Iodine deficiency has been linked with child mortality as well as permanent cognitive debilitation. Some references are on page 25 of the 2004 Copenhagen Consensus report on malnutrition; a WHO report paints a more vivid qualitative picture (page 6):

In areas of iodine deficiency, where thyroid hormone levels are low, brain development is impaired. In its most extreme form, this results in cretinism, but of much greater public health importance are the more subtle degrees of brain damage and reduced cognitive capacity … the mental ability of ostensibly normal children and adults living in areas of iodine deficiency is reduced … there is little chance of achievement and underdevelopment is perpetuated. Indeed, in an iodine-deficient population, everybody may seem to be slow and rather sleepy.

How do you and I avoid these disorders? The answer isn’t as simple as you might think. Within the last century, iodine deficiency was common in the U.S., and it has been combated using an explicit and sustained public health effort. The following is taken from the Micronutrient initiative’s global progress report:

The element iodine was discovered in 1811, but almost a century passed before it was established that lack of iodine caused the swelling of the thyroid gland commonly known as goitre … In the United States, the alarm was first raised in Michigan in 1918 when it was revealed that over 30% of men medically examined for war service had been found to have an enlarged thyroid. Many were declared unfit for service. By 1923 an Iodised Salt Committee had been formed, including physicians and representatives of the Salt Producers Association …. Later that same year, the Morton salt company began marketing iodised table salt nation-wide … by 1932 iodised salt accounted for 90% to 95% of all sales.

Iodine deficiency disorder is now extremely rare in the U.S., but it is still common in many other parts of the world (see the WHO 2004 report on iodine status worldwide). The effects on cognition and economic growth are widely unknown but potentially disastrous – and this is a problem that isn’t necessarily going away by itself, or going away as soon as wealth increases. (Especially if there’s a direct link between iodine deficiency and productivity.)

Iodizing salt may not have the same visceral appeal as water-related programs, but it’s a proven way to solve a truly debilitating problem and reduce both death and poverty. And it’s an area where there’s arguably no substitute for large-scale public health programs. Note that the Copenhagen Consensus rates it as the 3rd most cost-effective use of funds.

We were referred to the Against Malaria Foundation today. It’s the most transparent developing-world aid organization we’ve seen to date.

AMF grants funds to NGOs that distribute insecticide-treated nets (ITNs) to fight malaria. ITN distribution is a well-established method for saving lives and lowering the burden of malaria (see the “Insecticide-treated nets” section of the malaria chapter in the Disease Control Priorities Project).

But what sets AMF apart from other organizations carrying out similar programs is that they publish all the details for all of their projects.

This map lists all programs, by country, date, partners, and status (whether the nets are en route, have arrived, are being distributed, etc.) Click on an individual program and you can see the full proposal that was submitted and funded (and the proposals are quite concrete and specific), and, when applicable, other materials – including the post-project report and even shipping records. Pictures and videos are also available. Here’s an example of a project in progress; here’s a completed project.

Finally, you can see which donors’ gifts were used to fund the project. There’s been a lot of excitement over organizations such as Kiva and DonorsChoose because of their ability to link donors’ money directly with people served. This organization does something very similar, but it’s distinguished in that the types of projects it’s linking donors up with (bednet distribution projects) are larger-scale projects serving many people at once, and are well documented (see link above) in terms of their impact on human lives.

We’re going to have to spend more time with all of this information to check how the actual cost-effectiveness is living up to the top-line numbers. What we know now is that if all charities were as transparent as AMF, our job would be a lot easier.

In addition to choosing straightforward, cost-effective program-based interventions, we’re also planning to identify two regions to study in detail.

I’ve focused on finding priority region 1: an area that has both high and drastic disease burdens and relatively stable, low-corruption environments in which aid can likely be productive. This post details the criteria I used to narrow the field to a few finalists. (Note: We recently spoke to a private philanthropic advisor about this, and our methodology is quite similar to theirs.)

Corruption and poor governance

I used the latest versions of the Failed State Index (from the Fund for Peace and Foreign Policy Magazine) and Corruptions Perception Index (from Transparency International) to exclude countries where governance would be a large issue. In both cases, I removed countries with the worst rating on either index. (The FSI ranks 177 countries; 31 received the worst rank. The CPI ranks 180 countries; 38 received the worst rank.)

Disease burden and poor development

I used the 2007-08 United Nations Human Development Index, considering only countries that are marked “Low human development” (received by 22 of the 177 countries rated). Of those 22, only 9 passed the corruption/governance screen.

The UNHDI considers life expectancy (to assess health burden) but doesn’t consider morbidity. So, I also looked at DALY burden per 100,000 people (data from the WHO’s Burden of Disease Project) and include countries in the top decile of health burdens. This criterion excluded Senegal, Benin, and Eritrea.

That left me with 6 countries:

• Zambia
• Mozambique
• Mali
• Rwanda
• Tanzania
• Burkina Faso

Charitable activity in each country

We need to find a region that not only has both high and drastic disease burdens and relatively stable, low-corruption environments in which aid can likely be productive but also a region with a significant amount of aid being given (since our role is to identify outstanding charities rather than to create new ones, we’d rather work somewhere where we’ll have more options). One proxy for this idea is the total aid given by OECD countries to each of our six finalists (data from OECD). This measure is far from perfect since it reflects government aid, not private philanthropy. We also conducted a Guidestar search for the name of each country, and use the number of results as an approximation to the number of US-registered NGOs working there. The data is below.

Notes:

1. Population data comes from Wikipedia’s List of Countries by Population page.
2. OECD aid is the average annual aid over the last 5 years

These criteria would seem to indicate Zambia, Mozambique and Rwanda as our top contenders. We are also strongly considering Tanzania, as there may be superior availability of data on health and living conditions through the Living Standards Measurement Study.

Our plan now is to talk with our advisors for a) their thoughts on our process thus far and b) their ideas for picking a focus region from this list. We’re also planning to examine the Poverty Strategy Reduction Paper for each of these countries to get a better sense of the major challenges and available information there).

(Note: for the intrepid, you can access an Excel file with all the data used for this post here.)

Below is our basic outline for identifying the best options for donors within developing-world health. (Economic empowerment and possibly other developing-world causes will come after we have completed our report on direct health interventions.)

Focus on two priority regions and several priority interventions

As this post explains, we are simultaneously taking two approaches: a region-based approach (studying a particular region in depth, and aiming to fund interventions targeted to the specific needs of the region) and a program-based approach (identifying particularly promising interventions and funding their scale-up throughout the world).

Priority interventions: focus on the most proven, scalable, and cost-effective

Our general criteria for selecting program-based interventions are discussed here. To start, we are prioritizing what we call straightforward interventions, or interventions that can be carried out infrequently and for which the burden of monitoring and evaluation is relatively low. As discussed here, these interventions are also rated among the most cost-effective interventions by existing studies of cost-effectiveness. They are:

1. Vitamin supplementation programs, providing nutrients such as vitamin A (which reduces the risks of infant mortality, development of blindness, and deaths in childbirth – reference here).
2. Mass drug administration programs, particularly those aiming to treat school-age children who suffer from intestinal parasites. (Such interventions have been shown to improve school attendance and likely nutritional status.)
3. Vaccination campaigns to cost-effectively save lives.
4. Vitamin fortification programs such as the iodization of salt.
5. Surgical programs to correct deformities such as cleft palate and fistula.

We may add other priority interventions, particularly if we see particularly strong donor demand for interventions with fundamentally different goals.

Priority regions: help those in great need and those with great potential

Our region-based research will be less focused on strict definitions of “cost-effectiveness” and more on finding programs that address a region’s needs broadly and holistically, somewhat along the lines of Partners in Health (and more in line with the vision of the WHO commission on macroeconomics and health than that of the Copenhagen Consensus). The first step will be picking two priority regions.

Priority region 1: one priority region will reflect a goal of helping those in the most need. We are currently in the process of identifying countries that have both high and drastic disease burdens and relatively stable, low-corruption environments in which aid can likely be productive. Preliminarily, our strongest candidates are:

• Zambia
• Mozambique
• Mali
• Rwanda
• Tanzania
• Burkina Faso

The process for identifying these six countries is detailed here.

Priority region 2: the other priority region will reflect more of a triage approach: identifying an area where health conditions are poor and help is needed but strong economic opportunities exist for those at a reasonable level of personal health and productivity. Preliminarily, we are guessing that our work in this area will likely focus on somewhere in India, but we have not yet completed this analysis.