GiveWell Top Charities Explained: Deworming

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effective altruism, ozy blog post

[This is the first post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring.]

GiveWell’s top charities list includes four deworming charities: Sightsavers, the END Fund, the Deworm the World Initiative, and the Schistosomiasis Control Initiative. I’m combining them into one post because a lot of the stuff I can say about them is the same.

The most important thing to know about deworming charities is that they are NOT HEALTH CHARITIES. Deworming charities are economic development charities. You might think they are health charities, because they give pills to people in order to treat their diseases, and that is a thing one generally does if one is a health charity. If one is an economic development charity, one gives people cows or job training or money or something. But in fact that is just the deworming charities’ very clever disguise.

Deworming works in the sense that if you have worms, and take the pills, you won’t have worms anymore. But the effects of being dewormed on health are very small. Having worms generally doesn’t kill you, and it’s rare for people to get very sick because they have worms. A lot of meta-analyses find very small or no effect of deworming on things like weight, height, anemia, school performance, or cognition.

So that might lead you to ask why there are four (four!) GiveWell top charities that deworm people if it doesn’t make people healthier. The answer is that it is possible– but by no means certain– that deworming has an effect on children’s long-term development that causes them to earn more income.

Miguel and Kremer (2004) found that deworming leads to a 25% decrease in school absenteeism. The ten-year followup finds that people who were dewormed as children work more, earn more, are more likely to work in the high-earning manufacturing sector, eat more meals, and have better self-reported health. GiveWell has seen a preliminary 15-year followup that shows similar results.

There are lots of reasons to be uncertain about this study. It’s only one study, and there might be alternate explanations for the findings, or there might have been publication bias. There was a lot of flooding in the study area, so people were more likely to have worms than if there was less flooding. Some researchers argue that Miguel and Kremer (2004) and the followup are at risk of significant methodological bias. (Others disagree, including David Roodman, who reanalyzed the studies for GiveWell.)

The big advantage of deworming is that it is very very cheap. A person can be dewormed for less than a dollar. If you take the ten-year followup seriously, the annualized rate of return on deworming is 32%— that is, for every dollar invested in deworming, you earn 32 cents back every year, presumably until the beneficiaries die or retire. If there’s even a five percent chance that deworming works as advertised, it’s a good investment. Under any reasonable estimate of the likelihood that deworming works, it’s one of the most cost-effective interventions for making people richer.

The primary negative impact of deworming is side effects from the medications: deworming medications have unpleasant side effects, including headache, nausea, upset stomach, vomiting, abdominal pain, and fever. Deworming programs may also interfere with the provision of routine health care services because all the nurses are temporarily busy giving deworming medicine instead. The relationship between deworming treatment and malaria is complex and poorly understood, but it may be that deworming causes children to have a higher density of malaria parasites in their blood.

I have prepared the following table to help you choose which deworming charity to donate to:

 

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Name	Program	Room for more funding (in millions of dollars)	Kinda sketchy?	Coverage rate	Open questions
Deworm The World	Advocacy; monitoring/evaluation; technical assistance	$14.7	No	80-90%	None
Schistosomiasias Control Initiative	Advocacy; funding/ drug donations; monitoring/evaluation; technical assistance	$16.8	Yes	80-90%	Will SCI use additional funding to treat adults instead of children? How accurate are SCI’s coverage surveys?
END Fund	Filling funding gaps in other orgs	$15.5	Limited track record	50-60%	Do their programs reach a high percentage of children targeted? How much money will they raise from other funders? Will GiveWell-directed donations increase the amount they budget for deworming?
Sightsavers	Technical assistance; funding	$1.7	Limited track record	58-99%	Limited track record for implementing deworming. Spends a lot on fundraising. Will GiveWell-directed donations increase the amount they budget for deworming?

Why might you donate to deworming?

• You like high-risk high-reward bets, and AI risk is just too fashionable.
• You want to increase people’s income in a very cost-effective way, even if it might not work.
• You care more about increasing incomes and economic development than you do about improved health outcomes or preventing the death of children.
• In a war between epidemiologists and economists you are on Team Economist.
• You have a phobia of parasitic worms.

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GiveWell Top Charities Explained: Against Malaria Foundation

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effective altruism, ozy blog post

[This is the first post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring. In order to reward you for reading a whole blog post about a charity you already know about, I have included at the end the Most Interesting AMF Fact.]

The Against Malaria Foundation is one of the most iconic effective altruist charities. “Bednets”, to many people, are synonymous with “effective altruism.” With one year’s exception, AMF has consistently been a GiveWell top charity since 2010– not long after the term “effective altruism” was coined.

The Against Malaria Foundation provides long-lasting insecticide-treated bednets to partner organizations, which distribute the nets. Randomized controlled trials of insecticide-treated bednets find that insecticide-treated bednet distribution has the following benefits:

• Reduces the rate of malaria and severe malaria episodes.
• Reduces the rate of common complications of malaria, such as anemia, enlarged spleen, low birthweight, and placental malaria.
• Improves the nutritional status of children.
• Averts 5.53 deaths among children under 5 per 1000 children under 5 protected.
• Prevents miscarriages.

The last bullet point is not included in GiveWell’s cost-effectiveness analysis. Preliminary results from a friend of mine suggest that it costs about a thousand dollars to prevent a fetal loss by donating to the Against Malaria Foundation.

it is believed that bednet distributions also reduce mortality among people over the age of five, mostly because it would be really weird if they didn’t. However, no RCTs have addressed this question.

It is believed based on studies of previous malaria eradication programs that reducing the prevalence of malaria in a country increases the income of people in that country, which means that people are less likely to go hungry, can get medical treatment when they’re sick, can buy televisions, and so on.

The studies were conducted of insecticide-treated bednet distribution programs, not of bednets specifically. Some people were in the treatment group of the study but didn’t put up bednets, and they were still counted as part of the statistics. That makes us think the research is more likely to apply to a program like AMF. However, it’s often much easier to have a really, really good bednet distribution program in a small study than it is to have a really, really good bednet distribution program that gives millions of people bednets. If fewer people use AMF’s bednets than used the bednets in the study, the effects will be smaller.

The bednet usage rates that AMF finds in its surveys are comparable to the bednet usage rates in the small-scale studies, and AMF similarly works in places with high rates of malaria. In general, AMF is a well-run charity. However, to the best of my knowledge, no research has been conducted on the health effects of AMF’s program specifically. It is conceivable that AMF is making some error that we don’t understand and does not have effects as large as the effects found in large-scale surveys.

There is one fact that is very commonly believed about the Against Malaria Foundation. Unfortunately, all the evidence shows that this fact is incorrect. For this reason, I will set the record straight.

AMF’s malaria nets are not usually used for fishing. AMF’s malaria nets are not usually used for fishing. AMF’s malaria nets are not usually used for fishing. 

• AMF’s malaria nets are not usually used for fishing.

1. AMF’s malaria nets are not usually used for fishing.

AMF’S MALARIA NETS ARE NOT USUALLY USED FOR FISHING.

Tell your friends and family. Shout it in the streetcorners. Educate your children about it. Tie it as symbols on your hands and bind it to your foreheads. Write it on the doorframes of your houses and on the gates. AMF’s malaria nets are generally not used for fishing.

How do we know this? AMF requires all its partner organizations to do followup surveys every six to nine months for two and a half years after the malaria nets are distributed. Outside of the Congo, after one year of use, about 80% to 90% of nets are properly hung. (In the Congo, nets decayed more quickly than expected.) Of course, over time, nets are more likely to break, so the usage rates two and a half years are lower– but that’s because they’re broken, not because they are used for fishing. The cost-effectiveness analyses for AMF incorporate the fact that not all nets are properly hung, and have done so long before anyone thought of the “what if malaria nets are used for fishing?” issue.

Of the ten to twenty percent of nets that are not hung up, many are not going to be used for fishing: they’re sold, or thrown out, or left in a corner because people can’t get it together to hang them up, or perhaps used for some other purpose. But it is possible some of them are, in fact, used for fishing. On this subject, Kelsey Piper writes for Vox:

What about harm to fisheries from people fishing with nets? Researchers have only recently started looking into this. No one has measured detrimental effects yet, though they could emerge later…

The insecticide in anti-malarial bednets also does not have negative effects on humans, because the dosages involved are so low. It’s unclear whether there are any harmful effects from fishing with nets. (And, it’s worth noting, there is one oft-forgotten positive effect from the use of bednets for fishing: People are fed.)

The insecticide-treated bednets issue shows the importance of the effective altruist approach to charities. AMF proactively checks whether the bednets are used as expected instead of assuming that they are. Therefore, if malaria nets were commonly used as fishing nets, we’d be able to find that out right away and account for it in our cost-effectiveness models. If we didn’t monitor bednet usage, it would be easy not to notice that. The “but AMF’s malaria nets are used for fishing!” argument– commonly deployed as a gotcha for effective altruists– actually shows why effective altruism is important.

AMF distributes nets for free. Some people object to distributing nets for free, because it puts local net salespeople out of business and it teaches people that they should get bednets for free. However, way more people will take a free bednet than a bednet that they have to pay even a little bit of money for, and GiveWell thinks that outweighs the effects on local net markets.

Neither fishing nor the fact that the nets are free is a real concern. However, there is a real concern about AMF: insecticide resistance. Insecticide resistance is very hard to quantify, but GiveWell’s best guess is that insecticide-treated bed nets are about a third less effective than they would be in the absence of resistance; this is still very very cost-effective. AMF is going to begin distributing nets that use a different chemical to which mosquitos have yet to develop resistance. GiveWell has not addressed the role of insecticide-treated bed nets in causing insecticide resistance.

Sometimes, AMF has talked to partner organizations about funding a distribution, but ultimately not done it. When they haven’t done so, another organization has usually stepped in to buy nets eventually, but it usually takes at least six months. In the intervening time, people aren’t covered. GiveWell’s cost-effectiveness model accounts for the fact that at least sometimes a different funder will buy the nets if AMF doesn’t. 

It is very very unclear what the Against Malaria Foundation’s room for more funding is. However, AMF has a good track record for scaling up and productively spending large amounts of money, and it would cost hundreds of millions more than anyone is spending on malaria nets to buy everyone who needs a malaria net a malaria net. So probably they will be able to use any sum of money that we can expect people would give them.

In conclusion, as promised, here is the best AMF fact. AMF’s CEO does not take a salary; they receive other pro bono work from volunteers. GiveWell’s model of the costs of an AMF net distribution includes the amount the CEO and other volunteers would be paid if they were paid. AMF, however, has apparently requested that GiveWell include the following caveat:

Comment from AMF: AMF would like all donors reading this to know that the costs included for the CEO and pro bono services are not actually incurred. Each of them is very happy to provide their services for free.

Why might you donate to the Against Malaria Foundation?

• You care a lot about the deaths of children under five.
• You think the deaths of fetuses matter as much as the deaths of children under five.
• You want a program that is robustly good on a bunch of different axes: it makes people less sick and less likely to die and increases their income.
• You want a program that definitely works and has very few negative side effects, even if it might be less cost-effective than other programs.
• You grew up in a place with mosquitoes and have sworn eternal vengeance on the tiny blood-sucking monstrosities.

GiveWell Top Charities Explained: GiveDirectly

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effective altruism, ozy blog post

[This is the third post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring. In order to reward you for reading a whole blog post about a charity you already know about, I have included at the end the Most Interesting GiveDirectly Fact.]

Whoever said that you should buy warm fuzzies and utilons separately had never heard of GiveDirectly.

GiveDirectly gives money to people in the developing world, usually about $1000. This typically about doubles its recipients’ yearly income. You may see a more-or-less random sample of recipients’ responses to this program on GD Live. Recipients’ responses are unedited and only posted if they opt in to sharing. They may seem slightly overenthusiastic but imagine how you would feel if someone doubled your income for no reason. (I recommend only reading GD Live if you’re pretty sure you plan to donate to GiveDirectly; it has a known effect of causing people to be unable to resist the temptation to donate.)

Research on the effects of GiveDirectly’s cash transfers shows the following:

• Households spent $51 more per month; about half of the money was spent on food.
• Household assets increase by $463; most commonly, the money was spent on livestock, durable goods (particularly furniture), and savings.
• Recipients were 23% more likely to have iron roofs.
• Households spend $13 more per month on business expenses, typically non-durable expenses on non-agricultural businesses.
• Recipients spend $3 more per month on health expenses.
• Spending on alcohol and tobacco did not increase.
• Food security and sense of psychological well-being increased.
• Business revenues increased by $15; profits did not increase, but that might be a short-term effect due to e.g. investments that have not yet paid off.

Also, one guy bought a guitar and used it to write this catchy song:

My life is GiveDirectly
My house is GiveDirectly
My phone is GiveDirectly
My job is GiveDirectly
My love is GiveDirectly

My life, Give Direct
My house, Give Direct
My farm, Give Direct
I love Give Direct

My life, Give Direct
My house, Give Direct
My job, Give Direct
I love Give Direct

While there is high uncertainty, GiveWell’s best guess is that GiveDirectly does not have significant negative effects on households that don’t receive money.

GiveDirectly is a very well-run charity. 99.7% of recipients receive all funds promised. While staff fraud has occurred in the past, GiveDirectly has responded promptly and taken more steps to prevent future fraud.

GiveDirectly is also known for its commitment to randomized controlled trials. A very high proportion of its recipients (although not 100%) are enrolled in a randomized controlled trial, such as the RCT on the macroeconomic effects of cash transfers or GiveDirectly’s basic income trial. (Oh yeah! GiveDirectly is totally doing a trial on whether basic income cost-effectively improves people’s lives!)

GiveDirectly’s room for more funding is huge, because of how easy the program is to scale. GiveDirectly alone could productively use hundreds of millions of dollars in funding– more than every other GiveWell top charity combined.

Many people support GiveDirectly not just because of its program but because of its challenge to the international aid sector. GiveDirectly asks, “if the thing you’re doing doesn’t work better than giving people cash, why the fuck aren’t you just giving them cash?” Of course, this is a very hard impact to measure, and it’s unclear if giving GiveDirectly more money would cause them to have more effect on the rest of the aid sector, compared to GiveDirectly existing at all. But anecdotally more funders are asking themselves “does this outperform cash?” and give-cash control groups have expanded in popularity.

Many other people support GiveDirectly because they care about autonomy. A lot of donors to the developing world are incredibly condescending: they buy a cow from Heifer International or a merry-go-round pump from PlayPumps or help build a school on their mission trip. Surely, however, if people in the developing world need cows or schools or merry-go-round water pumps, they can buy that themselves? Is there some reason to believe that we know better than people in the developing world just because we’re rich? By far the most popular purchase with a GiveDirectly cash transfer is an iron roof; have you ever seen a charity fundraising to buy iron roofs for people in Kenya? We don’t know what it’s like to be members of the global poor, because we’ve never been poor. The poor know better than we do what their needs are. It is respectful of their dignity as people to let them make this sort of choice.

So, GiveDirectly is great. Why don’t we all just donate there?

Well, GiveWell has this handy little chart where they calculate what you get for your dollar. It’s super-fake and you shouldn’t take it literally, but the effect is large enough that that doesn’t necessarily matter. And what it found was that the cost to achieve an outcome that is just as good as saving a five-year-old’s life, according to the average values of GiveWell staffers, is twenty-three thousand dollars.

Now, of course, that depends on your values, and I encourage you to put your own moral weights into the sheet instead of relying on the average of GiveWell staffers’ values, which is a terrible way to do ethics. But if you care about saving the lives of small children and/or don’t mind high levels of uncertainty, you will get more value for your money by donating to a different GiveWell top charity.

The problem with “do we know better than people in the developing world just because we’re rich?” is that the answer is “yeah, sometimes.” Very, very few Kenyans have access to Sci-Hub so that they can develop an informed opinion on whether deworming medicines will increase their children’s income twenty years from now. Few Ugandans can explain the connection between those vitamin A pills the health worker is handing out and their children dying of diarrhea. Of course, the same things are true for most people in the developed world, but there exist any people in the developed world who understand those things, and the rest of us can follow their donation recommendations.

People in general tend to undervalue preventative health care. People in Africa don’t buy malaria nets for the same reason you never use your gym membership. If it works, nothing happens: you don’t see the malaria or heart attack you didn’t get. Nothing disastrous will happen if you put off going to the gym or buying the malaria net till next week, and exercising is boring and if you buy the malaria net you won’t get to eat for two days, so you never get around to buying it. As an outsider, you can say “this is a known cognitive bias, I’m going to give you a free malaria net and then your children won’t die of malaria.” So charities other than GiveDirectly can be more cost-effective.

In conclusion, as promised, here is the Best GiveDirectly Fact:

GiveDirectly started enrolling recipients from Homa Bay county, Kenya in mid-2015. There, it encountered unexpectedly high rates of refusals from potential recipients; while refusal rates in Uganda and Siaya, Kenya have historically been low (around 5%), refusal rates in Homa Bay have been about 45%. GiveDirectly believes the refusals are due to widespread skepticism towards GiveDirectly’s program and rumors that GiveDirectly is associated with the devil…

November 2017 update: We requested data from GiveDirectly on refusal rates (and other metrics) for January to March 2017 for Kenya and Uganda and March to June 2017 for Rwanda. Refusal rates remained fairly high in Kenya, with 22% refusing to participate in the census and 68% of complaints submitted to GiveDirectly categorized as “program is evil/from the devil.”

Why might you donate to GiveDirectly?

• You need a lot of warmfuzzies in order to motivate yourself to donate.
• You think encouraging cash benchmarking is really important, and giving GiveDirectly more money will help that.
• You want to encourage charities to do more RCTs on their programs by rewarding the charity that does that most enthusiastically.
• You care about increasing people’s happiness and don’t care about saving the lives of small children, and prefer a certainty of a somewhat good outcome to a small chance of a very good outcome.
• You believe, in principle, that we should let people make their own decisions about their lives.
• You want an intervention that definitely has at least a small positive effect.
• You have just looked at GDLive and are no longer responsible for your actions.

GiveWell Top Charities Explained: Helen Keller International

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effective altruism, ozy blog post

[This is the second post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring.]

Helen Keller International performs Vitamin A supplementation. It is not only a brand new top charity this year, it is also the second new cause GiveWell recommended donations in this year.

Vitamin A deficiency can cause stunting, anemia, blindness, more severe infections, and death. It is particularly harmful to pregnant or lactating people, infants, and children. People in developing countries who don’t eat much meat and don’t eat Vitamin-A-fortified food may suffer from deficiencies. (Vitamin A is also a nutrient of concern for vegans and vegetarians in the developed world, but if you have an ample and diverse diet of fruits and vegetables you probably don’t have to worry about it.) Luckily, your liver can store Vitamin A for several months; if you take a very high dose of Vitamin A once every six months, you won’t suffer from Vitamin A deficiency. It is recommended that children between 6 months and 5 years old get a supplement once every six months.

Helen Keller International provides technical assistance, advocacy, and funding. Technical assistance includes helping countries monitor how many children are getting Vitamin A supplements, running campaigns that educate parents about the importance of Vitamin A supplements, training health workers to give out supplements, and helping governments figure out why their vitamin A supplementation rates are so low and how they can fix them. Advocacy involves convincing governments that they should prioritize mass vitamin A supplementation. Helen Keller International also sometimes provides grants to governments to help them pay for vitamin A supplementation programs.

It is somewhat unclear whether vitamin A supplementation actually works to reduce mortality rates. Normally, this sort of thing is unclear because we don’t have any evidence about it. In the case of vitamin A supplementation, we have two pieces of really good evidence; they just point in opposite directions.

The Cochrane Collaboration, whom you may remember from the previous post as the people who aren’t sure whether flossing your teeth makes your teeth better, performed a meta-analysis that suggests that vitamin A supplementation reduces all-cause mortality by 24%, with a 95% confidence interval ranging from 17% to 31%. The Cochrane Collaboration primarily used studies that were conducted in the 1980s and 1990s.

Not long after the Cochrane Collaboration’s meta-analysis came out, we learned the results of the DEVTA trial. The DEVTA trial is the single largest randomized controlled trial ever conducted, with one million children participating. It estimated that Vitamin A supplementation reduces child mortality rates by 4% and could not rule out the possibility that it did not affect child mortality rates at all. You may notice that 4% is in fact much much smaller than 24%.

What the fuck is going on?

• It might just be random chance. That’s pretty unlikely: the Cochrane Collaborations 95% confidence interval doesn’t overlap at all with DEVTA’s.
• DEVTA might not have treated as high a percentage of the children in the study as claimed. DEVTA claims to have treated 86% of children, but some researchers are skeptical because DEVTA was done very cheaply. DEVTA seems to be using broadly reasonable strategies to get all children to take vitamin A supplements and to figure out how many children actually took it, but their strategies aren’t very well-documented and sometimes they didn’t implement them until halfway through the study. Nevertheless, the percentage of children treated in order to make ‘they didn’t treat enough kids’ plausible as an explanation is so much lower than the percentage of children claimed to have been treated that this is not a very plausible explanation.
• DEVTA might have treated a population with less severe or prevalent vitamin A deficiency. However, the rate of vitamin A deficiency, severe vitamin A deficiency, and complications related to vitamin A deficiency is similar in DEVTA as it is in other studies. It’s more likely they underestimated vitamin A deficiency than that they overestimated it.
• DEVTA’s population might be healthier than other populations. Vitamin A deficiency doesn’t generally kill children directly; it kills them indirectly, by making them more susceptible to infections. If those deaths are being prevented some other way (e.g. measles vaccianations, oral rehydration treatment), treating Vitamin A deficiency saves fewer children’s lives. DEVTA had a lower child mortality rate than most of the studies in the Cochrane review, and generally studies with a lower child mortality rate show a smaller effect from vitamin A supplementation. However, it’s unclear whether measles and diarrhea– the two biggest killers related to Vitamin A– were less common in DEVTA than in other studies.

GiveWell thinks the most likely explanation is the last one. That means that whether Vitamin A supplementation is cost-effective depends on not just how high the Vitamin A deficiency rates are but also how high the child mortality rate is.

The countries Helen Keller International works in typically have lower rates of vitamin A deficiency than in any study of the effects of vitamin A supplementation: they work in countries where 20% of preschool-aged children have vitamin A deficiency, compared to 59% in the Cochrane meta-analysis. Hellen Keller International works in countries where 12 children out of every 1000 die every year; previous studies have found an effect of vitamin A supplementation if more than 10 children out of every 1000 die every year.

However, there are a lot of limitations of this estimate. Helen Keller International typically works in regions, rather than in whole countries, which might have higher or lower child mortality rates than the country as a whole. It seems really unlikely that vitamin A supplementation doesn’t do anything below 10 children out of 1000 dying each year and then suddenly has a big effect as soon as you get to 10; it’s probably a smoother effect that’s harder to analyze. “Child mortality” is a statistic that includes a lot of different things. It’s unclear whether vitamin A supplementation helps with all infectious diseases or a subset, such as measles and diarrhea; it’s pretty clear that vitamin A supplementation has no effect on some other causes of child mortality, like car accidents. If a region has a high child mortality rate because there are a lot of car accidents, vitamin A supplementation might not do anything. More realistically, if vitamin A supplementation reduces deaths by causing children to be less likely to die if they get measles, then if a region has a low rate of measles, it won’t have a big effect from vitamin A supplementation, even if it has a high child mortality rate.

There are not likely to be any negative long-term side effects from vitamin A supplementation. In the short term, less than ten percent of children experience some sort of adverse side effect, such as headaches, nausea, vomiting, irritability, fever, or loose stools. Vitamin A supplementation does not cause vitamin A overdose or increase mortality when given alongside an inactivated vaccine.

Helen Keller International gives a relatively high percentage of target children vitamin A supplements (between 46% and 81%, depending on region).

GiveWell believes Helen Keller International’s grants cause vitamin A supplementation distributions that otherwise would not occur, but does not know whether its technical assistance helps countries to give vitamin A to children who otherwise wouldn’t receive vitamin A. For this reason, GiveWell’s analyses include only the effect of grantmaking, not the effect from technical assistance.

Helen Keller International needs $20.7 million over the next three years.

One big area of uncertainty comes from the fact that Helen Keller International has been investigated in less detail than other top charities. In general, over time, GiveWell tends to become more uncertain about charities, learn more about their limitations, and have a higher cost-per-life-saved-equivalent number attached to the charity.

Why might you donate to Helen Keller International?

• You want to save the lives of children under 6.
• You want to donate to something that definitely won’t cause significant harm, even if it might not have an effect.
• You’re optimistic about GiveWell’s further investigations finding that Helen Keller International is as effective as we thought, not less effective.
• You think Helen Keller International’s technical assistance is more likely to be effective than GiveWell thinks it is.
• You’re not too concerned about low rates of vitamin A deficiency or about the uncertainties associated with child mortality rates.

Givewell Top Charities Explained: Malaria Consortium

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effective altruism, ozy blog post

[This is the first post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring.]

The Malaria Consortium is a brand-new GiveWell top charity. They do seasonal malaria chemoprevention– that is, they give children under six preventative anti-malarial drugs, so that the children don’t get malaria and don’t die. And their cost-per-life-saved-equivalent is..

…drumroll please…

$2,292.

Okay, you shouldn’t take cost-effectiveness analysis literally. The GiveWell cost-effectiveness analyses are comprehensive, but there are a lot of factors that aren’t included, and there’s always a bunch of uncertainty that disappears with an overly precise number like “$2,292”. At the very least, you should go to that spreadsheet, click on the tab that says “moral weights,” and put in your own numbers, because otherwise you’re saying “my ethical beliefs are exactly equivalent to the average of what all GiveWell employees believe about ethics,” which is a stupid way to do ethics.

But nevertheless it is true that the cost-per-life-saved numbers for the Malaria Consortium are stupidly cheap.

If you’re a charity nerd like me, you’ve gotten a bit used to the situation with global poverty charities. The top charity is always bednets, and the cost-per-life-saved-equivalent is always about the same– sometimes it’s $3,500, sometimes it’s $4,000.

And this year not only do we have a new top charity, the cost-per-life-saved equivalent has dropped more than a thousand fucking dollars.

Like, what the fuck?

The Cochrane Collaboration summarizes the effects of seasonal malaria chemoprevention as follows:

[Seasonal malaria chemoprevention] prevents approximately three quarters of all clinical malaria episodes (rate ratio 0.26; 95% CI 0.17 to 0.38; 9321 participants, six trials, high quality evidence), and a similar proportion of severe malaria episodes (rate ratio 0.27, 95% CI 0.10 to 0.76; 5964 participants, two trials, high quality evidence). These effects remain present even where insecticide treated net (ITN) usage is high (two trials, 5964 participants, high quality evidence).

This is the Cochrane Collaboration we’re talking about here. These are the people who think there’s not adequate evidence that flossing makes your gums better. When Cochrane says “not only does this work, it prevents three quarters of all malaria episodes,” you sit up and take notice.

Unfortunately, it’s not clear that seasonal malaria chemoprevention reduces overall mortality. Not that many people die of malaria every year, so you need to have a huge study to be able to detect changes in overall mortality. One study, Cisse (2016), was supposed to be big enough to detect changes in mortality, but fewer children died than was expected, which probably makes the scientists involved feel like horrible people every time they complain about it.

GiveWell thinks the Malaria Consortium could productively use way more money than they’ll actually get: their room for more funding is $65.7 million.

So this is great, right? Time to give away all our money to the Malaria Consortium!

Well, there’s one little problem and one big problem.

The little problem is that the surveys to find out how many children get seasonal malaria chemoprevention suffer from some severe methodological limitations: for example, the villages often aren’t randomly chosen, and caregivers often say they’ve given a dose when they didn’t mark the card they were supposed to mark when they gave a dose. It’s true that the surveys sometimes show really low rates of children getting treated, which would be weird if the Malaria Consortium were deliberately giving GiveWell misleading results. But even if the Malaria Consortium isn’t being misleading it might be hard to know how well they’re implementing the program.

The big problem is drug resistance.

Seasonal malaria chemoprevention uses two drugs: sulfadoxine–pyrimethamine (SP) and amodiaquine (AQ). The good news is that both drugs are basically only used for malaria, so we don’t have to worry about any other nasty bugs developing resistance to them. The bad news is that they’re both very commonly used, effective, and cheap treatments for malaria, and if you give them to everyone under the age of five, it makes it much more likely that malaria will evolve resistance to them.

The experts GiveWell has talked to expect that seasonal malaria chemoprevention will not result in malaria evolving drug resistance to SP and AQ within the next five to ten years. But five to ten years is not a very long time. We’re probably still going to have malaria in the next five to ten years. It would suck if malaria were harder to treat.

The Malaria Consortium is doing a study right now of how fast resistance seems to be evolving, so we might have more information and better estimates in the future. But right now drug resistance is something I at least am really worried about.

The Malaria Consortium needs $39.4 million dollars over the next three years.

Why might you donate to the Malaria Consortium?

• You care a lot about saving the lives of children under six.
• You want to donate to a program that definitely works and is cost-effective, even if it might have other negative impacts.
• You’re optimistic about making significant progress in eradicating malaria in the next few decades, or about malaria not developing drug resistance.

Charity Overhead Is Not Evil

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effective altruism, ozy blog post

A lot of charitable watchdogs, such as Charity Navigator, divide the ways charities spend money into “program expenses” and “overhead.” Program expenses are money that the charity spends on its actual program: it’s the money that goes to buy malaria nets, stock the shelves with canned food, or pay the veterinarians who help the cute puppies with rare diseases. Overhead includes administrative and fundraising expenses. Administrative expenses are those associated with management and general operations.

It makes sense that people would care about overhead. In general, scam charities tend to spend very little on program expenses and a lot on overhead. If a charity claims to help cure rare diseases in cute puppies, and they’ve spend ten dollars on antibiotics for puppies, ten million dollars on fundraising, and twenty million dollars on the CEO’s salary and team-building trips to Tahiti, this is probably not a real charity.

However, concentrating too much on overhead can actually lead to charities becoming less efficient. Certain kinds of charities spend more on administration and fundraising than other kinds of charities do. For example, Charity Navigator notes, a food bank that takes donated canned goods will not spend very much on administration at all. Conversely, a charity that gives people cash might spend more money on administration, because they have to do accounting to keep track of all the cash. But it’s totally possible that the latter charity does better at helping poor people eat.

If charities are focusing on getting their overhead expenses as low as possible, it can lead to the charity actually being less efficient. For example, the office staff at a domestic violence shelter might use computers from 2008 because replacing the computers would count as overhead. Or they might underpay their managers, which means the managers burn out, quit, and take a bunch of institutional knowledge with them. Or they might avoid hiring an administrative assistant, which means that social workers spend time filling out forms instead of helping people.

Imagine that you were trying to buy a pair of shoes. You might look at how expensive the shoes are, or how well-made they are, or how good the conditions in the factory were for the employees, or whether they are fashionable; these are all reasonable things to take into account when you’re buying shoes. What you would not do is say “wow, I’m going to buy these shoes, the CEO only makes $13,000 a year and all the HR was done by unpaid interns and the office staff are all using out-of-date computers.” That is just totally uncorrelated with whether the shoes are good. Maybe it means the shoes are worse, because HR is actually kind of important in making a good pair of shoes, and you are unlikely to get good HR from a bunch of unpaid interns.

The same thing is true when you think about how to donate to charity. You should donate to a charity that, as best as you can tell, improves the world as much as possible, whatever that phrase means to you– just like you should buy the pair of shoes that fits the best. “Overhead ratio” is a good way of filtering out outright scams, but it is not a good way of separating the okay charities from the great charities. For that, you need to look at outcomes.

Why Reduce Chicken, Not Beef?

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effective altruism, ozy blog post

Many people are concerned about factory farming and animal cruelty. However, many people are not capable of becoming vegetarian or vegan right now: perhaps it would be unhealthy for them because their diet is otherwise limited; perhaps they don’t have access to vegan or vegetarian food; perhaps they’re in a stressful life situation where becoming vegetarian would add so much difficulty to eating that they can’t eat at all. Fortunately, many people who can’t eliminate meat entirely can reduce their meat consumption.

In my experience, many people who want to reduce their meat consumption start by cutting out beef and other red meat, while continuing to eat chicken, fish, and eggs. However, effective altruists generally recommend that you start by cutting out farmed fish, followed by battery-cage eggs, followed by chicken. Why are these perspectives so different?

[Please do the opposite of this.]

(In this post, I’m going to talk about diet from a perspective of animal welfare, not from a perspective of health or the environment. Reducing your meat consumption so that you consume less meat than the average American is one of the best things you can do for animal welfare and for the environment. According to most nutritionists, eating less meat than the average American does is good for your health. However, it would be really weird if the diet that’s best for animal welfare were also simultaneously the diet that’s best for your health and for the environment. I’m only going to talk about animal welfare right now, because otherwise this post would be very very long; if your primary reason for reducing your meat consumption is concern about the environment or your health, you may prioritize which meat you reduce differently.)

Most people cut out meat from mammals because they think mammals are smarter than birds, perhaps because mammals are more closely related to humans. (For those interested, here is a review of the cognitive capacities of chickens and here is a review of the cognitive capacities of cows.) However, when we think about which animals we eat, it’s important not just to think about the animal’s cognitive capacities but also to think about their size.

Chickens are very small: a single chicken can only produce meat for a few meals. However, cows are very large. A single cow can produce enough meat for hundreds of meals. This means that the average American eats less than a tenth of a cow per year. Conversely, Americans eat thirteen chickens every year! (While I only have statistics for the one country, chickens and cows are approximately the same sizes around the globe.) That means that if you avoid beef for a decade, you could save one cow from being factory farmed– but if you avoid chicken for a decade, you could save 130 chickens from being factory farmed.

Chickens are also generally raised in much worse conditions than cows. I try to avoid including descriptions of animal cruelty on this blog, but the interested reader may look at the Humane Society’s white papers on the subject. I’d estimate that a day in the life of a broiler chicken is about three times worse than a day in the life of a cow.

Of course, it is possible to have a set of values such that it is better to avoid beef than to avoid chicken. Brian Tomasik has a very interesting calculator which you can use. In general, if you prefer forty chickens to suffer a certain amount over a single cow suffering the same amount, you should cut out beef; otherwise, you should cut out chicken.

Similar arguments apply to farmed fish and to eggs, with some differences. A day in the life of a farmed fish is generally less bad than a day in the life of a chicken; however, farmed fish are also generally quite small. You can’t do a straightforward “how many animals?” calculation for egg-laying chickens, because egg-laying chickens live much much longer than chickens killed for meat; the more complicated calculations are laid out in this post by Peter Hurford.

I’d like to make it clear that when I say “farmed fish,” I am excluding wild-caught fish. The effects of fishing on animal welfare are extremely confusing, and wild-animal advocates have only begun to study them; I do not think avoiding wild-caught fish makes sense at this time. (Nearly seventy percent of fish labeled as ‘wild-caught’ in restaurants is actually farmed. I would recommend buying wild-caught fish from large chain grocery stores, as that is the most likely to be correctly labeled.)

Peter Hurford’s calculations suggest that one can get 85% of the animal-welfare benefit of going vegan simply by avoiding chicken, eggs, and farmed fish. You do not have to go vegan, or even vegetarian, to take big steps towards improving the welfare of animals.

Effective Altruism For Broke People

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effective altruism

I know a couple of people who would very much like to be effective altruists, but they’re poor and busy and in jobs which aren’t high impact, so they feel like they can’t.

So I have a couple of thoughts. First, you don’t have to be an effective altruist. A lot of people doing effective altruist outreach have more-or-less explicitly targeted rich people. If someone makes $200,000 a year, getting them to donate 10% to the Against Malaria Foundation saves about six lives, and the only cost is that they go on a slightly less nice vacation. If someone makes $20,000 a year, getting them to donate 10% to the Against Malaria Foundation saves about half a life, and the cost is that they might have problems paying rent or getting health care that they need. The former is an obviously better situation.

Even if you are an effective altruist, it’s okay not to donate. It’s unsustainable in the long run to sacrifice your financial stability, health, or happiness to donate more money. If you can’t afford to donate money, but you fully intend to donate when you’re in a less precarious financial situation, then you’re an effective altruist in my book. (Well, unless by “precarious financial situation” you mean “I can barely afford my fourth yacht”.)

But I do think it’s a good idea to get yourself in the habit of giving, even if your financial situation is a mess. Think about what you can do. Can you set aside twenty dollars a month? Ten dollars? One dollar? Can you put your spare change in a coffee mug and then when it’s full take it to the Coinstar machine and give it to UNICEF? (Sadly, Coinstar machines do not have the Against Malaria Foundation.) Whatever is possible for you is fine. If your financial situation becomes more stable, you can up the amount you give.

Finally, no less an authority than Peter Singer himself has said that donating ten percent of one’s income is unreasonable for most people. He suggests that people under the US poverty line ought not donate; for people making more than the poverty line but less than $105,000, he suggests a donation of between 1 and 5% depending on exactly how much you earn. You can plug your income into the calculator here. The suggested donation for a person making $20,000 a year is $206, which is about $17 a month. For some people, that’s still going to be way out of reach, and that’s totally fine– I suggest, well, giving what you can. But if that sounds a lot easier to you than giving ten percent, maybe give Singer’s pledge a shot instead.

GWWC Pledge Drive

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effective altruism, ozy blog post

If you’ve been reading this blog for any period of time, you probably know that I, like a lot of people, experience depression.

The worst thing about depression, for me, is that it robs me of all the things that make me like myself most and most like myself. I no longer take pleasure in small beautiful things. I don’t enjoy art. I am incapable of maintaining friendships. I can’t work.

The best thing about depression (which is not a title that there is a lot of competition for) is that, I think, I am a lot more familiar with what those things are than most people have. I have lived in the colorless world without light or joy, and so I know to give thanks when I am not there.

(Gratitude is one of the things depression robs me of.)

Oddly enough, one of the things I am grateful for– one of the things that depression clutches in its curved claws, cackles over, dangles out of my reach– is my sadness.

When I am depressed, it is hard to reach outside the endless gray apathy, the constant mild throbbing that doesn’t even deserve the title of “pain”. It is hard to care about others, even those most close to me. I can read stories of the greatest atrocities and feel nothing.

When I am in not depressed, my knowledge of the horrible things happening in the world makes me sad. These are some of the things that make me sad, when I am not depressed: autistic people electroshocked at the Judge Rotenberg Center; captive chimpanzees with PTSD and depression; neglect of the public health needs of prisoners; the absence of needle exchange programs for addicts; the rejection and abuse experienced by people with obstetric fistulas; people being coerced into having abortions, or into not having abortions. Perhaps you have your own list.

With the sadness comes a certain joy. There were 38 cases of polio this year, putting us tantalizingly close to eradication; a serial killer worse than any human serial killer, a murderer of children, who will never be in a position to kill again. I can look on Give Directly Live and read story after story of the benefits Give Directly has caused: houses built, children fed, small businesses founded. When I read these, I feel proud of my species, and of the small role I have played.

I recognize that, though it is a good and kind thing, it is not very wise, my sadness and my joy. It is not very good at multiplication; I feel as sad about the few hundred people at the Judge Rotenberg Center as I do about the million people with obstetric fistulas. It cares more about vivid stories than it does about statistical effects: even though Deworm the World and the Against Malaria Foundation are more effective, “another family doesn’t have malaria!” and “it is possible that there were large effects on income!” are not the kind of stories I get warm and fuzzy feelings from reading. It tends to be more horrified by things with an identifiable enemy: I am far more likely to be saddened by a situation of institutional abuse, which I loathe to the depth of my being, and my strong feelings about diseases mostly come from anthropomorphizing them. It is more motivated when I can imagine that I would have been a victim if I were not as unutterably lucky as I am: stories of addicts, or autistic people, or people with uteruses, will generally move me more than stories about groups I could not have been part of.

So I do not do what my sadness tells me to do. I do what my emotions would want me to do, if my feelings could do math, if I could rage as much about bad luck as about injustice and cruelty, if my empathy were strong enough to reach out to those very different from me. The charities I give to don’t help anyone on this list except the last, but I give in the name of the sick addicts and the tortured autistics, the chimpanzees and the prisoners, the people with no reproductive health care and the people whose reproductive health care abuses them, the children who will never have to live in an iron lung and the GiveDirectly mother who can give her children milk from their new cow. I give even when I am depressed, because I remember the person who I was, the person who depression stole from me; and that person cared, even when I do not, about the unimaginable pain and suffering there is in the world, and the power they have to make it better.

My housemate Linch asked me to write this post about taking the Giving What We Can pledge. I think that is a good thing to do for a lot of people; I myself have theoretically taken the pledge, except that I am absurdly bad at clicking buttons. But there are lots of people for whom that’s not the right choice. If you’re poor, I’d suggest taking the Life You Can Save pledge instead, in which the amount you’ve pledged to give is dependent on your income; in my experience, most people’s reaction to the TLYCS pledge is “wait, only X? I can definitely give X!” If you prefer having the flexibility to decide whether or not giving is the right way for you to do good right now, then don’t take the pledge, but I do encourage you to set aside some time to think about what good you’re doing and whether you’d like to do more.

And there are many other things that you can do, besides taking the pledge, if you feel the sadness and the joy I sometimes feel, or if you have been robbed of it as I sometimes have. You can build your career capital to increase your power to do good: I recommend looking through this list on 80,000 Hours, and if there’s anything that makes you go “aw, fuck”, then set a goal to work on that one. You can help people you know do good: creating community resources, mentoring, giving financial or emotional support. (I don’t just mean “in the effective altruist community” either– if you’re an economics professor, mentoring your altruism-minded students has the potential to do a lot of good.) You can go vegetarian or vegan; if vegetarianism or veganism aren’t possible for you, maybe one of these suggestions will. If you’re not in a highly effective career, you can transition to a career that lets you do good; 80,000 Hours has a new book which looks fascinating. If you are, you can try to do your job better. You can donate a kidney.

No one is going to do all of those things. But if one or a few makes you go “yeah, I can do that”… if you feel sad about your own personal list of the ways the world is unutterably fucked up… I hope you join me in trying to make it a little less fucked up. There’s a lot of problem. We need good people to help fix it.

I’m Not An Effective Altruist Because I Prefer…

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effective altruism, ozy blog post

[If I have made an error or bad argument in this post, please correct me in the comments and I will update this post.]

I’ll be honest: I am exactly the kind of globalist, cosmopolitan technocrat you imagine when you read the word “effective altruist.” But I also believe in working with people who have different sets of values than mine on issues that are important to both of us, and given how talent-constrained most effective altruist causes are, I think cooperation and collaboration are much better strategies than yelling at people. And I’m not a fan of making the perfect the enemy of the good: if you’re not going to help eradicate malaria or factory farming no matter what I do, I’d much rather you go about doing whatever other thing you’re doing well. Scared Straight doesn’t help anyone.

So, you’re not an effective altruist, because you support..

…local causes!

Many people believe that they have a special duty to their family, their friends, their city, or their country. That is perfectly fine; your values are your values. However, believing in a special duty to those close to you is not incompatible with being an effective altruist. Most people don’t have literally zero interest in humanity as a whole; if you care about humanity a little bit, you can be an effective altruist a little bit. For instance, some effective altruists who believe in that duty pair each donation to a friend, family member, or local/national cause with a donation to a global cause. You can also decide what percentage of your resources you want to devote to global causes and use those resources.

If you are determined to only care about local causes, I encourage you to take the following steps:

• Choose a highly important local cause area. For instance, in US policy, many effective altruists believe that land use reform, criminal justice reform, farm animal welfare, immigration policy, and macroeconomic stabilization policy are the most important. If you think existential or global catastrophic risks pose a threat to humanity, remember that you and those close to you are also part of humanity. You might think that another cause area is the most important. Think about tractability (whether you can do something about it), scale (how many people does it affect), and neglectedness (how many other people are already doing something about it).
• Take an evidence-based approach. Take care to avoid ineffective interventions. Encourage nonprofits you work with to collect information about the good they’re doing or even run randomized controlled trials. When you donate, don’t just consider overhead; think about how much good the charity does per dollar you donate.
• Consider sharing information you discover with the effective altruism community. There are a lot of world problems, and we really really don’t have enough talented people. If you’re working on a highly important cause area, we need your expertise, even if you don’t 100% share our values.

…anti-overpopulation charities!

I have seen a lot of people argue that they don’t want to save the lives of people in the developing world because they’re afraid of overpopulation. However, there are several options the overpopulation-concerned effective altruist could take.

First, the evidence appears to suggest that averting the deaths of children– as the Against Malaria Foundation does– tends to reduce fertility. If you think that argument’s true, then you don’t have to worry much about overpopulation effects. If you consider the evidence to be fairly weak, consider donating to a deworming charity or Give Directly, neither of which save lives; instead, they help people become richer. Since rich people tend to have fewer children, this also reduces world overpopulation in expectation.

If you’re skeptical about such indirect effects and want to have a direct effect on people in the developing world, consider donating to a reproductive health charity. Population Services International is a former GiveWell standout charity; it’s still believed to do very good work. You can also donate to IPPFAR, which is the Planned Parenthood organization that caters to Africa. If the topic interests you, consider researching other reproductive health organizations; if you can present evidence that a charity is comparable with GiveWell top charities, maybe other effective altruists will switch to supporting it.

…structural change! 

Great! We, too, like structural change. I don’t think anyone’s ideal vision of the world is “everyone in the developed world takes the Giving What We Can pledge; ten percent of the GDP of every developed country goes to the developing world for the rest of time as a sort of international welfare program”.

A lot depends on whether by “structural change” you mean something along the lines of “reform of foreign aid” or something along the lines of “global communist revolution”. If the former: I encourage you to check out 80,000 Hours, which has a lot of advice about how you can use your career to make structural change. For instance, depending on your skills, you can consider joining the civil service, becoming a journalist, becoming a foundation grantmaker, economics research, working for an effective nonprofit, researching structural change charities for an organization like Open Philanthropy Project, or founding a startup like Wave. You’ll probably want to concentrate on advocacy, research, and direct work careers, rather than earning to give.

If you’re not capable of getting work in any high-impact careers, consider donating to charities which may lead to structural change. For instance, GiveWell’s malaria and deworming charities both help with the eradication of their respective diseases, through reducing transmission and infection rates. If that isn’t structural enough for you, I’d like to gently suggest that– whether or not genuinely structural change is the best– we’re not talking about what’s the best thing to do overall. We’re talking about what the best thing to do is for you. There’s no shame in doing the best you can– particularly if the best you can is literally saving the lives of children. Don’t make the perfect the enemy of the good. It’s much better to help some people– even if you aren’t fixing everything in the world– than to help no one at all.

If by “structural change” you mean scrapping our entire political/economic system and replacing it with a new one… well, you’re definitely ambitious, and that’s awesome. It’s going to take ambition to solve the world’s problems. You’ve probably also noticed that the effective altruism movement is somewhat lacking in people who agree with you.

I don’t think that necessarily means it’s a bad idea for you to participate in effective altruism. Effective altruism is marked by its fondness for super-weird ideas; there’s no reason to believe that effective altruists won’t be willing to adopt your unusual ideas, if you back them up with evidence and reason. And, selfishly, if it turns out that the best thing to do is working on replacing our entire economic and political system, then I really want to know about that! If you can convince me, I want to be convinced!

If you decide not to work with effective altruists, I still think an emphasis on effectiveness is important for prospective revolutionaries. A really common way that leftist groups fail (and probably also rightist groups, although I’ve spent less time around them) is that they wind up wasting all their time in petty infighting, abstruse theorizing, or attempting to figure out whose life choices are the most Problematic. This is, uh, not great. Unfortunately, unlike local causes, this isn’t something where I can point to EA research about the most effective strategies. But I think some of the habits of mind are still useful: an emphasis on quantification; paying attention to tractability, neglectedness, and scale; monitoring whether the thing you’re doing has the effects you think it has, possibly including randomized controlled trials.

In addition, I would be remiss not to point out the existence of AI charities. I encourage everyone who’s primarily interested in structural change to pick up a copy of Nick Bostrom’s Superintelligence. While many people (including me) don’t really buy his arguments, you really can’t get much more structural than building a benevolent superintelligence to improve everyone’s lives.