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Conrad Cotton-Barratt

Neglected Tropical Diseases - Are they cost-effective to treat?

This blog post is going to be a quick summary of the major things we have discovered about the NTDs and the interventions targetting them, and what we now believe the cost per disability adjusted life year (DALY) achieved by treating NTDs to be.

When we launched in 2009, we estimated the cost-effectiveness of deworming treatments to be around $5 per DALY, which made it the most cost-effective charitable intervention that we could find. However, some of the sources used to arrive at this figure were subsequently shown to contain significant errors. As a result we are now much less confident about this figure. GiveWell has produced an independent cost-effectiveness estimate for deworming of around $170 per DALY, which we believe to be reliable as far as it goes. On the other hand, we think that this fails to fully take into account some factors - including the work the charities do to hand the programs over to governments - which will significantly raise the cost-effectiveness of deworming projects. Taking this into account, we expect deworming charities to be as cost-effective as preventing malaria by providing insecticide-treated nets, and possibly more cost-effective. Nonetheless we are quite uncertain about this, and recognise that more work needs to be done to more accurately estimate the full impact.

The term 'neglected tropical diseases' covers about 15 or so conditions which are particularly prevalent in low income regions in Africa, Asia, and the Americas. A lot of them are parasitic infections, and they are mostly quite cheap to treat. However these treatments are not well funded. We are going to focus on two types of NTDs: Soil-Transmitted Helminths (STHs), and Schistosomiasis (also knows as bilharzia, bilharziosis or snail fever), as these are the ones we believe are particularly cost-effective to treat, and are the target of two of our recommended charities.

STHs - more commonly known as intestinal worms - can cause diarrhoea, abdominal pain, weakness, and anaemia, and may impair learning ability and physical growth. Schistosomiasis is another parasitic worm, whose larvae live in and infect humans from, pools of freshwater. Schistosomiasis can cause progressive damage to the intestinal and urinary systems. Both STHs and schistosomiasis are easy to treat with cheap orally administered drugs that cost around $0.50 per person. Moreover, these treatments have no serious side-effects, so it is possible to give the treatment to whole populations without going through the expensive screening process first.

I'm going to talk about three main sources of information that have come to light since we first made the webpages. The first of these will be the errors we found in the Disease Control Priorities Project (DCP2) estimates, the second is going to be research GiveWell has done to come up with a better cost-effectiveness estimate for deworming treatment, and the third will be the new, updated, Cochrane review of STH-deworming treatments. These aren't the only new sources of information to come out over the last few years, but they are the three most significant.

One of the main sources we first used when recommending deworming as a cost-effective charity was the second round of the Disease Control Priorities Project (DCP2), which aimed to collate cost-effectiveness estimates, in $ per DALY, for a wide range of different interventions. DCP2 gave the cost of treating STHs as $3.41 per DALY saved (i.e. approximately one DALY averted for every seven $0.50 treatment given), and of between $3.36 and $6.92 per DALY for schistosomiasis. These numbers were in the ballpark of several other pieces of data we had, included a prominent paper by Miguel and Kremer (2004), and so these figures were then used to calculate the rough cost-effectiveness of deworming interventions.

However, in 2011 it emerged that in reporting estimate for schistosomiasis, DCP2 had mistakenly inserted a decimal point, and the figure should actually have been $336 - $692 per DALY. Moreover, it transpired that the spreadsheets used to calculate these figures for STHs had other serious mistakes, which led to this estimate also being wrong by a factor of about 100, making the revised figure for treating STHs to be $326. (For more details, see GiveWell's 

) On further investigation into the DCP2 figure, it emerged that the methods missed some important factors, and used error-prone estimates, making it likely that the corrected estimates were significantly more pessimistic than they ought to be.

Now, in light of this, GiveWell has been attempting to produce a transparent, reliable cost-per-DALY estimate of deworming treatments. They have produced an account of combination deworming, and a spreadsheet to estimate the cost-effectiveness. Without delving into the details, this model seems to be a corrected version of DCP2's methodology, and gives an estimate for combination deworming of around $5000 per life saved. Obviously, this is a slightly different measure to the DALY measure we were using before, and conversion between the two is non-trivial. As a rough, and probably conservative, estimate of this in DALYs, we can consider saving a life to be equivalent to approximately averting 30 DALYs, which makes the figure for combination deworming around $170 per DALY.

In July 2012 there was an updated Cochrane review, which aggregated 42 papers on the effects of STH-deworming treatment. The review came to a couple of main conclusions: that in small, screened trials - where people are first screened for STHs and then treated - treatment of infected individuals was associated with an increase in weight and haemoglobin, which implies a reduction in anaemia. However, it also concluded that there was no significant evidence that unscreened deworming - i.e. in which a whole population is treated without first checking for infections - had a significant effect on weight, nutrition, haemoglobin, or school performance (all of which have been previously thought to be an effect of the treatments).

Now, there being a significant effect in screened trials but not in unscreened trials doesn't make much sense, as it is the same drug in both cases, and the screening process change the bottom line. The most plausible explanations are that either the smaller sample sizes in screened trials make the smaller studies' results spurious, or that this is a result of how the significance of an effect is measured: those not infected 'dilute' the measurable effect the treatment has on the infected, causing the effect to drop out of statistical significance in unscreened populations. In any case, the review seems to indicate that STH-deworming is less effective than we at first thought, and it is clear that more research on the true impact is needed.

Reasons to Think Cost-Effectiveness is Still High

Those remain the main new and concrete sources of information on NTDs. However, there are still a couple of things we need to consider and several reasons why we think the cost-effectiveness might still be higher than the GiveWell estimate and the Cochrane review might lead us to believe.

One of the conclusions of the Cochrane report is that there is no good evidence that deworming has a positive effect on school attendance. However, Miguel and Kremer (authors of the influential 2004 paper) together with other experts in the field, have written a response arguing that this finding is misleading, draw erroneous conclusions about school attendance from the data, and maintaining that the educational benefits alone are sufficient to warrant deworming treatments. These arguments seem persuasive, and it appears likely that there are significant educational benefits. We would welcome further research on this subject.

Further, while we believe GiveWell's methodology for estimating the cost-effectiveness of deworming to be generally good, there are a few factors which we feel are not fully taken into account, and which may have a significant impact on the findings.

Perhaps most importantly, both SCI and Deworm the World (the two deworming charities we recommend) follow the guidelines of good developmental charity, and work with the local governments, eventually handing over the program to the government. They have a very good track record of doing this! This means that by going into a country, SCI (or DtW) bring forward the time at which a deworming program is implemented by the government by a number of years. For example: suppose that SCI goes into a country 20 years before a deworming program would otherwise have been started, and run the program for two years before handing it over to the country's government. The 2 years of work from SCI could result in 20 years of more deworming than would have otherwise occurred, meaning that their work was 10 times as cost-effective as if the program had simply stopped after two years. In this hypothetical case, this 'hand-over multiplier' would be 10, which is probably unrealistic. However we do not consider a figure of 5 to be implausible. By not taking into account this multiplier, our estimates implicitly set it to 1, which is unrealistically low. Since this number makes such a difference to the estimate, it needs to be taken into account. A goal of future research should be to find a realistic range.

Also, there is some dispute over the "disability-weight" given to the conditions caused by NTDs. The official figures for Schistosomiasis give a weight of 0.6% lasting for a year. Charles King has argued that this should be 5 to 10 times higher, lasting for the rest of the person's life. Using these figures would reduce the cost-per-life-saved to under $1000. Not being an expert in the subject, I don't feel qualified to judge who is right on this matter, but hopefully the disagreement will spur more discussion to clarify the issue. At this point we can probably expect that the true figure lies somewhere in between, which would make the real cost per life saved somewhere between $1000 and $5000.

Thus, to summarise: the DCP2 estimate - one of the sources we initially used to give a cost-effectiveness estimate - of treating NTDs was incorrectly calculated, and - due to the Cochrane review - we are less certain of our belief that deworming significantly improves school attendance and performance. GiveWell have corrected the DCP2 estimate, and enhanced the methodology to get an estimate of approximately $5000 per life saved (about $170 per DALY).

However, we believe that this estimate does not fully factor in that our recommended charities hand over the running of the program to the local government, and is calculated using the most conservative disability weightings. Moreover, the educational benefits remain unclear, and could be significant. These factors create a significant 'upside potential' as we further look into NTDs. It is possible that SCI and DtW are as cost-effective, or more cost effective, than providing insecticide-treated bednets for protection against malaria, though we do not yet have a good numerical estimate for the actual value. Future work, from us and other, needs to:

Look into the ongoing harm from NTDs and the appropriate disability weights to use

Look into the effect of handing these programs over to governments

Keep an eye on further research regarding the effects of mass deworming (in particular with regard to education)

We need to examine other charities and interventions whose cost-effectiveness is close to that of deworming and anti-malarial nets, to see if we have also neglected to consider the benefit of bringing forward the time at which governments run such programs.

GiveWell Webpage on Combination Deworming

GiveWell blog post on Errors in the DCP2 estimate

GiveWell's blog post on the Cochrane Review

Krisztina Csortea

Putting the sexy into sanitation 

Welcome to the inaugural post in our series bringing you news items and current affairs stories related to international development and charitable giving. In the first post, I will discuss the Bill & Melinda Gates Foundation’s Reinventing the Toilet Challenge.

The Bill and Melinda Gates Foundation has recently announced the winner and runners up in its 

. The Foundation has already invested approximately $3.2 million in the project and will further fund the testing of some of the prototypes entered into the competition. The success of the challenge demonstrates the usefulness of innovative methods in distributing funding: in this case the use of a competition to spur research and development. Furthermore the competition has succeeded in raising the public profile of a significant but often neglected development problem as it has garnered significant media attention. (See, for example, this 

 published on the BBC News website today.)

The UN estimates that there are about 2.5 billion people living without access to basic sanitation facilities. Preventable diseases linked to inadequate sanitation may cause the death of 1.5 million children annually, from conditions such as diarrhoea. Problems related to sanitation also have high attendant economic costs. For example, girls are often not sent to school if the building lacks sanitary facilities. The Foundation estimates that every $1 dollar invested in improving sanitation would produce a $9 return. Despite the serious human and economic costs of bad or non-existent sanitation the UN admits that the Millennium Development Goal for sanitation will probably not be met.

The goal of the challenge was to find sustainable solutions to sanitation that local communities would and could adopt. The most common method of sanitation, the flushing toilet unfortunately doesn't fit the bill. Flush toilets use up wasteful quantities of water and also require a sophisticated sewage system to function well. This makes them both unsustainable and very expensive. The flush toilet is clearly not a good solution in areas suffering from water shortage and without reliable infrastructure. Entrants to the Reinventing the Toilet Challenge had to come up with solutions which, unlike the flush toilet, are cheap, sustainable and easy to implement.

The winning toilet was developed by the California Institute of Technology. It is powered by solar energy and treats waste so that the end products are useful. It produces chlorine, a disinfectant, hydrogen which can be used for cooking and fertiliser. The runner up was designed by researchers at Loughborough University. It uses a chemical process to power itself and treat waste. In third place, the team from the University of Toronto created a toilet that powers itself and sanitises waste by using sand.

At the moment, the prototypes are quite expensive to make. But all three have the potential, when mass produced, to provide a cheap method of alleviating a problem blighting the lives of billions.

Simon Jenkins

Giving to Charity – A Pain in the Eye?

Giving What We Can put me in hospital. I was only a few steps from the postbox after posting my signed pledge back to GWWC. I’d been toying with the idea of becoming a member for something like a year, during which time I’d been agonising over a Masters dissertation on the very topic of how far our obligations to those in the developing world stretch. So after all this time, I was pleased with myself for having finally mustered up the courage to sign the pledge. I had felt a certain gravity and importance in the action of signing it and closing the envelope. I had gone to the letterbox, presumably with some kind of spring in my step, and I wouldn’t be surprised if I’d let out a resounding “ahhh” as I posted the letter into the slot.

But I can’t quite remember now, because a few seconds later I was stumbling around in pain. I was marching down the hill from the letterbox when some debris flew from a nearby building site and caught me in the eye. I’ve made this sound more serious than it is – whatever it was was tiny and there was no permanent damage. At any rate, I found myself in A&E that evening.

I can only speak for myself, but the juxtaposition of these two significant events made it feel natural to consider whether there was a connection between them. It felt like the universe was putting me in my place for being too self-satisfied about my increase in charitable giving. Or maybe it was trying to balance out the suffering that I’d averted.

Of course, the real answer is that it was just a coincidence. Really I don’t believe the universe works like that, and I only entertain these karmic ideas for fun. (There isn’t much to do in A&E, and you have to think about 

It was at this point, or somewhere thereabouts, that I realised how awful I was being. Sure, my eye hurt. Rather a lot. But there I was, sitting in a huge hospital, waiting for free (I’m a tax-dodging student) healthcare from some professionals who, from a global perspective at least, were top of their game. My suffering (and that even seems like too strong a word for it) was miniscule compared to everything else that goes on in the world.

This idea that we in the developed world are all so lucky and privileged and so on is of course not new. It’s a downright cliché that we’ve all heard millions of times, starting from when we were reminded of the “starving children in Africa” by our irate parents as they tried to get us to eat whatever wittles they’d put in front of us. You may even have rolled your eyes at my use of this cliché. But I suggest you roll them back. Yes, we’ve all heard thousands of times how minor all the bad things that happen to us are compared to the plight of billions the world over. But the very fact that this concept has become a cliché is absolutely appalling. My own mother (sorry ma) changes the channel whenever a charitable appeal comes on the telly because she finds them boring. 

. Imagine if you were starving to death (another cliché I suppose) and somebody came upon you, only to comment that your misery was, to them, merely yawn-inducing. “Seen it before, mate. Try something new”. You’d be absolutely aghast, if you weren’t too busy suffering to pay them any attention.

We’d do well to remind ourselves that, to the people who are affected, the situation is far from cliché. When I was growing up, it was just one of those facts of life that there were loads of people dying all around the world. I don’t think I felt powerless, I just don’t think it occurred to me to do anything about it. Now it has, and the hospital incident has descended into nothing more than a fun (maybe) story and a catchy (possibly) opening line for a blog entry. The eye pain is long gone. But the good feeling remains.

how we can help those living in poverty here.►

Ben Hoskin

Problems with “Overhead Costs” as a metric

This blog aims (among other things) to explain the methods we employ in our research at Giving What We Can. In that spirit, we’d like to start by explaining an important way in which we differ from many charity evaluators.

, there are also persistent myths about how to evaluate charities. One of the most prevalent, and most damaging, of these is that we should just look at the amount the charity spends on advertising, or salaries, or broader administration in order to decide which charities to donate to – supporting those which spend most of their revenue directly on the programs they operate.

if we assume the program has a certain value

, every dollar spent on admin is indeed a dollar not spent on the program. But the value of programs varies dramatically, and dollars not spent directly on programs can be used to improve the program, or raise even more money: we need to take these into account.

thousands of times more effective than others.

 If one charity A spends slightly more on administration than charity B, but operates a program that's ten times as effective, then overall it will still be much more effective. As overall effectiveness is what we care about, it would be misleading to focus on overhead costs.

The variance in charity effectiveness means there's great room for improvement. Improving the efficiency of its operations means a charity can achieve much more - but this requires spending money on gathering data, analysing it, producing a new strategy and implementing it. This is extremely beneficial, so it doesn't make sense to punish the charity for it - and yet that's exactly what the 'overhead' metric does.

Secondly, money raising is a valuable activity! If my $100 donation funds a media campaign that raises $200, then I've helped twice as many people as if my money was spent directly. As advertising generally raises more money than it costs, it's no bad thing for a charity to be undertaking. Obviously 

 of the money has to be spent on the program, but as long as investments in advertising is yielding more money to spend on interventions, it's a very good thing.

So while there is a grain of truth to the anti-administration argument, there are powerful considerations on the other side. The solution is to look at an overall metric, like 

. Since ultimately we want to help as many people as possible, and only care about the charities as a means to this end, it makes sense to look at QALYs instead. QALYs/dollar takes into account both the internal structure of the charity, their relationship with donors 

 the impact their intervention has. It allows us to avoid the messy question of judging the organisational structure of charities, and focus instead on 

William MacAskill

Welcome to the Giving What We Can Blog

It’s my great pleasure to write the inaugural blog post on our 

This blog will allow those involved with Giving What We Can to communicate more freely with the rest of the world. In the coming months, we’ll have plenty to tell you about. We’ll use this blog as a means to explain some of the core ideas surrounding our approach to giving, and our approach to assessing which charities to give to — ideas like ‘QALYs,’ ‘fungibility’ or ‘precommitment’. We’ll update you all about our current thinking in the course of our research into charity cost-effectiveness, and start discussions on issues related to the methodology of ascertaining cost-effectiveness. We’ll discuss important issues in developing world current affairs. And we’ll share stories about our members, our chapters, and the general goings-on within the community that has formed around Giving What We Can.

In other news, Giving What We Can has recently matured as an organisation, and now has three paid staff who form the core Giving What We Can team. The new updated website would not have been possible without them, and it’s my pleasure to briefly introduce them:

Michelle Hutchinson is the new Executive Director. Michelle has been a long-term volunteer, and is just finishing up her PhD in moral philosophy from Oxford University.

Tom Ash is the new Director of Operations. Tom gained his undergraduate degree in philosophy from Cambridge and his research Master’s from Oxford, after which he worked for the not-for-profit magazines 

Robert Wiblin is the new Director of Research. Rob graduated with Honours in economics and genetics from Australia National University, and has worked for the Australian Treasury and the 

Toby Ord will remain as President of Giving What We Can, and I as Vice-President. And, of course, we will continue to be indebted to the small army of dedicated volunteers who have done such an enormous amount to help grow Giving What We Can.