The GiveWell Blog

Fistula

(updated on: ) | by Elie

Coming across the current feature on the DCPP’s home page reminds me of how much I care about the issue of obstetric fistula.

The following are highlights from the article linked above (emphasis mine):

For countless women in developing countries, going into labor is the painful beginning of a lifetime of unremitting shame and misery as a despised social outcast—destitute, childless, and abandoned by family and friends.

These women have a condition called obstetric fistula. A fistula, the Latin word for “pipe,” is an “abnormal passage” between organs — in this case, between the vagina and the bladder, the rectum, or both. The hole makes the woman uncontrollably incontinent of urine or feces or both and transforms a healthy person into someone viewed as a leaking, reeking, “moving latrine,” in the words of Veronica Yakobe, a Malawian woman who endured 23 years of indignity before an operation at Nkhoma Hospital in her country’s central region closed the fistula.

  • 2 million to 3.5 million women worldwide currently [live] with obstetric fistula.
  • Statistics from Ethiopia, Nigeria, India, Pakistan, and elsewhere show that the majority of fistula sufferers are abandoned by their families, divorced by their husbands, and forced to fend for themselves, often by begging. Some, like a group of Somali women who leapt from a pier chained to one another, end their lives in despair.
  • Studies of patients undergoing fistula surgery find the majority in their early twenties or younger. In one Nigerian study, 72 percent were between the ages of 10 and 20, 82 percent having married between 10 and 15.
  • A number of facilities, most prominently the renowned Addis Ababa Fistula Hospital, in Ethiopia, repair thousands of fistulas each year at a cost of about $450 for each operation and related care.

The disability weight used for fistula in DALY calculations is .430 (Pg 121 of the Global Burden of Disease report (PDF)). For context, the disability weight for blindness is .600 (Pg 120). To me, fistula seems much worse. Not only does a person undergo severe physical trauma, but she also often suffers severe social consequences such as communal ostracization and abandonment by her family.

In fact, it’s hard for me to imagine a cause I’d rather attack. I’d much rather prevent a fistula than save a life. The fate described above seems worse than death.

We’re planning to look into fistula carefully, and I hope we’ll find donors a great option for helping those afflicted.

Health education is tricky

(updated on: ) | by Holden

In theory, you can fight HIV/AIDS by teaching safe sexual behavior; fight diarrhea by promoting hygienic practices; reduce child mortality by educating mothers; etc. However:

  • Research on the effectiveness of these sorts of programs is thin; and programs that combine documented effectiveness with clear replication models are, so far as we can tell, rare to nonexistent.
  • Changing people’s behavior isn’t straightforward. For an example, consider the finding – regarding hygiene education – that “The interventions promoting the single hygiene practice of washing one’s hands with soap tended to achieve greater reductions in disease than those that promoted several different behaviors … numerous messages dilute each other in the minds of the target audience” (see DCP pg 785 – references given there).

If it’s true that education works best when it’s focused, that means that planning an education program right means not just identifying behaviors that need changing, but analyzing which changes would be most beneficial. That’s a complex undertaking, and so is changing how people from another culture live their daily lives.

I’m generally not very optimistic about this category of intervention given what we know about it. Handwashing programs appear to be pretty well-documented and are a possible exception.

Direct food aid?

| by Holden

Both the Disease Control Priorities report (DCP) and Copenhagen Consensus (CC) acknowledge malnutrition as an extremely widespread and damaging problem, and both discuss a variety of interventions including breastfeeding promotion, vitamin supplementation, and fortification.

Yet both give hardly any space to the idea of direct food aid, i.e., providing healthy food (or the money necessary to purchase it) directly to people in poverty. CC states that such interventions are “cost-effective but more costly [than other interventions],” and that “because of the emphasis on costs and cost-effectiveness levels we focus on [other interventions such as supplementation] only” (Pg 6). DCP’s chapter on malnutrition (551-565) mentions direct aid only in one paragraph, in the context of comprehensive child nutrition programs, and states that “No consensus exists on when or how to include supplemental food to reduce undernutrition, and inefficient targeting is frequently a key constraint to effectiveness” (556).

Direct food aid seems to me to deserve much more attention, specifically because it is a potential solution to several of the most difficult types of malnutrition to address:

  • Iron deficiency, which can cause anemia and impair cognitive development (DCP 553-4), is extremely difficult to address through supplementation or fortification because of how frequently iron needs to be ingested (DCP 558). Might frequent consumption of meat be an easier sell than frequent consumption of supplements?
  • Protein-energy malnutrition can result in emaciation and stunted height (30-50% of under-5 children sub-Saharan Africa and South Asia suffer from these problems – see DCP Pg 552). As this condition results from insufficient calorie consumption, it does not appear to be treatable through vitamin supplements. Breastfeeding may ensure adequate calories for infants, but what about afterward?
  • There is also always the possibility that our understanding of nutrition isn’t sufficient to name all of the necessary nutrients, and that the best way to give someone a diet that works as well as ours is to give them similar food (rather than simply identifying what seem to be the essential nutrients and providing those).

Direct food aid programs have come under fire due to the practice of obtaining the food from the developed world, which may cause economic distortion and problems for developing-world farmers. But this problem doesn’t seem inherent to direct food aid, only to programs that insist on using developed-world surplus food; a program that bought what it could from nearby farmers, and provided the rest from overseas, would not obviously cause more distortion than other aid programs.

Direct food aid programs may be costly and complex, but they may also be the only way to ensure truly adequate nutrition in some parts of the world. Why aren’t they getting more attention from otherwise thorough analyses?

Vaccinations

| by Holden

According to the Disease Control Priorities Project, expanding vaccination is an excellent fit for donors who want proven, cost-effective, scalable ways of helping people. According to this table (more detailed version on page 401 of the full report), both South Asia and sub-Saharan Africa have relatively low levels of existing coverage (50-58%), and vaccinating more children could save lives for about $200 each. If saving lives is in fact your priority (and we know it isn’t for all donors), that’s hard to beat.

The most promising nonprofit I know for implementation is the GAVI Alliance, which we have yet to thoroughly evaluate.

Where does a donor fit in?

| by Holden

I get two very different pictures of how aid funding works, depending on whether I’m looking at my options as a donor (as I’ve been doing for the last couple of years) or reading papers intended for policy makers (Disease Control Priorities report, Report of the Commission on Macroeconomics and Health).

The latter sources focus almost entirely on the granting of aid to developing-world governments by “donors” including “bilaterals, multilaterals, global programs, foundations, and large NGOs” (pg 249) – i.e., megadonors (not people like me). Pgs 247-250 discuss the coordination problems caused by different donors’ earmarks and reporting requirements as well as the potential advantages of “ensuring the countries, not donors, drive the coordination” (249). The WHO Commission on Macroeconomics and Health takes a similar perspective, endorsing a top-down plan to be implemented in partnership with governments, using the Poverty Reduction Strategy Papers they create.

Yet as a donor, I’ve never looked at or discussed the possibility of giving money to developing-world governments. I’ve dealt with U.S. public charities, and the proposals they send (large list here) involve their own projects carried out by their own staff. We’ve never discussed their role in helping to carry out the kind of large-scale plans endorsed by the WHO commission. A quick glance at CARE’s Form 990 reveals that only 18% of its expenses are grants of any kind, so they certainly don’t appear to be directing the majority of their aid to governments.

It’s possible that the link goes the other way: the DCP report mentions governments’ hiring NGOs (Pg 252). But if the NGOs are contractors, not agenda-setters, where does an individual’s donation fit in?

Either way, it doesn’t help that few NGOs have been able to give us a clear explanation of what they do (in particular, how their top-level agendas are set).

Complicating the matter further are “alliances” such as GAVI and The Global Fund. These appear to be partnerships aiming to consolidate and coordinate funding, and they fund both governments and NGOs. Does that make them a more appropriate recipient of gifts than typical NGOs? How does the Global Fund to fight AIDS, Tuberculosis and Malaria coordinate with the Roll Back Malaria Partnership and Stop TB Partnership, which appear to have largely overlapping goals but still all solicit donations individually?

Let’s say I’m a donor who trusts the WHO Commission and just wants to be as helpful as I can, without imposing my opinions about particular diseases and priorities. Should I give to the WHO? To a developing-world government? An alliance? An NGO? We’re getting a better handle on the situation and starting to break down the options, but as of yet we still haven’t seen clear answers to these sorts of questions.

Disability-Adjusted Life Years II: Variations

(updated on: ) | by Holden

Previously, I outlined the basics of the Disability-Adjusted Life Year (DALY) metric. It takes the approach of converting all health burdens into equivalent “years of healthy life lost”: a year of blindness is counted as .6 lost years, a year of severe malnutrition is counted as .053 lost years, etc.

This post discusses two common “variations” on DALYs, meant to deal with relatively thorny disagreements about how different years of life should be valued. As before, page numbers refer to the Global Burden of Disease 2000 report.

Age-weighting

One variation has to do with the intuition some people have that a 20-year-old’s death is more tragic than an infant’s. (I expressed this intuition myself back in November, and I still hold this view.) In an attempt to square with this intuition (which is common and well-documented, as Pg 400 shows), the DALY metric includes an optional age weighting feature that lowers the value of a healthy year of life lived at very young and very old ages, relative to the value of a healthy year of life around age 20. DALYs can be computed with or without age-weighting (“without” just means that all years of healthy life are valued the same).

Discounting

The other variation has to do with valuing present vs. future benefits of aid. DALY calculations apply a discount rate to future benefits; for example, when using a discount rate of 3%, one would count a year of healthy life saved ten years from now as being worth only 74% as much as a year of healthy life saved this year (74% = 1/1.03^10).

I confess that I don’t fully follow the justification for discounting given in the Global Burden of Disease Report, which claims that “the strongest argument for discounting is … [that] not discounting future health would lead to the conclusion that all of society’s health resources should be invested in research programs or programs for disease eradication” (400), which apparently is considered obviously wrong by the authors. Personally, the most appealing argument I can think of for discounting is that helping a person can help them help others, so helping a person sooner is literally “worth more” than helping a person later.

Notation

DALYs(0,0) refers to DALYs calculated with a 0% discount rate and no age-weighting. DALYs(3,1) refers to DALYs calculated with a 3% discount rate and age-weighting. (The first number in parentheses is the discount rate; the second is a 1 if age-weighting is being used, and a 0 if not.) See Pg 401 for the specifics of how varying these numbers affects the valuation of different years.

In theory, you can calculate DALYs using whatever parameters best fit your own philosophical values. In practice, the reports we’ve seen using this metric (Global Burden of Disease Report, Copenhagen Consensus, Disease Control Priorities Project) will give you, at most, DALYs(0,0), DALYs(3,0) and DALYs(3,1), and will rarely give you the inputs into these numbers so you can calculate your own versions. That means that if you want to use a 6% discount rate, you’re completely out of luck; there’s no way to convert DALYs(3,0) to DALYs(6,0) without having more information. More importantly, it means that:

  • You can’t use your own version of age-weighting. Even the age-weighted version of DALYs still rates an infant death as about equally tragic to a 20-year-old death (it values a year more for a 20-year-old, but when you work it all out the value of a life comes out the same). There is evidence (see pg 401) that people find a 20-year-old’s death to be far worse; if you share that intuition, then DALYs as they are usually presented won’t reflect your values, and there will be no way to convert them into a unit that does.
  • You can’t use your own disability weights. Personally, this is the area I’d most like to see some variation in – the official disability weights disagree violently with my personal intuitions about, for example, how bad it is to be severely malnourished (current weights put it at only 5.3% as bad as a year of life lost – see Pg 121) or how bad it is to go through an abortion (it appears that this is counted as “no cost” by DALYs – see Pg 121 again).

The DALY metric does have some flexibility to accommodate different personal values, but in practice it ends up being pretty rigid. More on this in a future post.

Next in series:

Previously in series: