There are a number of high-profile public debates about the value of overseas aid (example). These debates generally have intelligent people and arguments on both sides, and they rightly give many people the sense that “Does aid work?” is a complex question with no simple answer.
However, we believe these debates are sometimes misinterpreted, causing unnecessary confusion and concern. Specifically, people sometimes ask questions along the lines of: “Since many well-informed people believe that aid does more harm than good, should I believe that GiveWell’s top charities are even helping?”
We believe that the most prominent people known as “aid critics” do not give significant arguments against the sorts of activities our top charities focus on, particularly with respect to health interventions. Instead, their critiques tend to focus on the harms of government-to-government aid, particularly when it is not effectively targeting those most in need and not effectively focusing on interventions with strong track records.
While we seek out and acknowledge the possible downsides of our top charities’ work (example), we don’t see a serious case to be made that the harms outweigh the benefits. Going through each potential harm and discussing how it relates to our top charities could make for a lengthy writeup (note that we address many potential harms in our research FAQ); this post has the simpler goal of discussing the people best known as “aid critics” and establishing that they provide few (if any) arguments against the sort of work our top charities carry out.
We focus on the three people we believe are best known as aid critics: Bill Easterly, Angus Deaton and Dambisa Moyo.
William Easterly
William Easterly has debated Jeffrey Sachs on the merits of ambitious aid programs and written several books questioning the effectiveness of what he calls “the West’s efforts to aid the rest.”
The best-known such book is probably The White Man’s Burden, which contains the following passage:
Once the West is willing to aid individuals rather than governments, some conundrums that tie foreign aid up in knots are resolved … Shorn of the impossible task of general economic development, aid can achieve much more than it is achieving now to relieve the sufferings of the poor … Put the focus back where it belongs: get the poorest people in the world such obvious goods as the vaccines, the antibiotics, the food supplements, the improved seeds, the fertilizer, the roads, the boreholes, the water pipes, the textbooks, and the nurses. This is not making the poor dependent on handouts; it is giving the poorest people the health, nutrition, education, and other inputs that raise the payoff to their own efforts to better their lives.
His other writings seem broadly consistent with this message. For example, Can the West Save Africa? looks at the track record of several broad classifications of aid, emphasizes the strong results from health-oriented aid (pages 53-62). The abstract states: “This survey contrasts the predominant ‘transformational’ approach (West saves Africa) to occasional swings to a ‘marginal’ approach (West takes one small step at a time to help individual Africans) … the ‘marginal’ approach has had some successes in improving the well-being of individual Africans, such as the dramatic fall in mortality.”
We have some disagreements with Prof. Easterly. But the brunt of his critiques of aid seem directed at a different kind of aid from that represented by our top charities, and as discussed above, he explicitly expresses a more positive attitude toward aid that focuses on relatively simple interventions aiming to help individuals directly.
Angus Deaton
Angus Deaton has received a fair amount of attention recently for his criticism of aid. He is the author of The Great Escape, which discusses the major and unequal improvements in wealth and health over the last 250 years and is quite skeptical of the role of aid. Recently, he won the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel.
Prof. Deaton seems to be positive on a particular kind of aid that has some overlap with the kind promoted by Prof. Easterly.
His book states:
Health campaigns, known as “vertical health programs,” have been effective in saving millions of lives. Other vertical initiatives include the successful campaign to eliminate smallpox throughout the world; the campaign against river blindness jointly mounted by the World Bank, the Carter Center, WHO, and Merck; and the ongoing— but as yet incomplete— attempt to eliminate polio.
Later in the book, he states: “There may … be cases in which aid is doing good, at least on balance. I have already made that case for aid directed toward health.”
He particularly mentions “the classic public goods of public health provision, such as safe water, basic sanitation, and pest control” as a promising fit for aid, stressing their suitability for “low-capacity settings.”
Much of his book argues that aid has not played a major (if any) role in the biggest improvements in wealth and health. It also points out the extent to which much aid is mistargeted:
One reason why today’s aid does not eliminate global poverty is that it rarely tries to do so. The World Bank flies under the flag of eliminating poverty, but most aid flows come not through multilateral organizations like the Bank but as “bilateral” aid, from one country to another, and different countries use aid for different purposes. In recent years, some donor countries have emphasized aid for poverty relief, with Britain’s Department for International Development (DFID) one of the leaders. But in most cases, aid is guided less by the needs of the recipients than by the donor country’s domestic and international interests. This is hardly surprising given that donor governments are democratic and are spending taxpayers’ money.
Like Prof. Easterly, Prof. Deaton does not specifically address GiveWell’s top charities. He expresses great skepticism of Peter Singer’s thought experiments and of being too literal/linear in estimating things like the “cost per life saved” (a view we share to some degree). But his work does not seem to provide much basis for accusing relatively simple, targeted aid programs (particularly those focused on public health) of doing harm.
Dambisa Moyo
Dambisa Moyo is the author of Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa. She is harshly critical of aid in general, and accuses it of doing active harm. However, she is also quite explicit that her book concerns only government aid, not private charity:
But this book is not concerned with emergency and charity-based aid … Besides, charity and emergency aid are small beer when compared with the billions transferred each year directly to poor countries’ governments.
In 2013, she reiterated this point in response to Bill Gates’s criticism of her: “I find it disappointing that Mr. Gates would not only conflate my arguments about structural aid with those about emergency or NGO aid, but also that he would then use this gross misrepresentation of my work to publicly attack my knowledge, background, and value system.”
Bottom line
The people discussed above raise many potentially important criticisms of aid. They question whether it has lived up to its ambitions, whether it has contributed meaningfully to economic growth, whether certain forms of it empower abusive governments, and more. But they are all also fairly explicit about the limits of their critiques.
Our current top charities focus on (a) focused public-health programs, bringing proven interventions to fight diseases (malaria and parasitic infections) that are essentially unknown in the U.S.; (b) direct cash transfers, generally structured as one-time transfers to avoid dependency. I think one has to stretch quite a bit to argue that these sorts of interventions are doing net harm, and I don’t think the arguments of prominent aid critics – important though they may be in many contexts – provide grounds for such an argument.
Comments
Thank you for this thoughtful review of the criticisms of aid. I find this discussion much more clear now!
My question would not be whether, from a (cosmopolitan) effective altruist standpoint, your work is doing net harm (clearly not) but whether a random US citizen should expect to be able to have more impact trying to change policies, as opposed to increasing charity. I posted this related little comment on the EA forum.
Thanks for writing this! What would you say about the argument that even aid to non-governmental organizations targeted at health help corrupt or incompetent governments stay in power by reducing a government’s need to spend money on health care, resulting in a de facto cash transfer to the government?
ICYMI, a recent article on foreign aid (responding to Deaton), and making the case that issue of perverse attribution of benefits can be relatively easily solved: http://insights.som.yale.edu/insights/nobel-prize-economics-and-dangers-foreign-aid
Awesome article, Kris, thanks a lot!
A characteristically sound and well-reasoned piece. Thanks. I would just add a little. One of the toughest questions is whether aid that targets a particular disease can weaken — or deflect attention from — the development of a broad-spectrum public health capacity in the receiving country. An honest, non-corrupt, patriotic Minister of Health can argue that outsiders’ interventions could be better funeled into capacity building for comprehensive care.
I don’t know if Deaton has said anything in depth about GiveWell or derworming, but he did make a brief comment in the Boston Review forum on Effective Altruism.
Here’s a part of that:
“It is an illusion that lives can be bought like cars. For a start, the evidence is nearly always in dispute. The alleged effectiveness of the Deworm the World Initiative—which, at the time of this writing, ranked fourth in GiveWell’s list of top charities—runs contrary to the latest extensive review of the evidence by the Cochrane Collaboration, an organization that compiles medical research data. Maybe Cochrane is wrong, but it is more likely that the effectiveness of deworming varies from place to place depending, among many other things, on climate and on local arrangements for disposing of human waste.”
Thanks for the comments, all!
Chris (Nov. 10), thanks for pointing out Prof. Deaton’s comment. I was aware of it and agree that this is addressing GiveWell’s top charities; what I meant to say (and didn’t say precisely) was that he hadn’t expressed a clear view on whether one should donate there/whether they are doing net good. BTW, we have addressed his argument about the Cochrane review.
Alex, this post tried to be simple and narrow in scope – addressing “is there a case for worrying that our top charities are harmful?” rather than “are our top charities the best possible giving opportunities?” The latter question is much more complex. Note that we also do policy-related work.
Trent, I find this argument to be a stretch for the kinds of things our top charities are doing. The services they’re providing are one-time and/or highly non-intensive; they aren’t removing the need for the government to provide basic services like roads, water & sanitation, health clinics & hospitals, etc. They’re also generally providing them in very low-income rural communities that don’t seem particularly well-positioned to put pressure on governments.
Conn, most of our top charity reviews have a “Diversion of skilled labor” section addressing what kinds of demands our top charities’ work puts on government staff & other infrastructure. I think the picture is generally that there is very little diversion going on. One might believe that infrastructure-strengthening work is more important, but I doubt that the top charities’ work is interfering with it enough to matter much.
I think it is quite a stretch to say that there is a lack of controversy about the charities that Givewell recommends: the so-called “Worm wars” were called the “Global Health debate of the summer”. The World Bank have done an anthology of the dozens of research articles, viewpoints, blogs and letters on this topic – I would call that a vigorous scientific debate. In case you missed it, some people seem to think that Macartan Humphreys’ piece is the final word on all this.
In fact, like it or not, Givewell are going to contribute the next piece of controversy to this story as 2/4 of their “Top Charity” picks are deworming-focussed organizations, with one charity being recommended largely on the basis that there is a possibility that deworming children leads to higher income in adulthood. So for their 2015 recommendations, Givewell can either
a) continue to back a few unpublished follow-up studies on long-term benefits of deworming over the findings of an updated Cochrane Library systematic review of randomised trials, notwithstanding the lack of a demonstrable causal mechanism for these long-term effects in the former.
or
b) downgrade their 2014 confidence in the evidence that suggests that deworming pills in childhood leads to higher life-longer earnings, and update their charity recommendations accordingly.
I guess neither of these are attractive options for Givewell, but either one would be controversial. Perhaps the very-recent NPR announcement that the Gates Foundation now plans to fund several new clinical trials to investigate the impacts of deworming in low-income settings might be of interest? Some philanthropists clearly would like their giving to be well-evidenced.
Thanks for the thoughts, Alex. I wasn’t trying to claim there is no controversy of any kind involving our top charities; this post is about the lack of a particular kind of controversy over whether “aid does harm.” The question of how strong the case for deworming is is quite separate, and I agree there is a great deal of controversy over it. I don’t think it is an easy question, and I respect your perspective on it, though I disagree. (My views echo those of Alexander’s post on the subject.)
That said, one comment of yours (in (b)) suggests you misunderstand our position. We do not have high confidence in the evidence for deworming. We believe the case is strong enough to make deworming an excellent value proposition even at a <50% probability that its evidence would hold up to maximal scrutiny and replication. The fact that deworming is extremely cheap relative to the potential benefits makes up, in our view, for the fact that it is far from a slam-dunk on the evidence.
Regarding further trials of deworming - we have actively discussed the idea of trying to fund such trials. However, we think it would likely take 10+ years to get the information we'd want (since our main interest is in long-term developmental impacts), and by that time there may be very little need for us to continue recommending deworming charities. For that and some other reasons that would be a bit of a tangent, funding such trials hasn't made it to the top of our priority list (though it is something we would ideally like to do and are interested in).
I’m not suggesting that giving advice to try to target aid well is a bad thing (quite the reverse), but the devil is in the details – does the kind of aid advice that Givewell (and similar organisations) generates ever do harm?
In a hypothetical situation, let’s imagine that ten years from now there have been several high-quality long-term trials that include measuring the effects of mass deworming in childhood on earnings in adulthood, conducted in various different places – I think this is what the Gates Foundation now plans to fund. Let’s say that most or all of these trials show negligible later-life developmental / financial impacts of deworming in childhood. In this case, it would be reasonable to conclude that the findings of the “Worms at Work” paper (and other papers that make similar claims) were either unreliable or non-generalizable. A lot of high-quality trials find “no effect”, so this wouldn’t be terribly surprising. In fact, it is pretty common in science for an exciting preliminary finding to be later contradicted by larger, better-designed studies.
In this situation, if charity-recommenders had consistently promoted mass deworming on the basis that it might improve life-long earnings up to the time that definitive evidence had contradicted this notion, then these organisations would have been responsible for directing aid funding away from charities that could have achieved more substantial benefits. Would that be an example of “aid advice” doing harm? The low per-pill costs will be largely irrelevant if these medicines have limited effects beyond getting rid of worms from the gut. Furthermore, what about the reputational implications for the “effective altruism” movement in general – how much future charitable giving might not occur if donors lose confidence in the ability of charity-recommenders to make worthwhile recommendations?
If these hypothetical future trials consistently show that mass deworming in childhood reliably improves development / earnings in adulthood, then no doubt the whole world will queue up to take these remarkable pills and congratulate the charity-recommenders on their foresight. If you have as much as 50% confidence that this will be the case, then I salute your optimism.
Alex, this post isn’t about whether aid advice can do harm, it’s about whether giving to our top charities can be worse than giving nowhere at all. It’s an important distinction: I agree that every gift has potential opportunity cost, and that all advice has potential costs if it is pushing people away from a superior default, but this post is aimed at people who worry that they shouldn’t give at all due to the potential for harm.
No matter what we recommend, there are potential costs of the kind you outline. If it turns out in the end that the deworming effects hold up, nearly everyone who recommended some other intervention will have “done harm.” If it turns out that they don’t, people who recommended deworming will have “done harm.” We can’t avoid a risk of this kind of harm, but we can try to maximize the expected value of our advice by thinking through both the probability and the stakes of each potential world.
We are being explicit that we see deworming as a high-upside intervention with a limited and problematic evidence base and a substantial probability of doing negligible good. I think that openness limits the reputational risks of being wrong. It’s our judgment that it’s better to give our honest view on where it is best to give, and why, and what the limitations and risks are, than to stick only to recommendations we are sure will never look bad in retrospect. If we opted for the latter we would probably only recommend GiveDirectly, which we think is a particularly good option for people who are more skeptical about evidence and cost-effectiveness analyses.
I have nothing to add to this edifying exchange except to say how much I appreciate it. Has GiveWell considered organizing one-day sessions – corporeal or electronic – in which serious philanthropoids get to talk about hard choices? [No bloviators or apologists allowed.]
In any case, thanks for the service.
Hi Conn, we hold events twice each year in San Francisco and New York for people interested in our research. (Audio and transcripts from past events here.)
Because we have limited space, we don’t post details about events publicly, but if you’re interested in attending, please email info@givewell.org.
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