The GiveWell Blog

The triage approach

One of the things we need to do, as a transparent grantmaker, is to take the intuitions and biases that make us prefer one charity over another and make them explicit, so that everyone is aware (as much as possible) of the principles that drive us. I’m going to be doing this “out loud” on our blog; please bear in mind that what I write here is unfiltered and personal (i.e., I am expressing my own views, not those of The Clear Fund, whose short-term decisions involve Elie and whose ultimate decisions involve the entire Board).

As I explore different approaches to our five causes, I’m realizing that many of the most difficult calls to make are between organizations that serve fundamentally different populations with different needs – for example, how do you choose between an organization that provides job training for people right on the brink of employability and one that provides a comprehensive set of services for people with more complex issues (including substance abuse, mental health issues, etc.)? When I run up against these questions, the approach that keeps popping into my head is that of a wartime triage.

We’re all familiar with the idea of helping those who need it most, but when resources are scarce (as in wartime, and charity), that’s not all there is to it. As Wikipedia so helpfully explains, there are times when the protocol is instead to help people who have better odds of survival (i.e., people who need less help) – because more lives can be saved that way. That means diverting resources from most wounded to those whose injuries are more treatable. The question becomes not just “What will happen to you if I don’t help?”, but also “What will happen to you if I do?”

You might think a charity that seeks out people who need just a little help is “cherry-picking.” But to me, this seems like a great approach. If we have one set of people stuck in poverty for a simple, stupid, easily fixed reason and another stuck in poverty for a whole complex of reasons – it makes sense to focus on the first group first.

This is cold, of course, and it’s unnerving to think of things that way. That’s why you rarely hear the idea of “helping those who can benefit more easily” – it’s a concept reserved for the direst of conditions, when there’s really no other choice. But to me, the state of the world is exactly that. There are more people in need than we can help. We need to think of charity not as a service to ease our guilt or give us warm feelings, but as a war on suffering. That means making tough choices, and this general approach – help the people who can benefit the most from the least – seems like a good way of making them. Thoughts?


  • carolyn on July 18, 2007 at 3:20 pm said:

    I like the approach in general. If a population exists that can be relieved of its suffering with relatively few resources, doesn’t that population become a resource when we begin to tackle the more complex problems? The fewer people that exist in suffering, the greater the number that will be able to contribute to its overall extinction.

    It’s certainly not as glamorous as the opposite approach, but it is theoretically far more effective.

  • Gillian on July 20, 2007 at 12:40 am said:


    the School of St Jude, in Tanzania, uses a rigorous process to identify academically capable children from the poorest families. In recent years there have been 15,000 (yes, that’s right) kids applying for the 170 places. First they have to pass tests that show they are bright, then, if their homes have more than two rooms, electricity, glass in the windows or more than a dirt floor, they don’t qualify.

    And the school takes only one kid from each family — so more families can be helped. This is heartbreaking triage… see my post on Sophie’s Choice…

    The thought behind the school is that these bright children are capable of benefiting the most from the resources provided by foreign donors. They really will be the future leaders of the country. Without this school, most of them would not have had even a high school education.

    I call this project ‘the best development project in Africa’. I can’t prove it scientifically, but there’s lots of evidence that the school is well-run and getting good outcomes. Their kids took 7 of the top 10 places in standard exams in their district of 17,000 kids.

    Not bad. Great triage. It doesn’t feel like ‘cherry picking’ when the need is so great.

  • Holden on July 20, 2007 at 11:16 am said:

    Regarding the School of St. Jude, FYI – we are in touch with them, but it’s unclear whether they meet our requirement of being a U.S.-registered public charity (they are looking into this). If they do, we’ll consider them.

  • Gillian on July 20, 2007 at 4:10 pm said:

    Hey, that’s great!

    I’m not sure that they are US registered. I understand that they are looking into it. They have links with Rotary folks who may be able to help them organise this. I know that they have received help from a US Foundation, to fund teacher training, but that Foundation may not have the requirement to be US registered.

  • That approach does make sense, and I dont see it as being cold at all. If you gave to a hopeless cause both the hopeless cause and the easily fixable cause would suffer, but if you give to the easily fixable cause at least one of the two would have its problems solved.

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