The cause of “water” is one of the more (initially) emotionally appealing, and probably marketable, causes in developing-world aid. Here are some thoughts on the cause, fresh off of reading the Copenhagen Consensus report on it:

From what I’ve seen - both in terms of water-related literature and in terms of general morbidity data - outright lack of water (i.e., dehydration in otherwise healthy people) is not a widespread problem. If you know of data showing otherwise, even for particular parts of the world, please share. However, I think most water and sanitation projects are instead concerned with:

1. Access to convenient water sources. Some people lose hours to maintaining their filters and/or boiling their water for cleanliness; people who live far from water sources can lose far more time (see Pg 11 of the Copenhagen Consensus report for a stark example). Improving water infrastructure may therefore free up time and make them economically better off. However, when this is the goal, it seems important to consider not only how much time potential beneficiaries would save, but how much this time is worth (i.e., what else they could do with it). Depending on market and/or weather conditions, extra time may not translate into extra money, or into much extra quality of life.

2. Access to clean water. Contaminated water can contribute to a variety of diseases that generally cause severe diarrhea (see Pg 34). However, it’s important to note that:

• Water is not the only source of contamination, and clean water alone - when unaccompanied by other sanitation interventions - can only dent the burden of these diseases (again see Pg 34).
• There are a variety of ways to purify water at the “point of use,” some of which - like boiling - are extremely simple and relatively inexpensive (see Pgs 90-91).
• Communities that suffer from contaminated water may also suffer from a host of other health problems (such as malaria and malnutrition) that can be at least as damaging as waterborne infections, while having solutions (such as supplementation, bednets, etc.) than are far cheaper and simpler than the provision of clean water.

In our first year, we saw no cases of well-documented water-focused projects that address key questions such as whether water quality and use were verified, whether an effect on quality of life was documented, etc. Literature on past programs’ effects also seems relatively thin.

At this point, I think of water projects as being pretty far from the sort of “proven, effective, scalable” programs we are looking for. If I change my mind, it will likely be for a program in the first category - providing water to people who otherwise would be spending inordinate amounts of time retrieving it - rather than for a program focusing exclusively on clean water.

If you could accomplish any of the following for the same cost, which would you choose?

(1) Prevent 100 deaths-in-infancy, knowing that in all likelihood these 100 people will grow up to have consistently low income and poor health for their ~40-year-long lives.

(2) Provide consistent, full nutrition and health care to 100 people, such that instead of growing up malnourished (leading to lower height, lower weight, lower intelligence, and other symptoms) they spend their lives relatively healthy. (For simplicity, though not accuracy, assume this doesn’t affect their actual lifespan - they still live about 40 years.)

(3) Prevent one case of relatively mild non-fatal malaria (say, a fever that lasts a few days) for each of 10,000 people, without having a significant impact on the rest of their lives.

For me, the answer is definitely #2. I am very excited by the idea of changing someone’s life in a lasting and significant way (2); I’m much less excited by the idea of a temporary, less significant life change (3), and I don’t think that the quality of a life equals the sum of the quality of the days in it. (1) excites me the least - I just don’t put that much value in “potential lives” (I think the death of a 20-year-old is more tragic than the death of an infant), and I especially don’t put much value in saving “potential lives” riddled with health problems.

I’m not interested in having a long philosophical argument about the validity of my views. I believe that different donors likely have fundamentally different values that you can’t change by throwing any number of thought experiments or philosophical abstractions at them. Our research will aim to serve as many different sorts of donors as possible, rather than holding up one philosophical value set as the “rational” one. But I am interested in what others think, and whether my attitude is common or rare.

To give a quick sense of the practical relevance of this question: programs targeted directly at under-5 mortality (including some vaccination programs and some micronutrient programs) are much more likely to get you (1)-type results; programs that distribute bednets or other health materials en masse are more likely to get you (3)-type results; an economic empowerment program (particularly focused on improved farming techniques) may aspire to (2)-type results, but I believe that these types of results are the most difficult and expensive to bring about.

Over the last few days I have been wondering just how severe and how fixable developing-world malnutrition may be. For a striking illustration, see “Grandmothers and Granddaughters: Old Age Pension and Intra-household Allocation in South Africa” by Esther Duflo.

This paper analyzes a survey of 9000 families in the early 1990s in South Africa, when a public pension program was broadened significantly, and tries to look at how the program (significant cash transfers to low-income, elderly people) affected child nutrition. Its key argument is that cash transfers to women significantly improved the nutrition of female children (but that cash transfers to men had no discernible effect on child nutrition).

I’m not convinced that the data support this argument (my chief concern is Figure 1, which makes it look like the children of eligible women got healthier before but not more than other children, and that the observed effect is an artifact of the time period studied). However, the argument reflects three key themes that, from the paper’s references and a few other things I’ve seen, seem to have significant research supporting them:

1. Malnutrition is widespread and severe among the very poor. Table 3 shows that prior to the program’s expansion, these low-income South African children were far shorter (for their age) than American children: their height-for-age averaged around -1.5 standard deviations (under standard assumptions, this would put the average South African child around the 7th percentile of American children). Height-for-age is strongly linked to nutrition in early childhood, as Duflo explains (with references) starting on Page 13.

2. Curbing malnutrition is not necessarily a thorny problem. Regardless of whether Duflo’s hypothesis about female vs. male recipients is correct, there is no question that the height gap described above fell sharply (down to 0.5 standard deviations, which corresponds to the 30th rather than 7th percentile of the general population) after the introduction of the pension program. Bear in mind that the program was no elaborate health intervention, but merely a cash transfer to families.

3. In the developing world, not all household income is equivalent. Duflo argues that income that comes to women is more likely to improve children’s health. This is the most questionable claim in the paper for me (for reasons outlined above), but the general idea is also argued in this study of Cote d’Ivoire, and possibly in other literature as well; this would give some explanation of why so many microfinance programs explicitly focus on women.

We completed our first year of research a few weeks ago, and are now starting up our second. (Our annual review and plan discuss what we’ve learned from our first year, and the many ways in which we’re changing our approach for year 2.)

We found some strong organizations the first time around, but our “bottom-up” approach (counting on our applicants to tell us about their activities) left us with a very partial picture of things. At this point we’re basically starting over, and trying to answer the following questions:

1. What are all the obstacles faced by people in different parts of the developing world?

I want to know as much as possible about the groups of people we’re helping (not just the diseases we’re fighting), because this helps us to (a) form better guesses about the most important problems to focus on; (b) focus on areas where a little aid goes a long way; (c) paint a picture for donors of what sort of difference a good program can make, beyond the usual idealized anecdotes or “cost per life/DALY saved” figures. (For example, when you save a life from malaria, what sort of a life is it? When you help improve someone’s income, what does that mean for what they’re able to buy?)

Ideally, we would know the following about as many different parts of the developing world as possible:

• Full details of the prevalence and severity of different health problems, including diseases (HIV/AIDS, tuberculosis, malaria, diarrhea, pneumonia, and NTDs), malnutrition (vitamin A deficiency, anemia, low weight-for-height and height-for-age), vision problems (including cataracts), and deformities (including cleft palate and obstetric fistula)
• Availability, and cost, of basic quality-of-life goods and services including health care, water, sanitation, electricity, financial services (savings, loans, insurance), and basic entertainment (televisions, radios, festivals).
• Availability, quality, and content of schooling.
• Common occupations, along with necessary skills/qualifications for each. I’m particularly interested in what it would take for someone to improve their occupation and income (are there plenty of opportunities if only they had basic help, along the lines of nutrition assistance or financial services? Or is the set of possible jobs highly limited?)
• What people most want to change about their lives, and what they most want help with.

I’ve been reading academic papers that answer some of these questions for certain areas using survey data; I’ve also talked to a couple of people who’ve spent significant time in the developing world, just to get a basic picture. I’ll share what I’ve learned so far in a future post.

2. What impact do different health problems generally have?

There are some diseases, such as AIDS, that we have a fairly good picture of in terms of their impact on quality/length of life. There are others - particularly the NTDs - that we know very little about. We need to examine enough medical literature to have a good sense of what possible symptoms are associated with different diseases, as well as a basic idea of how different health problems interrelate (for example, the extent to which malaria increases susceptibility to HIV/AIDS).

3. What are the most promising interventions and charities?

Answering #1 and #2, at least for some parts of the world, should have a major effect on how we think about #3, so we are focusing on #1 and #2 for now. The goal is to start with people and places, rather than programs. However, we want to make sure we’re checking out any particularly highly recommended, or otherwise promising, programs we come across (for example, recently we took a look at the Fred Hollows Foundation on several people’s recommendation).

We don’t expect to get anywhere close to “answering” all of the above questions, but that’s our framework for learning as much as we can to frame our investigations of charities. We have a lot of work to do. We’ll be sharing our findings as we go.

The goal of GiveWell is to help a large chunk of individual giving to become more effective (i.e., to help people more). As such, the two most important questions about our project are:

1. Can we produce useful, actionable research for donors?
2. Will donors use it?

Our first year was focused on #1. We raised money only from people who knew us, because we had no track record and no existing research to point to. We told our donors that if they funded our startup, we would produce a first set of useful, actionable reports for donors. We’ve now done that.

Now the big question is whether our research can move a lot of donations. The bottom line about GiveWell is that if our research ends up influencing a lot of people’s giving, the project will work: sharing information will be worth charities’ time, and doing research will be worth our time and expense. If we can’t influence donors, then our research isn’t worth doing, and we’ll rightly go out of business. We’re not going to answer this question fully in the coming year, but we’re hoping to get a start on it.

That’s why we’re introducing the GiveWell Pledge, which aims to demonstrably increase our influence while preserving donor choice. A GiveWell Pledge is a formal, advance commitment to give to one or more of the charities we recommend after an additional year of research. The donor gets the final choice of charity, and pays no fee to us, but we get the benefit of being able to (a) show exactly how much money we’re moving; (b) show our direct donors, the ones who pay our operating expenses, whether we’re succeeding in our mission; and (c) show the charities we’re asking for information what’s in it for them.

This is different from the model used by philanthropic advisors (in which donors pay extra for research) and from the model used by independent evaluators (which have no “carrot” to get detailed information from charities). We’re hoping it will maximize our chances of doing research that is both thorough and sustainable. For more, see our official plan for the coming year.

We’ve been releasing a lot of new material over the last few weeks, and I want to make sure that our blog readers are aware of it. GiveWell.net now includes:

• New research reports and charity recommendations on three causes.
  • Global Poverty: includes a thorough review of the logical and empirical case for microfinance. We have no recommended organization (though we awarded our grant in this cause to Opportunity International) due to how little information we were able to get from large MFIs.
  • Early childhood care: we recommend the Nurse-Family Partnership, an exceptional organization replicating a proven program.
  • K-12 education: we recommend the Knowledge is Power Program and Teach for America, though we believe that early childhood care (specifically the Nurse-Family Partnership) is a more promising approach to promoting equality of opportunity than either of these.
• New summaries of our research, which give the highlights rather than the details: see our summary of findings for all five causes, as well as our overviews of equality of opportunity in the U.S. and developing-world direct aid.
• A thorough review of the successes, shortcomings, and lessons from our first year, as well as our plan for the coming year.
• An overview of our modified funding model, the GiveWell Pledge. More on this in a future post.

Several people have recommended that we look at the Fred Hollows Foundation. We have been shown calculations implying that they are preventing or curing a person’s blindness for every $20-60 they spend. As we continue our research on developing-world aid, we checked them out a bit ourselves.

The Fred Hollows Foundation’s programs include surgeries to cure blindness caused by cataracts and trachoma. These surgeries are relatively straightforward and can therefore be performed relatively inexpensively (at less than $10 per trachoma surgery, according to the Diseases Control Priorities Project). But the cost per surgery doesn’t tell the whole story - for example, we also want to know:

• How bad would patients’ vision be without surgery? While improving someone’s sight is always valuable, “curing blindness” means something very different to me from helping someone who previously had vision in one eye, or slightly impaired vision in both.
• How old the people are who receive the surgeries? Again, curing blindness always has some value, but it means more to me when it means giving someone a full life of healthy vision (or when it helps someone to care for their dependents).

The Fred Hollows Foundation conducted a 65-person post-operative survey in Cambodia that sheds light on the above questions. (You can see the full report here; this is the only survey of its kind that I found on their website.)

• 44% of those who received surgeries had been able to work before undergoing surgery, as they were “usually only blind in one eye or had some vision in both eyes” (Pg 11).
• 77% of those who received surgeries were over the age of 60 and another 21% were over the age of 41 (pg 10).

I’m excited by the idea of vision correction surgery; it’s cheap and tangible, even considering the above. But these sorts of details about who is being helped significantly change my idea of what you get for your donation with this kind of program, and I’m far from convinced that it ultimately represents a better “value” than our current top health-related charities.

The Career Academies initiative recently released a report on academies’ impact on students eight years after graduation. I’m fascinated by this report and this initiative because:

The Career Academies initiative rejects conventional wisdom about education.

For much of my life I’ve assumed that learning math, reading, and other “liberal arts” related skills is the key to later success in life. All of the K-12 education-focused charities we’ve examined appear to have the same unspoken assumption, stressing the importance of academic success (and generally measuring success through outcomes such as graduation rates and test scores). Last year, however, we started questioning this basic logic (for which we’ve found no empirical support).

Career Academies, while not ignoring academics, explicitly focus on preparing students for specific jobs (for example, see the Introduction of the full report recently released). And according to the evaluation, they are improving students’ earnings without improving their graduation rates or test scores (more below). Rather than assuming that the academic gap is at the heart of the achievement gap, this initiative is going straight after the latter.

The evaluation design used by Career Academies causally connects education with later life outcomes.

None of the K-12 education-focused charities we’ve examined make any attempt to examine later life outcomes, particularly earnings. Only three of them use the kind of experimental design that points strongly to effects of the program, rather than to selection bias issues. The Career Academies evaluation does both - making it the only study I know of that can plausibly discuss the effects of a particular K-12 program on the outcomes we really care about (not test scores, but earnings).

Randomized lotteries were used to assign the limited number of slots at Career Academies, and the lotteried-out students were compared to lotteried-in students a full eight years after graduation. We’re still waiting for the “technical” companion to the evaluation to be published so we can fully examine the methodology, but according to Evidence-Based Programs, the study had important strengths such as low attrition and an intention-to-treat approach that imply that any differences between the two groups (lotteried-in and lotteried-out) can be attributed to the effect of the schools themselves. It found that lotteried-in students report over $200/mo more in earnings (see Pg 13 of the full report), and that Career Academies students report higher earnings whether they’re classified as high-, medium-, or low-risk students (Pg 26).

This benefit came despite no apparent impact (see Pgs 28-32) on traditional measures of educational progress, including test scores, graduation rates, and college enrollment/completion. (Also note that these measures show enormous selection bias; a less rigorous, more typical study would have erroneously concluded that Career Academies do affect academic performance.)

I wish we’d discovered Career Academies earlier, and checked it out as thoroughly as our K-12 applicants. Rather than chasing small (or perhaps illusory) improvements in test scores and/or graduation rates, in the hopes that classic unproven assumptions about the importance of a high school education are correct, we might have funded an intervention with a truly different approach and a truly thorough commitment to making sure it’s changing lives, not just grades.

The National Academy Foundation focuses on the Career Academies approach. We haven’t done a thorough investigation of it, but you might want to check it out.

We haven’t seen - either in charities’ grant application materials or in our own independent research - much discussion of how organizations decide where to focus their resources. This question seems particularly important for international aid organizations, which often work in many regions all over the world (but by necessity have to ignore many more).

When thinking about this question myself, one of the criteria that occurs to me is the triage approach: find regions where a little bit of aid goes a long way. For example, let’s say we’re trying to decide where to expand malaria-centered interventions (such as insecticide-treated bednets). Niger, Guinea, Malawi, and Zambia are all countries with relatively high malaria mortality rates (0.17-0.2%, mostly concentrated among young children). However, Malawi and Zambia also have severe problems with HIV/AIDS: approximately 15% of the adult population is HIV positive and 0.6-0.9% of the total population dies from AIDS each year in these countries. By contrast, Niger and Guinea are significantly less affected by this disease (1-1.5% HIV positive, 0.04%-0.1% mortality rate).

From these numbers alone (and of course there is much more to the story), I’d prefer to expand a malaria-focused intervention in Niger or Guinea than in Malawi or Zambia. Our aim is to help people live fully enabled lives; resolving one problem, in an area where that problem is the primary obstacle a person faces (because s/he can now live a fully enabled life), will have a greater impact than resolving one problem where it is one of many a person faces. I’d prefer to protect children who won’t have to grow up with so much to fear from HIV/AIDS, if I have to choose (and I do).

Of course, to really make this sort of analysis work you need to look at a lot more than by-country rates for two diseases; you need to look at smaller regions (which can vary wildly within a country) and get a full sense of the different problems people face, including not only mortality risks but more general health problems (such as malnutrition), access to education and economic opportunity, and political stability. The goal is to find places where a humanitarian intervention can truly make the difference in giving someone a life of opportunity (not just solve one of an overwhelming set of problems).

References:

• Mortality data (2002 estimates) comes from the WHO’s Burden of Disease Project, available here.
• HIV prevalence data comes from UNAIDS and the WHO’s Report on the Global AIDS Epidemic. We accessed it through Gapminder. You can download it here.

I came across an interesting article on microfinance by Tyler Cowen. Like us, Cowen is skeptical about the common anecdotes focusing on the “entrepreneurial” aspect of microfinance:

For better or worse, microborrowing often entails a kind of ­bait ­and ­switch. The borrower claims that the money is for a business, but uses it for other purposes. In effect, the cash allows a poor entrepreneur to maintain her business without having to sacrifice the life or education of her child. In that sense, the money is for the business, but most of all it is for the child. Such life­saving uses for the funds are obviously desirable, but it is also a sad reality that many microcredit loans help borrowers to survive or tread water more than they help them get ahead. This sounds unglamorous and even disappointing, but the ­alternative —­ such as no doctor’s visit for a child or no school for a ­year —­ is much ­worse.

This account is broadly in line with the position we’ve taken on what microfinance is (likely a very good thing for many disadvantaged people) and what it isn’t (the “make a loan, expand a business” picture that is often used to market it). What’s great about the article is that having made this distinction, it then goes on to give a detailed qualitative picture of how microfinance can actually help people:

Commentators often seem to assume that the experience of borrowing and lending is completely new for the poor. But moneylenders have offered money to the world’s poor for millennia, albeit at extortionate rates of interest. A typical moneylender is a single individual, ­well-­known in his neighborhood or village, who borrows money from his wealthier connections and in turn lends those funds to individuals in need, typically people he knows personally. But that personal connection is rarely good for a break; a moneylender may charge 200 to 400 percent interest on an annualized basis. He will insist on collateral (a television, for instance), and resort to intimidation and sometimes violence if he is not repaid on time. The moneylender operates informally, off the books, and usually outside the ­law.

…if you want to know how much net saving is going on, don’t look at money. Banks may be a ­day­long bus ride away or may be plagued, as in Ghana, by fraud. A cash hoard kept at home can be lost, stolen, taken by the taxman, damaged by floods, or even eaten by rats. It creates other kinds of problems as well. Needy friends and relatives knock on the door and ask for aid. In small communities it is often very hard, even impossible, to say no, especially if you have the cash on ­hand…. Under these kinds of conditions, a cow (or a goat or pig) is a much better medium for saving. It is sturdier than paper money. Friends and relatives can’t ask for small pieces of it…. With a small loan, people in rural areas can buy that cow and use cash that might otherwise be diverted to less useful purposes to pay back the microcredit institution. So even when microcredit looks like indebtedness, savings are going up rather than down.

This qualitative account helps me understand how it is that microfinance can be a worthy intervention, even when clients are carrying persistent debt loads at high interest rates (as they often are). For any region where the picture painted by Cowen holds - i.e., when the only source of credit is moneylenders charging exorbitant interest rates and using the threat of violence - I would happily invest in a microlending program.

But I know there’s at least one good example of a microfinance program that came into a region where credit wasn’t already scarce - and consequently failed to have any noticeable impact. In my mind, this “what are you replacing?” question is one of the very most important questions for a microfinance program - and one that we haven’t seen any organization provide strong documentation on.

I believe that most discussion of microfinance - by nonprofits, by the media, and by donors - is frustratingly superficial, focusing on extreme success stories and simple statistics like the “repayment rate,” rather than on getting a real picture of where microfinance is helping and where it isn’t. Cowen’s take is refreshing, and with more conversation along these lines I hope we can get a better picture of an extremely promising intervention.

Our first year of research implied, to me, that donors can have more impact focusing their giving on the developing world as opposed to the developed world. In a nutshell, developed-world interventions are expensive and the case for their effectiveness is often questionable, while developing-world interventions are often inexpensive and seemingly more reliable.

However, the fact that people in the developing-world face a diverse set of complex, interrelated problems means that well-intentioned interventions can easily have little effect if they’re not properly implemented.

A recent paper (Hotez 2008) may describe a unique opportunity for donors, however. Hotez discusses the existence of Neglected Tropical Diseases (diseases that are by-and-large not life threatening but can significantly disable adults and impair children’s physical and cognitive development) in the United States.

Hotez finds that these diseases largely affect those living in extreme poverty in six regions of the United States: Appalachia, the American South, the Mississippi Delta (including post-Katrina New Orleans), inner cities, Native-American tribal lands in the Southwest, and communities along the U.S.-Mexico border (see his map here). Hotez emphasizes the problems of:

• Helminth (parasitic worm) diseases, which can lead to malnutrition, anemia, and growth and cognitive delays (Hotez et al 2007). These diseases affect a few million people in Appalachia, the American South, and inner cities (see his table here)
• Dengue fever (which can be fatal) and Chagas disease (which can lead to a serious heart problems, (Hotez et all 2007)), which affect a few hundred thousand people in Appalachia and post-Katrine Louisana (see table linked above).

Many of these conditions can be treated with simple, proven interventions that charities distribute in the developing-world. For example, Albendazole can treat helminths, and costs pennies (see Molyneux, Hotez & Fenwick 2005). In addition, basic efforts to control vectors (such as rats and mosquitoes) and improve access to water and sanitation infrastructure may significantly reduce the burden of these diseases.

Since we just came across this paper, we know little about how viable an option this is for individual donors - a quick Google search didn’t turn up any charities obviously attacking these problems in the United States - but we’ll keep our eyes open for one. Fighting these diseases in the developed-world seems like a great option for a donor seeking the biggest impact by using the triage approach: helping those who can benefit most easily.

References:

1. Hotez PJ (2008) Neglected Infections of Poverty in the United States of America. PLoS Neglected Tropical Diseases 2(6): e256 doi:10.1371/journal.pntd.0000256 (Available online)
2. Molyneux DH, Hotez PJ, Fenwick A (2005) “Rapid-impact interventions”: How a policy of integrated control for Africa’s neglected tropical diseases could benefit the poor. PLoS Med 2(11): e336. (Available online)
3. Hotez, PJ., Molyneux, DH., Fenwick, A., Kumaresan, J., Sachs, SE., Sachs, JD., Savioli, L. (2007) Control of Neglected Tropical Diseases N Engl J Med 357: 1018-1027. (Available online)