Astral Codex Ten

Google Trends

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Google Trends

Article

Google Trends is a recurring organization in the Astral Codex Ten archive, appearing 4 times across 4 issues between May 10, 2021 and May 30, 2024. The archive places it in contexts such as “But what does Google Trends have to say?”; “Maybe Google Trends volume or number of hits on their Wikipedia page?”; “And here’s Google Trends”. It most often appears alongside Google, Obama, Osama bin Laden.

Metadata

  • Category: Organizations
  • Mention count: 4
  • Issue count: 4
  • First seen: May 10, 2021
  • Last seen: May 30, 2024

Appears In

Source Context

Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.

The Rise And Fall Of Online Culture Wars
May 10, 2021 · Original source
But what does Google Trends have to say?
I'm not saying there's literally only one thing the Internet gets in fights about at any given time. The Internet fights about lots of things. But intuitively it feels like there's kind of a power law distribution where one topic clearly outstrips the others - maybe not winner-take-all, but at least winner-take-most. I think you could describe the last twenty years of Internet history as going through three phases - one dominated by religion, one dominated by gender, and now one dominated by race. The race phase seems to have peaked in 2018 and started declining, before being given new life by George Floyd and BLM. The Google Trends results raise the tantalizing possibility that racial issues can’t keep increasing forever. They could eventually crash the same way religious and gender issues did (probably to be replaced by something else even more divisive and awful).
Since then it’s become less obvious. After the George Floyd protests, all Google Trends about race shot up, and haven’t fully returned back to their pre-protest trend even now, a year later. The woke stranglehold on corporations, governments, and now the CIA is stronger than ever.
Inline links: the CIA
Highlights From The Comments On Great Families
November 18, 2021 · Original source
I agree it’s awkward that we can only do these calculations well with Nobels (and maybe Olympic medalists?). A really rigorous attempt at this would try to find some way of quantifying extreme but not Nobel-level talent. Maybe Google Trends volume or number of hits on their Wikipedia page? With some kind of scaling factor based on recency or being in fields that tend to get lots of searches and Wikipedia hits?
Semaglutidonomics
November 24, 2022 · Original source
“Wegovy” sounds like either a cooperative governance platform, or some kind of obscure medieval sin. Weight loss pills have a bad reputation. But Wegovy is a big step up. It doesn’t work for everybody. But it works for 66-84% of people, depending on your threshold. (Source) Of six major weight loss drugs, only two - Wegovy and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug. Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile. Modeling Semaglutide Accessibility 40% of Americans are obese - that’s 140 million people. Most of them would prefer to be less obese. Suppose that a quarter of them want semaglutide. That’s 35 million prescriptions. Semaglutide costs about $15,000 per year, multiply it out, that’s about $500 billion. Americans currently spend $300 billion per year total on prescription drugs. So if a quarter of the obese population got semaglutide, that would cost almost twice as much as all other drug spending combined. It would probably bankrupt half the health care industry. So . . . most people who want semaglutide won’t get it? Unclear. America’s current policy for controlling medical costs is to buy random things at random prices, then send all the bills to an illiterate reindeer-herder named Yagmuk, who burns them for warmth. Anything could happen! Right now, only about 50,000 Americans take semaglutide for obesity. I’m basing this off this report claiming “20,000 weekly US prescriptions” of Wegovy; since it’s taken once per week, maybe this means there are 20,000 users? Or maybe each prescription contains enough Wegovy to last a month and there are 80,000 users? I’m not sure, but it’s somewhere in the mid five digits, which I’m rounding to 50,000. That’s only 0.1% of the potential 35 million. The next few sections of this post are about why so few people are on semaglutide, and whether we should expect that to change. I’ll start by going over my model of what determines semaglutide use, then look at a Morgan Stanley projection of what will happen over the next decade. Step 1: Awareness I model semaglutide use as interest * awareness * prescription accessibility * affordability. I already randomly guessed interest at 25%, so the next step is awareness. How many people are aware of semaglutide? The answer is: a lot more now than when I first started writing this article! Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, says the headline. And here’s Google Trends: Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: https://substackcdn.com/image/fetch/$s_!gShh!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fe4b4ffd4-3d5b-445c-961d-f562ca14ac0f_818x220.png, Source, here, in the comments, lose more weight, this report, Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, https://substackcdn.com/image/fetch/$s_!RABx!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F366df26d-e420-431d-8034-e2c4a6a8de60_1149x471.png, NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, modeled the economic future of obesity medications over the next decade, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Contra Stone On EA
May 30, 2024 · Original source
Stone finds that Google Trends shows that searches for “effective altruism” concentrate most in the San Francisco Bay Area and Boston. So he’s going to see if those two cities have higher charitable giving than average, and use that as his metric of whether EAs give more to charity than other people.
I’m not going to make a big deal about Stone’s use of Google Trends, because I think he’s right that SF and Boston are the most EA cities. But taken seriously, it would suggest that Montana is the most Democratic state. Stone could potentially still object that movements aren’t supposed to gather 10,000 committed adherents and grow at 10% per year. They have to take hold of the population! Capture the minds of the masses! Convert >5% of the population of a major metropolitan area! I don’t think effective altruism has succeeded as a mass movement. But I don’t think that’s it’s main strategy - for more on this, see the articles under EA Forum tag “value of movement growth”, which explains: It may seem that, in order for the effective altruism movement to do as much good as possible, the movement should aim to grow as much as possible. However, there are risks to rapid growth that may be avoidable if we aim to grow more slowly and deliberately. For example, rapid growth could lead to a large influx of people with specific interests/priorities who slowly reorient the entire movement to focus on those interests/priorities. Aren’t movements that don’t capture the population doomed to irrelevance? I don’t think so. Effective altruism has managed to get plenty done with only 10,000 people, because they’re the right 10,000 and they’ve influenced plenty of others. Stone fails to prove that effective altruists don’t donate more than other people, because he’s used bad methodology that couldn’t prove that even if it were true. His critique could potentially evolve into an argument that effective altruism hasn’t spread massively throughout the population, but nobody ever claimed that it did. II. You might imagine that a group fixated on “effective altruism” would have a high degree of concentration of giving in a small number of areas. Indeed, EAist groups tend to be hyper-focused on one or two causes, and even big groups like Open Philanthropy or GiveWell often have focus areas of especially intense work. And yet, the list of causes EAists work on is shockingly broad for a group whose whole appeal is supposed to be re-allocating funds towards their most effective uses. Again, click the link I attached above. EAists do everything from supporting malarian bednets (seems cool), to preventing blindness-related conditions (makes sense), to distributing vaccines (okay, I’m following), to developing vaccines in partnership with for profit entities (a bit more oblique but I see where you’re going with it), to institutional/policy interventions (contestable, but there’s a philosophical case I guess), to educational programs in rich countries (sympathetic I guess but hardly the Singer-esque “save the cheapest life” vibe), to promoting kidney transplants (noble to be sure but a huge personal cost for what seems like a modest total number of utils gained), to programs to reduce the pain experienced by shrimp in agriculture (seems… uh… oblique), to lobbying efforts to prevent AI from killing us all (lol), to space flight (what?), to more nebulous “long term risk” (i.e. “pay for PhDs to write white papers”), to other even more alternatively commendable, curious, or crazy causes. My point is not to mock the sillier programs (I’ll do that later). My point is just to question on what basis so broad a range of priorities can reasonably be considered a major gain in efficiency. Is it really the case that EAists have radically shifted our public understandings of the “effectiveness” of certain kinds of “altruism”? A few responses: Technically, it’s only correct to focus on the single most important area if you have a small amount of resources relative to the total amount in the system (Open Phil has $10 billion). Otherwise, you should (for example) spend your first million funding all good shrimp welfare programs until the marginal unfunded shrimp welfare program is worse than the best vaccine program. Then you’ll fund the best vaccine program, and maybe they can absorb another $10 million until they become less valuable than the marginal kidney transplant or whatever. This sounds theoretical when I put it this way, but if you work in charity, it can quickly becomes your whole life. It’s all very nice and well to say “fund kidney transplants”, but actually there are only specific discrete kidney transplant programs, some of them are vastly better than others, and none of them scale to infinity instantaneously or smoothly. The average amount that the charities I deal with most often can absorb is between $100K and $1MM. Again, Open Phil has $10 billion. But even aside from this technical point, people disagree on really big issues. Some people think animals matter and deserve the same rights as humans. Other people don’t care about them at all. Effective altruism can’t and doesn’t claim to resolve every single ancient philosophical dispute on animal sentience or the nature of rights. It just tries to evaluate if charities are good. If you care a lot about shrimp, there’s someone at some effective altruist organization who has a strong opinion on exactly which shrimp-related charity saves shrimp most cost-effectively. But nobody (except philosophers, or whatever) can tell you whether to care about shrimp or not. This is sort of a cop-out. Effective altruism does try to get beyond “I want to donate to my local college’s sports team”. I think this is because that’s an easy question. Usually if somebody says they want to donate there, you can ask “do you really think your local college’s sports team is more important than people starving to death in Sudan?” and they’ll think for a second and say “I guess not”. Whereas if you ask the same question about humans and animals, you’ll get all kinds of answers and no amount of short prompting can solve this disagreement. I think this puts EAs in a few basins of reflective equilibrium, compared to scattered across the map. So is there some sense, as Stone suggests, that “so broad a range of priorities [can’t] reasonably be considered a major gain in efficiency”? I think if you look at donations by the set of non-effective-altruist donors, and the set of effective-altruist donors, there will be much much more variance, and different types of variance, in the non-EAs than the EAs. Here’s where most US charity money goes (source): Try spotting existential risk prevention on here. I don’t think Stone can claim that an EA version of this chart wouldn’t look phenomenally different. But then what’s left of his argument? III. Effective altruists devote absolutely enormous amounts of mental energy and research costs to program assessment, measurement of effectiveness. Those studies yield usually-conflicting results with variable effect sizes across time horizons and model specifications, and tons of different programs end up with overlapping effect estimates. That is to say, the areas where EAist style program evaluations are most compelling are areas where we don’t need them: it’s been obvious for a long time how to reduce malaria deaths, program evaluations on that front have been encouraging and marginally useful, but not gamechanging. On the other hand, in more contestable areas, EAist style program evaluations don’t really yield much clarity. It’s very rare that a program evaluation gets published finding vastly larger benefits than you’d guess from simple back-of-the-envelope guesswork, and the smaller estimates are usually because a specific intervention had first-order failure or long-run tapering, not because “actually tuberculosis isn’t that bad” or something like that. Those kinds of precise program-delivery studies are actually not an EAist specialty, but more IPA’s specialty. My second critique, then is this: there is no evidence that the toolkit and philosophical approach EAists so loudly proclaim as morally superior actually yields any clarity, or that their involvement in global efforts is net-positive vs. similar-scale donations given through near-peer organizations. The IPA mentioned here is Innovations For Poverty Action, a group that studies how to fight poverty. They’re great and do great work. But IPA doesn’t recommend top charities or direct donations. Go to their website, try to find their recommended charities. Unless I’m missing something, there are none. GiveWell does have recommended charities - including ones that they decided to recommend based on IPA’s work - and moves ~$250 million per year to them. If IPA existed, but not GiveWell, the average donor wouldn’t know where to donate, and ~$250 million per year would fail to go to charities that IPA likes. I think from the perspective of people who actually work within this ecosystem, Stone’s concern is like saying “Farms have already solved the making-food problem, so why do we need grocery stores?” (also, effective altruism funds IPA) I’m focusing on IPA here because Stone brought them up, but I think EA does more than this. I don’t think there’s an IPA for figuring out whether asteroid deflection is more cost-effective than biosecurity, whether cow welfare is more effective than chicken welfare, or figuring out which AI safety institute to donate to. I think this is because IPA is working on a really specific problem (which kinds of poverty-related interventions work) and EA is working on a different problem (what charities should vaguely utilitarian-minded people donate to?) These are closely related questions but they’re not the same question - which is why, for example, IPA does (great) research into consumer protection, something EA doesn’t consider comparatively high-impact. And I’m still focusing on donation to charity, again because it’s what Stone brought up, but EA does other things - like incubating charities, or building networks that affect policy. IV. Let’s skip farm animal welfare for a second and look at the next few: Global Aid, “Effective Altruism,” potential AI risks, biosecurity, and global catastrophic risk. These are all definitely disproportionate areas of EAist interest. If you google these topics, you will find a wildly disproportionate number of people who are EAist, or have sex at EAist orgies, or are the friends of people who have sex at EAist orgies. These really are some of the unique social features of EAism. And they largely amount to subsidizing white collar worker wages. I’m sorry but there’s no other way to slice it: these are all jobs largely aimed at giving money to researchers, PhD-holders, university-adjacent-persons, think tanks, etc. That may be fine stuff, but the whole pitch of effective altruism is that it’s supposed to bypass a lot of the conventional nonprofit bureaucracy and its parasitism and just give money to effective charities. But as EAism as matured into a truly unique social movement, it is creating its own bureaucracy of researchers, think tanks, bureaucrats… the very things it critiqued. Suppose an EA organization funded a cancer researcher to study some new drug, and that new drug was a perfect universal cure for cancer. Would Stone reject this donation as somehow impure, because it went to a cancer researcher (a white-collar PhD holder)? EA gives hundreds of millions of dollars directly to malaria treatments that go to the poorest people in the world. It’s also one the main funders of GiveDirectly, a charity that has given money ($750 million so far) directly to the poorest people in the world. But in addition to giving out bednets directly, it sometimes funds malaria vaccines. In addition to giving to poor Africans, it also funds the people who do the studies to see whether giving to poor Africans works. Some of those are white-collar workers. EA has never been about critiquing the existence of researchers and think tanks. In fact, this is part of the story of EA’s founding. In 2007, the only charity evaluators accessible by normal people rated charities entirely on how much overhead they had - whether the money went to white-collar people or to sympathetic poor recipients. EAs weren’t the first to point out that this was a very weak way of evaluating charities. But they were the first to make the argument at scale and bring it into the public consciousness, and GiveWell (and to some degree the greater EA movement) were founded on the principle of “what if there was a charity evaluator that did better than just calculate overhead?” In accordance with this history, if you look on Giving What We Can’s List Of Misconceptions About Effective Altruism, their #1 Misconception about about charity evaluation is that “looking at a charity’s overhead costs is key to evaluating its effectiveness”. This is another part of my argument that EA is more than just IPA++. For years, the state of the art for charity evaluators was “grade them by how much overhead they had”. IPA and all the great people working on evidence-based charity at the time didn’t solve that problem - people either used CharityNavigator or did their own research. GiveWell did solve that problem, and that success sparked a broader movement to come up with a philosophy of charity that could solve more problems. Many individuals have always had good philosophies of charity, but I think EA was a step change in doing it at scale and trying to build useful tools / a community around it. V. You could of course say AI risk is a super big issue. I’m open to that! But surely the solution to AI risk is to invest in some drone-delivered bombs and geospatial data on computing centers! The idea that the primary solution here is going to be blog posts, white papers, podcasts, and even lobbying is just insane. If you are serious about ruinous AI risk, you cannot possibly tell me that the strategy pursued here is optimal vs. say waiting until a time when workers have all gone home and blowing up a bunch of data centers and corporate offices. In particular terrorism as a strategy may be efficient since explosives are rather cheap. To be clear I do not support a strategy of terrorism!!!! But I am questioning why AI-riskers don’t. Logically, they should. I think if you have to write in bold with four exclamation points at the end that you’re not explicitly advocating terrorism, you should step back and think about your assumptions further. So: Should people who worry about global warming bomb coal plants? Should people who worry that Trump is going to destroy American democracy bomb the Republican National Convention? Should people who worry about fertility collapse and underpopulation bomb abortion clinics? EAs aren’t the only group who think there are deeply important causes. But for some reason people who can think about other problems in Near Mode go crazy when they start thinking about EA. (Eliezer Yudkowsky has sometimes been accused of wanting to bomb data centers, but he supports international regulations backed by military force - his model is things like Israel bombing Iraq’s nuclear program in the context of global norms limiting nuclear proliferation - not lone wolves. As far as I know, all EAs are united against this kind of thing.) There are three reasons not to bomb coal plants/data centers/etc. The first is that bombing things is morally wrong. I take this one pretty seriously. The second is that terrorism doesn’t work. Imagine that someone actually tried to bomb a data center. First of all, I don’t have statistics but I assume 99% of terrorists get caught at the “your collaborator is an undercover fed” stage. Another 99% get eliminated at the “blown up by poor bomb hygiene and/or a spam text message” stage. And okay, 1/10,000 will destroy a datacenter, and then what? Google tells me there are 10,978 data centers in the world. After one successful attack, the other 10,977 will get better security. Probably many of these are in China or some other country that’s not trivial for an American to import high explosives into. The third is that - did I say terrorism didn’t work? I mean it massively massively backfires. Hamas tried terrorism, they frankly did a much better job than we would, and now 52% of the buildings in their entire country have been turned to rubble. Osama bin Laden tried terrorism, also did an impressive job, and the US took over the whole country that had supported him, then took over an unrelated country that seemed like the kinds of guys who might support him, then spent ten years hunting him down and killing him and everyone he had ever associated with. One f@#king time, a handful of EAs tried promoting their agenda by committing some crimes which were much less bad than terrorism. Along with all the direct suffering they caused, they destroyed EA’s reputation and political influence, drove thousands of people away from the movement, and everything they did remains a giant pit of shame that we’re still in the process of trying to climb our way out of. Not to bang the same drum again and again, but this is why EA needs to be a coherent philosophy and not just IPA++. You need some kind of theory of what kinds of activism are acceptable and effective, or else people will come up with morally repugnant and incredibly idiotic plans that will definitely backfire and destroy everything you thought you were fighting for. EA hasn’t always been the best at avoiding this failure mode, but at least we manage to outdo our critics. VI. Stone moves on to animal welfare: It’s important to grasp that [caring about animals] is, in evolutionary terms, an error in our programming. The mechanisms involved are entirely about intra-human dynamics (or, some argue, may also be about recognizing the signs of vulnerable prey animals or enabling better hunting). Yes humans have had domestic animals for quite a long time, but our sympathetic responses are far older than that. We developed accidental sympathies for animals and then we made friends with dogs, not vice versa. Again, this is part of why I think it’s useful to have people who think about philosophy, and not just people who do RCTs. People having kids of their own instead of donating to sperm banks is in some sense an “error” in our evolutionary program. The program just wanted us to reproduce; instead we got a bunch of weird proxy goals like “actually loving kids for their own sake”. Art is another error - I assume we were evolutionarily programmed to care about beauty because, I don’t know, flowers indicate good hunting grounds or something, not because evolution wanted us to paint beautiful pictures. Anyone who cares about a future they will never experience, or about people on far off continents who they’ll never meet, is in some sense succumbing to “errors” in their evolutionary programming. Stone describes the original mechanisms as “about intra-human dynamics”, but this is cope - they’re about intra-tribal dynamics. Plenty of cultures have been completely happy to enslave, kill, and murder people outside their tribes, and nothing in their evolutionary mechanism has told them not to. Does Stone think this, too, is an error? At some point you’ve got to go beyond evolutionary programming and decide what kind of person you want to be. I want to be the kind of person who cares about my family, about beauty, about people on other continents, and - yes - about animal suffering. This is the reflective equilibrium I’ve landed in after considering all the drives and desires within me, filtering it through my ability to use Reason, and imagining having to justify myself to whatever God may or may not exist. Stone suggests EAs don’t have answers to a lot of the basic questions around this. I can recommend him various posts like Axiology, Morality, Law, the super-old Consequentialism FAQ, and The Gift We Give To Tomorrow, but I think they’ll only address about half of his questions. The other half of the answers have to come from intuition, common sense, and moral conservatism. This isn’t embarrassing. Logicians have discovered many fine and helpful logical principles, but can’t 100% answer the problem of skepticism - you can fill in some of the internal links in the chain, but the beginning and end stay shrouded in mystery. This doesn’t mean you can ignore the logical principles we do know. It just means that life is a combination of formally-reasonable and not-formally-reasonable bits. You should follow the formal reason where you have it, and not freak out and collapse into Cartesian doubt where you don’t. This is how I think of morality too. Again, I really think it’s important to have a philosophy and not just a big pile of RCTs. Our critics make this point better than I ever could. They start with “all this stuff is just common sense, who needs philosophy, the RCTs basically interpret themselves”, then, in the same essay, digress into: If I wanted to do this stuff, I would try terrorism.
Inline links: “value of movement growth”, managed to get plenty done with only 10,000 people, source, https://substackcdn.com/image/fetch/$s_!kkAy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Fa7c07ed1-bf2c-4faf-a990-cd0a4b8543fd_909x662.png, Giving What We Can’s List Of Misconceptions About Effective Altruism, Israel bombing Iraq’s nuclear program, I take this one pretty seriously, a spam text message, Axiology, Morality, Law, Consequentialism FAQ, The Gift We Give To Tomorrow