OK, maybe I got a little carried away in my last post, as Elie is more than happy to point out. I’ve been screaming about “low prices,” when the truth is that curing an obstetric fistula or cleft can be worth the extra $-per-person for a variety of reasons.

Something you’ll see a lot of on this blog is me ranting/raving/foaming at the mouth about the cause of the day, even if it isn’t my personal favorite. That’s because I think there are a lot of great causes that might appeal to different people, and I want to promote all the good ones. But something that’s very important–and that I think most people don’t do nearly enough of–is deciding between the many good things you can do with your money.

I think it’s crazy to make 10 small donations when you could make 1-2 big ones. None of your small donations will solve the problems they’re attacking (i.e., there will still be plenty of the problem left), so why not spend all the money on the most important one? Plus, big donations get you attention: they give you the opportunity to tell a nonprofit what you do and don’t like, and have them listen. The most important reason to concentrate your giving, though, is exactly the reason that most people don’t want to: it forces you to make hard decisions. And that forces you to raise the stakes, learn more, and think harder. And that leads to better decisions and totally sweet websites.

So, after raving about the great deals on malaria and cleft and diarrhea and fistula like a kid in a (nightmarish) candy store, let me put my 2006 giving decisions front and center. There are a lot of great places to give. These are the ones I determined (based on about .01% of the information I wish I had) to be the best.

$5000 to New Visions for Public Schools. As cheap as it is to save lives in Africa, I see improving U.S. education as the most difficult and important problem of all. This country is rolling in it. It should be a utopia, for crying out loud, and it isn’t close. Poorer countries are eventually going to be this wealthy, but unless we figure out how to promote true equality of opportunity, that wealth isn’t going to translate into what it should. And New Visions has the most promising approach I’ve seen in this area: go straight at the public schools (eliminating the selection bias of charters), and go at them with extreme systematicity and rigor. Read the review for details.

$2000 to Interplast. Cleft was the cause I specialized in researching over the last few months, so this was partly a relationship-building donation. But I also think corrective surgery is the cheapest and most concrete way I’ve seen to convert a full life of misery to a much more reasonable (if still poverty-stricken) one. There’s a good chance I’ll change my mind as I learn more about fistula, child slavery, etc., but this is what I’m confident in for now.

$1000 to the Children’s Aid Society, also promoting equality of opportunity in the U.S., though in a very different way from New Visions. They’ve received my biggest donations in the past; they’re good (though New Visions now excites me more); and I want to maintain a relationship because they could be great if they did a better job tracking their activities and results.

$256 each to four smaller causes: two with personal connections, one as a thank-you to Alliance for Smiles for being open and helpful (though I ultimately went with Interplast), plus alma mater.

And that’s it. $9000 in tax-deductible donations (so between $5000 and $6000 of actual money). I could have protected people from malaria, helped fight global warming, fed the hungry, saved the children, or even bought some books for affluent communities. I chose to support two organizations trying to break down inner-city obstacles to opportunity, and one correcting deformities for those who can’t afford it. And I’ll be the first to admit that I didn’t give every penny I have. So, how did I do? For my take, tune in next time. For yours, post a comment.

I think in numbers. I’ve always thought in numbers. When I think about charity, my first instinct is to think of how to save the most lives with the fewest dollars. So Holden’s argument that malaria and diarrhea are “cheaper” than obstetric fistula–in a “dollars per person” sense–has obvious appeal.

But then, I think about women who have fistula. I keep thinking about a young teenage girl who has to live alone, whom no one will be near, whose life is effectively torture. I imagine that that girl is someone I know, and then, I can’t believe that the only thing preventing this girl from living a normal, happy life is something in the ballpark of $1000 (generally cited lower, but we’ve learned to take cited numbers with a large grain of salt). $1,000 is a lot of money, but it seems incredibly small when it’s the difference between someone suffering as those with fistula do and not having to suffer. And I’m not sure this is because I’m being emotional as opposed to rational. I think there’s a reasonable philosophical perspective that says we should try to improve lives (fistula, inner-city education, etc.) as opposed to merely trying to prevent death.

We haven’t researched fistula much yet, but a couple things strike me. First, many of the preventable diseases that kill people in the developing world (like malaria and diarrhea) largely affect children. Since fistula affects girls who have already reached their early teenage years, girls who are helped are largely safe from the main preventable diseases that kill people in Africa. On the other hand, providing a family with bednets does prevent malaria, but those very same people are susceptible to other dieases (diarrhea, for instance). Narrowly, this means that the cost of really saving a life is understated for diseases like malaria and diarrhea, where solving one problem still leaves a person exposed to a host of others. More broadly, I’m concerned about the kinds of lives we are saving. If fistula is literally the only thing keeping a girl from a relatively normal (if poor) life, while diarrhea is one of many debilitating problems for the people it affects, we may be accomplishing more by attacking fistula–even at a higher price tag.

My buddy Elie, a member of the GiveWell project and a passionate diarrhea guy, is trying to get you excited about the idea of saving lives for about $1000 a pop (see below). Hey, it is a good deal, and I agree with his take that repairing someone’s fistula is pretty comparable to saving her life. Why settle for pretty comparable, though? How much would you have to pay to literally stop a child from dying?

Turns out, the answer is less. Way less. For your real charity bargain shopping, go on down to Africa, especially the regions afflicted by malaria. According to this study, “About six lives can be saved each year for every 1000 children protected with insecticide-treated nets.” Insecticide-treated nets can be had through Nothing But Nets for a whopping $10 each (transportation and distribution included), and they last 3-5 years and generally cover 2 people each … which means buying 500 nets (for $5000) can cover 1000 children and save let’s say 24 lives over 4 years … which comes out to ~$200 per life saved.

Hang on. This is crazy. Let me say that again.

$200 to save a freaking life.

But that’s not all. The weirdest thing about Elie’s high-priced offer is that he’s forgetting about his own favorite cause, fatal diarrhea. This is one we don’t understand as well, largely because the organizations we’ve seen in this area don’t seem as careful about tracking their results. So I can’t give you an exact dollar figure … but I can tell you that an ORT, a tiny packet of nutrients that a child can swallow and ensure that he survives his bout of diarrhea, costs … wait for it …

5 cents.

There’s a word for this, friends. It’s called a bargain. We’re all familiar with the idea as it applies to junk: if someone cuts prices enough, you’re usually in, even if we’re talking about a DVD of Deuce Bigalow, European Gigolo. (Admit it, you smiled just now. No, I’m not proud.)

Well, it just so happens that this is your lucky day! Cause thanks to a combination of global disparities in wealth, ineffectively distributed charity, and horrible disease epidemics, SAVING LIVES HAS NEVER BEEN CHEAPER! WE’RE PRACTICALLY GIVING THESE THINGS AWAY!! ACT NOW BEFORE IT’S TOO LATE!

(And hopefully, this sale won’t last much longer.)

There’s a scarcity of $250,000 Ferrari 599 GTB Fioranos, and that’s ruining Christmas for 49 investment bankers who can’t buy the Christmas gift they want. I have an idea of what they can do with their money instead: Save 250 lives. How, you ask?

I recently learned about the problem of Obstetric Fistula. Briefly, childbirth is often more than a young, teenage girl’s body can bear, and it leads to, essentially, a hole in her body that does not close. Because of the hole, the young girl cannot control her wastes, and is often sent to live alone, far from other people. While these women don’t die, it’s hard to see the lives they end up living as anything much better than death.

Currently, approximately 2 million women have the condition, and the UN estimates that there are approximately 100,000 new cases each year. The Fistula Foundation and the UN claim that it costs $300 to perform one operation. (I’ve also seen estimates of $450.) We’ve found that a per-person cost estimates are often understated (ignoring necessary overhead, for example), so let’s be conservative and estimate the cost of curing one Fistula at $1,000. Assuming that there are currently 2 million afflicted women and that it costs $1000 to cure each, the total cost of curing everyone with Fistula is $2 billion. Assuming that 100,000 women are newly affected each year, it would cost $100 million/year going forward.

OK, not pocket change. On the other hand, this is the season of the Wall Street Christmas bonus, and stories abound with what the newly minted bonus babies will buy. The New York Times reported that Goldman Sachs will pay about $16.5 billion in employee compensation this year, much of it coming in year-end bonuses. Yes, that’s right. $16.5 billion. If each Goldman Sachs employee contributed 1/8th of their bonus, Goldman Sachs alone could essentially eradicate the problem of Obstetric Fistula. And that’s only Goldman Sachs. Well, that’s just Goldman Sachs – why put all the onus on them? CNN estimates that bonuses paid to the people working in the securities industrey will come to approximately $24 billion in 2006.

So, I’d like to offer a different perspective on bonus season. For each $5,200 hour you choose not to ride on a Gulfstream IV chartered jet, you can save 5 women. And, if you just can’t believe that there’s a dearth of Manhattan properties being offered in the $20 million range, don’t worry. You can spend $10 million on a starter apartment, and use the savings to save 10,000 lives.

Corrective surgery organizations love to make generalizations: $250 can save a child’s smile, $10000 makes children smile for miles, smiles are magical, frowns are a leading cause of death, etc. I asked the organizations I was looking at for more details, because there are all kinds of ways that numbers like that can be ambiguous … when I’m quoted $250 to fix a child’s cleft, does that include overhead? Donated supplies? Is it an average, or is it what I would actually be funding with a donation? Is it just for the initial surgery, and is that initial surgery enough to make the child smile/be functional for life?

My questions got a variety of responses, from actual information (more detailed budgets, information on followup surgery, etc.) to hostile accusations (I’ll talk about that one later) to … a movie (“In response to your request for added info, I wish to mail you a DVD”). Well, I’m a sucker for movies, so I was pretty pumped about this, and even talked myself into how a movie can capture what you can’t put into words etc. When the DVD arrived, I insisted to my GiveWell buddies that we get out some pretzels and watch it together.

Within seconds, the room was filled with moans: “Holden, what the !@#$?” “You’re going to give me nightmares, you !@#$!” “What are you making us watch?” I should have seen it coming, really. There has often been a disconnect between what I want to see and what nonprofits want me to see, but this is as big as it’s gotten, because I most definitely do not want to see this, and that movie was nothing but slide after slide of it. I went easy on you with that link, too–we were looking at closeups, surgeries in progress, the whole deal.

“Look, the guy told me to watch this video, he saw the questions I was asking, there must be something useful here,” I pleaded. “Just let me fast forward.” I fast-forwarded through more horrifying pictures, and more, and more … and we realized that we were basically looking at rotten.com, and there was no end in sight. Finally, with about 2 minutes left in the 10-minute video, we started seeing post-surgery pictures: smiling children with little scars on their lips. Great. I shut off the video and took out the DVD, which we voted to destroy.

Having a cleft sucks. I get it. Worse than not looking good is a host of other problems: feeding difficulties leading to malnutrition, speech defects, and societies that are often superstitious and ostracize deformed people in ways that the developed world doesn’t. I’ve been told that Chinese children with clefts are commonly left by the side of the road; on other regions, they’re believed to be supernaturally evil and are feared and shunned; in most places, they don’t go to school at all. I don’t need to spend 10 minutes trying not to puke up my dinner to understand this. I’ve moved on from “Can you have a reasonable life despite a cleft?” (you can’t) to a host of other questions about cost-effectiveness of methods, needs for followup surgeries, and most importantly: what ultimately happens to a person who gets his/her cleft fixed? What kinds of lives are made possible by these nonprofits’ activities?

With some exceptions, cleft nonprofits don’t market around these questions; they market around before-and-after pictures. It’s what I call Guilt Marketing: making someone feel bad, and reach for their wallet to ease the pain. It’s the wrong reason to give to charity. If you think of giving as something you have to do, you’ll treat it the same way you treat other things you have to do, like homework or taxes: you’ll wait until someone asks you to do it, and then you’ll basically do what you’re told.

I don’t think of charity as an obligation—none of this stuff is my fault, or yours—but as an opportunity, a chance to buy a better life for someone for about the same cost as a PlayStation. And just like buying a PlayStation, this is a decision I can’t make based on a picture.