The GiveWell Blog

The goal of GiveWell is to help a large chunk of individual giving to become more effective (i.e., to help people more). As such, the two most important questions about our project are:

1. Can we produce useful, actionable research for donors?
2. Will donors use it?

Our first year was focused on #1. We raised money only from people who knew us, because we had no track record and no existing research to point to. We told our donors that if they funded our startup, we would produce a first set of useful, actionable reports for donors. We’ve now done that.

Now the big question is whether our research can move a lot of donations. The bottom line about GiveWell is that if our research ends up influencing a lot of people’s giving, the project will work: sharing information will be worth charities’ time, and doing research will be worth our time and expense. If we can’t influence donors, then our research isn’t worth doing, and we’ll rightly go out of business. We’re not going to answer this question fully in the coming year, but we’re hoping to get a start on it.

That’s why we’re introducing the GiveWell Pledge, which aims to demonstrably increase our influence while preserving donor choice. A GiveWell Pledge is a formal, advance commitment to give to one or more of the charities we recommend after an additional year of research. The donor gets the final choice of charity, and pays no fee to us, but we get the benefit of being able to (a) show exactly how much money we’re moving; (b) show our direct donors, the ones who pay our operating expenses, whether we’re succeeding in our mission; and (c) show the charities we’re asking for information what’s in it for them.

This is different from the model used by philanthropic advisors (in which donors pay extra for research) and from the model used by independent evaluators (which have no “carrot” to get detailed information from charities). We’re hoping it will maximize our chances of doing research that is both thorough and sustainable. For more, see our official plan for the coming year.

We’ve been releasing a lot of new material over the last few weeks, and I want to make sure that our blog readers are aware of it. GiveWell.net now includes:

• New research reports and charity recommendations on three causes.
  • Global Poverty: includes a thorough review of the logical and empirical case for microfinance. We have no recommended organization (though we awarded our grant in this cause to Opportunity International) due to how little information we were able to get from large MFIs.
  • Early childhood care: we recommend the Nurse-Family Partnership, an exceptional organization replicating a proven program.
  • K-12 education: we recommend the Knowledge is Power Program and Teach for America, though we believe that early childhood care (specifically the Nurse-Family Partnership) is a more promising approach to promoting equality of opportunity than either of these.
• New summaries of our research, which give the highlights rather than the details: see our summary of findings for all five causes, as well as our overviews of equality of opportunity in the U.S. and developing-world direct aid.
• A thorough review of the successes, shortcomings, and lessons from our first year, as well as our plan for the coming year.
• An overview of our modified funding model, the GiveWell Pledge. More on this in a future post.

Several people have recommended that we look at the Fred Hollows Foundation. We have been shown calculations implying that they are preventing or curing a person’s blindness for every $20-60 they spend. As we continue our research on developing-world aid, we checked them out a bit ourselves.

The Fred Hollows Foundation’s programs include surgeries to cure blindness caused by cataracts and trachoma. These surgeries are relatively straightforward and can therefore be performed relatively inexpensively (at less than $10 per trachoma surgery, according to the Diseases Control Priorities Project). But the cost per surgery doesn’t tell the whole story - for example, we also want to know:

• How bad would patients’ vision be without surgery? While improving someone’s sight is always valuable, “curing blindness” means something very different to me from helping someone who previously had vision in one eye, or slightly impaired vision in both.
• How old the people are who receive the surgeries? Again, curing blindness always has some value, but it means more to me when it means giving someone a full life of healthy vision (or when it helps someone to care for their dependents).

The Fred Hollows Foundation conducted a 65-person post-operative survey in Cambodia that sheds light on the above questions. (You can see the full report here; this is the only survey of its kind that I found on their website.)

• 44% of those who received surgeries had been able to work before undergoing surgery, as they were “usually only blind in one eye or had some vision in both eyes” (Pg 11).
• 77% of those who received surgeries were over the age of 60 and another 21% were over the age of 41 (pg 10).

I’m excited by the idea of vision correction surgery; it’s cheap and tangible, even considering the above. But these sorts of details about who is being helped significantly change my idea of what you get for your donation with this kind of program, and I’m far from convinced that it ultimately represents a better “value” than our current top health-related charities.

The Career Academies initiative recently released a report on academies’ impact on students eight years after graduation. I’m fascinated by this report and this initiative because:

The Career Academies initiative rejects conventional wisdom about education.

For much of my life I’ve assumed that learning math, reading, and other “liberal arts” related skills is the key to later success in life. All of the K-12 education-focused charities we’ve examined appear to have the same unspoken assumption, stressing the importance of academic success (and generally measuring success through outcomes such as graduation rates and test scores). Last year, however, we started questioning this basic logic (for which we’ve found no empirical support).

Career Academies, while not ignoring academics, explicitly focus on preparing students for specific jobs (for example, see the Introduction of the full report recently released). And according to the evaluation, they are improving students’ earnings without improving their graduation rates or test scores (more below). Rather than assuming that the academic gap is at the heart of the achievement gap, this initiative is going straight after the latter.

The evaluation design used by Career Academies causally connects education with later life outcomes.

None of the K-12 education-focused charities we’ve examined make any attempt to examine later life outcomes, particularly earnings. Only three of them use the kind of experimental design that points strongly to effects of the program, rather than to selection bias issues. The Career Academies evaluation does both - making it the only study I know of that can plausibly discuss the effects of a particular K-12 program on the outcomes we really care about (not test scores, but earnings).

Randomized lotteries were used to assign the limited number of slots at Career Academies, and the lotteried-out students were compared to lotteried-in students a full eight years after graduation. We’re still waiting for the “technical” companion to the evaluation to be published so we can fully examine the methodology, but according to Evidence-Based Programs, the study had important strengths such as low attrition and an intention-to-treat approach that imply that any differences between the two groups (lotteried-in and lotteried-out) can be attributed to the effect of the schools themselves. It found that lotteried-in students report over $200/mo more in earnings (see Pg 13 of the full report), and that Career Academies students report higher earnings whether they’re classified as high-, medium-, or low-risk students (Pg 26).

This benefit came despite no apparent impact (see Pgs 28-32) on traditional measures of educational progress, including test scores, graduation rates, and college enrollment/completion. (Also note that these measures show enormous selection bias; a less rigorous, more typical study would have erroneously concluded that Career Academies do affect academic performance.)

I wish we’d discovered Career Academies earlier, and checked it out as thoroughly as our K-12 applicants. Rather than chasing small (or perhaps illusory) improvements in test scores and/or graduation rates, in the hopes that classic unproven assumptions about the importance of a high school education are correct, we might have funded an intervention with a truly different approach and a truly thorough commitment to making sure it’s changing lives, not just grades.

The National Academy Foundation focuses on the Career Academies approach. We haven’t done a thorough investigation of it, but you might want to check it out.

We haven’t seen - either in charities’ grant application materials or in our own independent research - much discussion of how organizations decide where to focus their resources. This question seems particularly important for international aid organizations, which often work in many regions all over the world (but by necessity have to ignore many more).

When thinking about this question myself, one of the criteria that occurs to me is the triage approach: find regions where a little bit of aid goes a long way. For example, let’s say we’re trying to decide where to expand malaria-centered interventions (such as insecticide-treated bednets). Niger, Guinea, Malawi, and Zambia are all countries with relatively high malaria mortality rates (0.17-0.2%, mostly concentrated among young children). However, Malawi and Zambia also have severe problems with HIV/AIDS: approximately 15% of the adult population is HIV positive and 0.6-0.9% of the total population dies from AIDS each year in these countries. By contrast, Niger and Guinea are significantly less affected by this disease (1-1.5% HIV positive, 0.04%-0.1% mortality rate).

From these numbers alone (and of course there is much more to the story), I’d prefer to expand a malaria-focused intervention in Niger or Guinea than in Malawi or Zambia. Our aim is to help people live fully enabled lives; resolving one problem, in an area where that problem is the primary obstacle a person faces (because s/he can now live a fully enabled life), will have a greater impact than resolving one problem where it is one of many a person faces. I’d prefer to protect children who won’t have to grow up with so much to fear from HIV/AIDS, if I have to choose (and I do).

Of course, to really make this sort of analysis work you need to look at a lot more than by-country rates for two diseases; you need to look at smaller regions (which can vary wildly within a country) and get a full sense of the different problems people face, including not only mortality risks but more general health problems (such as malnutrition), access to education and economic opportunity, and political stability. The goal is to find places where a humanitarian intervention can truly make the difference in giving someone a life of opportunity (not just solve one of an overwhelming set of problems).

References:

• Mortality data (2002 estimates) comes from the WHO’s Burden of Disease Project, available here.
• HIV prevalence data comes from UNAIDS and the WHO’s Report on the Global AIDS Epidemic. We accessed it through Gapminder. You can download it here.

I came across an interesting article on microfinance by Tyler Cowen. Like us, Cowen is skeptical about the common anecdotes focusing on the “entrepreneurial” aspect of microfinance:

For better or worse, microborrowing often entails a kind of ­bait ­and ­switch. The borrower claims that the money is for a business, but uses it for other purposes. In effect, the cash allows a poor entrepreneur to maintain her business without having to sacrifice the life or education of her child. In that sense, the money is for the business, but most of all it is for the child. Such life­saving uses for the funds are obviously desirable, but it is also a sad reality that many microcredit loans help borrowers to survive or tread water more than they help them get ahead. This sounds unglamorous and even disappointing, but the ­alternative —­ such as no doctor’s visit for a child or no school for a ­year —­ is much ­worse.

This account is broadly in line with the position we’ve taken on what microfinance is (likely a very good thing for many disadvantaged people) and what it isn’t (the “make a loan, expand a business” picture that is often used to market it). What’s great about the article is that having made this distinction, it then goes on to give a detailed qualitative picture of how microfinance can actually help people:

Commentators often seem to assume that the experience of borrowing and lending is completely new for the poor. But moneylenders have offered money to the world’s poor for millennia, albeit at extortionate rates of interest. A typical moneylender is a single individual, ­well-­known in his neighborhood or village, who borrows money from his wealthier connections and in turn lends those funds to individuals in need, typically people he knows personally. But that personal connection is rarely good for a break; a moneylender may charge 200 to 400 percent interest on an annualized basis. He will insist on collateral (a television, for instance), and resort to intimidation and sometimes violence if he is not repaid on time. The moneylender operates informally, off the books, and usually outside the ­law.

…if you want to know how much net saving is going on, don’t look at money. Banks may be a ­day­long bus ride away or may be plagued, as in Ghana, by fraud. A cash hoard kept at home can be lost, stolen, taken by the taxman, damaged by floods, or even eaten by rats. It creates other kinds of problems as well. Needy friends and relatives knock on the door and ask for aid. In small communities it is often very hard, even impossible, to say no, especially if you have the cash on ­hand…. Under these kinds of conditions, a cow (or a goat or pig) is a much better medium for saving. It is sturdier than paper money. Friends and relatives can’t ask for small pieces of it…. With a small loan, people in rural areas can buy that cow and use cash that might otherwise be diverted to less useful purposes to pay back the microcredit institution. So even when microcredit looks like indebtedness, savings are going up rather than down.

This qualitative account helps me understand how it is that microfinance can be a worthy intervention, even when clients are carrying persistent debt loads at high interest rates (as they often are). For any region where the picture painted by Cowen holds - i.e., when the only source of credit is moneylenders charging exorbitant interest rates and using the threat of violence - I would happily invest in a microlending program.

But I know there’s at least one good example of a microfinance program that came into a region where credit wasn’t already scarce - and consequently failed to have any noticeable impact. In my mind, this “what are you replacing?” question is one of the very most important questions for a microfinance program - and one that we haven’t seen any organization provide strong documentation on.

I believe that most discussion of microfinance - by nonprofits, by the media, and by donors - is frustratingly superficial, focusing on extreme success stories and simple statistics like the “repayment rate,” rather than on getting a real picture of where microfinance is helping and where it isn’t. Cowen’s take is refreshing, and with more conversation along these lines I hope we can get a better picture of an extremely promising intervention.

Our first year of research implied, to me, that donors can have more impact focusing their giving on the developing world as opposed to the developed world. In a nutshell, developed-world interventions are expensive and the case for their effectiveness is often questionable, while developing-world interventions are often inexpensive and seemingly more reliable.

However, the fact that people in the developing-world face a diverse set of complex, interrelated problems means that well-intentioned interventions can easily have little effect if they’re not properly implemented.

A recent paper (Hotez 2008) may describe a unique opportunity for donors, however. Hotez discusses the existence of Neglected Tropical Diseases (diseases that are by-and-large not life threatening but can significantly disable adults and impair children’s physical and cognitive development) in the United States.

Hotez finds that these diseases largely affect those living in extreme poverty in six regions of the United States: Appalachia, the American South, the Mississippi Delta (including post-Katrina New Orleans), inner cities, Native-American tribal lands in the Southwest, and communities along the U.S.-Mexico border (see his map here). Hotez emphasizes the problems of:

• Helminth (parasitic worm) diseases, which can lead to malnutrition, anemia, and growth and cognitive delays (Hotez et al 2007). These diseases affect a few million people in Appalachia, the American South, and inner cities (see his table here)
• Dengue fever (which can be fatal) and Chagas disease (which can lead to a serious heart problems, (Hotez et all 2007)), which affect a few hundred thousand people in Appalachia and post-Katrine Louisana (see table linked above).

Many of these conditions can be treated with simple, proven interventions that charities distribute in the developing-world. For example, Albendazole can treat helminths, and costs pennies (see Molyneux, Hotez & Fenwick 2005). In addition, basic efforts to control vectors (such as rats and mosquitoes) and improve access to water and sanitation infrastructure may significantly reduce the burden of these diseases.

Since we just came across this paper, we know little about how viable an option this is for individual donors - a quick Google search didn’t turn up any charities obviously attacking these problems in the United States - but we’ll keep our eyes open for one. Fighting these diseases in the developed-world seems like a great option for a donor seeking the biggest impact by using the triage approach: helping those who can benefit most easily.

References:

1. Hotez PJ (2008) Neglected Infections of Poverty in the United States of America. PLoS Neglected Tropical Diseases 2(6): e256 doi:10.1371/journal.pntd.0000256 (Available online)
2. Molyneux DH, Hotez PJ, Fenwick A (2005) “Rapid-impact interventions”: How a policy of integrated control for Africa’s neglected tropical diseases could benefit the poor. PLoS Med 2(11): e336. (Available online)
3. Hotez, PJ., Molyneux, DH., Fenwick, A., Kumaresan, J., Sachs, SE., Sachs, JD., Savioli, L. (2007) Control of Neglected Tropical Diseases N Engl J Med 357: 1018-1027. (Available online)

This week, Giving USA released their 2007 estimate of U.S. charitable giving.

Its data forms one of our favorite figures, and one of the biggest factors behind our decision to start GiveWell. Taken together, individuals account for 75% of total US giving; that’s 6x as much as all foundations combined. (In fact, it makes more sense to count “Bequests” as individuals, and many “Foundations” are in fact family foundations that have little to no staff, and have a similar lack of access to the information they need.)

When I talk about this chart, many ask: “Sure, individual donors give a lot, but doesn’t most of it go to religious institutions and universities? Is it really going to the types of charities GiveWell focuses on: humanitarian organizations focused on providing for people’s needs?”

A paper released last year by The Center on Philanthropy at Indiana University examines precisely that question, using survey data to estimate how much giving is “focused on the needs of the poor” (including an estimate for how much of the money given to “multipurpose organizations,” including churches, has this focus). Note that this report gives a higher total for individual giving than Giving USA, possibly because it is from reported data rather than IRS data, and may therefore include gifts that weren’t taken as deductions. The researchers found that:

When summed, the giving to help meet basic needs and other estimated giving that is focused on the poor come to $77.30 billion, or about 30.6 percent of total estimated household contributions of $252.55.

However you slice it, individual donors are the largest philanthropist in the United States.

Would you rather hear about a good charity or a bad one?

When I’m explaining GiveWell to someone, there often comes a moment where his/her eyes suddenly light up, and s/he says something like, “So you bust the bad guys, eh? Can you tell me about a really bad one you’ve nailed?” (Paraphrased.)

This sort of person is usually pretty disappointed if and when they look at our actual reviews. “I don’t get it - you said you didn’t grant this organization because you didn’t have enough evidence to assess them. So you don’t KNOW that they’re bad …”

Finding bad charities is a fundamentally different endeavor from finding good ones. In some ways, it’s more fun and more exciting to find bad ones. Scandals are juicy; qualified statements that an organization appears to be improving lives, though many factors remain unexplored, are less so. “Good vs. evil” makes headlines and produces adrenaline in a way that “Proven vs. unproven” doesn’t.

But if you’re looking to accomplish as much good as possible with your donation, and you’re looking for an organization that you can be confident is changing lives for the better, I submit that you’re much better off focusing your energies on the few charities that might be able to convincingly document their effectiveness. Evaluating well-documented charities is more than enough work. Trying to nail down the effects of charities that don’t have strong self-documentation is an enormous undertaking, one that I think is worth your time only if you have a personal connection or other strong reason to believe you’re already dealing with an exceptional organization. Spending any time on organizations that don’t stand out in any way - and bothering to make distinctions between “bad” and “worst” - doesn’t seem like a good use of time at all. The question is, are you trying to make a good story or make a donation?

From 2004-2006, I gave all my donations to organizations focused on helping inner-city youth (particularly academically). Equality of opportunity was my favorite cause, and I assumed (without having time to really look into it) that inequality stemmed from the gap in quality between different grade schools. I now believe that this assumption was badly wrong, and that as a result, my donations were mistargeted.

The most surprising thing I’ve learned about the achievement gap between black and white / low-income and high-income students is how early in life the gap is present. Every source I’ve looked at is consistent in this regard: children from different socioeconomic and ethnic backgrounds have large, systematic differences in academic performance in kindergarten, and these differences grow only slightly as children get older. In other words, most of the systematic academic inequality we observe is present by age 5. There is a good deal of literature on this subject, but the paper I’d recommend for starting to take a look is “Understanding Trends in the Black-White Achievement Gaps during the First Years of School” by Murnane, Willet, Bub, and McCartney (Brookings-Wharton Papers on Urban Affairs, 2006).

This is a relatively simple observation, but it completely changes the way I think about promoting equality of opportunity in the U.S.

• It makes me much more interested in interventions that focus on early childhood, the period during which most of the “achievement gap” appears.
• It makes me much more skeptical of the idea that equalizing children’s schools will equalize their educations, something that once seemed obvious to me. It makes me much less optimistic about what one can accomplish with “small schools” (a Gates-backed initiative that has produced disappointing results), private-school scholarships, etc. (The Murnane paper also references research on disappointing results from programs in this category.)
• It makes me especially skeptical of low-intensity grade-school or high-school interventions such as after-school tutoring. I find it very possible that a few hours of extra help a week just aren’t enough to make a dent in deep-rooted disadvantages.

I think it’s interesting that this extremely basic, fundamental, and important fact about the achievement gap - how much of the gap is present by age 5 - has not come up in any of our conversations with (or applications from) charities themselves. That includes both education charities and child-care charities. It seems to me that most development and fundraising professionals are focused on reinforcing and serving donors’ existing assumptions; if you want to challenge your assumptions to get the best understanding possible, you have to look elsewhere.

A new study sponsored by several major foundations (Gates, Packard, Hewlett, Irvine, and Robert Wood Johnson) found that among “engaged”* Americans, only:

• 43% can name a foundation on their first try
• 15% can cite an example of a foundation’s impact in their community
• 11% can cite an example of a foundation’s impact on an issue they care about

Individuals - who don’t have access to information about how well charitable programs are working - donate over $220 billion dollars to charity every year. Foundations retain expert staff to evaluate programs and make grant decisions. If foundations want to increase their relevance to individual citizens (and those citizens’ awareness of them), one good start might be addressing this information gap: using their expertise to help donors make more informed giving decisions.

* U.S. adults aged 18 and older who have held a leadership, committee or board level role in a group or organization working on a community or social issue within the past year.

The Brookings Institution is hosting a conference this week called “What works in development?” including an interesting paper by Simon Johnson (International Monetary Fund) and Peter Boone (London School of Economics) titled, “Do Health Interventions Work? Which and in What Sense?”

Johnson and Boone review the existing literature and conclude that there is very little knowledge about the most effective methods for reducing child mortality in the developing world, and that without improved knowledge, aid organizations may fail to reduce child mortality as much as they hope.

Knowledge is limited in the following ways:

• We know what works clinically, but know far less about the most effective ways to fully implement an intervention.

  This rings true to me and makes me think of bednets. We know that insecticide treated bednets, when used properly and consistently prevent deaths from malaria (at least in the short term), but we don’t know the most effective way to ensure proper use, a critical component of the intervention. Evidence for the effectiveness of bednets comes from aid experience in very specific contexts (e.g., the way in which the nets are distributed, the education level of those who receive them, etc) which means that the distributing bednets may not be as effective when implemented in a context different from that of the initial evaluations.

• When we have multiple, proven interventions, we generally don’t know which to implement where or how they’d work as a package.

  Keeping the point above in mind, there’s strong evidence that both insecticide treated bednets and artemisinin-based therapies reduce child mortality when implemented properly. However, little is known about how they work together (as a package) or which situations are best suited to one or the other. (It doesn’t make sense to implement both everywhere because a) the more the treatment is used the more quickly resistant strands of malaria will likely develop and b) the cost of implementing both everywhere will obviously exceed an approach that implements only what is necessary).

• Evaluations of interventions’ effectiveness often stop at measuring reduction in incidence as opposed to total mortality.

  Often, evaluations of interventions focus on an intervention’s effect on disease incidence (e.g., the reduction in cases of diarrhea caused by building improved water and sanitation infrastructure). This is a problem because many of the causes of death in the developing world are interrelated - i.e., one problem increases the likelihood of death from another. UNICEF estimates that malnutrition is a contributing factor to 50% of child deaths (from malria, diarrhea, etc.), and the WHO finds that measles contributes deaths from pneumonia and diarrhea. Because of these interrelationships, evaluations that only asses an intervention’s effect on disease incidence may not accurately identify the effect on mortality.

  This problem is illustrated in a recent paper cited by Johnson and Boone that finds that while water and sanitation projects reduce incidence of diarrhea, they have a minimal impact on child mortality. Johnson and Boone hypothesize that:

  It seems plausible that the much wider coverage of water and sanitation today, along with the advent of vaccines and treatments for the main causes of death from infectious disease, mean that further improvements in water and sanitation are no longer necessary or very significant to eliminate remaining deaths (pg 21).

Johnson and Boone have their own view on the best approach: targeting parental knowledge rather than distribution of materials. They observe that:

• Many interventions are extremely inexpensive (e.g., Oral rehydration therapy costs $.10/packet and malaria treatment costs $.50 cents/dose - Pg 17), and are not beyond the means of many people in the developing-world.
• There is good evidence that parents are not very knowledgeable about health (Pg 25), and parents’ education is highly correlated with child mortality (Pg 23).

It’s a plausible hypothesis, but could easily be flawed, as Johnson and Boone point out themselves. For example, it’s possible that the observed correlation between parental education and child health is a simple consequence of the fact that more educated parents also tend to be wealthier, and that wealth is in fact the primary factor here.

Knowing that their hypothesis could be right or wrong, Johnson and Boone have set out to test it. Working with Effective Intervention, a UK-based charity, they’re planning to implement a series of randomized controlled trials of comprehensive aid programs focusing on a) educating parents and b) providing access to necessary health products. In some areas, they’ll also include education for children as part of the intervention, planning to follow the children at least 10 years after the completion of the trial. Eventually, they plan to run trials in 600 villages in Africa and India covering 500,000 children. They say it will take three years for the first findings.

This is the first we’ve heard of Effective Intervention, but they are taking exactly the approach we identify with most: starting with a systematic review of what we do know, pinpointing what it is we want to know next, and then focusing on producing that knowledge rather than on scaling up a program with unknown effectiveness. We’re looking forward to their results.

I recently read Better by Atul Gawande, and found myself particularly struck - and reminded of our own situation - by his analysis of hospital care.

According to Dr. Gawande, conventional wisdom has long been that the vast majority of hospitals provides top-notch, quality care, and only a fraction treats their patients incompetently. This implies that the most important thing a patient can do is weed out incompetent hospitals - but worrying about “average” vs. “exceptional” isn’t worth it. But a systematic study found otherwise.

The Cystic Fibrosis Foundation had long monitored the well-being of CF patients at hospitals around the country. When they evaluated the data, they found that quality of care and patient outcomes, such as life expectancy and quality of life, varied more than they had expected. A relatively small group of hospitals provided low-quality care, but another group provided top-notch care. Their patients lived longer and lived better. (The foundation also found that the vast majority of hospitals fell in the giant, indistinguishable middle, providing average care that was neither incompetent nor excellent.)

The differences in impact weren’t just academic. The evaluation found that average life expectancy for someone diagnosed with CF was 30 yrs, but at top hospitals, life expectancy was significantly longer, averaging 46 yrs. While alive, patients at average hospitals had lower quality of life than those without CF because they had lower lung function and consequently couldn’t participate in a host of normal activities. At top hospitals, patients’ lung function was equivalent to those without the illness. The differences were real and they were stunning.

Recognizing the significance of the results, the Cystic Fibrosis Foundation did the only thing they could: they made all the information public. Patients should know which hospitals provide best care, shouldn’t they? Doctors should know which methods work best, shouldn’t they?

Critics feared that demand for care at the best hospitals would outstrip the hospitals’ ability to provide it, but instead something else happened. Care improved across the board as hospitals’ staff met and implemented the practices of those at the top.

The reported conventional wisdom on hospitals reminds me of the conventional wisdom we constantly hear expressed about charities: that the vast majority of them do great work, and that it’s important to weed out the “frauds” but that distinguishing between “legitimate” charities amounts to nitpicking. Our instinct, however, is that charities are like hospitals, companies, and any other set of highly complex organizations that vary in their people and approach to difficult problems. Our instinct is that in charity as in most other things, the difference between “best” and “average” is at least as important as the difference between “legitimate” and “illegitimate” - and that starting to examine the differences, publicize them, and push for the best may lead to improvement across the board.

In the wake of the cyclone in Myanmar, donors need help.

Google “Myanmar” and you’ll see a huge list of organizations advertising for donations. I don’t know whether they’re coordinating on the ground, but they’re certainly competing when it comes to raising money - and donors, including myself, have virtually nothing to go on in picking one.

Today’s conference call, hosted by Arabella Advisors, had so much interest that it ran out of phone lines (there were hundreds of people listening in). During the Q&A session, they announced that “The single most common question that’s coming in is ‘Tell us who to give money to.’” Their primary answer was to point to a list of InterAction.org list of “vetted” charities - a whopping 46 “recommended” charities, including practically every big name, alphabetically arranged, with small blurbs provided by each charity. (The vetting standards themselves are familiar for their emphasis on accounting and governance; these are important things, but there is absolutely no mention of, for example, charities’ track record in past disasters.) It’s a familiar sight: a generic, non-judgmental set of standards has been used to try and avoid the worst, not to help find the best.

Arabella also brought up the option of consulting “community foundations and other organizations you already trust.”

While I appreciated much of the content of the call, their way of handling this question sounded to me like “Donors, you’re on your own.” I’m guessing the reason the question was so popular is because donors don’t have “already trusted organizations”; they don’t know where to give. That’s certainly the case for our donors, who have been emailing me for advice and even using words like “helpless” and “desperate” to describe how they feel - wanting to help, deluged with appeals, and entirely without means to answer the simple question: “where should I donate?”

Right now, I believe that donors need emergency help. I don’t mean this the way that fundraisers sometimes mean it, i.e., as a plea to help donors feel better about themselves by providing emotional reassurance about their donations. I mean that we need to help well-meaning people help others, by understanding that they don’t have a pre-existing wealth of knowledge about Myanmar, that they don’t have a pre-existing commitment to and knowledge of the best aid organizations, by understanding that they just want to help in the best way possible - and, therefore, by giving substantive, well-supported, specific recommendations for where to give.

We’re looking into whether we’ll be able to provide such recommendations, in a relevant time frame. In the meantime, I haven’t found any philanthropic experts giving donors the help they need.

I had a typical reaction to the disaster in Myanmar: wanting to do something. I have spent very little time looking into the area of disaster relief, so after a bit of Googling and discussion with Elie, I gave to Population Services International for two reasons:

• PSI was the winner of our “saving lives” cause for 2007; we are extremely impressed with the organization as a whole, particularly its commitment to thorough self-monitoring. We don’t know much about their relief operations, but I would bet on PSI over any other international relief organization I know of just in terms of the extent to which it “runs a tight ship” with solid monitoring and oversight that allows accountability from the field to the top.
• PSI has a major and long-established presence in Myanmar; I believe (based mostly on this article) that having a pre-existing presence is important, particularly in a situation like this where the idiosyncracies of the area and particularly government seem important. I’m most comfortable with an organization that is used to getting work done in this political and cultural environment.

This is an informal, personal recommendation; it is backed not by an in-depth research project, but by the quick heuristics above.

This also got me thinking, though, about the more general cause of “disaster relief.” We looked into this cause back in 2006 (when we were still a part-time group of volunteers) and found very little. We aren’t aware of any organizations that are exclusively committed to disaster relief; rather, it seems to us that most relief efforts come from large humanitarian organizations, such as PSI, the Red Cross, World Vision, CARE, Direct Relief International, etc. that spend most of their time and money on direct, day-to-day (not disaster-related) aid. This makes sense, since it means emergency aid efforts can be aided by already-on-the-ground presences.

However, it isn’t necessarily the case that the best “day-to-day” relief organization is the best disaster relief organization. The former may be best accomplished through meticulously planned long-term projects that rely on proven techniques to get the maximal dollar-for-dollar impact; by contrast, I would guess that a disaster presents problems that are unusually simple to solve (people who need basic supplies, but who don’t necessarily suffer from a host of interrelated physical, economic, and cultural obstacles), and that speed and efficiency are more important. I’d be very interested in a compiled summary of disaster relief efforts over the last 10 or so years - which organizations were first, and most instrumental, in each relief effort. It seems feasible that such a summary could be created by polling affected governments and citizens, but I’ve never seen one.

I also wonder whether there are cost-effective “disaster preparedness” measures that can aid particularly vulnerable areas in advance. I was shocked at the death toll from this particular disaster, and I wonder whether a similar storm in the U.S. could have been nearly as devastating. It’s possible that disaster preparedness comes mostly from widespread economic prosperity, and that nonprofits are ill-equipped to bring about the kinds of drastic changes that would be needed to improve preparedness (and/or that the areas least equipped for disasters also have other, more important problems). But it also seems possible to me that constructing some extra shelters - or equipping communication infrastructure to provide effective early warnings - could save lives far more effectively than focusing only on after-the-fact interventions.

Looking into these questions, as with just about any area of philanthropy I can think of, would take significant time and resources. I’m not sure whether we’ll get to do it anytime in the near future. But it seems likely to me that the costs of such investigation would be more than justified. When disaster strikes, a lot of people reach straight for their wallets, and give without having time to think about their different options. But the thinking could be done, centrally, in advance - imagine what a difference that would make.