# Considering policy advocacy organizations: Why GiveWell made a grant to the Centre for Pesticide Suicide Prevention

In August 2017, GiveWell recommended a grant of $1.3 million to the Centre for Pesticide Suicide Prevention (CPSP). This grant was made as part of GiveWell’s Incubation Grants program to seed the development of potential future GiveWell top charities and to grow the pipeline of organizations we can consider for a recommendation. CPSP implements a different type of program from work GiveWell has funded in the past. Namely, CPSP identifies the pesticides which are most commonly used in suicides and advocates for governments to ban the most lethal pesticides. Because CPSP’s goal is to encourage governments to enact bans, its work falls into the broader category of policy advocacy, an area we are newly focused on. We plan to investigate or are in the process of investigating several other policy causes, including tobacco control, lead paint regulation, and measures to improve road traffic safety. Summary This post will discuss: • GiveWell’s interest in researching policy advocacy interventions as possible priority programs. (More) • Why CPSP is promising as a policy advocacy organization and Incubation Grant recipient. (More) • Our plans for following CPSP’s work going forward. (More) ### Policy advocacy work One of the key criteria we use to evaluate potential top charities is their cost-effectiveness—how much good each dollar donated to that charity can accomplish. In recent years, we’ve identified several charities that we estimate to be around 4 to 10 times as cost-effective as GiveDirectly, which we use as a benchmark for cost-effectiveness. Our top charities are extremely cost-effective, but we wonder whether we might be able to find opportunities that are significantly more cost-effective than the charities we currently recommend. Our current top charities largely focus on direct implementation of health and poverty alleviation interventions. One of our best guesses for where we might find significantly more cost-effective charities is in the area of policy advocacy, or programs that aim to influence government policy. Our intuition is that spending a relatively small amount of money on advocacy could lead to policy changes resulting in long-run benefits for many people, and thus could be among the most cost-effective ways to help people. As a result, researching policy advocacy interventions is one of our biggest priorities for the year ahead. Policy advocacy work may have the following advantages: • Leverage: A relatively small amount of spending on advocacy may influence larger amounts of government funding; • Sustainability: A policy may be in place for years after its adoption; and • Feasibility: Some effective interventions can only be effectively implemented by governments, such as increasing taxes on tobacco to reduce consumption. Policy advocacy also poses serious challenges for GiveWell when we consider it as a potential priority area: • Evidence of effectiveness will likely be lower quality than what we’ve seen from our top charities, e.g. it may involve analyzing trends over time (where confounding factors may complicate analysis) rather than randomized controlled trials or quasi-experimental evidence; • Causal attribution will be challenging in that multiple players are likely to be involved in any policy change and policymakers are likely to be influenced by a variety of factors; • There may be a substantial chance of failure to pass the desired legislation; and • Regulation may have undesirable secondary effects. Overall, evaluating policy advocacy requires a different approach to assessing evidence and probability of success than our top charities work has in the past. ### Incubation Grant to the Centre for Pesticide Suicide Prevention CPSP began work in 2016 and aims to reduce deaths due to deliberate ingestion of lethal pesticides. With this Incubation Grant, which is intended to cover two years of expenses, CPSP expects to collect data on which pesticides are most often used in suicide attempts and which are most lethal, and then to use this data to advocate to the governments of India and Nepal to implement bans of certain lethal pesticides. Research suggests that worldwide, approximately 14% to 20% of suicides involved the deliberate ingestion of pesticides. This method of suicide may be particularly common in agricultural populations. The case we see for this grant relies largely on data from Sri Lanka, where bans on the pesticides that were most lethal and most commonly used in suicide coincided with a substantial decrease in the overall suicide rate; we find the case that the decline in suicides was primarily caused by the pesticide bans reasonably compelling. CPSP’s director, Michael Eddleston, was involved in advocating for some of those bans. Read more here. GiveWell learned of CPSP’s work through James Snowden, who joined GiveWell as a Research Consultant in early 2017. We decided to recommend support to CPSP based on the evidence that pesticide regulation may reduce overall suicide rates, our impression that an advocacy organization could effect changes in regulations, our view that Michael Eddleston and Leah Utyasheva (the co-founders) are well-positioned to do this type of work, and our expectation that we would be able to evaluate CPSP’s impact on pesticide regulation in Nepal and India over the next few years. We thus think CPSP is a plausible future GiveWell top charity and a good fit for an Incubation Grant. While deciding whether to make this grant, GiveWell staff discussed how to think about the impact of preventing a suicide. Thinking about this question depends on limited empirical information, and staff did not come to an internal consensus. Our best guess at this point is that CPSP generally prevents suicide by people who are making impulsive decisions. We see several risks to the success of this grant: • Banning lethal pesticides may be ineffective as a means of preventing suicide, in India and Nepal or more broadly. The case for this area of policy advocacy relies largely on the observational studies from Sri Lanka mentioned above, supported by Sri Lankan medical records suggesting the decline is partially explained by a shift to less lethal pesticides in suicide attempts. • CPSP may not be able to translate its research into policy change. This risk of failure to achieve legislative change characterizes policy advocacy work in general, to some extent, and requires us to make a type of prediction that is not needed when evaluating a charity directly implementing a program. • Banning pesticides could lead to offsetting effects in agricultural production. The limited evidence we have seen on this question suggests that past pesticide bans have not led to notable decreases in agricultural production, but we still believe this is a risk. • CPSP is a new organization, so it does not have a track record of successfully conducting this type of research and achieving policy change. To quantify the risks above, GiveWell Executive Director Elie Hassenfeld and James Snowden each recorded predictions about the outcomes of this grant at the time the grant was made. Briefly (more predictions here), Elie and James predict with 33% and 55% probability, respectively, that Nepal will pass legislation banning at least one of the three pesticides most commonly used in suicide by July 1, 2020, and with 15% and 35% probability, respectively, that at least one state in India will do so. ### Going forward We plan to continue having regular conversations with CPSP, and a more substantial check-in one year after the grant was made. At that point, we intend to assess whether CPSP has been meeting the milestones it expected to meet and decide whether to provide a third year of funding. If this grant is successful, we hope we may be able to evaluate CPSP as a potential top charity. If you or anyone you know are feeling depressed, anxious, upset, or are just needing to speak to a professional hotline counselor, GiveWell encourages you to use the following resource, available worldwide: https://www.befrienders.org/. ### Comments • Austen Forrester on March 24, 2018 at 3:22 am said: You guys are brilliant! You are really showing leadership in effective altruism by entering pesticide regulation and policy change more generally. I was thinking of what the next most high impact policy change work would be outside of suicide means restriction, and I think it could be to lobby major foreign aid players to include Community Integrity Building in all their grants. CIB, developed by Integrity Action, is the only proven method of meaningfully decreasing corruption. A successful campaign could result in tens of billions of dollars a year in aid that will help the poor and not get embezzeled. • Austen Forrester on March 27, 2018 at 10:37 am said: Basically, an investment in lobbying World Bank, USAID, etc, to tie CIB to their grants could have thousands-fold returns. CIB decreases corruption by 80% on infrastructure projects (50% overall), and costs only 1% of the project.$1 million put towards this use, if successful in persuading major donors, could see tens of billions of dollars annually going towards the poor that would otherwise have been lost to corruption.
Possible scenario: $1 million grant to Integrity Action for lobbying. The aid community agrees that it makes no sense not to include CIB in all their grants, resulting in$20 billion/year more going to help the poor. Over 10 years, you have caused $200 billion more to go to the poor with a million dollar grant, a 200,000-fold return on investment!! What do you think? • Isabel Arjmand on March 27, 2018 at 2:02 pm said: Hi Austen, thanks for the kind words and for your suggestion. We will keep Community Integrity Building in mind going forward as we prioritize and review additional opportunities in policy advocacy. • Austen Forrester on March 31, 2018 at 5:16 pm said: Thanks, Isabel. I think the expected value of promoting CIB is ultra high. Actually, paying for it directly (ie. by funding Integrity Action) already has a very high value, but lobbying or raising awareness about it, exponentially so. Perhaps the most highly leveraged strategy would be to build a coalition of NGOs to demand that major aid donors include CIB to their grants. It also may be feasible to recommend funding CIB directly for important social programs. It doesn’t matter whether it is funded domestically or from foreigners. For instance, you can identify health care funding in a state of India as being both high on corruption and potential impact and then recommend people fund CIB for the program specifically. Or CIB can be recommended based on location, rather than program. I think the most important thing is to popularize CIB and put in on the global agenda. With corruption at$2.6 trillion/year, CIB has the potential to direct a cool trillion dollars a year to the poor.

• gawain on April 4, 2018 at 4:53 pm said:

super interesting project – and very odd given that I’ve read a lot about the problem of farmer suicides (in India) and the idea of banning pesticides never emerged once in those debates. I laughed out loud when I heard of this project.

curious if you evaluated other big problems that are targets of policy/advocacy interventions (like child nutrition, peri-natal interventions, etc) before settling on suicides. It rarely shows up when I see rankings. Then curious if you or the grantee considered other interventions to address the problem of farmer suicides before settling on banning pesticides. More usually I hear about things like household debt forgiveness, mental health services, agronomic interventions, removal incentives for suicide. In some ways, banning pesticides seems like a more effective way to prevent suicides, but doesn’t address underlying problems of despair, mental illness, poor agricultural inputs. And the effect of banning pesticides needs careful analysis.

anyway – super interesting and wish the best to givewell and and CPSP.

• Austen Forrester on April 5, 2018 at 5:05 pm said:

Hi Gawain,

The CPSP founder has researched how to decrease pesticide deaths (and overall suicides) since 1995, and found only bans worked. The analyst at GiveWell that recommended the grant, studied the topic for a long time before he was even hired by GiveWell. Almost no one knows about how highly hazardous pesticides increase overall suicides because the pesticide industry knows how to keep people silent. I studied suicide prevention for a long time before I came across pesticide bans myself. It is astonishing how something that has killed 15 million people has been so successfully hidden by powerful interests. Seems like it wouldn’t even be possible, but there you have it.

People kill themselves for any number of reasons. Anything that can cause someone to be unhappy/hopeless for even a moment can precipitate it, so “addressing the cause” is hard to take seriously for a single organization. There are already a lot of people working on every social issue. Not enough, of course, but one group can’t do everything. Saving lives is always the priority. A doctor will perform life-saving surgery even if it doesn’t cure the patient’s underlying disease. Most pesticide self-harmers don’t re-attempt with pesticides or another method.

• James Snowden (GiveWell) on April 6, 2018 at 6:22 am said:

Thanks Gawain.

We haven’t completed a comprehensive review of targets for policy / advocacy interventions. This year, we’re planning to review a number of other promising areas at a shallow level and decide which, if any, to investigate deeper. As well as the scale of the problem, our decision will be based on our estimates of (i) how effective a particular policy would be, (ii) how tractable achieving that change is, and (iii) whether we believe there is room for more funding.

Professor Eddleston, the co-founder of CPSP, considered improved treatment of pesticide poisoning patients, and locked safe storage boxes, as alternative ways to reduce pesticide suicide when he previously worked in Sri Lanka, but he believes (and we agree) the evidence / expected effect size is stronger / higher for pesticide bans.

I recommend this ~1 hour video if you’d like to find out more https://www.youtube.com/watch?v=n1W4ioJyOQU&t=, or this Lancet article http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2817%2931961-X/fulltext?elsca1=tlpr

We haven’t deeply investigated methods for reducing suicide other than through means restriction, but would be surprised if they were in a comparable range of cost-effectiveness (while acknowledging that, all else equal, it would be better to address the underlying problems that lead to suicide).

• Charlie. on April 10, 2018 at 4:23 pm said:

I find it very unnerving how much its taken for granted that suicide prevention is a good thing in this discussion.
I appreciate you mention that you think the suicide attempts are most likely impulsive, but this for me is the first thing that I would want to find out. Hating your life whilst not having any sure-fire means to suicide, can make arguably the worst kind of suffering drag on for decades. Committing suicide for many people is very very hard.
I am inclined to think that there are answers to these questions however, and not only the answer implied by your comment that these people may go on to appreciate their lives. People who really are looking for a way out within the agricultural industry probably also do have other methods available to them. Finally, I would imagine that there are a lot of other dependents lives to consider as well.
My only point in making this comment is that I found it a little alarming how much it is assumed that it’s the suicides – and not the causes of them – that are bad, and would have like to have seen more addressing this. It strikes me as an extremely thorny issue.
Apologies if anyone finds this comment insensitive.

• Austen Forrester on April 11, 2018 at 2:21 pm said:

Hi Charlie,

The problem with discussing suicide prevention via blog comments is that it is too complex an issue to be discussed through this medium. Suicide and related issues are far more complex than people think they are. I average about 30 minutes of talking to someone in person before I get them to understand the importance of means restriction in suicide prevention. That would talk many pages of writing. And discussing suicide in general takes much longer than that for the person to get a grasp of this uber-misunderstood subject.

Absolutely, the causes (ie. sources of misery) for people are important, but there are many organizations addressing every issue out there. Most “causes” are normal life stressors (severe as they may be), anyhow, such as a family argument, temporary depression, financial woes. Lack of resilience is ultimately the only “cause” of suicide according to many suicidologists. Why can’t there be one (at least) organization for the last line of defence?

Also, addressing underlying issues usually has little effect on suicides because only a small portion of people with X problem go on to kill themselves, and often they are the ones that least respond to the interventions. Many suicide prevention programs also have little or even a negative effect on suicides because for every life saved by encouraging someone to seek help, you lose a life by putting the idea into someone’s head.

I disagree with your position that suicide should be an option for people with long term problems. Isn’t that most people, when you really think about it? There are always better options. For instance, a women in a terrible marriage who can’t leave because it is a major social taboo in that region, rather than taking her life, should still leave her husband and simply deal with the social consequences. She may be able to move to a city where she can start over, for instance. There are always better options than killing yourself or someone else to solve a problem. But just as important, suicide creates serious life-long trauma for the family and friends who are in turn more likely to take their own lives. More suicide creates a destructive cycle of trauma, destructive behavior, poverty, and more suicide.

I also should note that over 10,000 people (many of them children) a year die accidentally from pesticides… the same ones that CPSP is trying to ban to prevent suicide.

• Steven on April 12, 2018 at 8:48 pm said:

I also don’t think that it’s a good idea to try to take away people’s options, even if we think they shouldn’t take those options. Those people know their own lives far better than we do. I certainly would not want someone else to prevent me from ending my own life if that’s what I decided to do. It isn’t right to rank this intervention against medical programs in terms of “lives saved/\$” if the lives being saved are people who would rather be dead.

• Austen Forrester on April 15, 2018 at 6:59 pm said:

Hello Steven,

I get how it seems on the surface that means restriction is limiting a person’s options. However, studies show that survivors of suicide by jumping usually feel like they want to survive after they leap (in other words, they change their mind once in the air), even if they were sure they wanted to die beforehand and thought about killing themselves for a long time. It is amazing how even people who think they want to die basically always just want a better life. But they can’t always see that without others’ help, or until they are staring death in the face.

More important than the apparent number of choices a person has is the number of choices that she is able to comprehend and see as viable. Having the “nuclear option” of suicide available to people in a distressed, suicidal state, may seem to increase their options on the physical level, but on the psychological level, it will likely decrease their choices. People in that state of mind have extreme difficulty brainstorming ideas and adequately analyzing every possible solution to their problems. Their mental states causes them to see even reasonable solutions as hopeless.

The choice argument against means restriction assumes that people are always able to think and act clearly to properly assess the best course of actions, but this is seldom the case for people who are severely depressed… their minds just can’t get away from the death option. By restricting the means of suicide, therefore, suicidal people see death as less of an option and are thus better able to look at other solutions. Thus, on the mental level, suicide means restriction increases, not decreases, available options.

Ultimately, dead people have no options. Once a suicide is completed, the person has exactly zero options forever. If someone with a life expectancy of 70 years dies of suicide at 30, he has lost out on 40 years of having any option whatsoever. The notion that making suicide easy for everyone is in their interest because it gives them one more option ignores the fact it actually reduces the number of options to zero for the length of the decrease in life expectancy resulting from the suicide. Therefore, the “more choice is necessarily better” argument overwhelmingly favours all forms of suicide prevention, including means restriction, over the duration of life expectancy.

• Isabel Arjmand on April 16, 2018 at 5:46 pm said:

Hi Charlie and Steven, thanks for commenting. The impact of preventing a suicide via means restriction is something the GiveWell research team discussed while investigating this grant opportunity. While we haven’t written much on this topic, we did explore the limited empirical information that addresses this question, and also discussed various moral frameworks. Staff did not come to a consensus; in our cost-effectiveness analysis, you can see some variation in how GiveWell research team members consider the impact. Some notes on evidence we encountered while exploring this question can be found here.