I think in numbers. I’ve always thought in numbers. When I think about charity, my first instinct is to think of how to save the most lives with the fewest dollars. So Holden’s argument that malaria and diarrhea are “cheaper” than obstetric fistula–in a “dollars per person” sense–has obvious appeal.

But then, I think about women who have fistula. I keep thinking about a young teenage girl who has to live alone, whom no one will be near, whose life is effectively torture. I imagine that that girl is someone I know, and then, I can’t believe that the only thing preventing this girl from living a normal, happy life is something in the ballpark of $1000 (generally cited lower, but we’ve learned to take cited numbers with a large grain of salt). $1,000 is a lot of money, but it seems incredibly small when it’s the difference between someone suffering as those with fistula do and not having to suffer. And I’m not sure this is because I’m being emotional as opposed to rational. I think there’s a reasonable philosophical perspective that says we should try to improve lives (fistula, inner-city education, etc.) as opposed to merely trying to prevent death.

We haven’t researched fistula much yet, but a couple things strike me. First, many of the preventable diseases that kill people in the developing world (like malaria and diarrhea) largely affect children. Since fistula affects girls who have already reached their early teenage years, girls who are helped are largely safe from the main preventable diseases that kill people in Africa. On the other hand, providing a family with bednets does prevent malaria, but those very same people are susceptible to other dieases (diarrhea, for instance). Narrowly, this means that the cost of really saving a life is understated for diseases like malaria and diarrhea, where solving one problem still leaves a person exposed to a host of others. More broadly, I’m concerned about the kinds of lives we are saving. If fistula is literally the only thing keeping a girl from a relatively normal (if poor) life, while diarrhea is one of many debilitating problems for the people it affects, we may be accomplishing more by attacking fistula–even at a higher price tag.