# Investigating the Ebola response

Should you donate to efforts to contain the Ebola outbreak in west Africa? With hundreds of millions of dollars coming in from other donors, will your donation make a difference? How does this compare to giving to GiveWell’s top charities?

These are difficult questions. It’s always hard to estimate how much good a donation does; it’s much harder in the midst of a rapidly evolving situation like this one. It requires predicting the future path of the pandemic and the effects of response efforts. New information (and new donations) are constantly changing the picture. Further complicating matters, the people who best understand the situation are extremely busy, and we need to be careful with how we request their time. Even coming up with a rough take on Ebola involves major effort. However, at this point – due to some preliminary analysis and estimates – we are in the midst of conducting a small investigation, and hope to publish our take on donating for Ebola response within the next week or two.

In this post, we lay out the steps we’ve taken and the steps we’re planning next for our investigation. We then discuss what goes into our decisions about how to respond to sudden, prominent donation opportunities like this one, and why we’ve decided to do an investigation in this case.

Our investigation
The basic question we’re trying to answer is: what is the cost-effectiveness (in terms of lives saved and similar benefits per dollar spent) of additional donations to the Ebola response (beyond what’s already been raised, and including factors such as the risk that Ebola might spread to more countries in Africa or become endemic if not contained)?

Unfortunately, we don’t know of any published efforts to answer this question. We also don’t know of efforts to answer related questions such as “What is the expected death toll of the Ebola outbreak conditional on the current planned response, and how would this change if the response were better-funded?” The information and analysis we do have that seems most relevant is:

• A CDC model that projects Ebola deaths under different assumptions about what proportion of cases are effectively isolated. The projection goes only through January 20, and covers only Liberia and Sierra Leone. There are also some other models with broadly similar properties. We initially tried using these models, but now provisionally believe they cannot be used for our purposes (more below).
• Some basic information on the status of the UN fundraising appeal. As of now, $988 million has been requested;$486 million has been raised and an additional $233 million has been pledged. • Some basic information on the World Health Organization (WHO)’s hopes for the containment effort. A recent press briefing with a WHO representative states: “…the numbers we need to get behind are 70:70:60; that number is 70% safe burials, 70% cases being managed and cared for properly; and within 60 days of our start date which for UNMEER we’re taking as 1st October. So, our goal is to have that in place by 60 days which would be 1st December.” Initially, we tried to focus on using the CDC model to forecast Ebola cases at higher and lower levels of response efforts, which we tried to map to higher or lower levels of funding. However, we ran into several issues here. • One fundamental issue is that we know too little about the relationship between “how much money is raised” and “what sort of response is possible”: it might be that the activities most crucial to containing the epidemic can already be funded at current levels, and that additional donations would do relatively little. • Another major issue turned out to be that the CDC model already appears to be out of date (and specifically, overly pessimistic). The model incorporates data on cases through late August; reported Ebola cases since then are lower than the model predicted even in the maximal “strong response effort” scenario. It is possible that the recent reports of Ebola cases reflect issues with data collection (for example, perhaps people with Ebola are now avoiding care or healthcare workers are too overwhelmed to report data); but based purely on the numbers, we don’t feel we can use the CDC model to make good forecasts for cost-effectiveness analysis. • Even if we resolved the above two issues, there would be major questions remaining. The CDC model covers only two countries, and only through January 20; it does not address cases in Guinea, the possibility that Ebola becomes endemic, or the possibility that Ebola spreads to other countries. We know little about the organizations involved in the response effort and how well they’re performing, and it’s unlikely that we’ll be able to find out much about this question while the epidemic is ongoing. We have also experimented with using a model published more recently by the Virginia Bioinformatics Institute, but we haven’t yet determined whether this model could be useful. We haven’t been able to compare this model’s predictions to recent reports directly, but it appears to make similar projections to the CDC’s for Ebola cases conditional on strong control as of December 31. We would need a better understanding of the model, and more discussion, in order to determine whether it might be used for a cost-effectiveness estimate (but even if we did use it for such an estimate, the estimate would remain problematic for many of the reasons listed above). At this point, we’re focusing on trying to set up conversations to gain more information about the following questions: • If we were to recommend donations to the response effort, how quickly could donations be utilized on the ground? Would they make a difference to the response effort? • What would these donations allow that could not be funded otherwise? Would they expand the most important response activities? Should we think of additional donations as having similar impact to the average dollar in the response effort? • How significant is the risk that Ebola spreads to other countries and/or becomes endemic? How should we think about the likely longer-term death toll, factoring in unlikely but extremely bad scenarios? • Should we infer from recent data that the CDC model was overly pessimistic, or is there another explanation for the low (relative to the CDC model’s projections) reports of further cases? • If one donates to the response effort, whom specifically should they donate to? We’re first trying to see whether we can gain information by speaking with people who aren’t directly involved with the effort, and who can therefore take time to speak with us in a low-stakes way. If necessary, we may need to create an estimate of how much money we might be able to raise for the response, in order to give people more information about whether talking to us is worth their time. How we decide which crises to investigate When a humanitarian crisis hits the headlines, we usually get a lot of questions along the lines of “How can I help and where should I give?” At the same time, there are several reasons that headline-dominating-crises tend not to make for the best giving opportunities, and particularly tend to be a poor fit for our work. • The people best positioned to understand, and help with, Ebola response are probably the people who have been working on pandemic containment, developing-world health systems, and other related areas for years before this crisis emerged. The best opportunities to prevent or contain the epidemic were probably before it was widely recognized as a crisis (and perhaps before Ebola had broken out at all – more funding for preventive surveillance could have made a big difference). We’d guess that a similar dynamic holds in general: it takes years to build expertise and context in an area, and the most crucial opportunities to make a difference will often be before the issue is getting widespread attention. In general, we think we’ll find the best giving opportunities by picking good causes to focus on and working on them for years, not by scrambling to catch up on the state of knowledge about an urgent and chaotic situation. As it happens, biosecurity is one of our leading contenders for a focus area, and we have been actively investigating the area for a few months. One of our main focuses is on strengthening routine preventive surveillance. However, we are far from having the network and knowledge needed for a rapid diagnosis of the Ebola outbreak. • When an issue is getting a lot of media coverage, it often attracts a lot of funding. All else equal, this makes giving less attractive, since we emphasize room for more funding. In past investigations (2010 Haiti earthquake, Japan tsunami), we found evidence that money was not the limiting factor for the relief effort. • Urgent issues also tend to be particularly difficult to investigate. The people who know the most about them tend to be extremely busy, and issues tend to be more newsworthy when they are more unprecedented and chaotic. • If we do choose to investigate a crisis, we generally need to make the investigation an urgent top priority in order to keep up with developing news. That means high involvement from senior staff and major disruptions to our workflow. It can be worth it, but the costs are high. In some past crises, we have made major efforts to put out helpful content – particularly the 2010 Haiti earthquake and 2011 Japan tsunami. Our work attracted a fair amount of media coverage, and helped us formulate general principles for disaster relief giving, but it also took a lot of time and did not result in large amounts of donations (in 2011, when we covered both the Japan tsunami and the Somalia famine and recommended Doctors Without Borders for both, we tracked ~$50,000 in money moved to Doctors Without Borders; note that in these cases, we also stated that we did not feel the giving opportunity was as strong as giving to our top charities). We provided more limited coverage for the 2011 Somalia famine and choose only to provide general tips in response to the 2013 Philippines earthquake.

When a crisis starts getting coverage, we weigh factors such as (a) how many people are asking for our views and (b) how much capacity we have for an investigation, as well as (c) the likely “cost per life saved” (or similar metric) for donating to the relief effort.

In the case of the Ebola outbreak, we initially guessed that the outbreak would remain relatively contained, and that ample funding for the relief effort would come in. (High-profile donations from individuals and significant attention from governments both contributed to this view.) Recently, several things have changed:

• Over the past week, we’ve heard from more people – particularly people who follow GiveWell closely – than we had in previous weeks.
• The crisis has now been attracting significant attention, yet funding remains substantially below what has been requested.
• The crisis appears quite relevant to our ongoing investigation of preventive surveillance. Many of the people we are speaking to about surveillance are heavily involved in the Ebola response.
• In light of the above factors, we decided to put some time into a very rough estimate of what the “cost per life saved” might look like for the Ebola response. Some initial calculations indicated that the cost-effectiveness could be quite strong, consistent with the idea that containing a small number of cases now could prevent a large number of cases later. However, in light of our questions about the CDC model (among other issues), we don’t think our estimate is usable, and decided to gather more information along the lines described above.

Ebola response may be an outstanding use of funds, largely because the right preventive measures could stop the problem from becoming much larger and more costly to contain. The same logic would apply at an even earlier stage – to the strengthening of everyday preventive surveillance, of the kind that could have led to much earlier detection and containment of this epidemic. If that’s right, surveillance could turn out to be an outstanding cause to specialize in, under the heading of the Open Philanthropy Project.