A single-parent family of three in New York, making $8000 per year, makes under half the income level of the Federal poverty line and qualifies for food stamps, TANF (direct cash benefits) and Medicaid. (Details at our guide to U.S. public assistance)

And yet, at $2,667 per person per year, this family is wealthier than 70% of the people in the world. (See the Global Rich List calculator as well as the Giving What We Can version, which may be using more up-to-date data.)

In the poorest parts of the world, fewer than half have access to a latrine or toilet; only 17% own a television; and 19-45% lack access to a reliable source of clean water. In the U.S., practically everyone has all three. (Details.) As we wrote yesterday, the two areas have completely different concepts of “hunger.” And finally, while anyone in the U.S. can ultimately be served in an emergency room, people across the world die or suffer from health conditions for which proven solutions exist.

In the U.S., helping the less fortunate usually means tackling a thorny “equality of opportunity” problem such as improving education or helping struggling adults to find and retain jobs. These problems have a long history of failure and few proven approaches to them. By contrast, helping people overseas can mean delivering something as proven and life-changing as a bednet or tuberculosis treatment.

Hopefully, these observations give some context on why a charitable dollar goes so much further overseas. If you are looking to use your wealth to help those less fortunate, we believe it’s hard to argue the case for U.S. as opposed to international charity, unless you believe that American lives are orders of magnitude more valuable.

There has been a fair amount of buzz lately (examples here, here, here, here) about “food insecurity” in the U.S. According to the Reuters headline, one in seven Americans is short of food. In looking into the data, what has surprised us is how different the meaning of “hunger” is when we’re talking about the U.S. vs. the developing world.

Developing-world hunger: 30% of children underweight

Developing-world hunger is usually discussed in terms of incredibly severe indicators of hunger. For example, a 2008 Lancet study estimates that

• 32% of under-5 children in developing countries are “stunted” (height-for-age severely below normal, such that only 2.3% of children should be “stunted” in a normal distribution)
  
• 20% are “underweight” (weight-for-age severely below normal, such that only 2.3% of children should be “underweight” in a normal distribution)
• 3.5% are “wasted” (weight-for-age even more severely below normal, such that only 0.13% of children should be “wasted” in a normal distribution).

These are indicators of severe, long-term consequences of constant undernutrition for young children.

Food insecurity in the U.S. means anything other than complete and constant food security

The recent USDA release that has formed the basis of the recent discussion of U.S. hunger states:

Eighty-five percent of American households were food secure throughout the entire year in 2008, meaning that they had access at all times to enough food for an active, healthy life for all household members. The remaining households (14.6 percent) were food insecure at least some time during the year, including 5.7 percent with very low food security—meaning that the food intake of one or more household members was reduced and their eating patterns were disrupted at times during the year because the household lacked money and other resources for food. (Emphasis mine)

The report’s summary specifies that food insecurity is usually temporary as opposed to chronic (pg 9) and that children are usually protected from food insecurity even in food-insecure households (pg 6-7).

The “food insecurity” categories are derived from people’s answers to questions like “We worried about whether our food would run out before we got money to buy more” and “We couldn’t afford to eat balanced meals” (full list on pg 3). The details of the answers are found on page 45:

These data imply that anything approaching the sort of hunger measured in the developing world is practically nonexistent in the U.S.

Note in particular the difference regarding children. In the developing world, as shown above, severe child hunger is rampant. In the U.S., even in “food insecure” families, it’s extraordinarily rare for children to go hungry even temporarily. And indeed, World Bank data estimates that 1.3% of U.S. children under 5 are “underweight” - less than the 2.3% that would be expected in a fully normal distribution.

Also note that the USDA report estimates costs for different levels of “food plans” (pg 55), and that its “Thrifty” plan - the cheapest - ranges from $21-$40 per week ($3-$6 per day) depending on age. In the developing world, meanwhile, over 2.5 billion people are estimated to live on less than US$2.50 a day total.

Bottom line

We have no intention of trivializing the situation of those in poverty in the U.S. But for a donor making choices, it can be stunning to see what a different meaning “hunger” takes on when applied at home vs. abroad. Do you value the lives of Americans so much more that you’d rather help people with the second kind of hunger than people with the first?

When we argue that donors should give internationally, one of the most common questions we get is, “Sure, you may be able to save a life in Africa, but what type of life are you saving? If you save a child from malaria will s/he likely die from something else soon after? Will s/he suffer from other problems that significantly reduce his/her quality of life?”

We recently published a report on standard of living in the developing world that tries to answer that question. It looks at what facts are available from relatively broad, plausibly representative studies to answer “what is life like in a poor country?” Here’s a summary of what we learned:

• There’s a strong cross-country correlation between income and reported happiness. The Gallup Poll asked people around the world to rate their life satisfaction on a scale from 1 (the worst) to 10 (the best). People in poor countries are less satisfied with their lives (they ranked their satisfaction as 4.3 out of 10, while rich country residents ranked theirs as 6.7). (More at our review of the Gallup World Poll data.)
• A child who lives past his/her 5th birthday will likely live a full life. Child mortality is much higher in poor countries than in rich countries. But those who live past age 5 have nearly a 70% chance of living until age 60. (More at our overview of life expectancy in the developing world.)
• Most people in the developing world do not have AIDS, river blindness or other severe chronic conditions. Many of the diseases commonly associated with the developing world are fairly rare across all developing counties. Fewer than 1 out of 100 people have HIV/AIDS, 1 out of 40 have lymphatic filariasis, and about 1 out of 2,700 have river blindness. (More on the prevalence of disease in the developing world.)
• Less severe chronic conditions, such as malnutrition and parasite infections, are very common. For example, about a third of children are stunted (significantly shorter than normal due to undernutrition). We are not sure to what extent stunting and other results of a poor or inadequate diet are likely to affect a child’s standard of living over the long term. (More on non-fatal health problems.)
• Incomes are low, but discretionary spending does exist even among the poorest. People in extreme poverty (defined in the past as under US $1 a day of income) do not spend every “additional dollar” on additional food; they frequently own TVs and radios and participate in festivals. (More on what it means to live on less than $1 or $2 per day)

Bottom line

On one hand, people in the developing world have a tangibly lower quality of life. On the other hand, a life saved probably means many more years of functional life. We feel strongly that it’s worth addressing a major problem (such as tuberculosis or immunizations) even if other problems remain unaddressed.

You donate some money to a charity in the hopes that it will (a) carry out a project that (b) improves people’s lives. In order to feel confident in your donation, you should feel confident in both of these.

In most areas of charity, we feel that people overfocus on “did it happen?” relative to “did it work?” People often worry about charities’ stealing their money, swallowing it up in overhead, etc., while assuming that if the charity ultimately uses the funds as it says it will, the result will be good. Yet improving lives is more complicated than charities generally make it sound (see this recent post of ours). This partial list of failed programs is made up entirely of programs that appear to have been carried out quite competently, and simply didn’t improve the lives of clients.

In international aid, the relative importance of “did it happen?” grows for a couple of reasons:

• International charities work far away and often in many different countries at once. It often isn’t feasible for their main stakeholders (Board members, major donors, etc.) to check that projects are being carried out.
• International charities are working within foreign political systems, cultures, etc. Materials can be stolen or misappropriated en route. Locals can take advantage of their superior knowledge and “game the system.”
• Many of the activities international charities carry out are proven to work (though many are not as well). Using insecticide-treated nets will reduce risk of malaria (more); an appropriate drug regimen will cure tuberculosis (more); vaccinations will prevent deadly diseases (writeup forthcoming). These claims have been proven and are essentially not subject to debate. This is not the case in the developed world - most of the programs charities work on have not been shown to improve outcome measures of health, standard of living, etc. (See, for example, this guest blog post.)

“Did it happen?” is a question that can largely be answered by informal, qualitative spot-checks. That’s why we would like to see more and better qualitative evidence. By contrast, to know whether a program worked, you need to somehow compare what happened to clients with what would have happened without the program - something that is often hard to have confidence in without formal outcomes tracking and evaluation.

Therefore, we believe that the role of site visits, qualitative evidence, spot-checks, etc. is likely more important in international giving than in domestic giving. In international aid, delivering proven programs (particularly medical ones) is a large part of the battle. In the U.S., most reputable charities are probably doing what they say they’re doing; the question is whether what they’re doing is effective.

Education used to be my favorite cause. My enthusiasm waned as I saw both the cost-effectiveness of international aid and the apparent futility of education. (Elie’s 2007 post captures many of my thoughts.) The study that I’ve been blogging about today (here and here) provides a firmer grounding for our optimism about high-intensity charter schools, and challenges the idea that there aren’t good opportunities for donors in education.

However, I’m still not ready to prioritize education again, personally. One of the things that surprised me most in studying education was not just the difficulty in finding programs that could improve academic performance, but also the complete lack of rigorous evidence that education is key to later life outcomes. I would be fascinated to see a rigorous study of how the students who benefit from excellent charter schools perform later in life - in terms of income, job satisfaction, criminal records, etc. Without evidence, I’m not convinced that raising a child’s math score raises their life prospects, especially in a way that goes beyond “signaling” (i.e., allowing them to outcompete other people due to a superior credentials).

Would putting every child in America in a good school that makes sure they can do math lead to a much better society? I used to assume it would; I’m no longer so sure, and recent information doesn’t change that.

For now, I’m going to wait and see. I’d like to see the academic reaction the Fryer and Dobbie paper on the Harlem Chilren’s Zone. If others agree about the rigor and significance of its findings, I’d like to see who steps forward to continue replicating and examining this approach. The Social Innovation Fund would seem to be one strong candidate.

In the meantime, I’m going to be putting my own money into programs that are proven and replicable and don’t have enough funding - things like tuberculosis control and distribution of insecticide-treated nets.

Perhaps, at some point, I will feel that there is an education program that meets all three of these criteria as well. At that point I may start giving to it, even if it’s many times as expensive per person as developing-world aid.

Related posts:

• Fryer and Dobbie on Harlem Children’s Zone: what they found
• Fryer and Dobbie on the Harlem Children’s Zone: significance
• Followup on Fryer/Dobbie study of “Harlem miracle”