The GiveWell Blog

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.

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I like it. How do I fund it?

| by Holden

The Community-Led Total Sanitation program looks like a potentially good target of funding.

But I can’t find out how to fund it.

The program’s summary page links to three organizations. One appears devoted to research rather than replication. Another is a water and sanitation omnibus program whose activities include many of the activities I’m less confident in. CLTS is nowhere on its list of global initiatives. The third organization is CARE, a giant organization whose website barely mentions CLTS (and its only use of the program appears to be as an “entry point” to other programs).

We think programs that are proven, cost-effective and scalable should be popular. But in many cases, there isn’t even a mechanism for this to happen – some of the most promising interventions aren’t even on a donor’s menu.

Disability-Adjusted Life Years: Introduction

(updated on: ) | by Holden

We’ve had many discussions in the comments about the metric known as Disability-Adjusted Life-Years (DALYs). The DALY essentially converts the burdens imposed by all health issues – from premature death to blindness to injuries – into a single, consistent unit. It is the metric of choice for the Disease Control Priorities Project as well as a centerpiece of the Copenhagen Consensus analysis, and is used widely by the World Health Organization – yet it isn’t, and likely won’t be, the central metric in our analysis.

At this point I want to start a more thorough discussion of why this is. I’m going to start at the beginning, with a full description of what DALYs are (and the different ways of calculating them). Some readers will already be familiar with what’s below, but we want to make sure we clearly describe the metric and give examples of its implications before discussing its strengths and weaknesses.

The most complete account of DALYs I know of is in the Global Burden of Disease report. Page numbers below refer to this report.

The basics: burden of health problems in terms of years of life

A DALY is a measure of the “burden” of a health problem; two common uses of this measure are (a) ranking diseases and risk factors (from most to least burdensome), as the Global Burden of Disease report does, and (b) ranking different interventions (in terms of how much they can be expected to reduce burdens, “per dollar”), as projects including DCPP do. The basic DALY formula is on page 48:

DALY = YLL (Years of Life Lost) + YLD (Years of Life lost due to Disability)

YLL is the more straightforward component. Putting aside discounting/weighting issues (to be discussed later), the death of a male infant (life expectancy 80 years) would be counted as 80 years of life lost, while the death of a 45-year-old female (life expectancy 83.72 years) would be counted as 38.72 years of life lost (see page 402 for the life expectancy figures). Without further adjustments, this implies that the death of a single infant is considered about as bad in and of itself as the death of two adults.

Quantifying morbidity

YLD represents an attempt to convert years of life affected by a disability into the same terms as years of life lost due to premature death. For example:

  • A year spent with blindness (as opposed to a year spent with “normal health”) is counted as 60% as “bad” (i.e., as much burden) as a year of life lost due to premature death. So the metric would count a condition that permanently blinds five 30-year-olds as about equally “burdensome” to a condition that results in the death of three 30-year-olds.
  • A year spent with protein-energy malnutrition to the point of wasting (i.e., being severely underweight) is counted as 5.3% as “bad” as a year of life lost due to premature death. This implies that if a child is malnourished to the point of being severely underweight and having a lower life expectancy (say 30 years), the burden in DALYs is equal to about 51.59 (50 years of life lost due to early death; 30 years of malnutrition * 5.3% = 1.59 YLD), which is about 60% the burden of an infant death.

As for where these numbers come from (why is a year of blindness 60% as bad as a year lost, and a year of wasting 5.3% as bad?), they were obtained through a variety of methods usually involving surveying groups of people on their subjective attitudes (Pg 50 has more on this). The complete list of disability weights – giving a conversion factor for every kind of health condition analyzed by the GBD – is found on pages 119-125.

This basic framework – evaluating all health burdens in terms of “life-years,” with a year lost to death counted as a full year and a year otherwise afflicted counted according to the disability weights – is common to all DALY calculations. In the next post on this topic, I’ll discuss some of the variations between different versions of DALYs; some versions “discount” life-years that are early in a person’s life, late in a person’s life, or far in the future. After that, I will explain what we think the limitations of this metric are as it applies to our work.

Sources

  • Copenhagen Consensus Center. Copenhagen Consensus 2008. http://www.copenhagenconsensus.com/Home.aspx (accessed April 15, 2010). Archived by WebCite® at http://www.webcitation.org/5p0sJczhJ.
  • Jamison, Dean T. et al., eds. 2006. Disease control priorities in developing countries (2nd Edition) (PDF). New York: Oxford University Press.
  • Lopez, Alan D. et al., eds. 2006. Global burden of disease and risk factors (PDF). New York: Oxford University Press.
  • World Health Organization. Global burden of disease (GBD). http://www.who.int/healthinfo/global_burden_disease/en/index.html (accessed April 15, 2010). Archived by WebCite® at http://www.webcitation.org/5p118giwH.

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