The GiveWell Blog

Cause 1: Where we stand

Now that Holden and I have finished drafting reviews for Cause 5 (to be made public in a couple of weeks), we’ve moved our focus to Cause 1: Help people in Africa avoid death and extreme debiliation.

Unlike Cause 5, in which organizations roughly followed the same model to help people, organizations applying for a Cause 1 grant take wildly divergent approaches. And, in most cases they are taking not just one approach, but are running a huge set of projects that don’t always have a clear overarching theme or approach. This obviously presents a large challenge, and makes it impossible for us to compare organizations as directly and quantitatively as we did for Cause 5.

Here’s what we’re thinking so far. Mostly, our applicants fall into the following broad categories: comprehensive community aid, providing lots of different kinds of services to a small group of a people; distribution, getting lots of small, inexpensive items to many people; corrective surgery, providing a relatively expensive but life-changing surgery to those with congenital deformities; and mammoths, which do just about everything for everyone everywhere.

Comprehensive community aid. These organizations go into a village and attempt to provide everything for the village including primary health services (for childbirth, pneumonia, etc.), distributing necessary medicine/products (bed-nets, ORS, de-worming pills), education about hygiene and protected sex, economic aid including farming technology, and much more. This is the model with the most intuitive appeal to us. When you’re trying to help people thousands of miles away from a culture you’ll probably never fully understand, it seems smart to work intensely with one group of people and document all the ways in which their lives change – that way you’re more likely to catch unintended consequences, adapt to changing problems, etc., and make sure you’re actually changing their lives for the better. (This seems far superior to deciding in advance on one problem, like AIDS, and attacking it furiously while leaving other problems unaddresed.)

But that documentation is essential – immersion doesn’t equal understanding, and if a charity isn’t measuring and reporting life change, we aren’t going to bet on it. So far (though we’re still working on it), we haven’t been able to get a real picture of the life change effected by an organization using this approach. Organizations do many activities for which they often offer no evidence of the eventual impact (e.g., they tell us how many families attended their HIV/AIDS awareness campaign, but don’t offer evidence for what effect they expect that to have).

Distributors. These organizations distribute cheap and potentially life-saving items: ORS to treat diarrhea, vitamin A supplements to prevent malnutrition and blindness, bednets to fight malaria, condoms to prevent HIV/AIDS, etc. The advantage of this approach, it seems, is the potential cost-effectiveness: by focusing on the cheapest, simplest diseases to treat, you can treat a lot more people.

We estimate that the stronger candidates in this area are saving lives for around $50-120 a pop … but this estimate is based largely on combining reports on number of units sold/distributed with academic research on the effects of these units (e.g., studying the effects of Vitamin A in developed-world hospitals,), plus a lot of guesswork about utilization (i.e., it’s one thing to sell or distribute condoms – but how much are they actually getting used?) Organizations only sometimes monitor the utilization of the products they distribute, and they rarely, if ever, measure the change in actual disease prevalence for the people they serve. So charities in this area may be helping a lot of people, but it’s hard for us to be confident in their effects.

Corrective surgery. These organizations perform a very specific procedure (or set of procedures) for people suffering from an ailment. They perform surgeries to correct debilitating deformities (cleft palate, severe burns, etc.) or correct vision impairment. The best of these organizations can tell us how many surgeries they perform and what conditions they correct, which along with their total expenses gives us a picture of how many lives they’re changing for each dollar they spend. These organizations don’t tell us a lot about how debilitating the conditions they fix truly are (leaving us to question the impact they’re having).

This model is attractive because each surgery affects a specific person. Knowing how many surgeries each organization performs tells how many people’s lives have been changed – there’s not a lot of doubt. But, this model doesn’t come close to achieving the cost-effectiveness of the (albeit somewhat theoretical) distribution model, with $/life impacted at 10-20x the cost. And, without a clear picture of the debilitation these surgeries prevent (to what degree they are somewhat cosmetic), we worry that their impact is even lower.

UNICEF. UNICEF does everything, everywhere. They distribute, perform surgeries, and somtimes just focus on providing all services to a set group of people. We won’t be able to evaluate the entirety of UNICEF’s programs, but we may be able to evaluate their Accelerated Childhood Survival and Development Program, which has an approach similar to “comprehensive community care” above, and which appears to be slated for a very large and growing role in UNICEF’s programming.

So, where are we going from here? At the moment, the only organizations that we can confidently say are helping people are those peforming corrective surgeries. But, we’re waiting on more information from distributors which, we hope, gives us more confidence that people are actually using the products they receive. We’re disappointed in what we’ve seen thus far from comprehensive community care. Even though it makes a lot of sense to provide everything to a small group of people (even at higher costs), we’re not convinced of the impact these programs (which are mostly more convential Africa-aid organizations) are having.

One more note: with so many different approaches to helping people, there’s no way that they’re going to be close in terms of cost-effectiveness. There’s no reason to think that an organization distributing inexpensive items across a continent is in the same ballpark as an organization providing corrective surgeries to a few thousand children each year. Donors need to understand what they’re getting for their dollar.


  • michael vassar on October 24, 2007 at 10:29 am said:

    Aren’t Jeffrey Sachs’ Millenial Villages an example of the first approach with good documentation?
    OTOH, I have serious concerns about Sachs, from his possible involvement with corrupt economic advisers in the former USSR to his denial of receiving wages from the UN to his general arrogance to the content of his book on ending poverty.

  • michael vassar on October 24, 2007 at 10:36 am said:

    I like the surgery model because it seems to have the least potential for unintended consequences. It appeals to the “selfishly risk averse” component of my desire to help people, the component that ignores expected utility and just wants to be utterly sure that the world is a better rather than a worse place as a result of my having lived. As a result, this is the only sort of poverty alleviation I have ever actually spent money on. In utility calculus I’m pretty sure that salt iodinization crushes it, but that’s a political solution, so the low impact possibilities are relatively credible. Also, in utility calculus, as I have stated before, exotic options involving extreme global risk seem almost sure to take first place, and those options are much less likely to receive Gates Foundation money, so it’s up to me to a much higher extent.
    Oh, BTW, this is another post I lost the first time due to the fact that the anti-spam system on this blog deletes messages when it doesn’t accept your spam word.

  • Michael, a few comments:

    -We have looked into the Sachs thing. It appears right now that it is in a very experimental phase, funded for the next few years, and does not yet have the kind of documentation we’re going to need. But we’ve got our eye on it.

    -I completely agree with you about the appeal of the surgery model. At the same time, I don’t know if I can bring myself to fund surgeries over an approach that seems intuitively so much more cost-effective … seems like we should do what clearly seems right, even if we can’t quantify/document it quite as well.

    -I will try to look into the spam word issue. I’m not sure whether there’s anything I can do about it in the short term – we were getting too many spam comments to go without the captcha, so it’s a question of whether I can find another captcha or a hack to this one. For now I’d just encourage you to hit ctrl-A ctrl-C before posting your comment, and that way it’s on the clipboard in case you lose it. I apologize for how annoying this is.

  • michael vassar on October 24, 2007 at 1:46 pm said:

    Holden: I imagine that you might want to ask Peter Singer to keep his eye on the Sachs thing for you, since he is probably going to be paying attention to it anyway and seems competent enough to understand your needs and to handle something like that. Alternatively, Toby Ord.

    I will use my clipboard for spam words. It’s probably not worth changing your system with the number of commentators you have now.

    Intuitively, both cheap surgery a-la Fred Hollows AND distribution of vitamins, Iron, worm medicine, nets etc seem so cheap that it’s somewhat baffling that they aren’t already fully supplied, given how much money already goes to charity. Much of the answer has to be that our intuitions are very unreliable on this, which is why givewell exists in the first place. Intuitions are very important for determining what propositions merit empirical investigation, but are obviously no substitute for investigation.

    Intuitively, it seems impossible that nuclear materials could go unsecured because no-one in government got around to supplying the budget for it, but in fact, that actually happened, which is why the nuclear threat initiative was founded. Ultimately, Buffet and Turner ended up footing the bill to keep things moving, but there are probably many similar situations.

    Intuitively political efforts aimed at producing better governance in the first world seem much cheaper than directly fixing the third world, even for governments that can afford to largely fix the third world and their own nations out of the economic surplus they create with better policies. I suspect that this intuition is largely correct, but it requires much elaboration to work out how these efforts should be organized. Here’s one nice relevant article but there seem to be potential policy improvements much larger than the differences between Democratic and Republican parties, and no I’m not a Libertarian.

  • I totally disagree with your intuition regarding politics. There’s a fundamental difference that in politics you are going up against other determined, intelligent, funded people who want the opposite of what you want. So there’s no limit to how much money you can spend to accomplish nothing, even if you spend it intelligently. By contrast, it seems that saving lives using health care is a matter of doing something well enough, not better than the other guy.

    The Nader Trader idea is a cool one, though like most cool ideas, it’s the kind of thing that seems to spring from intelligence and passion, not money. (And, I don’t have a good sense of how much there is to be gained from helping one of our two major parties triumph over the other – as you recognize.)

    As for intuition, not all intuitions are equal, though I agree that all are inferior to facts when available. Corrective surgery involves flying a developed-world doctor thousands of miles to use his limited time performing a complicated operation, often with little hope of providing appropriate followup. Meanwhile, people are dying for reasons like “didn’t know to wash their hands” or “didn’t have a $5 bednet available.” This by itself isn’t enough to prefer the latter, because there are lots of ways to address the latter that might not work at all (like giving out materials to the wrong people or failing to help people understand their use). But if someone can demonstrate that they’re addressing the latter problem in a way that’s really helping people and saving lives, I don’t think I would choose the corrective surgery over it just because it’s more quantifiable.

  • michael vassar on October 30, 2007 at 11:51 am said:

    I think that we differ substantially regarding our estimates of how intelligent and determined, and even how funded, the political opposition typically is. If they were more intelligent they would exploit more of the available “pareto efficiency improvements”. I agree that opposing intelligent, determined, and well funded people is almost always a bad idea, or as I say it, “never play tug-o-war”.

    In fairness, politicians aren’t necessarily “dumb”. It’s more accurate to say that they are deluged in biased and inaccurate information and lack career incentives (actually face disincentives) for reaching valid conclusions. They also have limited time available to dedicate to things like learning economics given that their time is taken up by the applied social science of getting elected. We should probably work out our disagreements on this issue, if any remain, verbally, as print seems to be a poor medium for resolving disagreement.

    Ideas that spring from passion can still usually benefit greatly from small amounts of funding that make it possible for a few intelligent passionate people to quit their day jobs.

  • “Ideas that spring from passion can still usually benefit greatly from small amounts of funding that make it possible for a few intelligent passionate people to quit their day jobs.”

    Absolutely. You just have to find the people. The thing I am wary of is projects that promise to “invest in researching ____” without demonstrating that those passionate, intelligent people are there, ready to leave their day jobs.

    Yes, we do differ substantially on the political opposition. I think there’s no such thing as “everyone wins” in politics (if only because priorities/attention span/agenda space are so limited), so you’re always going to run up against someone – and whether or not political people are good at economics and thinking about policy, I believe they are excellent (certainly better than I) at politicking.

  • michael vassar on October 31, 2007 at 2:35 am said:

    Actually, when you get down to it, I’m already funding the extremely intelligent passionate people I know who are focused on improving the world and who only need small amounts of money to not have to work standard jobs. The next step would be to try to expand to fund the highly intelligent but not passionate people and the highly passionate but not intelligent people I know (Casually, I can’t think of any in the latter class) who are willing and able to work cheap, but as this group is much more numerous I’m not in a position to do that. I guess there’s still the highly intelligent and passionate author of, but she’s not passionate about fixing the world, just about writing excellent surreal fiction.

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