Below is the email I received from Kelli M. Donley, Program Director at Esperanca, in response to the questions I asked in Part I and Part II of this series:

Dear Elie,

Hi there! I am going to try to answer your questions to the best of my
knowledge. I hope this helps:

These questions apply to your malnutrition programs in Mozambique and
Nicaragua (except where noted):

– Is the problem “receiving enough food” or receiving the right types of
food (Mozambique)?

Both. There is not enough food in Mozambique at the moment because of
poverty, the way the population has changed with the civil war, etc. Also,
the food they are able to grow is limited. Where we work, it is
predominantly swap. So, they grow corn, rice and millet, but have little
variety to the fruit and vegetables they are consuming.

In Nicaragua, poverty and environmental concerns have limited the diet and
access to a balanced diet.
– What does Esperanca teach community members? Which foods to plant? How to
cultivate and plant them?

In Mozambique we focus solely on three areas: cholera, malaria and HIV
prevention and treatment. Our partnering agency in this country – Care for
Life – has a small farm where they teach small animal husbandry, improved
seed cultivation, improved environmental techniques to prevent erosion, etc.

In Nicaragua, we have seed banks that promote long-term growing of healthier
crops. We also focus on environmental concerns, as in how to prevent soil
erosion. I like to think our midwifery training program also helps minimize
malnutrition by working with pregnant women to teach them to breastfeed and
why it is important.

– How often do they hold classes and how long each does each last?

This varies by country and by community. These classes are run by the
nonprofits we partner with in the country.
– How well do community members retain and implement what they’re taught?

They regularly attend courses and are putting this knowledge to use
immediately in their communities. One would hope they are retaining a lot of
it.
– What nutrients do the foods contain and how does this match up to the
nutrients community members likely lack?

I do not have this information to share with you. I can tell you that meat
and dairy are extreme luxuries in both areas. Fresh fruit and vegetables are
often limited in scope and supply.
– How effectively does this program reduce malnutrition of specific
nutrients?
– What effect does this have on the outcomes (e.g., mortality rate, general
health, I.Q.) of community members?
– How many people do they help?
– How much does this program cost?

Our programs are not broken down into these sorts of statistics for
analysis. We have general overhead costs for each project. We reach 11,000
people in Mozambique and 30,000 in Nicaragua each year. One would hope we
are improving their quality of life and their life-spans, although we do not
employ any sort of researcher to determine this. It is all through
word-of-mouth and monthly reporting from our field officers that we see
results.

I also have some questions about programs to fight malnutrition in general:

Again, I don’t have the information to answer these specific malnutrition
questions. I hope what I’ve provided will be of some use!

– What specific nutrients are people missing that affect them? Without
knowing this, there’s no way to decide (regardless of the type of
intervention listed above) which nutrients are the most important. Is it
vitamin A? Iron? Iodine?
– What happens because of each type of deficiency (e.g., anemia because of
lack of iron, blindness because of lack of vitamin A, death)? How likely are
each of these outcomes given a particular deficiency? Understanding this
will help me decide which sort of program is most appealing to me – not a
fully scientific/objective decision, since my view of the “good life”
affects which disorders I most want to address.
– In what region do the people most affected live? What age are they? Any
special circumstances (i.e., pregnant women)? Before focusing on helping a
group of people, I think it’s important to know what other obstacles they
face. I want to help people for which malnutrition is the main (or a
significant) obstacle to living a full, happy life. If the people face many
more obstacles (e.g., other diseases, war, etc.) helping them here may not
do as much good.

In Part I, I listed some questions about malnutrition that I think you’d have to answer to have any sense of what you’re accomplishing with your donation, and how it compares to your other options. I then went on a search – similar to what we did part-time before we started GiveWell – to see what sorts of answers, and organizations, I could easily find.

Googling “Charity Malnutrition” doesn’t turn up anything that looks like an obvious first choice, and results from a Charity Navigator search for “malnutrition” provide nine organizations, five of which serve people in the United States.

We’ve already looked closely at Helen Keller International (click for more info), and the mission for the Children’s Shelter of Cebu doesn’t sound like what I’m looking for. This leaves Curamericas Global and Esperanca, two organizations that, based on their mission statements available on Charity Navigator have extremely broad mandates to improve health in the developing world. I chose to look into Esperanca.

Esperanca is a relatively small organization, with expenses, according to its 2006 IRS Form 990 (free registration required at Guidestar) in 2006 of $1.8 million.

Esparanca’s website provides information on their ongoing projects in Bolivia, Mozambique, and Nicaragua. The programs in Mozambique and Nicaragua explicitly address malnutrition:

• Mozambique: “In conjunction with Care for life, our public health programs in Mozambique include:Teaching community members how to make sure their families are receiving enough food”
• Nicaragua: “One of our foremost public health concerns in Nicragua is nutrition. We provide the necessary supplies and training to families and community groups to start neighborhood gardens. These gardens grow quickly and supplement traditional diets with much needed fruits and vegetables. Malnutrition accounts for 54% of all deaths of children under age five, (WHO).”

Esparanca’s Annual Report doesn’t add any information about the programs in these two countries.

The only program related information in Espranca’s 2006 IRS Form 990 is in response to the IRS requirement (in Part III) that “all organizations must describe their exempt purpose achievements in a clear and concise manner.” Esparanca responds, “Provide medical services and public health programs in the poorest areas of the world throughout North America, South America, and Africa, serving 100,000 people.” (Box a)

Given that information, I’m left with a set of unanswered questions. I emailed these questions to Esperanca (they responded yesterday, though we aren’t going to post their response until/unless we get their permission). The questions that follow apply to both programs, except where noted:

• Is the problem “receiving enough food” or receiving the right types of food (Mozambique)?
• What does Esperanca teach community members? Which foods to plant? How to cultivate and plant them?
• How often do they hold classes and how long each does each last?
• How well do community members retain and implement what they’re taught?
• What nutrients do the foods contain and how does this match up to the nutrients community members likely lack?
• How effectively does this program reduce malnutrition of specific nutrients?
• What effect does this have on the outcomes (e.g., mortality rate, general health, I.Q.) of community members?
• How many people do they help?
• How much does this program cost?

Note that these questions aren’t just about the scientific/factual details of malnutrition; they’re about the organization’s competence, effectiveness, and even philosophical priorities. It seems clear that two equally legitimate and well-meaning organizations could produce wildly different answers to them, and thus could be diverging wildly in terms of how what they do fits with my goal of helping people. That’s why I think it’s important to answer them. And I can’t find answers anywhere on the website, Annual Report, or tax forms.

I also checked out CARE’s nutrition page, but it does not help with the questions above. CARE’s website has a searchable database of ongoing projects, but the example project I looked at only provided information on the country in which the project takes place, the goal, and the broad method for implementation (in this case, flour fortification). That’s all somewhat helpful, but in order to donate to this CARE project, I’d have to do a lot of independent research along the lines of the questions I listed above.

My intent here isn’t to criticize the charities above – the information they’re giving may have more to do with what’s being asked for than with what they have. But regardless, the fact remains – if I want to help people with malnutrition, at this point I seem to be stuck. Without more research, my only option is blind faith.

In this post, I’m going to take a fresh look at malnutrition, a cause that interests me a lot. I have two goals in mind here:

• Think through the issue, and what I’d need to know to decide where to donate. This is particularly relevant since there’s a good chance we’ll be studying malnutrition in the coming year.
• Give you a sense of what an individual donor would have to do to make an informed giving decision (and how quickly finding information becomes tricky). This process is roughly what we went through almost two years ago, ultimately resulting in GiveWell’s creation.

The problem

Malnutrition is a major debilitating factor in the developing world:

• According to this report from UNCIEF, malnutrition plays a role in 50% of childhood mortality.
• The New York Times has reported that iodine deficiency is “the leading preventable cause of mental retardation. Even moderate deficiency, especially in pregnant women and infants lowers intelligence by 10 to 15 I.Q. points.”We’ve learned a bit more about malnutrition (for the charity nerds among you), but … 50% of childhood mortality? Leading preventable cause of mental retardation? 10-15 I.Q. points? Wow. Where should I give?

  Potential solutions

  There are several interventions that seem like they fit with this problem. Each raises its own set of concerns about whether it’s being implemented effectively.

  • Educating people (or helping them) eat a more varied diet. As with all “training” interventions, I’d be concerned about whether an organization is effectively bridging cultural divides and changing behavior, not easy things to do. I’d want to know 1) what’s taught (i.e., does it seem logical that the program offered would lead to the desired effect) and 2) how the organization monitors that those who are taught take action consistent with what’s taught in the class.
  • Food fortified with specific nutrients. This raises some concerns about economic disruption (i.e., competing with local farmers), as well as questions about whether people are eating sufficient quantities to get the nutrients they need.
  • Direct administration of a vitamin supplement. Here the specifics of the vitamin are very important: it’s essential to know the number of doses necessary, how the organization monitors the number of doses given, and the consistency with which the supplement works. It’s easy to imagine a vitamin supplementation program which is ineffective because of wasted supplements (i.e., those that the intended users never take) or too few (or too many) doses given to the same person.
  • Removal of other causes of malnutrition (i.e., treating intestinal parasites). It’s important to know how effective treatments are in the short and long term.

  When trying to combat malnutrition, my aim isn’t merely to help some people imrpove their nutritional status to some extent it’s to help as many people improve their nutritional status to the greatest degree possible. In order to find the most effective intervention, I’d try to answer these questions:

  • What specific nutrients are people missing that affect them? Without knowing this, there’s no way to decide (regardless of the type of intervention listed above) which nutrients are the most important. Is it vitamin A? Iron? Iodine?
  • What happens because of each type of deficiency (e.g., anemia because of lack of iron, blindness because of lack of vitamin A, death)? How likely are each of these outcomes given a particular deficiency? Understanding this will help me decide which sort of program is most appealing to me – not a fully scientific/objective decision, since my view of the “good life” affects which disorders I most want to address.
  • In what region do the people most affected live? What age are they? Any special circumstances (i.e., pregnant women)? Before focusing on helping a group of people, I think it’s important to know what other obstacles they face. Personally, I want to help people for which malnutrition is the main (or a significant) obstacle to living a full, happy life.

  Next time, I’m going to try to find some answers as well as an organization to support.

Sean Stannard-Stockton wants to see more research focused on particular nonprofits, rather than on “techniques” for helping people; his reasoning is that this would be more useful to donors.

I don’t believe it’s possible to evaluate a nonprofit as an organization, completely in isolation from what it does and whether it works. Especially if I’m trying to make a case to individual donors who don’t know me or the people running the nonprofit. (I’ve argued this more fully in the past).

Phil Steinmeyer is more interested in techniques than in nonprofits; his reasoning is that differences in the effectiveness of different techniques are large enough to overwhelm organizational differences. (One example of this that I’d give is the question of fighting diarrhea by building wells/latrines or focusing on promotion of oral rehydration therapy; there is little obvious synergy between the two, and little reason to believe that they’d be similar in terms of effectiveness.)

I believe there is some value in evaluating “techniques” in the abstract, but doing so is not sufficient if you’re trying to figure out where to donate. The devil is in the details: it’s essential to know whether a nonprofit is carrying out a “technique” in a manner and context that match up with the “technique” you’ve read about. I don’t know of any “techniques” that are so simple, and so clearly effective, that I would bet on a charity simply because of formal adherence to such “techniques,” regardless of where, when, and with whom (and how faithfully) it’s adhering to them.

That’s why it’s crucial that we look at specific charities, judging them on what they do and what the evidence is that it works. It’s not the only analysis we do (we also look at independent research), and it has been the most intensive and expensive part of our process, but we see it as necessary for anyone trying to produce truly valuable and actionable information for individual donors.

Sean asks (via email):

What’s your view on whether funders should do research on techniques and then fund organizations that use those techniques or do research on organizations and let them decide on techniques? I was intrigued with your education research post, but was wondering if it might make more sense to find smart dynamic nonprofits who will figure out the best techniques to use and change strategy as more information becomes available.

My literal response is that it depends on the funder’s priorities and techniques – I don’t think there is much to be gained by debating the approach “funders” should take in the abstract. But I want to share how we deal with this question, as naive funders (i.e., not experts in the issues) aiming to serve more naive funders (i.e., individual donors), because we do have a specific philosophy on it and we’d appreciate feedback.

My ideal is to fund at the highest level I can have confidence in, i.e., delegate as many decisions as possible to to someone who I feel confident will make those decisions well.

So, my ideal would be to donate not to a charity, but to another funder. If a major foundation, such as the Gates Foundation, could convince me that they consistently make decisions using (a) a strong process, (b) good reasoning, and (c) subjective/philosophical values that are close to mine, I would give to them and let them do the rest (and get rid of our own, now redundant overhead). This was one of the first things we tried when GiveWell was still a part-time volunteer club. What stopped us was that we couldn’t find a single foundation that publicizes substantive information about how it makes its decisions, why it chooses to do A instead of B, and what evidence there is regarding its past and likely future impact. We couldn’t be confident in the institutions without such information; we couldn’t think of a way to get them to share information, since such institutions generally don’t have incentives that we can affect. So we moved on to trying to find great charities.

Again, the goal was ultimately to find a great organization – one that’s better at what it does than we could ever be, and can make its own compelling, evidence-based case for its effectiveness – and give with no strings attached. In some cases, we found exactly this: for example, the Nurse-Family Partnership‘s outcomes evaluation is available via peer-reviewed publications, its basic model is clearly described on its website, and it provided documents to fill in gaps in our understanding. PSI was a similar case: after some independent checks on its estimates, we felt we could trust its process as a whole, even for activities we haven’t researched.

In other causes, the strongest applicants could provide some pieces of the puzzle, but not the full top-down case for why their approach was the best available. That’s where we had to start looking on our own for information about what approaches are likely to work, and pick organizations that fit with what we had found. There’s a spectrum here. KIPP gave us about 60% of what we needed to have confidence in it, and after some independent analysis, we ended up feeling that it was our best bet. By contrast, our Cause 2 (global poverty) applicants gave us so little to go on that we ended up betting on an approach, more than an organization.

Between blind faith and micromanagement is conditional confidence: trusting an organization to make decisions because of an evidence-based case that they can make them well. That’s our ideal; when it isn’t available, some degree of micromanagement (i.e., picking an organization based on its approach) seems preferable to blind faith.

About a year ago, we participated in a Giving Carnival on the topic of metrics in philanthropy, and laid out the metrics we were planning on using – along with caveats. Seeing a continuing interest in this topic (even including a panel called “Metrics Mania”), I’d like to share a bit of my progressed thinking on the matter – specifically that debating metrics in the abstract seems unlikely to go anywhere useful.

As promised, our research tried to divide charities into causes to make “apples to apples” comparisons; but as many predicted (and as we acknowledged would be true to some extent), even after this narrowing it was impossible to truly put different charities in the same terms. Any two given job training programs serve different groups of people; comparing them directly on “people placed in jobs” is a futile endeavor. We looked at health programs’ abilities to “save lives,” but not all lives are the same, and different health programs have wildly different and difficult-to-quantify impacts on non-life-threatening conditions.

This doesn’t mean that metrics are futile or useless. There’s a big difference between being able to demonstrate emotionally relevant results (such as lives saved) and having no evidence other than an unfamiliar development officer’s report of a gut feeling. And there can be enormous differences in the “cost per person” associated with different approaches, enough – when taken in context and accompanied by intuitive judgment calls – to make a big difference in my view of things. For example, it’s typical for employment assistance programs to cost in the neighborhood of $10,000-$20,000 per person served, while we’re ballparking certain developing-world aid programs as $1,000 per life saved – though the story doesn’t end there, that difference is larger than I would have guessed and larger than I can ignore.

Bottom line, both the metrics we used and the ways we used them (particularly the weight of metrics vs. intuition) ended up depending, pretty much entirely, on exactly what decision we were trying to make. We took one approach when all we knew was our general areas of focus; we modified our approach when we had more info about our options; we frankly got nothing out of the completely abstract discussions of whether metrics should be used “in general.” There are as many metrics as there are charities, and there are as many necessary debates about metrics as there are giving decisions.

I agree with those who say metrics are important, and those who say we can’t let them dictate everything (and it seems that nearly everyone who weighs in on “the metrics debate” says both of these things). But I don’t feel we can have the really important conversation at that level of abstraction. Instead, the conversation we need to have is on the specifics. In our case, and that of anyone who’s interested in NYC employment assistance or global health interventions, that means asking: did we use appropriate metrics for the charities we’ve evaluated? Are there other approaches that would have been a better use of our time and resources? Did we compare our applicants as well as we could have with the resources we had?

This is a conversation with a lot of room for important and fruitful disagreement. If you’re interested in the question of metrics, I ask that you consider engaging in it – or, if you don’t find our causes compelling, conducting and publishing your own evaluations – rather than trying to settle the question for the whole nonprofit sector at once.