Our research for saving lives in Africa comes out soon. While we’ve mostly stuck to finding the best organization – rather than generalizing about “how to save lives” – we’ve formed a couple informal opinions along the way, and this seems like a good time to share.

First off, I think bed nets are a little overrated as a cheap way to save lives. You may have heard sales pitches like this: “With just $10 you can send a bed net to stop mosquitoes in their tracks. Send a net. Save a life.” (From the Nothing but Nets Campaign.) Or, from Nicholas Kristof: “For $5 you can buy a family a large mosquito net and save several people from malaria.”

The thing is, while it’s true that $5-10 buys a net, that’s a very long way from saving a life. We’re looking at PSI’s net-selling program, which costs between $5-10/net including distribution, marketing, etc., and we’re finding the following things need to be considered:

• Relatively few children die from malaria. That means you have to give out a lot of nets to make a difference in a few lives. By our estimates, you need to distribute about 25 nets to reach a child who would have died. And, some nets are likely distributed to areas where the mortality rate is even lower.
• Not all nets that are distributed are eventually used properly. Distributing something for free is great because everyone gets it, but it’s also likely that many people choose not to use it, and if they do, may use it for something far different than what it’s intended for. Since PSI sells rather than gives nets, we’d guess the concern is smaller than usual with them, but it’s still a concern.
• Nets only save lives if at-risk people sleep under them. Malaria largely kills children under the age of five (as well as pregnant women). If the wrong family members are under the nets – or they’re just not using the nets, period – the nets won’t do any good. Proper use, awareness of who’s at risk, etc. can’t exactly be taken as given, although unlike other distribution campaigns we’ve seen, at least PSI has some data on how often the nets actually get used (about 70% of those who own them use them on a given night, in the region PSI studied).
• Sleeping under a net only reduces your risk of contracting malaria by 50%. You can still get bitten during the day, when you go to the bathroom, etc.
• A net doesn’t last forever. Nets tear, and some need to be retreated with insecticide to remain effective.

When we do all the math (not available yet but will be this coming Monday), we estimate that you don’t end up saving a life per net – you end up saving a life for every 70 or so nets at best, and maybe even more like 300 (so around $500 to $2000). Even PSI’s own estimate of lives saved comes out close to around 70 nets per life saved. And that’s looking at an organization whose customers purchase nets, defraying the cost somewhat and also probably reducing the number of nets that go to waste. Giving nets, though it may ultimately be effective, may involve even higher expenses.

Too expensive? Of course not, $2000 for a life is still a ridiculous deal. We just think you can do better.

For example, I think condoms are pretty underrated as a way of saving lives from HIV/AIDS. A lot of the focus in HIV/AIDS is on antiretroviral therapy, an extremely expensive form of continual treatment for existing AIDS patients, but promoting safe sexual behavior of any kind can stop AIDS before it starts for many people, and has many additional benefits as well. Looking at the same organization (PSI), we think their condom marketing is saving lives for more like around $250-1000 a pop – and that isn’t including other benefits, such as:

• Reducing unwanted pregnancies (which also means reducing deaths in childbirth, actually one of the leading killers of African adults).
• Reducing sexually transmitted diseases aside from HIV/AIDS (also a killer and generally a pain in the neck).
• Slowing the spread of HIV/AIDS.

Of course, these numbers and claims rely on a lot of assumptions; our full research will be available within the week, so you’ll get the chance to check it all out then. These are just informal observations. But even though our estimates are rough, it seems to me that all things considered, a successful condom marketing program (or any program that increases safe sexual behavior) is a pretty good life saver, and probably better than the good old nets. I’ll take either one in a heartbeat over antiretriviral therapy, which was all the rage for a long time despite the fact that it’s one of the most expensive and complex ways to help people in a region littered with cheap and simple opportunities.

Then there are things I think might be even more cost-effective, but don’t know much about yet:

• Immunizations. They’re great because they fully protect a child from a disease for the rest of his life (unlike nets which only last for a few years), and as far as we know, the actual vaccine costs little. Measles, for which an effective vaccine already exists is still one of the leading causes of death among children in the developing world. We don’t know why vaccines don’t reach those children – it’s certainly plausible that the areas they live in are so hard to reach that the cost of vaccinating them is extremely high – but we’d like to know more about this, because it’s hard to find a simpler way to save a life.
• Vitamin A supplementation. Research suggests that providing vitamin A supplements (a product that costs less than a quarter) to children under five can reduce child mortaility by pretty huge amounts. We have some questions about the research, as well as the ease of expanding coverage (as in vaccinations), but it’s possible that (unsexy though it may be) reducing Vitamin A deficiency is one of the most promising ways to lower infant mortality and improve general health.

Thoughts?

Eduwonkette gives a clear examination of data that is generally anything but.

This post is more about public policy than charity, but it shows – at a glance – a lot of the problems with the traditional approach to charity (giving as an act of the heart without the brain; trusting charities that mean well, without carefully studying their outcomes). The fact is that we don’t know what works in education. Blind faith won’t cut it, and neither will flimsy data.

A favorite saying of foundation people is, “You can’t be afraid to fail. You have to be ready to take bold risks.”

I’ve thought about it, and I think they’re going too easy on themselves. I put it to you: we need both funders of innovative projects and funders who focus on what already works. But right now, the latter is the one we need more of.

I believe that foundations today almost exclusively focus on high-risk, high-reward, unproven, innovative projects. Exclusively, to the point where there is no mechanism for proven, effective, scalable projects to get as big as they should be. My evidence is not as concrete as I’d like it to be, because foundations are too busy cowering behind locked doors to tell anyone anything about what they do. But here it is anyway.

• Exhibit A: from the horse’s mouth. Joel Orosz, Insider’s Guide to Grantmaking (pg 19): “Most foundations focus on encouraging innovation rather than on supporting the ongoing programs of nonprofit organizations.” Orosz reasons that individual donors, who give far more, will pick up the slack of funding what works. Problem is, they have no way of doing so. Take it from a guy who tried.

  As I’ll argue below, figuring out what works is actually far harder than figuring out what might work. That’s where foundations’ staffs and resources are most needed.

• Exhibit B: from the charities. Check out our Round 1 instructions, especially these parts:
  • “We know that helping people can be difficult to measure, but we have a strong preference for methods that we see strong reason to believe have helped people in the past.” (Pg 2)
  • “we suggest that you pick an existing, established, well-documented program for which you have thorough information readily available.” (Pg 3)
  • “Please focus on your existing programs and activities … [we] will likely not award programs for which little precedent exists. Rather, we are looking for organizations whose activities have worked well …” (Pg 4, emphasis in original)

  Now check out the Round 1 submissions (available under each cause on www.givewell.org). Note that even though we worked exclusively with large established charities and asked for projects that have worked before, we still received huge numbers of proposals for completely new projects. The only explanation I can think of is that charities are that accustomed to sending in new ideas, and that unaccustomed to talking about what they already do.

  Now check out the applications that didn’t misread our instructions, and did talk about existing programs. The evaluations are, frankly, a mess, with practically no exceptions. They’re in draft form, they’re disorganized, they neglect to mention clear methodological concerns … for the most part, not even our finalists were able to show us in a clear and readable way what their programs have accomplished in the past.

  I don’t blame charities, I blame foundations. We thought our questions would be easy for charities to answer, but as it turns out, “what do you already do?” is a question that none of them seem ready for. If foundations were asking this question, I have to think they would be.

• Exhibit C: the logic of laziness. There is no pressure on foundation people to do anything – so I expect them to take the easy way out. Although many point to their “courage” in taking on high-risk projects, in reality a high-risk approach is the easy way out for a funder. When you’re looking at what might work, instead of what does work, you don’t need any analytical abilities; you don’t need to interpret data; and you don’t need to be ashamed when you fail, because after all, you were taking a risk. You can follow your gut and your personal relationships all day long, and shrug your shoulders when it doesn’t pan out. I’m not saying there’s no place for this type of grantmaking, but it sure seems less sweaty than grantmaking based in the here and now.

Since Straw Man boxing is a favorite sport in this sector, I expect many of those who read this to respond, “But what would we do if nobody funded new innovative ideas?” I’m not suggesting that nobody fund new innovative ideas. GiveWell exists because some people took a chance on an idea. So does every other charity. What I’m saying is that right now, foundations work almost exclusively in the high-risk sphere, and that we desperately need more people identifying and scaling up what already works.

We need to learn more about what already works, so we can get those low-risk dollars from individuals to fund it and help lots of people. We need funders who go beyond people they like with ideas that sound cool, and get into the messy business of learning how the world actually is. We need more people who hold themselves to a high burden of proof, and the hard work and analysis that comes with it. We need more people who are afraid to fail. Could you be one of them?

There’s a saying that I think about a lot: “If you can’t explain it to your Uncle Bob, you don’t understand it.” (Note: may be a rewording of a real saying, or not a real saying at all; I’m not sure. If it’s unclaimed, mark it down as mine, thanks.)

How many times have you sat down to write something – for a blog, for a report, heck, for an email – that you were 100% sure of, then realized as you were writing that you have to rethink things entirely? It happens. When you’re talking to no one but yourself, everything you vaguely recall and intuitively believe sounds reasonable; you’ve got no check on it. When you’re talking to your fellow Program Officer, there’s a little more of a check, but the two of you are still in the same bubble, and you can still use jargon to skip over concepts you should be reexamining. When you talk to your Uncle Bob, that’s when you have to be clear – and that means getting clear in your own head.

That’s why, as we’ve written up our reviews for our public website, our opinions have changed drastically. Because as I write a review, I’m not trying to explain my reasoning to Elie, I’m trying to explain it to Uncle Bob. I’m trying to put it down so I can literally send a link to my grandma and have her understand why I’d rather give to Year Up than St. Nick’s. And even before anyone actually reads it, this makes me think much harder about it, question all the little assumptions I’ve been making (without knowing I’m making them), recheck all the sources for things I’ve been vaguely recalling, and get really clear on what I think.

I put it to you that in terms of clarifying and improving your thoughts, there is no substitute for the process of explaining your decision to a general audience. Everyone who thinks for a living knows this. Except, perhaps, for Program Officers at foundations.

Cause what I’m saying comes down to this. I believe that what we’re doing is exactly what every foundation, everywhere, all the time, should be doing: documenting everything we decide, with links to every single material we used to decide it, and releasing it so that anyone can see it and critique it. The benefits are obvious in terms of public information sharing, but one of the lame objections that is sometimes raised is that documenting your views for the public is “too time-consuming.”

Well heck yeah, it’s time consuming. But not because of the typing – because of the thinking. We’re spending ungodly amounts of time writing up decisions we think we’ve already made … and we’re getting every second’s worth back in terms of improving our decisions, clarifying them for others and for ourselves. Even before anyone has jumped in the ring to challenge our views (and a few people have), we’ve gotten a good dose of skepticism, feedback, and improvement from Uncle Bob.

Every single foundation should be writing up its decisions in public. Uncle Bob is fine with that statement. Who wants to challenge it?