Yeah, or if you live nearby.

Rob Wiblin: I guess it ends up in the soil if you live nearby. So that’s going to be concentrated in particular locations, but then very severe in those spots.

Lucia Coulter: Exactly.

Rob Wiblin: Then, I did not know this until recently, but there’s lead put sometimes in crockery that people are eating off of. And you’re saying there’s lead glazes, so sometimes you put colourful decorations onto bowls that people are eating out of, and that can have very high concentrations of lead in it.

Lucia Coulter: Yeah. So the kind of paint put on bowls or whatever, that can have very high concentrations of lead. But also just the normal glaze that’s used to seal a piece of pottery, like just the normal ceramic, that often has very high levels of lead. It can be sealed and fired at high temperatures and done in a way that means that the lead doesn’t leach into the foods very much, but in many low- and middle-income countries, it’s done in a way where it does leach into the food a lot. In South America and Latin America that’s been a big problem, probably also in a number of other regions as well.

Rob Wiblin: But people haven’t even identified that it’s an issue yet. We mentioned earlier that you brought in this x-ray gun, which costs about as much as a car, that you can put up against objects. I guess it’s shooting x-rays at the material and then it’s telling back what wavelengths are being shot back. And there’s a very specific signature of lead when it’s hit by x-rays, so it can tell roughly the density of lead in this material — in parts per million, it was doing.

So I actually brought in some of my pots and pans from home, because my wife is pregnant and we’ve been slightly worried — having read this stuff this year about there’s lead in bowls and so on — that maybe we could be ingesting lead accidentally that way. Fortunately, as it turned out, most of the cups and bowls in our house it seems are pretty safe. There wasn’t zero lead, but it was really very low, enough that we shouldn’t really stress about it.

But you tested some bowls in the UK, and you found that it’s actually alarming levels, even in London.

Lucia Coulter: Yeah, I tested my parents’ plates at home, and it was above the limit that the machine will test: so over 10% lead in the glaze on our just everyday dinner plates.

Rob Wiblin: What?!

Lucia Coulter: Which is actually legal in the UK, because the regulation is about leachability. So they’ll test how much lead leaches into a solution when you’re using the item. But I’m suspicious, because —

Rob Wiblin: I would not eat off of a hunk of lead if someone said it was pretty well sealed.

Lucia Coulter: Yeah. I mean, also, these plates are 30 years old. They’ve got scrapes on them. So surely —

Rob Wiblin: So these are antique —

Lucia Coulter: Well they’re not antique. My parents are just…

Rob Wiblin: Just don’t replace their bowls very often.

Lucia Coulter: But even newer things: we were testing some newer items from — I don’t know if I should name the well-known brands — but testing new items.

Rob Wiblin: And it was a very well-known supermarket chain in the UK. You shop at it if you live in the UK.

Lucia Coulter: Yeah, exactly. So that’s kind of scary.

Rob Wiblin: What was it at that place?

Lucia Coulter: Above 10,000.

Rob Wiblin: So it was more than 1% lead on the outside?

Lucia Coulter: Yeah, it was the parts that were coloured and patterned, so I think it was the paint. But then we also tested a teapot from another well-known UK brand, and that was very, very high lead. And that was the glaze, I think, as opposed to the paint. So yeah, it’s pretty crazy.

Rob Wiblin: We were saying before we started recording that someone really needs to buy one of these x-ray guns and make an Instagram account and a Twitter account, and just go across shops pointing out how many objects that people use in their everyday life have lead. Put a photo of it, put a photo of the gun, and then say — well, I won’t say the name of any particular supermarket; I won’t single them out, but — “X supermarket, you’re selling pots that have 10% lead, 1% lead for people to eat off of. This is not reasonable.”

I think it could make a massive difference. I think it would be a hit. I mean, people are obsessed, maybe even to an excessive degree in some cases, about toxins in their environment. This is among the worst toxins that we know of, and we’re putting it in everyday objects, hoping that people are never going to eat off of a cracked plate or continue eating off of this stuff after it’s past its usual use-by date.

Lucia Coulter: Yeah, I would follow that account for sure. It would go big.

Rob Wiblin: Yeah. I think there’s also issues with tin cans sometimes, where they’re soldered shut using something that has a little bit of lead in it?

Lucia Coulter: Yeah. It used to be the case that they would be just soldered shut with lead, but now I think it’s more that aluminium can often be contaminated with lead. So aluminium — or aluminum — is melted at a lower temperature than other metals. And in the recycling chain, lead just gets in there. So I think even in high-income countries, you can find a bit of lead in aluminium. But in a lot of low- and middle-income countries, the pots and pans that people cook from every day can be made from aluminium, and can have extremely high levels of lead.

Rob Wiblin: The pots that we have at home here, could we plausibly have meaningful lead in them?

Lucia Coulter: Probably, if they’re older or if they are from another country. I know that on Amazon you can buy aluminium pressure cookers that are made in other countries that can have extremely high levels of lead. My mother-in-law is from Pakistan. We tested her aluminium cookware, which she had bought from Pakistan, and that was 8,000 parts per million lead. And with aluminium cookware, I think there is evidence that it does leach into food. It’s not like with the glaze, which can, in theory, not. But this is really a big problem.

Rob Wiblin: Isn’t most cookware stainless steel? I would have thought that most of my pots and pans were stainless steel.

Lucia Coulter: They might be. But I think aluminium is a very popular material in a lot of places.

Rob Wiblin: So I suppose one option would be to use stainless steel rather than aluminium, if you were worried about this.

Lucia Coulter: Yeah, aluminium and brass are the higher-risk ones.

Rob Wiblin: I find it really surprising that we’re not more on top of this, personally. But I guess, as you’re saying, it’s the same reason that it’s ignored everywhere: it’s this invisible thing that people don’t even know later in life if they’ve been exposed to an unreasonable amount of lead. And then if they do find that out, they can’t identify that it’s a pot. So the amount of damage that can be done is really quite large before it ever gets picked up and people get angry about it.

Lucia Coulter: Exactly.

Rob Wiblin: OK, so we had lead-acid batteries. We had these things that you’re eating off of or cooking in. What were the other main ones?

Lucia Coulter: Cosmetics is one of them.

Rob Wiblin: Cosmetics. But these are fairly unusual cosmetics that are used in particular places, right?

Lucia Coulter: They’re probably not used very widely in the UK. But these are things like black eyeliners, sometimes called kohl or kajal or surma, and they have different names in Africa. They are quite popular in certain cultures, and sometimes they are made with lead sulphide. So they’re basically lead. This has been found in South Asia, the Middle East, parts of Africa as well. And they can be put on children; they’re often used on children, so that could be quite an important source of exposure.

Rob Wiblin: Extraordinary. And what are the others?

Lucia Coulter: Lead-adulterated spices.

Rob Wiblin: Yeah, turmeric salespeople and turmeric producers have found themselves putting a lead chemical in with their turmeric because it gives it a brighter yellow colour, which allows it to fetch a higher price. But then, of course, everyone is eating lead in their spices.

Lucia Coulter: Exactly. So you think lead in paint is bad, but the same pigment that is going in the paint is literally going in the food.

Rob Wiblin: Yeah, it’s bonkers. If people are putting lead on their face in makeup, couldn’t they end up with acute lead poisoning from that? I guess you don’t eat makeup, but it wouldn’t shock me —

Lucia Coulter: And a child is going to get it on their hands and put it in their mouth. So I think you probably could end up with acute lead poisoning.

Rob Wiblin: Another source is lead from leaded gasoline in the past, that has ended up in soil right near roads. So if children end up playing in soil, they can end up exposed to quite a bit of lead that way. And that’s quite hard to fix, because the concentration is not that high and it’s not easy to remediate sites like that.

Lucia Coulter: Yeah, exactly.

Rob Wiblin: OK, so those are the main sources?

Lucia Coulter: Well, maybe. I mean, we don’t really know what the main sources are, or what the relative contribution is, and there could be others that we’re not even aware of as being important.

Rob Wiblin: Yeah, OK. So those are some sources. In order to attribute the lead that you find in people’s bodies, how do you figure out where it’s come from? Is the problem that it’s not at all straightforward to do that?

Lucia Coulter: Yeah, it’s not straightforward to do that. There are some studies where you measure lead in people’s blood, and then you measure sources of lead in the environment, and you try and kind of draw correlations between high blood lead levels and which sources are present. But it’s not that easy to do. And it’s not that easy to pick out the widespread lower-level exposures. It’s easier to pick out the hotspot exposures. So obviously, if you’re living next to a lead-acid battery recycling site, that’s pretty easy to draw out that association. But if everyone’s using lead-contaminated aluminium cookware, and everyone’s living in the lead-painted home, it can be quite hard.

Rob Wiblin: Hard to pick it out because there’s not enough variation and it doesn’t stand out. There’s not a strong signature. One thing we didn’t come back to was the lead in water because of leaded piping. How big a problem is that?

Lucia Coulter: So there’s still a lot of lead piping in high-income countries. It’s probably less of a contributor than old lead paint, but still not good. In low- and middle-income countries, there has been found to be high levels of lead in water in some places. I think PVC piping is more predominant, or different materials of piping is more predominant than lead piping. But there can be other parts of the water system that can use lead, so that could be a problem. I don’t think it’s very well characterised in low- and middle-income countries.

Rob Wiblin: As I understand it, in the UK, it’s not at all uncommon to have lead piping, but typically I think the water companies have run chemicals through the water and it produces this kind of coating on the inside of the pipe that’s meant to ensure that the water never touches the leaded metal. I guess the problem would arise if that didn’t work completely or that broke down?

Lucia Coulter: Or if you’re moving the pipes. Something like that.

Rob Wiblin: So the typical situation is not that much lead, but you could have a hotspot if something goes wrong.

Lucia Coulter: Yeah. And “not that much lead” is still bad. That’s the scary thing.

Rob Wiblin: Because you’re drinking it in great quantities.

Lucia Coulter: Yeah, and there’s no level of lead exposure that has been shown to be safe. Like we were talking about before, even 1 microgram per decilitre, there’s evidence that there’s harms associated with that. And there’s that really steep relationship at the lower end of blood lead levels, between blood lead levels and harms.

Rob Wiblin: Yeah. So you’ve chosen to work on paint. If I recall correctly, you’ve had to guesstimate this a bit, but you think that maybe 20% of the lead in people’s blood in the countries that you’re targeting is from paint, as opposed to other sources. But that leaves this other 80%, roughly, that’s coming from other things. If you were to change to focusing on a different source of lead, what would be the pros and cons of working on some of the most plausible alternatives?

Lucia Coulter: So just back to the 20% number is really very uncertain. And in our new model, we calculate it a bit differently and we come to something similar in that range, but varying between countries, between 7% and closer to 20%, depending on the country. But yeah, it’s very uncertain. So the other part of the question was what are some of the kind of pros and cons of working on other sources?

Rob Wiblin: Exactly. I imagine that you’ve considered working on something other than paint, and probably you found some ways that would be better and ways that would be worse than what you’re doing.

Lucia Coulter: Yeah, exactly. One that we thought is pretty interesting is lead in spices. That’s because where spice adulteration is happening is likely to cause really high blood lead levels, and it looks to be really tractable to address, in a similar way to paint: it’s being added and it’s unnecessary, and with proper enforcement, you can just crack down on it.

I think the argument against is that it’s probably only happening in a handful of countries, maybe around five to 10 countries, and that there are other actors involved in some of these countries, so it’s probably a bit less neglected. But there are also a lot of countries where it hasn’t been studied. Actually we’re carrying out a study right now into spices in Ethiopia. Ethiopia is a country that has a lot of production and consumption of brightly coloured spices, and there’s no data on whether or not there might be any lead contamination, any lead adulteration going on. We think it’s unlikely that we’ll find high levels of lead, but we think it’s an important data gap and worth finding out. So that’s spices. Pretty interesting, and if we found it, we’d work on it.

Rob Wiblin: Maybe we should just briefly tell the story of the lead in turmeric in Bangladesh. So basically, six or seven years ago now, some researchers identified that a spike in lead poisoning in Bangladesh was due to this adding of lead to turmeric. They jumped on this because it was just such a severe problem. I mean, obviously there’s no benefit, there’s no meaningful benefit to adding lead to turmeric.

Lucia Coulter: Don’t you love the bright colour?

Rob Wiblin: Yeah, so pretty! And it was causing an enormous amount of health damage. And I think a handful of people, basically over a period of years, with a budget in the tens of thousands, possibly in the low hundreds of thousands of dollars, have managed to basically fix this problem.

As it turned out, the people who were doing this, just sticking this chemical in the food, I think they realised that they were doing something that they probably shouldn’t be doing, but they didn’t realise just how extraordinarily poisonous this was at extremely low levels, and they were not happy to find out what they had been doing. And the government got involved and has started testing this and people now go to the markets and make sure that everyone’s following the rules and not adding lead to the turmeric.

So this is an extraordinary success story in terms of years of healthy life delivered per dollar of work. It’s going to be absolutely off the charts and hard to ever match. I guess the problem is that you can’t scale it, because something this awful isn’t happening everywhere in the world all the time. There’s some other countries that have had this issue — I think Georgia is another one where people have had to target this, and I guess possibly Ethiopia could turn out to be another case — but it’s an absolute jewel; there are not that many of them available.

Lucia Coulter: Yeah, exactly. I think another thing about it is that it’s a pretty similar intervention to ours, so it would be a pretty good synergy with the type of work that we’re doing.

Rob Wiblin: Yeah. So if, tragically, you don’t find lead in spices in Ethiopia, what other things might be on the hit list that are competitive with lead paint?

Lucia Coulter: Aluminium cookware is pretty interesting. It seems to be pretty widespread, in the limited research that’s been done so far. I think I’d want to see a bit more data on the extent to which it leaches into food and under what conditions, and there’s some of that research going on at the moment.

A problem there is that it’s unclear how easy a regulatory intervention would be for aluminium cookware. It’s not like people are adding it intentionally and can just stop doing it: it’s just getting into the recycling chain; it’s just being melted down with other scrap metals. So maybe there would be some kind of technological solution. It’s also probably a much more diffuse practice. So I think a bit more scoping out of the solution space there would be pretty helpful before knowing what an effective intervention would be.

Rob Wiblin: Right. So you could identify there’s a lot of aluminium cookware that has some lead in it, but it might just be that everywhere has a bit. And people are going to say, “What do you want me to do? Throw out all of my aluminium cookware? None of us produce more aluminium cookware because we can’t get aluminium that has no lead in it?” And so you could get a lot more stuck at that second stage.

Lucia Coulter: Yeah, I think it could be a challenge, but I don’t know for sure. We haven’t explored this enough to be able to say this isn’t tractable.

Rob Wiblin: Why would you use aluminium cookware over stainless steel? Is there a technical advantage?

Lucia Coulter: I don’t know. A lot of people like cooking with it. I know a lot of people prefer it to cook in. It’s also lightweight, which is nice. I don’t know if there’s a price difference, but it is a popular choice.

Rob Wiblin: OK, what’s another one?

Lucia Coulter: We’ve been thinking about cosmetics. Cosmetics is pretty interesting. I talked about how it’s quite widespread, this lead in the black eyeliner, and it’s a case where it’s an intentionally added ingredient, and we know that there are alternatives available: you can buy black eyeliner and similar types of products that are lead-free. And a lot of it is produced in Pakistan, and we have a really good relationship with the regulatory authority there. So that could be a pretty interesting one to explore. Like all sources, we don’t really know how much it’s contributing to the overall burden of lead poisoning, but if it looks tractable, it could be pretty interesting.

Rob Wiblin: So I suppose it’s possible that these other approaches could be more cost effective than working on paint. But you’re having so much success with the leaded paint that I imagine there’s a pretty strong temptation to just keep going with the leaded paint until you’ve kind of plucked the low-hanging fruit on that. Because if you’re in 17 countries, you’re some meaningful fraction of the way towards hitting all of the ones that you reasonably could, and then maybe you could move on to some of these other approaches.

Lucia Coulter: Yeah, I think the way we’re thinking about it is that we’ve got this intervention that works, and it’s like there’s impact on the table. We want to scale up to as many countries as we can to do this cost effectively. And alongside that, keep exploring these other ideas, these other opportunities, so that we’re not missing other opportunities for impact as well.

Funding [00:59:44]

Rob Wiblin: What’s the limiting factor to how quickly you can hit all 100 countries that you might want to target for the issue of leaded paint? Is it access to the right people to hire? Is it maybe not having enough funding to scale as quickly as you want? Or maybe you’re just going as quickly as you can, and it’s just a matter of implementing something that’s working basically as well as it could be?

Lucia Coulter: So far, funding has been the main limiting factor on our ability to scale up over the last few months. Initially, the limiting factor was finding out whether this intervention works, and then finding out if it’s replicable and improving the intervention. But now we’re pretty confident that we can help get lead paint off the market, and it’s just a matter of progressing through the process in the countries that we’re working in now, and scaling up to more.

We think there are probably around 50 more countries where it’ll be tractable enough, and there’ll be large enough burdens of lead poisoning from paint, to run our intervention cost effectively. And if we were able to reach those 50 countries, that would cover around 90% of the population of children in low- and middle-income countries. So that’s the goal.

Rob Wiblin: That’s the goal. What’s your budget now, and how much money could you plausibly absorb? Asking for a friend.

Lucia Coulter: Our budget at the moment is just over $1 million a year. We have a funding gap of $2.5 million for the next three years to help us scale up towards those 50 countries. But how much we could plausibly absorb, I think we estimate it’ll be around $20 million to get lead paint off the market in those countries.

Rob Wiblin: And how many years might that take? Over five years or something?

Lucia Coulter: Five to seven years.

Rob Wiblin: So $4 million a year for a couple of years would be enough to do this.

Lucia Coulter: Optimistically.

Rob Wiblin: There’s a lot of money in global health and development. Why do you think it is that people aren’t throwing this money at you?

Lucia Coulter: I think it’s the same thing we keep coming back to, which is this is just such a neglected area with really low awareness. I think also it falls between different areas: Is it an environmental health issue? Is it global health? Is it education? Is it economic development?

There’s very little funding in lead exposure. I think probably only around $10 million a year for philanthropic funding for international lead work, across everything — which is shocking compared to other global health problems of similar scale. There’s also very few actors, a small handful of actors in this space doing lead exposure reduction work internationally. I think we’re probably the second biggest organisation, and we’ve got nine people.

Rob Wiblin: Pure Earth is the other one?

Lucia Coulter: Yeah, Pure Earth and IPEN — the International Pollutants Environment Network.

Rob Wiblin: And that’s a nonprofit?

Lucia Coulter: It’s a network of nonprofits. They work on various toxic chemicals.

Rob Wiblin: So there’s really just a handful of you, and you’re all pretty small. I guess Pure Earth is a couple of million a year?

Lucia Coulter: Yeah. Pure Earth is bigger than us. It’s probably a bit more than that.

Rob Wiblin: All right, well, if anyone in the audience doesn’t like children having lead poisoning and has some money burning a hole in their pocket, your website is leadelimination.org, is that right?

Lucia Coulter: That’s right: leadelimination.org.

Rob Wiblin: And people can just donate, right? I imagine it’s tax-deductible in the UK and US?

Lucia Coulter: Yeah, and some other places. The other thing to mention is that we will hopefully be hiring in early 2024. So if anyone is interested in potentially working for LEEP, you could follow us on LinkedIn or Facebook or Twitter, and then you’ll see when we put out the job descriptions.

Thinking in terms of expected value [01:03:19]

Rob Wiblin: As we’ll talk about in a minute, you came through this Charity Entrepreneurship Incubation Program, which is this effort to get people to start innovative nonprofits with the goal of maximising their expected value using evidence and analysis, as the saying goes.

Many people might think that taking that expected value, maximising impact mindset is all very well in theory — in principle, of course, thinking in that way should allow you to have more impact. But maybe in practice, it doesn’t do that much because you can’t estimate things very accurately; it’s too hard to do the analysis well. Or maybe what’s really challenging isn’t doing that initial idea stage, but rather it’s the grind of making an organisation grow and making it function effectively.

But I think your experience suggests otherwise: that maybe the first step — where you do the cost-effectiveness analysis and think, How much benefit would this have? Is this really neglected? Is there a lot of tractability here? — maybe that you do get an enormous amount of juice thinking in expected value terms, and trying to find the diamonds on the beach. Do you think this does suggest that the effective altruist-flavoured mindset actually does offer a lot of bang for buck?

Lucia Coulter: Yeah, I think it is a point in favour of that. Obviously, the initial identification of the idea and the intervention benefits from that kind of framework and thinking. But I also think in the implementation and execution, I find that it’s just constant decision-making. Implementation is just constant decision-making.

And I think having those sorts of frameworks, that focus on evidence and cost effectiveness and impact, is valuable all the way through. I think it would be easy to start with an idea that looks really good on a cost-effectiveness analysis, but then stray if you’re not keeping in mind that focus on the cost effectiveness and ultimate impact and that sort of thing.

Rob Wiblin: So that’s really baked into your decision-making across the org. Do you actually do expected value calculations in your mind and on paper?

Lucia Coulter: Yeah, we do. And I think our whole team kind of thinks in that way.

Rob Wiblin: I think many people are leery of that to a point. I mean, even I feel wary of doing that sometimes, because I worry that it might produce this thing like with GiveWell that we were talking about, where you end up overvaluing stuff that’s highly measurable. Or alternatively, I guess people worry that it could lead you in the other direction, where something that’s super speculative and unlikely, maybe you just end up veering towards that, because it might work and you don’t know what the likelihood is of it working.

Lucia Coulter: Yeah, I don’t think you’d want to be too literal with it, but it’s more like, “Would this multistakeholder meeting be valuable to fund? How much might it bring forward regulation? OK, that looks like it will meaningfully contribute to impact.” It can be tempered in reality; I think that they’re just thinking about the likely value of different decisions.

Rob Wiblin: I think one thing I’ve found is the cases in which thinking in terms of expected value does the most good is when you ask, “What would have to be true for this to be the best use of my time?” And if the numbers that you have to put on it are completely implausible for it to seem like the best option, then you shouldn’t do it. On the other hand, if you can’t think of any numbers that you could conceivably put on it that don’t make you laugh that would suggest that you shouldn’t do it, then probably you really ought to. Because sometimes it is just super clear, and other times it’s not so clear, but those are the times when it doesn’t matter so much what you end up choosing. That’s your experience as well?

Lucia Coulter: Yeah, I think so. That sounds right.

Could we follow the strategy that worked with leaded petrol? [01:06:41]

Rob Wiblin: I’d like to now put some ideas that occurred to me while prepping for this interview to you. These are me fishing around for whether there might be ways of getting rid of lead in even more sweeping scale than what LEEP is managing to do with its current programme. You can shoot them down.

As I mentioned earlier, lead used to be used in car petrol everywhere, and that has now been basically completely eliminated. And that shift was super fast in some places. It took a decade or two for most rich countries to eliminate lead after some of the first countries moved. But then in 2002, leaded gasoline was used everywhere in sub-Saharan Africa. Then the United Nations Environment Programme made it a priority to try to change that, and by 2006, it had been banned everywhere in the entire region. So just within a couple of years, you get this complete removal of the source of the overwhelming amount of lead that people were getting exposed to.

That shift has to be one of the most cost-effective things humanity has ever done in terms of improving health relative to how much inconvenience it was to no longer have leaded petrol. I guess maybe it’s competitive with smallpox elimination or something like that, conceivably.

Could we do the same thing with leaded paint here somehow? Maybe what you need is a UN agency to just tell every country, “You are out of your minds to have leaded paint. You all need to ban it and make it a priority to put a bureaucrat on testing this.” And then you could maybe get the same sweeping change that you’re trying to achieve as a nonprofit in a slightly unofficial way.

Lucia Coulter: I really like this question, and it was something that we actually were pretty interested in trying to understand. How did this leaded gasoline thing happen in sub-Saharan Africa? It was called the Partnership for Clean Fuels and Vehicles.

So our intern Johannes did a little case study on how that happened. A few things that stood out for me. I think it was 2002 to 2006, sub-Saharan Africa pretty much ended the use of leaded gasoline. So one thing that was going on there — which doesn’t really apply in our scenario, but is interesting — is that catalytic converters started being used in cars. Did you read about this?

Rob Wiblin: I’ve heard of them. They’re meant to make the smog that comes out less horrible, right?

Lucia Coulter: I don’t actually know what they do.

Rob Wiblin: They convert things, catalytically.

Lucia Coulter: But they break if you use leaded fuel. So that was a big reason why leaded fuel just didn’t make sense anymore, and also meant that more industry was behind it, especially the car industry was behind it as well. So that was very helpful.

Another thing about leaded gasoline is that almost all of the leaded gasoline used in sub-Saharan Africa was produced in just 20 refineries.

Rob Wiblin: It’s a much more concentrated industry.

Lucia Coulter: Yeah, and they were consolidated in just a handful of countries. So it was a really clear focus.

And also, those countries that those refineries were concentrated in were also in sub-Saharan Africa — so the governments have the incentive that cracking down on that will also benefit the population. So that’s good, and that’s the case for paint as well, which I think is helpful. Not the consolidation, but the fact that the industry is occurring in the same place that the people are being harmed.

There was also really strong political will in sub-Saharan Africa for it — but interestingly, not a lot of public awareness.

Rob Wiblin: So this was something occurring at the government level, where people got very passionate about this?

Lucia Coulter: Yeah. And in fact, the Global Alliance to Eliminate Lead Paint — which is this body jointly led by the WHO and UNEP that LEEP’s a member of — that was modelled after the Partnership for Clean Fuels and Vehicles, and they have made significant progress together with this NGO IPEN, which is another partner of the Global Alliance to Eliminate Lead Paint. I think that a lack of funding for the Alliance has been a big reason why progress hasn’t been faster. I think more funding would make a difference there.

Rob Wiblin: Yeah. OK, so I guess it was maybe 10 times worse. So maybe that’s one reason why it was easier to get people really excited about leaded gasoline: because it was actually just doing more health damage than leaded paint is. So I guess we can start with that.

And then it was a very concentrated industry. So there were 20 places that this was being made in the entire continent, and if you could just hassle those particular places, and hassle the regulators in those jurisdictions, then you could basically shut down the problem because people wouldn’t be able to get leaded gasoline anywhere. So that’s a reasonable difference — whereas there’s probably thousands of paint producers across Africa?

Lucia Coulter: Yeah.

Rob Wiblin: I see. It sounds like if you get sufficient funding — $20 million, not that much money in the scheme of things — you could hit most of these countries? It sounds like you might be able to actually get something like this to happen over a period of five years. Maybe what’s odd about this is that you’re able to do this as a nonprofit, that doesn’t really have any official power, just by bringing the money and the personpower and the attention to do some testing that probably should have been happening anyway. Maybe I should be thinking it’s remarkable that a nonprofit can do this just off its own bat, without having to have the imprimatur of the United Nations behind it.

Lucia Coulter: I mean, we do have the Global Alliance as a real point of credibility, and the fact that they’re saying that this should be a priority as well really helps, I think.

Rob Wiblin: Yeah. Who started that alliance?

Lucia Coulter: It is a joint initiative of the WHO and the UN Environment Programme. It’s chaired by the US EPA, but it’s got loads of members.

Rob Wiblin: OK, so there’s this other more official government group. To what extent do you think that kind of group — a group coming out of the World Bank or the WHO or the United Nations Environment Programme — is in a better position to push this agenda than you are as a nonprofit? If you had it with a similar amount of money or a similar amount of attention going into it, what are the comparative advantages of each group?

Lucia Coulter: There are definitely pros and cons. So the WHO has really strong advocacy power and strong credibility. But as a small nonprofit, we have a lot more flexibility and we can be a lot more fast moving, so that can be quite helpful at times. So working together is, in a way, the best — because you can have the WHO with their advocacy power and adding credibility to the thing, and then we can be going in and actually filling whatever gaps are coming up, or identifying these low-hanging fruit and adding value in that way.

An example I could give is the Madagascar Ministry of Environment was looking for funding for a paint study for many years, because they thought it would be really key for motivating and informing the development of lead paint regulation. And the Global Alliance to Eliminate Lead Paint, the WHO and UN Environment Programme, they didn’t have a budget for that sort of thing, for a paint study — but they were able to tell us about that, and we could just go immediately and fund that $4,000 or something like that, and that could be really catalytic in that process.

Rob Wiblin: OK, so they have a lot of credibility. They might be given a lot of weight by governments receiving their advice. But on the other hand, they’re very inflexible with the budgets, very inflexible with the personnel. For things to happen, you have to get approval from many more people. Whereas, I guess at LEEP, what Lucia says goes, unlike the UN Environment Programme — so you could just jump in and do something in Madagascar because you think it’s a good idea, from one day to the next almost?

Lucia Coulter: Exactly.

Rob Wiblin: Yeah. Interesting. So do you think you’re getting a lot of juice out of this combination of the two, where they refer stuff to you and then you produce the information they need to act?

Lucia Coulter: Yeah, I think so. The Global Alliance also has this role in tracking the situation globally. So we have meetings every couple months where we go through the global status, and that’s really helpful for us picking up when a country looks like there’s a ripe opportunity for us to offer support. And that seems like a really great synergy.

What if we had cheap lead tests? [01:13:58]

Rob Wiblin: Yeah. OK, a different angle on how to get a really big systemic change here: How much does it cost to test for lead in someone’s blood? We said it was $27 or so for a sample of paint. How much for a person’s blood sample?

Lucia Coulter: It’s probably similar. Probably you could get it at around that price.

Rob Wiblin: How much of a game changer would it be to have a way of easily and really cheaply measuring lead in blood or in objects or in paint? What if you could do it for a dollar or less?

Lucia Coulter: That would be huge. That would be a game changer. If you could measure the lead content of objects — like paint or other sources of exposure — cheaply, accurately, and also in a really low-tech, simple, easy way, that would be huge for the government testing capacity problem. You could imagine, like this lead gun that we have here, if a government regulatory authority could have one of those and it was going to be accurate and it wasn’t going to break, that they could just go around testing loads of things and enforce on the basis of it. So I think that would be a real game changer.

There is work to try and get these portable XRF devices, to try and figure out with what method can the result be accurate enough that it could be used for enforcement by a low- or middle-income country government. We were talking just over the last few weeks with Stanford University and Mercer University, where they’ve been working on methods to get accurate results so that you can use XRF for paint testing. And they’re hoping to get a project funded so that that can be an approved method by these international standards bodies. And then if it were an approved method, then governments could actually do that, and that would be pretty big, I think.

Rob Wiblin: Got it. So there are some ways of doing this that there’s ways that we could try to make it a bunch cheaper. Our current issue is that these things are kind of roughly accurate, but they’re not nearly as precisely accurate. So governments are wary of imposing penalties on businesses or telling them they can’t sell something based on the x-ray gun because it’s not quite as precise as sending it off to a lab for measurement.

Lucia Coulter: Yeah. And also the x-ray guns are expensive. They can cost like $20,000 or $30,000. But they’re less expensive than the lab-based methods.

Rob Wiblin: If you test enough things, yeah.

Lucia Coulter: And you wouldn’t need many of them. I mean, they’re less expensive than the lab-based methods if you have to have your own testing equipment. If you can use an international lab, then that would be pretty low cost.

Rob Wiblin: One thing I’m a little confused by is when you stick that lead gun up against a bit of paint, sometimes it says this is 100 times as much lead as is legally permissible on this. You might say this isn’t quite as precise as sending it away to a lab, but there’s no ambiguity about whether this is leaded paint or not. It’s very clear. So it seems like having that level of precision doesn’t necessarily matter. You could basically still send them a letter saying, “We know you have leaded paint, guys — we just did it with his gun — and if you don’t get rid of it, we’re going to test it properly in a month.”

Lucia Coulter: Yeah, exactly. Or you could have a study or a method that says if it’s testing above this level, then you can enforce on this basis.

Rob Wiblin: Because it’s implausible that the real measurement is less.

Lucia Coulter: Exactly. And that would be really valuable. But it needs to be credibly published by an authoritative body for low- and middle-income country governments to realistically be able to do that.

Rob Wiblin: Got it. Because all of the legislation or all of the norms of how you do this testing would be based on some older technology that’s very official and has to be very precise.

Lucia Coulter: Yeah, exactly. Then on the blood lead testing, that would also be huge. At the moment, to get an accurate result, you have to take a venous blood sample and then you have to test it on this really complex and expensive machinery that most countries don’t have. So most countries, if they want to do blood lead level testing, they’d have to send the blood samples abroad. There is a device that allows you to do point-of-care fingerprick testing, but it has some issues with accuracy and it’s had some other issues as well, and it only tests down to 3.5 micrograms per decilitre, so that’s not really low enough.

Rob Wiblin: So it would pick up serious lead levels, but not the levels that you might see commonly in the US.

Lucia Coulter: Exactly. Yeah. So if we could have a low-cost, field-friendly, point-of-care fingerprick blood lead testing device that was accurate down to low levels, that would be, I think, another game changer. And I think all of this is technically feasible. I don’t think that there’s any reason why this shouldn’t be possible. I think it’s just that there haven’t been the drivers.

Rob Wiblin: Of course, the reason I’m raising this is that we keep coming back to the fact that we think the underlying reason why all of this harm is being allowed to occur is that it’s really not a very visible problem.

Imagine if every child at the age of three was just, as a matter of course, at the same time as they’re getting their standard vaccinations, also got a lead blood test, and then the parents were told the result and they were notified of how much damage has that done to their child’s intellectual potential. I think that would make this a massive political issue, potentially, inasmuch as there were serious lead levels anywhere and parents are being told how much damage was being done. Including in the UK.

I think this would shift policy in a major way, because there would actually be pressure on politicians to act on it, pressure on bureaucrats to do something that at the moment that might be financially feasible for the UK, although maybe they wouldn’t want to allocate the budget for it, but it’s not really feasible for much poorer countries.

Lucia Coulter: Yeah, I think it would be huge for awareness and the advocacy power of knowing that this is a problem and for helping governments prioritise it.

One potential way in which this could be feasible in low- and middle-income countries is adding it to existing health surveys. So USAID leads the Demographic and Health Surveys, which are these big surveys in a bunch of countries that do these nationally representative studies. And they do fingerprick testing for anaemia, so in theory, they could add blood lead testing as well, and that would add really valuable data. UNICEF does a similar sort of thing and are looking into doing this. I think a barrier has been this testing method, but there might be ways around it. But really, better technologies would be huge.

Another thing to think about is if you then know that there’s loads of lead poisoning in the country, but you don’t know what the sources are, and the governments can’t really do anything about it, that would be pretty difficult. So in some ways, understanding the sources is more important, because it more directly leads to the intervention. But I think that understanding the prevalence of the problem is also just really important, and really catalytic for driving awareness and attention to solving it. So I think both of them.

Rob Wiblin: I was thinking if we had way more people tested for lead, and it was done maybe more regularly, then you’d be able to identify, or people would get a more intuitive sense, perhaps, or there’ll be more data to go on at least for what things correlate with people having weirdly higher lead levels than their neighbours do.

Lucia Coulter: Exactly. Yeah. So identifying which are the most exposed populations and then maybe why. And then also tracking progress and knowing if interventions are working.

Rob Wiblin: So at the moment, blood tests are really quite expensive and quite inconvenient. I guess that’s because to the entire lead blood testing industry, which I imagine is not very big, this is quite a boutique test. This is not something that is done routinely on tonnes of people. No one’s been thinking about how we get to a scale where globally we can do a billion or 10 billion blood lead level tests every year, because we want to eliminate this and we want to find every trace of lead.

But conceivably, we could come up with a different mechanism for testing that would be way cheaper and could be scaled enormously. But there’s kind of a chicken-and-egg problem here: no one’s really thinking about this because that doesn’t exist, and so who’s going to fund the research to make it, because it’s not on anyone’s mind.

This is a classic case where advance market commitments could be useful: where, if a government commits to buy a particular number of a given test that meets certain specifications at a given price, should it be invented in the next 10 years, then that can give industry a reason to try to invent that thing, because they can say they’ll be able to sell 100 million units for $10 each. It’s a classic thing that can stimulate R&D among industry.

Lucia Coulter: Yeah, we’ve had a few conversations with people who design these sorts of challenges or advance market commitments about both the blood lead and the environmental testing thing. It seems like it’s a good fit for it, but probably not something LEEP should be focusing on. But if anyone else wants to, that would be great.

“Very brief opportunistic interventions” [01:21:50]

Rob Wiblin: OK, here’s a completely different angle: I suppose this is not actually a more systematic intervention; this is almost the opposite of that. But I think doctors sometimes do what are called “very brief opportunistic interventions,” where they just ask someone when they happen to be in with another health issue, they happen to be in the GP office, are they interested in quitting smoking? And then if they say yes, then they help them out and instruct them on how to do that.

Now, this doesn’t prompt that many people to quit, as you might imagine. It’s a very light-touch intervention. But it can be really cost effective in terms of quits per hour of physician time, because it takes almost no effort per person to do this. So it’s recommended that physicians give this a go basically every time they get the chance.

Maybe the same principle could work here. Could you just call up every paint factory, basically, in sub-Saharan Africa and say, “Do you know whether you use lead? Do you realise that this is extremely bad for children’s health? Have you considered quitting lead? Have you considered putting something else in your paint?” And then maybe 1% of them or 10% of them, that might be all that’s needed in order to prompt them to take action. What do you reckon?

Lucia Coulter: I love it. I don’t think that’s a crazy idea. The other thing you could do is raw material suppliers. Suppliers of non-lead alternatives provide free samples. So you could also say, “And would you like to receive a free sample?” And then just send it to them.

I think usually it is harder to engage with manufacturers when you haven’t done a paint study and you don’t have the results. And usually they won’t act until regulation is on the horizon. But that’s not always the case, and I think you’d get some hits. So, over the past few months, we have started trying to engage manufacturers a lot earlier. And it does seem promising, but I think if anyone’s got some free hours and just wants to start cold calling…

Rob Wiblin: “Our paint technicians are standing by to reformulate your paint.” To be honest, I don’t know if this is actually a good idea, because it seems like with a reasonable amount of money, you’re on track to target all of the paint factories in large countries, at least in sub-Saharan Africa, for example, by doing these paint studies and getting the government to take action. So maybe if you had one person who had only $10,000, maybe this would be the best that they could do. But given that you have more people and more expertise and you are trying to scale, this probably seems less cost effective to me.

Lucia Coulter: Yeah, maybe for us, but if someone’s got free time…

Rob Wiblin: That’d be such an idiosyncratic hobby.

Lucia Coulter: Imagine explaining that to your friends.

Rob Wiblin: Yeah. How do you even get the details of a paint factory in Nigeria? I don’t know. I’ll ask through my networks.

What LEEP does now and how it works [01:24:21]

Rob Wiblin: OK, so that’s been some alternative high-level approaches to tackling lead. Earlier we were talking about your experience in Malawi several years ago. What has happened since then? What countries have you expanded to, and what’s your experience been?

Lucia Coulter: So since then we have expanded to 17 countries. Most of them are in Africa — Zimbabwe, Madagascar, Sierra Leone, Niger, a number of others — and then a few outside of Africa as well — Pakistan, Bolivia, Uzbekistan. Basically we prioritise countries based on the expected burden of lead poisoning from paint. Obviously, it’s pretty difficult to estimate. Also on neglectedness: are there any other actors doing anything there? And also on tractability — the classic, basically INT.

Rob Wiblin: I’ve heard of it, yeah. What goes into the calculation trying to figure out the burden of leaded paint?

Lucia Coulter: A big part is population size. If it’s a big country, it’s more likely there’s more lead poisoning from paint. Anything we know about the size of the paint market, use of paint in the country, anything we know about whether there’s likely to be a lot of lead paint on the market.

Rob Wiblin: Do some countries use more paint than others? Are some countries big on paint and others are not?

Lucia Coulter: Yeah, in some countries, a lot of the population live in rural areas where there’s just not much painting going on — usually less economically developed countries. But in those countries, there might be very rapid paint market growth, so they might actually be quite important.

Rob Wiblin: Yeah. I guess you want to ideally get a country right before an explosion of urbanisation or construction.

Lucia Coulter: Yeah, exactly.

Rob Wiblin: So where are you at in the different countries? You’ve gone from you did one country three years ago, now you’re operating in 17. It’s a big increase. Have you been hiring hand over fist?

Lucia Coulter: Our team is nine, so it’s a small team. I think it highlights the fact that it’s a relatively light-touch intervention: it’s really the civil servants in government that are doing most of the work, and we’re there to support — we’re there to help them overcome whatever barriers come up.

So where are we at in the various countries? In all of them we’ve now established good collaborative relationships with the relevant government authority. In 11 of them we’ve completed paint studies, and in eight of them we have commitments from the relevant government authority to either introduce regulation or to start implementing regulation if it already exists. And in four of the countries, we already have reports that paint manufacturers representing over half of the market share have started switching to lead-free.

Rob Wiblin: Has the responsiveness of the government been at the same level as in Malawi? Has anywhere dragged their feet?

Lucia Coulter: Not really. I think when we first started LEEP, we were expecting a big part of our role to be advocacy, to be convincing governments that this is an important issue. But that hasn’t really been the case. It’s more that there’s sometimes a lack of awareness to begin with, and then we can communicate about the problem and do the paint study to bring that awareness. Then they’re convinced; they’re on board. Obviously no one wants lead paint in their country. So the barriers are more about the relevant part of government having limited capacity, limited time.

Rob Wiblin: Yeah, I would have thought that would be an issue: that you’d contact someone and they say, “Sorry, I’m busy and my hands are full. I agree with you, but I can’t act on this.” Does anyone say, “I don’t have a budget to deal with it,” or “I don’t have budget to do the testing,” or “I don’t feel like I have the authority to act”?

Lucia Coulter: Yeah, the budget thing comes up a lot, and that’s where we can help. So we’ll offer support with funding the paint study, and actually we often do the study in collaboration with a government partner.

And then we offer support with funding for multistakeholder meetings. That’s often a big step to getting progress on an issue: the lead government authority will need to get other parts of government involved, and they’ll need to engage industry and bring them along. So they need to have all these meetings, and sometimes it’s to agree on draft laws and that sort of thing. So we can help provide funding for the meetings.

And then we can also help with the testing capacity to some extent: we can help with accessing international testing or improving their internal capacity. And then we can also do a lot of the industry outreach side of it as well. So if we can offer all of that, then the budgetary constraints are usually not a problem.

Rob Wiblin: I see. Is it an issue that in many of these countries, they presumably don’t have great testing for lead? They maybe don’t have the best scientific facilities to handle this?

Lucia Coulter: Yeah, I think probably most low- and middle-income countries don’t have existing ability to test for lead in things. The approved method is using a lab-based technique. The machine costs at least like $30,000 to $140,000. And then there’s also consumables, there’s also training that’s needed. So that can be something that limits their ability to enforce a regulation.

Rob Wiblin: But I think you were testing samples for $14 or $15 or something overseas. Why don’t they just mail them out to a lab overseas? It sounds like it costs peanuts.

Lucia Coulter: Yeah, that’s a good option. And it’s something that we help get set up, and we provide training on how to prepare the samples so that they can be sent abroad. We’ll even cover the costs of the international analysis for a period of time while they’re getting set up. It’s a very cost-effective option, but I think a lot of regulatory authorities would ideally like to have their own capacity.

Rob Wiblin: Just as a matter of principle, that they don’t like stuff that comes from outside? They feel a bit embarrassed, maybe, that they’re having to ship this to another country?

Lucia Coulter: I think it’s been mentioned before that sometimes they don’t really like the idea of sending money abroad. Like, “Why can’t we do this in our own country or locally?” I think also, if you’re a regulatory authority whose job is to run a lab and test for things, it’s quite nice to just be able to do that and not have to rely on externals.

Rob Wiblin: I see. It could be more convenient to just be able to send it to the people in the basement rather than mail it overseas, from a logistical point of view.

Lucia Coulter: Yeah. And mailing paint can be a bit tricky sometimes. You can’t actually ship wet paint because it’s flammable, so you have to prepare dry samples. But then sometimes mailing companies think that you can’t ship dry samples. So it’s a little bit inconvenient, but it’s pretty easy overall.

Rob Wiblin: I guess maybe one reason that leaded paint is still an issue is that it’s usually produced locally, right? It’s this kind of commodity business, where it’s an extremely heavy item that’s sold at relatively low cost and it’s also relatively low tech. So most countries are producing their own paint, or even most cities have their own paint supplier. And the fact that it’s at that medium scale means that it hasn’t been possible to just identify a handful of places in the world where paint is being produced and tell them to stop. You have to go kind of city by city, country by country.

Lucia Coulter: Yeah, exactly. In the vast majority of the countries that we work in, the vast majority of the market is locally produced paint.

Rob Wiblin: How big a deal is it that you offer this paint technician or paint formula specialist? I have to say that is one of my favourite examples of a super-high-impact career: I don’t think anyone would ever have guessed that you should go into paint formulation and then this is going to allow you to save the lives of thousands, tens of thousands of children. But that’s how it’s turned out. What’s the guy’s name again?

Lucia Coulter: He’s called Phil. Phil Green. He’s amazing.

Rob Wiblin: How important is that to the paint companies? Is it often an impediment to them that they just don’t know how to make yellow paint or red paint without his help?

Lucia Coulter: It depends on the paint company. Some have internal chemists that are really experienced with formulation, but others don’t. And it’s not actually a simple thing. It’s not like a one-for-one replacement; it’s more like baking a cake — where if you substitute an ingredient, you have to adjust other things to make sure it has all the right properties. So having someone who has a lot of experience with both different types of formulations, but also the local context, and what suppliers are available, and what raw materials you can actually get where, and how that could work, and how reliable all the different raw material suppliers are, is just absolutely amazing. So I think that’s a very high-impact career.

Rob Wiblin: I guess inasmuch as the companies are reluctant to push forward, after they speak to Phil they can kind of be persuaded that maybe this isn’t going to be as much of a pain in the ass as they were expecting.

Lucia Coulter: Yeah, exactly.

Rob Wiblin: A good general principle in life is to look for ways in which you might be able to get 80% of the benefit from something for 20% of the effort. And I noticed in the distribution of lead in paint in the samples that you were testing, it seemed like even among paints that had more lead than you’d like — more than this 90 parts per million level — some of them had 100 times as much lead as others. There were some that were just chock-a-block full of lead, and others that had relatively minor amounts. Is it possible to get most of the juice just by focusing on the specific paints that have the greatest concentration of lead in them?

Lucia Coulter: Yeah possibly. Some of them have like 7% lead or something like that: really, really high levels. We prioritise in part on market share, so we might focus first on the manufacturers that are selling most of the paint on the market. But yeah, definitely the higher the lead concentration, probably the worse it is. Although another key factor in the relationship between lead paint and exposure is also the quality of the paint, whether the paint is flaking or deteriorating. I don’t really know what the difference is between different levels of lead in paint versus exposure when you take into account all the other complex factors.

Rob Wiblin: It sounds like this has all been suspiciously smooth. You go in, you find that there’s lead in the paint, you call out the government. The government mostly follows up, you hassle them a little bit, you pay for them to have some meetings, pay for them to run some more tests. What part of the whole process here takes the most person time, or the most money? Is there any stage that is kind of a hassle for you?

Lucia Coulter: I think the bit that takes the most time is the part between getting the government on board, establishing that relationship, doing the paint study, identifying that there’s a lot of lead in paint — but then actually getting regulation in place. And that’s just because it’s a complex process: it varies by country, it involves a lot of different steps, complicating factors can come up. And also the civil servants that we’re working with are juggling a lot of plates, so that can take a long period of time.

Our approach is just to try and be in really close contact — lots of calls, emails, WhatsApp messages, and visits — to just make sure that we are as responsive as possible to whatever part of that process that we can help with. And that varies a lot by country, but that period takes up a lot of time, basically.

Rob Wiblin: I did an interview with Karen Levy two years ago, talking about all sorts of things that she’s learned as a consultant working in development for many years. Have you worked with Karen?

Lucia Coulter: Yeah, we work with Karen. She’s really great.

Rob Wiblin: Wonderful. One thing that was a recurring theme in the conversation with her was just how often governments in extremely poor countries might find themselves completely unable to do a project that seems extremely high value for the lack of a tiny amount of money, for the lack of tens of thousands of dollars. So they do not have the staff capacity to just hire one person to coordinate this extremely obviously valuable health programme.

And it sounds like something like this may be going on here, where if there’s just no person, if there’s nothing in the budget of a bureaucracy for someone to be focused on paint, then that can mean that no one is practically thinking about this until you come in and hassle them.

Lucia Coulter: Yeah, I wouldn’t frame it as hassling them. I think it’s more that we try and add that capacity. So we just try and make it as easy as possible for them to do what they want to be doing. It’s not that we have to hassle them to do it; they want to do it. It’s that we can help them with that capacity, with that technical input, with taking on some of the things that maybe take a bit more time or that require a bit more funding, where the budget would be really difficult to get, and that sort of thing.

Rob Wiblin: If I recall, an issue is budgets in these bureaucracies tend to be quite inflexible. There’s not someone who can just reallocate things at a whim, because they feel like this week they’ve heard about lead in paint and they’re like, this is a great idea. And so you can kind of have this issue of the kingdom was lost for want of a nail — where the entire process of enforcing a safety on paint can be lost, because there just wasn’t something in this particular line item. Because the person who was managing it years ago when the budget crystallised wasn’t aware that there should be someone doing that.

Lucia Coulter: Yeah. And why would they be aware? Lead hasn’t been on anyone’s radar. It’s not on the radar of any of the global health agendas, development agendas. So yeah, that’s exactly it.

Rob Wiblin: Is corruption ever a factor here? Maybe testing has been going on, but someone’s been getting paid off to ignore the issue, or not report that there’s lead in paint?

Lucia Coulter: Not that we’ve come across. The main thing that’s going on is just this lack of resources, and then sometimes the lack of awareness as well. The other thing is that there isn’t really like a Big Lead Paint lobby.

Rob Wiblin: That’s good to know. I don’t know why I’m laughing, because I don’t know, there are so many industries where there is a lobby.

Lucia Coulter: Yeah. There isn’t a huge amount of industry resistance. And in fact, industry is sometimes supportive of regulation, because they might want to switch to lead-free but they don’t want to be undercut by people that aren’t. So they’ll be keen on regulation for the sake of the level playing field.

Rob Wiblin: That’s a really good point. There might be no reason why industry wants to resist this, because it’s not increasing costs enough that there’s going to be any material change in the amount of paint that people use in aggregate across the country. The paint industry is going to remain the same size.

And as an individual company, now everyone’s paint gets 1% or 2% more expensive because they’ve all had to substitute away from lead. But so what? Your costs have gone up by 2%, your revenue will go up by 2%. Now you don’t have to feel like you’re poisoning children with lead in your paint. So as long as it is enforced uniformly across the entire industry, so there’s no change competitively, then it’s no skin off their nose at all. Is that kind of the situation?

Lucia Coulter: Yeah. So there’s this relationship between regulation and industry, where industry might be pro-regulation if it’s going to be enforced across the board, because then it creates this level playing field. And then also the government authority is more keen on regulation if industry is on board, because they don’t want to do something that’s going to be really difficult to enforce, or something that’s just not going to be feasible. So there’s kind of this bidirectional thing where, if it just happens, everyone’s happy with it.

Rob Wiblin: I guess that’s quite different than climate change worries about fossil fuels, because the whole goal is to use less fossil fuels. If you’re an energy company that was completely indifferent between supplying oil versus wind energy, then that might be an analogous situation. But that’s of course just not how it is. And likewise with smoking, the idea is not you’re going to switch to a different cigarette: you’ve just got to stop smoking, and so their product doesn’t get consumed. But so long as people are going to continue consuming the same thing in roughly the same quantity, then regulation is much more straightforward to get up.

Lucia Coulter: Yeah, exactly.

Rob Wiblin: Have you found any messages in your emails or your meetings that are particularly motivating to policymakers or even to paint suppliers in these countries?

Lucia Coulter: With policymakers, I think the local data is really important. So like the paint study data, or the fact that we are offering to do a paint study with them, I think that’s really appealing — that they can generate this data that’s really important for understanding the situation relevant to their role in government.

Other messaging that I think is quite important is about the feasibility. As I mentioned, practically, they do really care about this being feasible for industry, because if it’s just going to be near impossible to enforce, then what’s the point? And also I don’t think they want to be causing huge economic harm or something like that. So the feasibility is important messaging.

I think another one is the international precedent: the fact that other countries are doing lead paint regulation. It’s the future, basically.

Rob Wiblin: People don’t want to be behind the curve.

Lucia Coulter: Yeah. And I think also, people don’t necessarily want to do something that’s really unusual. So I think that’s quite helpful. Then the fact that the WHO and the UN Environment Programme are behind this, and there’s a Global Alliance to Eliminate Lead Paint, and there’s the UN model law for lead paint regulation. I think all of that brings a lot of credibility to the issue.

But overall, the majority of our work is less about persuasion or advocacy; it’s a lot more about technical assistance. It’s like, they’re on board: how can we help them? So it’s about the technical assistance, providing funding where it’s needed, and that sort of thing.

Rob Wiblin: I guess the general observation is that you’re having a very easy time. There’s probably a whole bunch of different reasons. One is that everyone kind of knows that leaded paint is bad, it’s been banned in lots of countries, it’s cheap to do, there’s no one arguing against it, really. All of the authorities internationally agree that this would be a good thing to get rid of. The health data is fairly clear. It’s easy to measure, at least for you to measure the lead in paint.

So I guess there was just a crazy amount of low-hanging fruit here to begin with. You’ve just found an extremely easy hill to slide down, and now you just have to implement it. Is that kind of the basic situation?

Lucia Coulter: Yeah, that’s pretty much it.

Rob Wiblin: So all the hard work is done by finding the initial opportunity, and then I suppose there’s hard work with the follow-through. But that’s kind of the key insight, maybe, is the original thing.

Lucia Coulter: Yeah, I think so.

Rob Wiblin: With the other countries, are you getting roughly consistent cost-effectiveness results? You were thinking $14 per year of healthy life in Malawi, and maybe it’s going to be roughly similar in all of these other countries that you’re expanding to?

Lucia Coulter: I don’t want to speak too soon, because I haven’t finished with the new model and I haven’t gotten feedback on it and that sort of thing, but it varies a bit by country. So some of the really big countries like Pakistan are a lot more cost effective, because a huge population has a huge impact, but the cost doesn’t scale with that impact. So a lot more cost effective there, but broadly pretty similar.

Rob Wiblin: OK, so it could actually be more effective if you hit larger countries. I imagine maybe influencing policy and bureaucracies in Pakistan is more expensive than Malawi, because it’s a bigger country, the bureaucracy is bigger, there might be slightly higher operating costs. But nonetheless, the population is 50 times larger and it’s not going to cost 50 times as much.

Lucia Coulter: Yeah, sometimes I think about it in terms of “enforcement units.” So in some countries, like in Pakistan, enforcement can be done on a provincial level: there’s a few provinces, and so there’s more time that you need to support the different areas of the country, but it doesn’t scale to the extent that the impact does, so it makes it still more cost effective.

Why GiveWell declined to fund LEEP a few years ago [01:42:57]

Rob Wiblin: I asked for audience questions for this interview, and we got a very cheeky one from a previous guest of the show, James Snowden, who used to work at GiveWell and now works at Open Philanthropy. He actually declined to fund you guys back in 2020 or 2021 when he was working at GiveWell, but I think he’s given you a grant more recently, working at Open Philanthropy. He asked: “GiveWell declined to fund you when you were first starting out, but more recently you’ve gotten this Open Philanthropy grant. Why was that? And what do you think they missed?”

Lucia Coulter: Thanks, James. So when GiveWell were first looking into lead as an area, they were prioritising their time and using quite broad heuristics — like how confident can they be in paint as an important source of exposure, or where can absorb a lot of funding soon? And at the time, they weren’t convinced, and they didn’t have a [cost-effectiveness analysis] that they felt confident in, but they planned to come back and look at it more. And then James moved to Open Phil, and lead kind of moved with him as an area. Now Open Philanthropy is thinking about the lead space more holistically, and is excited about LEEP.

I did ask him what had changed. I think he mentioned that he’d updated on the health and mortality effects with the new evidence, and also that he’d previously underestimated how tractable the work would be, and also how many countries we would be able to get to. I think he said he was partly sceptical about our relative inexperience in the field and also our track record, but that he’d now endorse a less conservative attitude towards that.

Rob Wiblin: Yeah, a concern that I’ve had about the GiveWell mindset — which is looking for opportunities to do good where you can really demonstrate that they’re having impact, and you can kind of repeat the same thing again and again that’s been shown to work in the past — a worry that I’ve had from the beginning is just that it could push people against systematic solutions, very high-level solutions, where the effect isn’t that predictable, but the impact when you succeed might just be really enormous. And this is a common critique or a common concern of the GiveWell mindset that they’re very well aware of — and I think, actually, that they’ve been trying to resolve by funding more things like LEEP over the years.

But if you think about it, the UK didn’t solve waterborne diseases by putting chlorine dispensers in each house: it solved it by having government build enormous sewage systems and enormous piping systems that brought clean water to everyone simultaneously. And there might just be no real alternative to having governments at a massive level do the things that only governments can do, or that only city governments can do, at least. And likewise here: we didn’t solve the problem of people getting exposed to lead in the air through leaded gasoline by giving people face masks or telling them to change their behaviour. We just said, “No, we’re getting rid of it. It’s gone; we’re banning it.”

I guess you’re doing something that’s a bit of a hybrid model, where you’ve got this replicable model where you can demonstrate that this worked in Malawi, and it’s probably going to work in these future countries the same way. But you’re leveraging the power of the state to just fix problems somewhat by force, saying, “We’re now just not doing leaded paint anymore, and if you do this we’re going to send you to prison. Ultimately that’s where this will end. So no more leaded paint, please.”

But I do worry that the fact that GiveWell didn’t fund this I think maybe does show a weakness in the research methodology, or it shows that it’s not going to be able to identify — or at least the mindset most strictly applied is not always going to be able to identify — really amazing, high-expected-value interventions. Because things that are extremely high expected value will often have too much uncertainty, too much that’s unmeasurable about what they’re going to do. Do you have any reaction to that?

Lucia Coulter: Yeah, I think that sounds right. I think it’s just much harder to identify interventions like that, like health policy, regulatory interventions. It’s much harder to identify with that level of certainty the expected impact. And maybe GiveWell is not best placed to be doing that with their methodology, or maybe it’s something that they could expand their scope into, but there’s been very little of that type of thing that they’ve looked into or recommended — especially now that James has left; I think that was something that James is very interested in.

Rob Wiblin: Yeah. So I might get some of this wrong, but I think GiveWell has paid attention to this critique, and has been open to funding more of these things. We talked about that with Elie Hassenfeld earlier in the year. So James Snowden has gone to Open Philanthropy, which has a bit more of this high-risk, high-return mindset — I think they call it “hits-based giving” mindset — where they’re going to make 100 grants thinking that one of them is going to hit it out of the park and pay for the entire portfolio. And he’s maybe taking more of that approach on the global health and wellbeing side at Open Philanthropy. So this is maybe exactly in his wheelhouse now.

If there’s any entrepreneurs out there who are thinking of starting charities to focus on issues in the developing world, it would not surprise me if the highest impact opportunities are exactly the kind of thing that you’re doing: it’s improving policy in neglected areas, where you can just have an enormous impact by getting the policy settings right, by getting government to take responsibility for things that government ought to be taking responsibility for. You’re nodding your head. Same intuition?

Lucia Coulter: That sounds right, yeah.

Charity Entrepreneurship [01:47:59]

Rob Wiblin: All right, let’s talk a bit about the Charity Entrepreneurship programme, which is how LEEP got off the ground in the first place back in 2020. What’s the nature of that programme?

Lucia Coulter: So the Charity Entrepreneurship programme’s aim is to help people start high-impact nonprofits. And what they do is they research potential intervention ideas and then they narrow those down to a shortlist. And people apply to an incubation programme, and they are presented with these ideas. During the programme, you learn all about the basics of how to start a high-impact nonprofit: everything from decision-making, how to do your cost-effectiveness analysis, how to hire, how to do M&E — kind of everything you might need to know that you should know.

And by the end of it, you’re paired up with a cofounder and you’ve chosen your idea, and you submit a proposal for your project, and then you can be granted seed funding. And it doesn’t really stop there, because after that two-month programme, you carry on getting support and mentorship from the Charity Entrepreneurship team, and you’re also part of this Charity Entrepreneurship community — which is amazing, because you’re in touch with loads of people who’ve done things before. So whenever you get stuck or have a question, you just hop on Slack and you’re like, “Who’s come across this before?” So that’s what Charity Entrepreneurship is.

Rob Wiblin: I think you’re actually the third guest who’s been through the Charity Entrepreneurship programme.

Lucia Coulter: Oh, so your listeners probably know already.

Rob Wiblin: Well, at least the most loyal listeners will know, but not all of them. Varsha Venugopal was on a couple of years ago, and she’s been working on a programme in India to do SMS reminders for vaccinations. And then there’s also Andrés Jiménez Zorrilla, who was on an episode on 80k After Hours that we cross-posted to this feed, and he’s working on the Shrimp Welfare Project. I can strongly recommend listening to that episode if you haven’t already. It’s another fascinating exploration of a world that I knew nothing about.

I guess all of you arrive at this Charity Entrepreneurship Incubation Program. At that point, you don’t necessarily have a cofounder, or you don’t know what charity you want to start — you’re not bringing the idea of doing a lead charity to the programme; you’re coming in saying, “I just want to do some nonprofit entrepreneurship thing that’s extremely high impact.” And then does the programme present you with a menu of preexisting great ideas that people haven’t taken up yet?

Lucia Coulter: Yeah, so each year they research new ideas and then they present them in reports, explaining why they think this is likely to be a high-impact, cost-effective charity idea. Then throughout the programme, you explore those different ideas. Each day, you might do a different mini project that might be focused on one idea or the other. So you get quite familiar with these interventions and what might they look like. And then you prioritise, yourself, which one you think you might want to found.

Rob Wiblin: Has there ever been fighting over who gets to do them? “No, I want to do lead! I want to remove lead!” I guess that didn’t happen in your cohort?

Lucia Coulter: I think sometimes there are multiple people interested in the same idea, but I haven’t seen fighting over it.

Rob Wiblin: Hasn’t come to blows.

Lucia Coulter: I think most people are really sensitive to counterfactuals.

Rob Wiblin: Right, I see. Of course. So if someone else wants to do it, then that makes them more reluctant to.

Lucia Coulter: I think that can happen, yeah.

Rob Wiblin: And you came without a cofounder. How did you get paired up with… Who’s your main cofounder?

Lucia Coulter: Jack Rafferty.

Rob Wiblin: How’d you get paired up with Jack?

Lucia Coulter: Jack and I worked together on various projects throughout the first half of the incubation programme. The way it starts is each day you’re paired with someone different, you do a little project with them. And we just found that we worked really well together, and so we were pretty keen on working together. And then also we were both interested in the same idea. So those two factors together.

Rob Wiblin: You were working in the NHS before this, is that right? Were you doing intensive care?

Lucia Coulter: I was a junior doctor. I was mainly working in acute and emergency medicine.

Rob Wiblin: Was it a big step for you to decide to go and do this? I guess it’s still within health, but it’s a reasonably large career shift.

Lucia Coulter: Yeah, it was a bit scary. I’d gone into medicine initially thinking that I might want to work in global health, public health, something that could result in more systemic change. And I’d been involved in the effective altruism world for a long time, so I was always thinking about what high-impact thing I might want my career to end up looking like. I’d considered maybe specialising in public health or maybe working for a big intergovernmental organisation or something like that. I hadn’t really considered nonprofit entrepreneurship as an option. It seemed very scary and unusual.

But then my friend Nikita Patel, who founded Fortify Health, I saw her do that, and I was like, “Wow, this is cool. This is really cool that she’s doing this.” And it made it a bit more concrete and relatable, seeing her experience and what it actually looked like. And it kind of opened up that idea as an option.

And then there was a time in my junior doctor career where I could take some time out of medicine and easily go back again. So I thought this is a good time for me to try something different. And I thought about what I should try. I did some 80k careers advising, and then it happened to be that the application time for the incubation programme lined up with a community psychiatry placement, which meant that I didn’t have crazy hours. So I was like, “OK, I’ll do this application. I don’t think I’ll necessarily be a good fit. I don’t see myself as an entrepreneur or anything like that, but why not give it a go?” And then I did get into the programme, and I was like, well, let’s see what happens here. And yeah, that was it.

Rob Wiblin: Charity Entrepreneurship has had quite a few hits now, I think you might be the biggest hit, or the most legible hit at least — where just from the very beginning, you’ve been hitting it completely out of the park. But what are some of the other cool projects that they’ve gotten off the ground, in your opinion? Maybe other than the ones that we’ve already done interviews on?

Lucia Coulter: I think Family Empowerment Media is doing really cool work. Fortify Health also had a role in that, which has been GiveWell-incubated. Fish Welfare Initiative seems to be having a lot of impact. I’m less familiar with the newer cohorts, but the ideas seem really cool. I’m excited to find out what they get up to.

Rob Wiblin: What is it that the incubation programme is bringing to the table? It does seem like, given that track record, it’s helping. It’s helping people do stuff that I think otherwise they would not have been doing. I wonder whether having that menu at the beginning of prescreened ideas that they think are extremely promising, based on somewhat expert judgement, do you think that is really pushing people towards ideas that have a lot of promise and maybe are going to be relatively straightforward to have a big impact with?

Lucia Coulter: Yeah, I think so. I think that the ideas are a huge added value. I think it’s really hard to come up with good ideas, and they have a really systematic process for prioritising. I think it’s also just making it feel possible to people. I would never have founded a nonprofit on my own. I wouldn’t have known what I needed to know. I would have felt completely lost. And just guiding you through the steps of the process and making it doable is really impactful, I think.

Rob Wiblin: Yeah. What’s some of the key advice that Charity Entrepreneurship gives most of the groups going through the incubation programme, if there’s any kind of general advice?

Lucia Coulter: There’s a lot of advice. And we do think about it a lot; I find myself thinking back to the way that certain ways of thinking about things were framed and how to approach things. I think one thing that I come back to a lot is the importance of coming back to the theory of change and challenging it, testing it. And the things we learned about the monitoring and evaluation and linking that to the theory of change.

Another thing is what not to focus on. This is a bit of a trivial example, but you don’t need to spend a long time thinking about your website or your logo. In the incubation programme, we made websites for our nonprofits in just like a few hours. You just really need to focus on figuring out, is your intervention going to work, how can you make it work? Being really action orientated.

Rob Wiblin: Got it. Is there any specific advice that they gave to you guys when you were going through the programme?

Lucia Coulter: One piece of advice that I think we took quite seriously was just to move quite quickly and just test it out. You could imagine starting up a nonprofit and spending a long time in the early phases of figuring everything out in detail. But in the second month, we were in Malawi, we were just testing our theory of change, the first part of it. And I think that was really good advice, because we learned a lot more a lot more quickly by doing that. And we could have wasted months and months and months otherwise.

Rob Wiblin: Are there any other charity ideas that you’d be really excited to see people start? What was going to be the second on your list if you weren’t going to do lead elimination? Do you remember?

Lucia Coulter: I’m pretty excited to see what other public health policy and regulatory intervention ideas come up. At the moment, the CE research team is looking into organophosphate pesticides and other neurotoxicants to see if there’s a neglected intervention similar to LEEP’s. So I’m really excited to see what they find there.

Rob Wiblin: Yeah. I think that they’ve also looked at taxation of tobacco and taxation of alcohol. I think obviously those are other massive causes of ill health; potentially discouraging excessive consumption of those could be really impactful.

Lucia Coulter: Yeah.

Rob Wiblin: Is it difficult to get into the programme? What sort of stuff are they looking for among applicants?

Lucia Coulter: They have a lot of applicants and only a few make it onto the programme each year, so it’s pretty selective. I think they’re looking for what they describe as people who are “ambitiously altruistic” — so ambitious but really driven to have a large positive impact in the work that they’re doing. They’re looking for people who have good decision-making. They don’t really care about experience, particularly. I think they found that deep experience in a field doesn’t necessarily correlate with having a successful nonprofit.

They list all the things that they prioritise on the website, and you can also do a quiz to find out if you might be a good fit for applying. And I think also the application process helps you prioritise career options during the process. So I’d encourage people to apply even if they’re just wanting to think a bit more about whether it could be a good fit. Like I was saying before, I didn’t think I would be a good fit.

Rob Wiblin: It’s a live programme in London, right?

Lucia Coulter: So most of the programme is remote, but there are two weeks in person, so you can apply living anywhere in the world. And for the remote part of it, they do make sure that it works for different time zones and that sort of thing. And then for the two weeks in person, they cover all the expenses, and they also give stipends and help with visas. So they’re keen on having a very international cohort.

Rob Wiblin: Yeah. Are they still helping you out these days? Or maybe have you ever kind of graduated, and you know more about what you’re doing than they do?

Lucia Coulter: We still definitely ask for advice sometimes from the Charity Entrepreneurship community and the people that work there themselves, because there are people who are further along in the nonprofit stage. So when it comes to hiring for more senior roles, or something that we haven’t done before like that, we can get really helpful advice.

For a conflict-of-interest declaration, I am on the board of CE at the moment.

Rob Wiblin: When did you join the board? Was that before or after you did the [programme]?

Lucia Coulter: It was quite recently.

Rob Wiblin: Quite recently. OK, so you loved CE before you were on the board, not just advertising it now that you have… I suppose you don’t have a financial interest. You just have responsibility.

Lucia Coulter: Exactly.

Rob Wiblin: For balance, maybe we should find something negative to say about the programme. Are there any weaknesses of it or ways in which it wasn’t as helpful as you maybe you hoped?

Lucia Coulter: One thing I’ve noticed is that there does seem to be a bit of a feeling that you need to work really, really hard to have a successful charity. I don’t think that that would necessarily be endorsed, but I feel like that comes across sometimes. And I think that is a bit risky, because burnout is a real risk. And I don’t think it’s necessarily true: I think you can have a balanced life and get a lot of work done and have a lot of impact.

So that would be one thing that I would look out for. But I think that they would probably agree with that, and wouldn’t really want to be communicating that. But I think it just comes across in the culture of moving fast.

Rob Wiblin: They’re a little bit workaholic themselves maybe, so that’s kind of the culture that tends to be transmitted. But in reality, it does seem like you could work kind of 9–5 on LEEP and it would be pretty successful. Maybe not. All right, you could work 9–9.

Lucia Coulter: I think I could work reasonable hours and it would be fine. I think it’s hard to limit yourself when you know what the stakes are. Every few weeks that we can get lead paint off the market sooner is a real impact. So it can be quite hard to balance knowing that with having a normal, healthy routine.

Rob Wiblin: Is that one of the most difficult parts of the work?

Lucia Coulter: I think for me at the moment, that’s one of the most difficult parts of the work. But I don’t think it has to be like that. And I have an intention to sort out my work-life balance.

Rob Wiblin: Have something that you could stick with long term and feel happy.

Lucia Coulter: It needs to be sustainable. It’s a marathon. But I do love it. It’s so satisfying. Nothing brings me greater joy than hearing a manufacturer tell me that they’ve switched to lead-free. Just chasing those highs.

Rob Wiblin: You should have a bell that you ring every time you get a result where it was leaded before and now it’s not.

Lucia Coulter: Yeah. But no, it’s incredibly fulfilling and satisfying, and I think that’s probably what makes it hard to balance sometimes.

Rob Wiblin: Yeah, I guess this is a perpetual issue. It’s very challenging. I mean, everyone who’s doing really important work finds where to draw the line between how much they’re willing to put in and how much is healthy to put in. I guess the thing I wouldn’t want is for someone to not go into a high-impact job because they feel like they then couldn’t do it 9–5. If that’s the dealbreaker for you, you should definitely do the high-impact job and just work 9–5 — rather than not do something that’s important, so you don’t have the stress of being near something that matters.

Lucia Coulter: Absolutely. Yeah. I think 9–5 is absolutely doable.

Rob Wiblin: I guess you’re the co-executive director of LEEP, so you’re more likely to be a bottleneck. There’s maybe more pressure on you to work extra hours. But as a staff member who’s just doing work on the ground, it’s less urgent for them to put in extra time.

Giving What We Can Pledge [02:02:18]

Rob Wiblin: All right, finally, let’s talk about something random and different that you’ve done, which is sign the Giving What We Can Pledge. Can you explain what that is for people who haven’t heard of it?

Lucia Coulter: Yeah. So the Giving What We Can Pledge is a commitment to donate 10% of your income throughout your life to charities that you think will do the most good with the money.

Rob Wiblin: OK, so pledge to give 10%. It’s forever, right? It’s pretax, but you get to choose what charity you think is most impactful. When did you take the Pledge and what prompted you to do that?

Lucia Coulter: I took it in my second or third year of university. I’d known about it for a while, but I hadn’t taken it yet because I was like, it’s a long time until I’m going to be earning any money, especially doing a medical degree. It takes like six years. So I wasn’t in a massive rush, but then I was involved in the Giving What We Can chapter in Cambridge, and I thought I might as well do it now. It just seemed like a good idea.

Rob Wiblin: I guess the basic picture is that the benefit to the people who benefit from the charity is much greater than the harm to you from the reduction in income, given that you’re living a comfortable life.

Lucia Coulter: Yeah, exactly. I think one thing that stood out to me was a statistic. I don’t know if it’s still true, but at the time it was like the average graduate salary in the UK puts you in the top 5% of income globally. So I knew that on a global scale, I would be very comfortable in my life, and that that additional 10% was not going to be a dealbreaker for me, whereas it could have a lot of impact elsewhere. So it just seemed like a good idea, and it seemed like a good idea to do it when I was a student, so that I would never really notice the decrease because I’d always be doing it.

Rob Wiblin: Which charities have you ended up donating to since you signed it?

Lucia Coulter: It changes year on year, and I deliberate every year.

Rob Wiblin: Oh, wow. That’s slightly bad, given the importance of your time.

Lucia Coulter: I know, yeah. Sometimes it’s been GiveWell-recommended charities, sometimes it’s been recommended animal charities. More recently, sometimes Charity Entrepreneurship–incubated charities. I think that there’s maybe a good opportunity in an early stage of a charity, where they’re not big enough or established enough or have enough of a track record to get funding from more established donors, and they’re definitely not going to be funded by any of the big EA-type of funders. So looking out for those opportunities I quite like doing.

Rob Wiblin: I guess given your association with Charity Entrepreneurship, you’re in a good place to be one of these sort of angel funders, who provides a bit of money to things that are really early stage.

Lucia Coulter: Yeah, it’s not that much money though. [laughs]

Rob Wiblin: We were talking earlier about how it’s plausible that you’re delivering a year of healthy life for $14. I guess that’s always been part of the pitch for people taking the Giving What We Can Pledge, or just donating to effective charities: the impact that people might have by donating to these organisations to allow them to scale more quickly might be far larger than what people intuitively think. If you sit with it for a minute, how much benefit that is to someone: that they have a year, and not just a typical year, but actually a year at peak health. That’s the sort of benefit that you’re providing to someone — and you’re able to do it for $14, at least in these more high-risk, high-return giving strategies.

It’s actually a little bit alarming. On the one hand, it’s an amazing opportunity, and it makes you feel really good. On the other hand, it’s a symptom of these amazing opportunities that are being not taken, or these amazing things that really should be happening that would benefit people so much, that could just get left there for lack of a tiny amount of money.

Lucia Coulter: Yeah.

Rob Wiblin: Did you have any major reservations about taking the Pledge?

Lucia Coulter: Not really. I think there was a thought of, “Am I just doing this because I’m relatively young and I don’t really know how important this will be as a commitment later in my life, and I’m being a bit naive?” or something like that. But I was also thinking, “Well, if I’m just being naive, let’s roll with it. It’ll probably have a positive impact overall.” But I don’t think that really turned out to be true. I still think it’s the right decision, and I’m happy with it.

Rob Wiblin: Do you think that having 10% less income meaningfully affects your wellbeing? It must affect it a little bit, right?

Lucia Coulter: Not noticeably.

Rob Wiblin: Noticeably, yeah. You work for a nonprofit now that’s kind of early stage. I don’t imagine you’re raking in income. But you nonetheless feel like it’s fine for you personally?

Lucia Coulter: Yes, it’s fine for me personally.

Rob Wiblin: You just don’t have expensive taste.

Lucia Coulter: I don’t think I have expensive taste. Maybe if you have kids or something like that, your calculus could change.

Rob Wiblin: Yeah. Could get more challenging. You’re living in London, right? It’s not a cheap city. But yeah, you’re just a reasonably frugal person by nature.

Lucia Coulter: I mean, am I a reasonably frugal person by nature? I think about it with my purchasing decisions. So I used to be one of those people who every time they bought something, they’d be thinking, “This is a malaria net.”

Rob Wiblin: We’ve all been there.

Lucia Coulter: Exactly. So I find it really helpful just having this as the set amount, and I don’t have to deliberate over every decision. That’s really nice for me.

Rob Wiblin: One of the best arguments I’ve heard for not taking the Giving What We Can Pledge, even from an impact point of view, is just that the kinds of people who are dedicated enough to this that they’re seriously considering taking the Giving What We Can Pledge, very often the thing that they can do that will have the biggest impact is to change their career — is to start an organisation like LEEP. And probably, I would guess, you’re doing a lot more good through your work, realistically, than you are by donating 10% of your income. It might be like 10 or 100 times as much.

And then some people argue it’s maybe a distraction a bit to focus on the giving rather than on the career change. And also, if you go into a role like being a nonprofit entrepreneur, then you might be more reluctant to do that if you know that you’re only going to be able to keep 90% of what is potentially a much lower income than you might have otherwise gotten anyway.

So I think that is maybe my one reservation for people taking the Giving What We Can Pledge, even if they’re otherwise living in the UK and financially comfortable, is just I wouldn’t want that to come at the expense of someone doing something like what you’ve done: trying to have a direct impact by pursuing a really high-impact career, even if that means earning quite a bit less than they might otherwise.

Lucia Coulter: Yeah. Hopefully if that were impacting a decision to do something really high impact, you’d be able to notice that and be like, that doesn’t make sense. So I will not donate that 10% because it will allow me to do this higher-impact thing. Something like that.

Rob Wiblin: Yeah. I guess people have different takes on this. I feel like it would be in the spirit of the Pledge to say, “Unfortunately, I can’t keep this pledge anymore, because now I’m dedicating my entire career to pursuing global health and development, for example, in a way that I didn’t previously expect to.”

Lucia Coulter: I don’t know what the strict definition of the Pledge is, but you could think of it in a way as you’re taking a lower salary by working in this role, and that’s kind of salary-sacrificing in place of making that donation.

Rob Wiblin: Yeah, Giving What We Can has been doing pretty well recently. I think they’ve got 8,500 members now. And I think they might have had their biggest year last year, because they got 1,500 or something new members. I should probably tell people I worked there many years ago, back in 2012. And I think back then, we were pretty happy to have 300 people join in a year. So yeah, it’s growing a lot faster than back in my day.

Lucia Coulter: That’s awesome.

Rob Wiblin: OK, final question on the Giving What We Can thing: have you found it useful to take the Pledge specifically? I mean, you could donate 10% just every year because you think it’s a good idea, without having signed up to the thing officially.

Lucia Coulter: Yeah. I like the Pledge because it’s legible and something you can communicate about to other people as well. I think it’s helped friends and other people consider taking it. It’s nice to feel like it’s a real thing that you’re doing with other people. And the structure of it is nice as well. It’s like, “This is the thing I’ve decided to do.” It’s not just a thing I’ve decided now that I might change my mind on, or should it be a lower amount or a higher amount this year? It’s like, “This is what I’m doing” and it’s just clear and simple. So I like that it’s like an actual thing, as opposed to just a decision that I’ve made.

Kids [02:10:09]

Rob Wiblin: All right. We’ve been going for quite a while, and we should probably wrap up. I suppose we’ve been thinking about the burden of responsibility, of doing something really important with your life, and how that can weigh on you. But if somehow all the world’s problem’s had already been solved, what do you think you’d be doing with your time or your career instead?

Lucia Coulter: When I was younger, the thing I always said I wanted to do was be a mum, have loads of kids. So I think that’s what I would do: probably have a bunch of children, maybe homeschool for a bit. I would love that. That’d be so much fun.

Rob Wiblin: Sounds like a lot of work.

Lucia Coulter: Yeah.

Rob Wiblin: Don’t want to play computer games or something?

Lucia Coulter: I think that would be so great.

Rob Wiblin: Yeah. Wonderful. Do you think you’ll have kids despite your commitment to your work?

Lucia Coulter: Yeah, I think so. Probably just not as many.

Rob Wiblin: Do you have a target number in mind?

Lucia Coulter: I’d quite like three kids. I think that’d be nice.

Rob Wiblin: That’s a reasonable family. That’s quite a lot of fulfilment.

Lucia Coulter: Yeah, that’d be great.

Rob Wiblin: Cool. My guest today has been Lucia Coulter. Thanks so much for coming on The 80,000 Hours Podcast, Lucia.

Lucia Coulter: Thank you so much. It’s been really fun.

Rob’s outro [02:11:14]

Rob Wiblin: As I mentioned in the intro, if LEEP’s work sounded as great to you as it did to me, you usually give to global health and wellbeing causes, and you haven’t done your holiday giving yet, you could do a lot worse than to head to leadelimination.org and give some lovely children the holiday gift of not getting lead poisoning.

And as I mentioned in the intro, LEEP is about to hire a few program managers, so if you especially love LEEP you could consider getting a job and working with them! Those job ads should go up on their website around the 20th of December, but if you go to leadelimination.org/jobs you can join a mailing list now and get directly notified about them when they go up.

As we mention in the blog post, some researchers at Founders Pledge, a grantmaking organisation, estimated that:

LEEP’s programs are extremely cost-effective. We estimate that it costs $1.66 to prevent one child’s lead exposure (in expectation). As of August 2023, that makes LEEP one of our most cost-effective charities.

I’ll just quote from an email from Lucia on some of the complications here:

Founders Pledge did a CEA of around ten of our programs and said ‘We estimate that it costs $1.66 to prevent one child’s lead exposure (in expectation)’. It is a bit more complicated than it sounds though — based on my understanding of their analysis, it actually means $1.66 for a blood lead level reduction equivalent to an average child’s blood lead level. Because our intervention reduces one source of lead exposure across a large population, it’s more like $1.66 for reducing five children’s lead exposure by one fifth. But I don’t think that simplification matters too much. Their CEA [cost-effectiveness analysis] includes discounting for the probability of success of our programs.

Just a reminder, if you’d like to support this work, head to leadelimination.org.

If you enjoyed that episode, you might want to go check out:

• #153 – Elie Hassenfeld on two big-picture critiques of GiveWell’s approach, and six lessons from their recent work
• #124 – Karen Levy on fads and misaligned incentives in global development, and scaling deworming to reach hundreds of millions
• #111 – Mushtaq Khan on using institutional economics to predict effective government reforms

All right, The 80,000 Hours Podcast is produced and edited by Keiran Harris.

The audio engineering team is led by Ben Cordell, with mastering and technical editing by Milo McGuire and Dominic Armstrong.

Full transcripts and an extensive collection of links to learn more are available on our site, and put together as always by Katy Moore.

Thanks for joining, talk to you again soon.