The GiveWell Blog

We are doing both region-based and program-based research on developing-world health. First I will discuss our program-based research, which will focus on (a) finding particular interventions (and/or clusters of interventions) that appeal to us; (b) finding organizations that implement these interventions “vertically,” i.e., replicating the same basic program across a variety of regions.

For these purposes, we particularly value interventions that are proven, scalable, and cost-effective.

Unlike most foundations, we are seeking explicitly to serve individual donors - donors who don’t have personal connections to particular organizations or expertise in the issues, and who therefore are better suited to expanding what already works (i.e., interventions that are proven and scalable) than to exploring unproven innovations. More on this idea at our FAQ, as well as in this blog post.

We think of an intervention as proven when:

• It has been previously carried out and carefully, publicly evaluated (often through academic research) in a way that provides strong empirical evidence for its positive impact on people’s lives. (A future post will further discuss our position on the “evaluation hierarchy” and what sorts of evidence we think are necessary under different circumstances.)
• The conditions under which it has been evaluated match the conditions under which it is likely to be carried out again, in as many relevant ways as possible.

We think of an intervention as scalable when:

• There is a significant amount of unmet “need” for the intervention, i.e., conditions under which the intervention would be helpful but has not yet been funded.
• Donations can be used to replicate the intervention in a variety of areas, while recording enough information about its execution to be reasonably confident that it is working as intended.

Defining “cost-effectiveness” is significantly more complex, and will be discussed in the next post.

Deciding where to give involves making major judgment calls: decisions that rest on subjective and otherwise highly debatable claims (such as the decision of which sort of life change to aim for). We have no pretense of being able to make such judgment calls “objectively” or “perfectly. Rather, we try to:

• Be explicit about which values we are pursuing and which judgment calls we’re making. For example, we’ve already declared our preference for funding proven and repeatable interventions, and we’ve declared our decision to focus on developing-world direct aid for the coming year.
• When practical, leave major judgment calls to our donors rather than making them ourselves, by recommending a variety of charities that are strong according to different criteria. This approach is especially important for judgment calls that our donors haven’t agreed to in advance (unlike the two listed directly above).

We are currently focusing on health interventions for the developing world (we will research other aspects of developing-world aid later in our process). One of the major judgment calls involved in choosing a health intervention is the decision between a region-based approach and a program-based approach to giving.

Taking a region-based approach means focusing on a particular part of the world; learning as much as possible about the people who live there, the opportunities they have, and the problems they face; and then finding a program that is well-suited to addressing the particular needs of this region. For regions with many interrelated health problems, such a program will likely be one that aims to strengthen the general quality of health care in the region, which will make it possible to address many health issues at once. (One such program is Partners in Health, a recommended charity from our last round of research that focuses on bringing full-service health care systems to poor rural areas.)

Taking a program-based approach means focusing on a particular intervention (or cluster of interventions); learning as much as possible about the conditions under which this intervention has been shown to improve lives in the past; and then finding a program that replicates this intervention across many regions. (This is the approach we took in evaluating Population Services International, which markets materials such as condoms and bednets across the world.)

A region-based approach has the advantage that it is more likely to be well-fitted to the particular people it serves and their needs. A program-based approach, however, may in some cases be a simpler and/or more cost-effective way to address a particular health problem, which means that it may be a more efficient and reliable way of changing lives for the better.

We will be taking both approaches, and presenting the options for donors that correspond to each. In future posts, we will discuss the specifics of (a) our region-based approach, i.e., how we will be choosing one or more countries to focus on; (b) our program-based approach, i.e., how we will be choosing one or more interventions to focus on.

Elie thinks that fistula is worse than death. jsalvati disagrees.

I’d rather bring someone to full health than save an infant’s life. Ryan agrees, but Basti does not and Ron Noble emphatically does not.

It’s possible that we would all agree if we knew more about the lives of people in the developing world, or if we just had a long enough to argue about our values. It’s also possible that we wouldn’t. And as long as we disagree, we’ll have different opinions on what the most “cost-effective” interventions are. For example, if it’s true that fistulas can be repaired for $450 each, is this a better or worse use of donations than preventing children’s deaths for $200 each through vaccinations? My answer would be “It depends on the donor.”

Converting disease burdens and intervention benefits into DALYs doesn’t resolve questions like this. Rather, it obfuscates them, by converting the two interventions into the same terms using a single set of philosophical values. If the numbers above ($200/death averted for vaccinations, $450/surgery for fistula) are accurate, they allow different donors to make their own judgment calls, while being informed about their options. But these aren’t the numbers you’ll find in the Disease Control Priorities Project’s summary tables; instead, you’ll see only that surgical services cost an average of $136 per DALY averted (source) and that the vaccinations interventions costs an average of $7 per DALY averted (source).

Some simplification and information loss is necessary in order to compare different options, but reducing everything to a single unit means being able to serve only a single kind of donor. I’d prefer to estimate the effect of different interventions on a variety of “life outcomes” that different donors might value differently. We will discuss this variety more in a future post, but here’s a quick list:

• Total life-years saved.
• Adult lives saved (as it is common to value adult lives more than children’s lives).
• Cases of extreme misery, such as fistula or perhaps severe elephantiasis, averted.
• People brought to a “normal” level of health, i.e., without any debilitating nutritional or other conditions.

All of these things need to be separately estimated to produce DALY estimates. The DCP report did so with admirable thoroughness and far more staff than we have. Yet because they published only their DALY estimates (not, with some exceptions, the estimates of different health problems that went into them), they buried a great deal of this work, and produce cost-effective estimates that are useful only if you’re completely on board with all of their values (from how bad each disability is to how to value different years of life). We’re currently trying to get in touch with the authors so we can get access to more of the details; if we don’t, we’ll have to repeat much of their work (with less capacity to do so).

Tactical Philanthropy:

Sooner or later, donors are going to start being willing to pay for advice on how to give. This will transform philanthropy.

I agree that donors should be willing to pay for advice on how to give. I certainly would have done so back when I was in the for-profit sector, if I could have found an advisor I had confidence in for a price I could afford.

But it’s conceivable that donors - especially small donors - will never have to pay for philanthropic advice, because someone else will pay to give them that advice. To give a simplified example: say that you care passionately about the cause of K-12 education, but know little about it. Now say that for $1,000, you can fund a philanthropic researcher to produce a report for other donors whose gifts to K-12 education charities will total $10,000. That means you have the choice of giving $1,000 directly to a K-12 charity (though you don’t have much to go on in picking one), or spending that $1,000 to “redirect” $10,000 of uninformed giving to the charities recommended by researchers.

The latter can be a pretty good deal. Unlike in investing, in philanthropy it makes perfect sense to pay for the privilege of redirecting other people’s money. (In fact, this practice is already widespread - large donors often fund fundraising campaigns, with the aim of raising money from others, and lots of people are happy to fund advocacy charities that are ultimately aiming to redirect government funding.)

Picture a world where some donors use philanthropic research for free, and other donors pay for that research with the knowledge that it’s redirecting the first group’s money. This isn’t the only, or necessarily the most aesthetically appealing, way for philanthropic research to get funded. But it’s a perfectly good deal for all parties involved (the donors that get the free research and the donors that pay to improve others’ giving). It’s a model that couldn’t work in for-profit investing, but when it comes to philanthropy where donors are seeking to create public goods rather than add to their own wealth, I see nothing unsustainable about this setup.

That’s the basic arrangement we’re currently pursuing. We are seeking GiveWell Pledges from donors who might be happy to use our research, but don’t necessarily want to pay for it. Meanwhile, a different set of donors pays our operating expenses, in the hopes that we’ll be able to move money from the first group.

Coming across the current feature on the DCPP’s home page reminds me of how much I care about the issue of obstetric fistula.

The following are highlights from the article linked above (emphasis mine):

For countless women in developing countries, going into labor is the painful beginning of a lifetime of unremitting shame and misery as a despised social outcast—destitute, childless, and abandoned by family and friends.

These women have a condition called obstetric fistula. A fistula, the Latin word for “pipe,” is an “abnormal passage” between organs — in this case, between the vagina and the bladder, the rectum, or both. The hole makes the woman uncontrollably incontinent of urine or feces or both and transforms a healthy person into someone viewed as a leaking, reeking, “moving latrine,” in the words of Veronica Yakobe, a Malawian woman who endured 23 years of indignity before an operation at Nkhoma Hospital in her country’s central region closed the fistula.

• 2 million to 3.5 million women worldwide currently [live] with obstetric fistula.
• Statistics from Ethiopia, Nigeria, India, Pakistan, and elsewhere show that the majority of fistula sufferers are abandoned by their families, divorced by their husbands, and forced to fend for themselves, often by begging. Some, like a group of Somali women who leapt from a pier chained to one another, end their lives in despair.
• Studies of patients undergoing fistula surgery find the majority in their early twenties or younger. In one Nigerian study, 72 percent were between the ages of 10 and 20, 82 percent having married between 10 and 15.
• A number of facilities, most prominently the renowned Addis Ababa Fistula Hospital, in Ethiopia, repair thousands of fistulas each year at a cost of about $450 for each operation and related care.

The disability weight used for fistula in DALY calculations is .430 (Pg 121 of the Global Burden of Disease report (PDF)). For context, the disability weight for blindness is .600 (Pg 120). To me, fistula seems much worse. Not only does a person undergo severe physical trauma, but she also often suffers severe social consequences such as communal ostracization and abandonment by her family.

In fact, it’s hard for me to imagine a cause I’d rather attack. I’d much rather prevent a fistula than save a life. The fate described above seems worse than death.

We’re planning to look into fistula carefully, and I hope we’ll find donors a great option for helping those afflicted.

In theory, you can fight HIV/AIDS by teaching safe sexual behavior; fight diarrhea by promoting hygienic practices; reduce child mortality by educating mothers; etc. However:

• Research on the effectiveness of these sorts of programs is thin; and programs that combine documented effectiveness with clear replication models are, so far as we can tell, rare to nonexistent.
• Changing people’s behavior isn’t straightforward. For an example, consider the finding - regarding hygiene education - that “The interventions promoting the single hygiene practice of washing one’s hands with soap tended to achieve greater reductions in disease than those that promoted several different behaviors … numerous messages dilute each other in the minds of the target audience” (see DCP pg 785 - references given there).

If it’s true that education works best when it’s focused, that means that planning an education program right means not just identifying behaviors that need changing, but analyzing which changes would be most beneficial. That’s a complex undertaking, and so is changing how people from another culture live their daily lives.

I’m generally not very optimistic about this category of intervention given what we know about it. Handwashing programs appear to be pretty well-documented and are a possible exception.

Both the Disease Control Priorities report (DCP) and Copenhagen Consensus (CC) acknowledge malnutrition as an extremely widespread and damaging problem, and both discuss a variety of interventions including breastfeeding promotion, vitamin supplementation, and fortification.

Yet both give hardly any space to the idea of direct food aid, i.e., providing healthy food (or the money necessary to purchase it) directly to people in poverty. CC states that such interventions are “cost-effective but more costly [than other interventions],” and that “because of the emphasis on costs and cost-effectiveness levels we focus on [other interventions such as supplementation] only” (Pg 6). DCP’s chapter on malnutrition (551-565) mentions direct aid only in one paragraph, in the context of comprehensive child nutrition programs, and states that “No consensus exists on when or how to include supplemental food to reduce undernutrition, and inefficient targeting is frequently a key constraint to effectiveness” (556).

Direct food aid seems to me to deserve much more attention, specifically because it is a potential solution to several of the most difficult types of malnutrition to address:

• Iron deficiency, which can cause anemia and impair cognitive development (DCP 553-4), is extremely difficult to address through supplementation or fortification because of how frequently iron needs to be ingested (DCP 558). Might frequent consumption of meat be an easier sell than frequent consumption of supplements?
• Protein-energy malnutrition can result in emaciation and stunted height (30-50% of under-5 children sub-Saharan Africa and South Asia suffer from these problems - see DCP Pg 552). As this condition results from insufficient calorie consumption, it does not appear to be treatable through vitamin supplements. Breastfeeding may ensure adequate calories for infants, but what about afterward?
• There is also always the possibility that our understanding of nutrition isn’t sufficient to name all of the necessary nutrients, and that the best way to give someone a diet that works as well as ours is to give them similar food (rather than simply identifying what seem to be the essential nutrients and providing those).

Direct food aid programs have come under fire due to the practice of obtaining the food from the developed world, which may cause economic distortion and problems for developing-world farmers. But this problem doesn’t seem inherent to direct food aid, only to programs that insist on using developed-world surplus food; a program that bought what it could from nearby farmers, and provided the rest from overseas, would not obviously cause more distortion than other aid programs.

Direct food aid programs may be costly and complex, but they may also be the only way to ensure truly adequate nutrition in some parts of the world. Why aren’t they getting more attention from otherwise thorough analyses?

According to the Disease Control Priorities Project, expanding vaccination is an excellent fit for donors who want proven, cost-effective, scalable ways of helping people. According to this table (more detailed version on page 401 of the full report), both South Asia and sub-Saharan Africa have relatively low levels of existing coverage (50-58%), and vaccinating more children could save lives for about $200 each. If saving lives is in fact your priority (and we know it isn’t for all donors), that’s hard to beat.

The most promising nonprofit I know for implementation is the GAVI Alliance, which we have yet to thoroughly evaluate.

I get two very different pictures of how aid funding works, depending on whether I’m looking at my options as a donor (as I’ve been doing for the last couple of years) or reading papers intended for policy makers (Disease Control Priorities report, Report of the Commission on Macroeconomics and Health).

The latter sources focus almost entirely on the granting of aid to developing-world governments by “donors” including “bilaterals, multilaterals, global programs, foundations, and large NGOs” (pg 249) - i.e., megadonors (not people like me). Pgs 247-250 discuss the coordination problems caused by different donors’ earmarks and reporting requirements as well as the potential advantages of “ensuring the countries, not donors, drive the coordination” (249). The WHO Commission on Macroeconomics and Health takes a similar perspective, endorsing a top-down plan to be implemented in partnership with governments, using the Poverty Reduction Strategy Papers they create.

Yet as a donor, I’ve never looked at or discussed the possibility of giving money to developing-world governments. I’ve dealt with U.S. public charities, and the proposals they send (large list here) involve their own projects carried out by their own staff. We’ve never discussed their role in helping to carry out the kind of large-scale plans endorsed by the WHO commission. A quick glance at CARE’s Form 990 reveals that only 18% of its expenses are grants of any kind, so they certainly don’t appear to be directing the majority of their aid to governments.

It’s possible that the link goes the other way: the DCP report mentions governments’ hiring NGOs (Pg 252). But if the NGOs are contractors, not agenda-setters, where does an individual’s donation fit in?

Either way, it doesn’t help that few NGOs have been able to give us a clear explanation of what they do (in particular, how their top-level agendas are set).

Complicating the matter further are “alliances” such as GAVI and The Global Fund. These appear to be partnerships aiming to consolidate and coordinate funding, and they fund both governments and NGOs. Does that make them a more appropriate recipient of gifts than typical NGOs? How does the Global Fund to fight AIDS, Tuberculosis and Malaria coordinate with the Roll Back Malaria Partnership and Stop TB Partnership, which appear to have largely overlapping goals but still all solicit donations individually?

Let’s say I’m a donor who trusts the WHO Commission and just wants to be as helpful as I can, without imposing my opinions about particular diseases and priorities. Should I give to the WHO? To a developing-world government? An alliance? An NGO? We’re getting a better handle on the situation and starting to break down the options, but as of yet we still haven’t seen clear answers to these sorts of questions.

Previously, I outlined the basics of the Disability-Adjusted Life Year (DALY) metric. It takes the approach of converting all health burdens into equivalent “years of healthy life lost”: a year of blindness is counted as .6 lost years, a year of severe malnutrition is counted as .053 lost years, etc.

This post discusses two common “variations” on DALYs, meant to deal with relatively thorny disagreements about how different years of life should be valued. As before, page numbers refer to the Global Burden of Disease 2000 report.

Age-weighting

One variation has to do with the intuition some people have that a 20-year-old’s death is more tragic than an infant’s. (I expressed this intuition myself back in November, and I still hold this view.) In an attempt to square with this intuition (which is common and well-documented, as Pg 400 shows), the DALY metric includes an optional age weighting feature that lowers the value of a healthy year of life lived at very young and very old ages, relative to the value of a healthy year of life around age 20. DALYs can be computed with or without age-weighting (”without” just means that all years of healthy life are valued the same).

Discounting

The other variation has to do with valuing present vs. future benefits of aid. DALY calculations apply a discount rate to future benefits; for example, when using a discount rate of 3%, one would count a year of healthy life saved ten years from now as being worth only 74% as much as a year of healthy life saved this year (74% = 1/1.03^10).

I confess that I don’t fully follow the justification for discounting given in the Global Burden of Disease Report, which claims that “the strongest argument for discounting is … [that] not discounting future health would lead to the conclusion that all of society’s health resources should be invested in research programs or programs for disease eradication” (400), which apparently is considered obviously wrong by the authors. Personally, the most appealing argument I can think of for discounting is that helping a person can help them help others, so helping a person sooner is literally “worth more” than helping a person later.

Notation

DALYs(0,0) refers to DALYs calculated with a 0% discount rate and no age-weighting. DALYs(3,1) refers to DALYs calculated with a 3% discount rate and age-weighting. (The first number in parentheses is the discount rate; the second is a 1 if age-weighting is being used, and a 0 if not.) See Pg 401 for the specifics of how varying these numbers affects the valuation of different years.

In theory, you can calculate DALYs using whatever parameters best fit your own philosophical values. In practice, the reports we’ve seen using this metric (Global Burden of Disease Report, Copenhagen Consensus, Disease Control Priorities Project) will give you, at most, DALYs(0,0), DALYs(3,0) and DALYs(3,1), and will rarely give you the inputs into these numbers so you can calculate your own versions. That means that if you want to use a 6% discount rate, you’re completely out of luck; there’s no way to convert DALYs(3,0) to DALYs(6,0) without having more information. More importantly, it means that:

• You can’t use your own version of age-weighting. Even the age-weighted version of DALYs still rates an infant death as about equally tragic to a 20-year-old death (it values a year more for a 20-year-old, but when you work it all out the value of a life comes out the same). There is evidence (see pg 401) that people find a 20-year-old’s death to be far worse; if you share that intuition, then DALYs as they are usually presented won’t reflect your values, and there will be no way to convert them into a unit that does.
• You can’t use your own disability weights. Personally, this is the area I’d most like to see some variation in - the official disability weights disagree violently with my personal intuitions about, for example, how bad it is to be severely malnourished (current weights put it at only 5.3% as bad as a year of life lost - see Pg 121) or how bad it is to go through an abortion (it appears that this is counted as “no cost” by DALYs - see Pg 121 again).

The DALY metric does have some flexibility to accommodate different personal values, but in practice it ends up being pretty rigid. More on this in a future post.

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

• I like the approach: attacking all of the many sources of contamination (see diagram) rather than focusing narrowly on water.
• It’s been done before, with potentially encouraging results (see page 9). I haven’t seen enough on it to call it a “proven” approach, but it might be.
• It may be significantly more cost-effective than other approaches to sanitation (see page 21), as it focuses on behavior rather than infrastructure.
• It’s now being replicated in many areas; that implies that there’s a process in place for replication, and that more funds could result in more people reached.

But I can’t find out how to fund it.

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

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

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

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

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

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

A DALY is a measure of the “burden” of a health problem; two common uses of this measure are (a) ranking diseases and risk factors (from most to least burdensome), as the Global Burden of Disease report does, and (b) ranking different interventions (in terms of how much they can be expected to reduce burdens, “per dollar”), as projects including DCPP do. The basic DALY formula is on page 47 (also here):

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

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

Quantifying morbidity

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

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

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

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

When looking at programs that mostly target infant mortality, I’ve mostly thought of them as “population-increasing” programs. I’ve sympathized with donors who say that bigger populations might be the last thing poor villages need, and I’ve also assumed that “strict utilitarians” are likely to value such programs more than I do. It’s interesting to see the Report of the Commission on Macroeconomics and Health try to turn this issue on its head:

…high mortality rates of children tend to provoke high fertility rates among poor couples. In general, the high fertility more than compensates for the high mortality … In one numerical illustration, households whose children have a 75-percent survival rate choose to have six children, of whom an average of 4.5 survive. The households whose children have a 95-percent survival rate have two children, of whom an average of 1.9 survive … This pattern helps us to understand the surprising fact that countries with high infant mortality rates have the fastest growing populations in the world…

The report includes charts (see Pgs 35-38) showing a pretty strong association between low infant mortality and low population growth across the world’s nations.

This statistical association doesn’t necessarily mean the above logic is correct; it could be that something else, such as economic prosperity or education, is associated with both low infant mortality and low population growth, and that simply lowering infant mortality wouldn’t reduce fertility.

Not being aware of any studies on this specific relationship, I looked a little further using Gapminder. Rather than looking across the world’s countries (as the Report does), I looked specifically at countries within sub-Saharan Africa over time, which seems more relevant to the hypothesis that lowering infant mortality in high-mortality, high-fertility countries (such as those in sub-Saharan Africa) is associated with lowering fertility.

Since 1950, these countries have seen noticeable declines in both infant mortality and fertility (children per woman). However, the trends don’t sync up. In particular, since 1990, infant mortality has largely remained flat while fertility has continued to decline. (Note that literacy has improved over this time period as well.)

I’m hesitant to go as far as the report in calling infant mortality a primary, or the primary, driver of lower fertility. Still, it is clear at least that reducing infant mortality need not result in population growth. I don’t know of any more thorough studies on the link, and would be interested in any references.

The cause of “water” is one of the more (initially) emotionally appealing, and probably marketable, causes in developing-world aid. Here are some thoughts on the cause, fresh off of reading the Copenhagen Consensus report on it:

From what I’ve seen - both in terms of water-related literature and in terms of general morbidity data - outright lack of water (i.e., dehydration in otherwise healthy people) is not a widespread problem. If you know of data showing otherwise, even for particular parts of the world, please share. However, I think most water and sanitation projects are instead concerned with:

1. Access to convenient water sources. Some people lose hours to maintaining their filters and/or boiling their water for cleanliness; people who live far from water sources can lose far more time (see Pg 11 of the Copenhagen Consensus report for a stark example). Improving water infrastructure may therefore free up time and make them economically better off. However, when this is the goal, it seems important to consider not only how much time potential beneficiaries would save, but how much this time is worth (i.e., what else they could do with it). Depending on market and/or weather conditions, extra time may not translate into extra money, or into much extra quality of life.

2. Access to clean water. Contaminated water can contribute to a variety of diseases that generally cause severe diarrhea (see Pg 34). However, it’s important to note that:

• Water is not the only source of contamination, and clean water alone - when unaccompanied by other sanitation interventions - can only dent the burden of these diseases (again see Pg 34).
• There are a variety of ways to purify water at the “point of use,” some of which - like boiling - are extremely simple and relatively inexpensive (see Pgs 90-91).
• Communities that suffer from contaminated water may also suffer from a host of other health problems (such as malaria and malnutrition) that can be at least as damaging as waterborne infections, while having solutions (such as supplementation, bednets, etc.) than are far cheaper and simpler than the provision of clean water.

In our first year, we saw no cases of well-documented water-focused projects that address key questions such as whether water quality and use were verified, whether an effect on quality of life was documented, etc. Literature on past programs’ effects also seems relatively thin.

At this point, I think of water projects as being pretty far from the sort of “proven, effective, scalable” programs we are looking for. If I change my mind, it will likely be for a program in the first category - providing water to people who otherwise would be spending inordinate amounts of time retrieving it - rather than for a program focusing exclusively on clean water.

If you could accomplish any of the following for the same cost, which would you choose?

(1) Prevent 100 deaths-in-infancy, knowing that in all likelihood these 100 people will grow up to have consistently low income and poor health for their ~40-year-long lives.

(2) Provide consistent, full nutrition and health care to 100 people, such that instead of growing up malnourished (leading to lower height, lower weight, lower intelligence, and other symptoms) they spend their lives relatively healthy. (For simplicity, though not accuracy, assume this doesn’t affect their actual lifespan - they still live about 40 years.)

(3) Prevent one case of relatively mild non-fatal malaria (say, a fever that lasts a few days) for each of 10,000 people, without having a significant impact on the rest of their lives.

For me, the answer is definitely #2. I am very excited by the idea of changing someone’s life in a lasting and significant way (2); I’m much less excited by the idea of a temporary, less significant life change (3), and I don’t think that the quality of a life equals the sum of the quality of the days in it. (1) excites me the least - I just don’t put that much value in “potential lives” (I think the death of a 20-year-old is more tragic than the death of an infant), and I especially don’t put much value in saving “potential lives” riddled with health problems.

I’m not interested in having a long philosophical argument about the validity of my views. I believe that different donors likely have fundamentally different values that you can’t change by throwing any number of thought experiments or philosophical abstractions at them. Our research will aim to serve as many different sorts of donors as possible, rather than holding up one philosophical value set as the “rational” one. But I am interested in what others think, and whether my attitude is common or rare.

To give a quick sense of the practical relevance of this question: programs targeted directly at under-5 mortality (including some vaccination programs and some micronutrient programs) are much more likely to get you (1)-type results; programs that distribute bednets or other health materials en masse are more likely to get you (3)-type results; an economic empowerment program (particularly focused on improved farming techniques) may aspire to (2)-type results, but I believe that these types of results are the most difficult and expensive to bring about.