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James Snowden

This post is intended as a quick overview and primer on essential surgeries for those of us who care deeply about the relief of poverty in the developing world, but don’t actually know much about it.

Surgical interventions, until recently the “neglected stepchild” of public health, are getting increasing attention from public health professionals as new evidence emerges of their cost-effectiveness. While it may still be too early to say if there are any specific charities which are as cost effective as Giving What We Can’s recommendations, essential surgeries should definitely be on our collective radar.

Much of the information in this post comes from the 

Disease Control Priorities 3 (DCP3) report on essential surgeries

Essential surgeries, as defined in Disease Control Priorities 3, are 44 surgical procedures which have been selected because they:

Some examples of essential surgeries are caesarean births and cleft palate repair.

To the contrary, organ transplants (too expensive), and most cosmetic surgery (which does not address substantial need) count as non-essential surgeries.

Surgery is a ‘horizontal’ healthcare service provision, defined by the healthcare capabilities it requires rather than by the condition treated. Horizontal provisions tend to be provided by publicly funded health systems (i.e. government, not charity).

The required capabilities to perform surgery are:

Although surgery itself is a horizontal provision, many charitable interventions use a ‘vertical’ approach, treating particular conditions; either by sending surgical missions, or by employing/training local surgeons. Different types of essential surgery have different costs and benefits. Donors may therefore prefer to fund types of surgery which are particularly cost-effective. There may be significant benefits to both 

It is estimated that universal provision of essential surgical procedures would avert about 1.5 million deaths per annum. This represents 

6-7% of all avertable deaths in lower and middle-income countries

Much of the disease burden associated with essential surgery results in severe disability rather than death. For example, cataracts is a leading cause of blindness in the developing world but can be easily fixed with a simple surgery. 

The total avertable DALY burden for essential surgical procedures is 87 million.

Essential surgeries treat conditions across the spectrum of healthcare but most can be split into 5 categories.

The first three are generally treated at first-level hospitals (which have about 50-200 beds and basic surgical capabilities) and treatment is often urgent:

 C-sections and other birth-related surgeries

The remaining two categories generally have to be treated at specialised facilities but as they tend to be elective rather than urgent, patients can be scheduled efficiently, improving cost-effectiveness:

Essential surgeries can also be carried out by short-term surgical missions or on self-contained mobile platforms.

Much of the charitable contribution to treating essential surgeries is through running surgical missions to address these more 

Increasingly, essential surgery is viewed as cost effective.

Historically, surgery has been regarded by experts in public health as a luxury which only the relatively wealthy can afford. This is no longer the case. There is an increasing body of evidence which demonstrates that essential surgery is within the range of interventions which should be considered the most effective available. In some cases, the cost per DALY averted seems to be in a comparable range to interventions recommended by Giving What We Can.

Conditions requiring surgical treatment are an increasing proportion of the disease burden in developing countries.

DCP3 indicates a large part of the surgically treatable disease burden comes from injuries. As injuries, particularly road traffic accidents, increase in low income countries as an unfortunate consequence of development, there is a greater need to 

 conducted a review of studies on the cost-effectiveness of surgical interventions. This yielded 121 cost-effectiveness studies in seven categories of surgical intervention.

The most effective surgical interventions were:

Adult male circumcision (median of $14 per DALY)

With the exception of male circumcision (which reduces the risk of HIV infection), for which only three datapoints were available, and for which the estimates are probably most unreliable (because of the epidemiological factors), surgical interventions cost-effectiveness estimates could be more robust than those of horizontal health interventions. This is because when a patient comes into a hospital for surgery, there is low uncertainty about the cost of the hospital and the surgery, the associated disease burden, and the health outcome can be measured quite exactly. Nevertheless, these figures might be an overestimate of the true cost. But these estimates are in the same range of the cost effective interventions for infectious diseases:

Soil-transmitted helminths (worms) (~$100 per DALY averted and having effects on earnings)

Malarial bednets (~$100 per DALY averted)

Vaccines (~$13-$26) (which might not have much room for more funding due to GAVI's big budget)

And surgery might be more cost effective than other widely accepted interventions:

Other systematic reviews of the literature in 

 came to similar conclusions (although the range for the effectiveness of male circumcision was much higher).

I want to donate to essential surgeries, how should I do it?

 (formerly Interplast), who send surgical missions to treat cleft lips and palates, as well as running outreach centres and some training.

Alternatively, you could consider donating to a larger charity whose cost-effectiveness is difficult to measure. 

 run hospitals treating a range of trauma injuries. Evidence on the cost-effectiveness of two of their hospitals ($172 and $223 per DALY) can be found 

Would you recommend donating to charities that carry out essential surgeries?

The evidence that does exist suggests that, 

while essential surgery might be more effective than many current interventions, only some surgeries are as cost effective as the most effective interventions and we do not know of a charity that prioritizes these highly cost-effective surgeries

There remains significant uncertainty about the cost-effectiveness of surgery. The volume of existing evidence, while growing, remains limited relative to the most effective interventions. Conducting or funding additional research may be another area to look at, although this may be best left to the experts.

Money may not be the constraining factor in providing effective surgery interventions. There is a chronic shortage of surgeons in developing countries and funding surgical missions may just change who gets treated, rather than how many. One interesting area for further research is in surgical task-shifting, allowing non-surgeon health workers to undertake some surgical procedures. However, there is some concern that this may lead to lower quality of care. A more long term solution would be training additional surgeons.

Overall, essential surgeries are important and effective interventions, but at this stage we should continue prioritising giving to 

Explain like I'm five: Essential surgeries

Giving What We Can

Extreme poverty is one of the worst ongoing disasters in the world today. Giving What We Can’s entire mission is predicated on recognising the substantial privileges that those of us fortunate enough to be born in the developed world enjoy, and using our relative wealth to make a meaningful and ongoing difference to the lives of hundreds of thousands of people around the world. We recognise that we have a responsibility to conduct ourselves in a way that doesn’t essentialise, stereotype, or otherwise take away from the dignity of people who do live in extreme poverty.

Giving What We Can has received information that one of our student groups was planning to run an event that did not adhere to these values. The information provided to us about the event shows that it was clearly insensitive and completely inappropriate. We were unaware that the event was going to take place, but to the extent that it was planned by a student group with a connection to us, we sincerely and unreservedly apologise.

To be clear, nobody at Giving What We Can was aware of these plans, prior to hearing about them through the understandable backlash generated by the event. This was an event independently organised by students at a university chapter, and had we had any idea that this event, we would have asked them to cancel it immediately.

We will learn from this — we obviously need to be clearer in the guidance that we give to our student chapters, to avoid something like this happening again. As a rapidly growing organisation, it hasn’t been possible for us to individually vet all the events that our worldwide network of student chapters. So far, nearly all of these events have been handled sensitively, and have raised awareness and thousands of dollars for charities like the Against Malaria Foundation and the Schistosomiasis Control Initiative, which do amazing work reducing suffering around the world. We don’t want this to happen again, and we’ll do our best to make sure that it doesn’t.

Giving What We Can is committed to creating an inclusive, diverse, welcoming community, where people from all backgrounds can stand together in a commitment to ending the ravages of extreme poverty. We hope that we can put this incident behind us, learn from it, and continue to work towards our goal of people pledging to give a substantial portion of their income to the most effective charities in the world.

A Statement from Giving What We Can

Carolina Flores

As many as 45 million women in the world, most of them in sub-Saharan Africa [1], suffer from a painful sexual health condition. This scourge of women’s health may cause bleeding and pain (especially during sexual intercourse) [2], decrease fertility [3], and make women more susceptible to STDs [4,5]. The lesions, often acquired in childhood, can and do persist through adult life [6, 7]. Yet this condition is fully preventable: all we need is a cultural shift towards valuing women’s lives everywhere in the world.

You may be surprised to learn that I am not talking about female genital mutilation (FGM) [a]. FGM has received plenty of attention in mainstream media in the last few years, leading to a number of global campaigns pledging to stop this practice [8, 9, 10]. The problem I am talking about is female genital schistosomiasis (FGS), and you are very unlikely to have heard of it in the mainstream media. For example, whereas a quick search in The Guardian returns about 382,000 results on FGM, there isn’t a single article mentioning FGS.

While it is true that ending FGM mainly requires a shift in local traditions and views of women, this is by no means easy to achieve [11]. In contrast, wherever we are, we can all work on the cultural shift needed to end FGS. What we need is to value all human lives equally, and act in accordance – both individually, through giving, and politically, through campaigning for global justice.

And you should care about ending FGS, even if it is the first time you’ve heard about it. Here is why:

Female Genital Schistosomiasis is caused by infection with the S. haematobium, a parasite which infects people exposed to affected water. It is often contracted in childhood, with serious symptoms observed in girls as young as 3. [12] This parasite then continues its life cycle inside the human body. When its eggs lodge in the female reproductive system, the body’s reaction leads to a host of unpleasant lesions. [13, 14]

The most characteristic ones are ‘sandy patches’ (thickening and scarring of tissue), breaches and open wounds in the mucosal surface and skin. [13, 14] Scars in tissue are a lifelong condition once contracted. [6, 7] Other associated symptoms are stress incontinence [15], irregular bleeding [16] , discharge [4], and pain during intercourse [2]. It may also be associated with infertility [3] and severe acute diseases such as ectopic pregnancy [17].

It can lead to cancer and death at a young age

The internal injuries I mentioned above are not only painful, but they also facilitate the implementation of HPV [4, 5], which can lead to cervical cancer. As FGS favours a rapid propagation of the virus and eases the spread of malignant cells, it contributes to a higher chance of developing cancer more quickly.[18, 19]

Because girls often contract FGS at a young age, this type of cancer occurs shockingly early in sub-Saharan Africa. For example, a study in Tanzania found that 18% of women with FGS and cancer were younger than 25, whereas only 5% of women with cervical cancer and without FGS were in the same age group. [20]

There is evidence that what applies to HPV also applies to other STDs: FGS makes it far easier to contract them. This means that STDs will spread more where more women have FGS, worsening the sexual health of the whole population.

It makes HIV transmission much more likely

FGS is associated with a 3-4 fold increase in acquiring HIV/AIDS during sexual intercourse, which means that FGS may be one of the most important co-factors in HIV transmission in Sub-Saharan Africa’s HIV epidemic. It has been estimated that 16 million women will acquire FGS and that, if cured, 120 000 new cases of HIV could be averted through regular FGS treatments in the next decade [21, 22, 23]

More research needs to be done on the topic, but we now know that FGS causally contributes to HIV transmission by increasing the number of HIV-receptive cells in a woman’s reproductive system. A woman infected with both diseases poses an additional risk of infecting her partners, as the dual infection leads to increased HIV levels in genital ulcers. [23]

Finally, HIV in a woman with FGS is very likely to have a fast progression to AIDS. As with HPV, this is because FGS facilitates virus replication. All of this tends to happen at a very young age, because FGS is often contracted before women become sexually active.

You can read more about some recent research on the HIV-Schistosomiasis interaction 

It is a factor in gender inequality, poverty and social exclusion

It should be no surprise that suffering from disruptive symptoms since childhood, with a higher risk of contracting life-threatening illnesses, contributes to staying in poverty. But there is more to FGS than the health problems mentioned above.

Though men also contract schistosomiasis, these infections have a disproportionate impact on women’s quality of life through FGS symptoms. This is compounded by the social stigma associated to the disease, by other disruptive symptoms of schistosomiasis [24], and by the association between schistosomiasis and being unable to go to school or to work [25]. All together, suffering from FGS compromises women’s agency and makes it very difficult to escape poverty.

Here is the happy ending to this post: there is effective treatment for schistosomiasis ( praziquantel), and it is given for free by pharmaceutical companies in a program coordinated by the World Health Organization (

http://www.who.int/schistosomiasis/strategy/en/

). If we add the cost of organizing and monitoring distribution, we get the result that treating a child costs US$1.23 (through the 

 recommended charities). What are you waiting for?

http://www.who.int/neglected_diseases/integrated_media_urogenital_schistosomiasis/en/

[Morice, P. et al. (1996) [Genital bilharziasis and female infertility.Review of the literature and three case reports]. Contracept. Fertil. Sex24, 56–61](

[Kjetland, E.F. et al. (2008) Female genital schistosomiasis – adifferential diagnosis to sexually transmitted disease: genital itchand vaginal discharge as indicators of genital S. haematobiummorbidity in a cross-sectional study in endemic rural Zimbabwe.Trop. Med. Int. Health 13, 1509–1517](

[Mosunjac, M.B. et al. (2003) Cervical schistosomiasis, humanpapilloma virus (HPV), and human immunodeficiency virus (HIV): adangerous coexistence or coincidence? Gynecol. Oncol. 90, 211–214](

[Kjetland, E.F. et al. (2008) Prevention of gynecologic contact bleedingand genital sandy patches by childhood anti-schistosomal treatment.Am. J. Trop. Med. Hyg. 79, 79–83](

[Silva, I.M. et al. (2005) Therapeutic failure of praziquantel in thetreatment of Schistosoma haematobium infection in Braziliansreturning from Africa. Mem. Inst. Oswaldo Cruz 100, 445–449 

[a] Interestingly, the two may be historically related. A recent paper (

https://www.researchgate.net/publication/236052203_Female_genital_mutilation_and_female_genital_schistosomiasis-bourouwel_the_worm_Traditional_belief_or_medical_explanation_for_a_cruel_practice

) suggests that FGM may have started as a misguided attempt to cure visible symptoms of FGS. In fact, the areas with high prevalence of FGS and of FGM overlap.

WHO: Effectiveness of interventions designed to reduce the prevalence of female genital mutilation/cutting

El-Adnani, M.S., Saleh, K.M., 1982. Extraurinary schistosomiasisin Southern Iraq. Histopathology 6, 747–752

Poggensee, G., Feldmeier, H. (2001) Female genital schistosomiasis: facts and hypotheses. Acta Tropica 79, 193-210

Eyrun F. Kjetland, E. F, Leutscher, P. D. C., Ndhlov, P.D. (2002) A review of female genital schistosomiasis. Trends in Parasitology Vol. 28, No. 2, 58-65

Kjetland, E.F. et al. (2005) Simple clinical manifestations of genitalSchistosoma haematobium infection in rural Zimbabwean women. Am.J. Trop. Med. Hyg. 72, 311–319

Bland, K.G. and Gelfand, M. (1970) The effects of schistosomiasis onthe cervix uteri in the African female. J. Obstet. Gynaecol. Br.Commonw. 77, 1127–1131

Ville, Y. et al. (1991) Tubal schistosomiasis as a cause of ectopicpregnancy in endemic areas? A report of three cases. Eur. J. Obstet.Gynaecol. Rep. Biol. 42, 77–79

Moubayed, P., Ziehe, A., Peters, J., Mwakyoma, H., Schmidt,D., 1995. Carcinoma of the uterine cervix associated withschistosomiasis and induced by human papillomaviruses.Int. J. Gynaecol. Obstet. 49, 175–179.

Ylitalo, N., Sorensen, P., Josefsson, A.M., Magnusson,P.K.E., Andersen, P.K., Ponte´n, J., Adami, H.O., Gyllensetein,U.B., Melbyl, M., 2000. Consistent high viralload of human papillomavirus 16 and risk of cervicalcarcinoma in situ: a nested case-control study. Lancet 355,2194–2198.

Moubayed, P., Lepere, J.F., Mwakyoma, H., Neuvians, D.,1994. Carcinoma of the uterine cervix and schistosomiasis.Int. J. Gynaecol. Obstet. 45, 133–139.

Hotez, P.J. et al. (2009) Africa’s 32 cents solution for HIV/AIDS. PLoSNegl. Trop. Dis. 3, e430

Feldmeier, H. et al. (1994) Female genital schistosomiasis as a riskfactorfor the transmission of HIV. AIDS 5, 368–372

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0001396

King, C.H. and Dangerfield-Cha, M. (2008) The unacknowledgedimpact of chronic schistosomiasis. Chronic Illn. 4, 65–79

The scourge of women's health you've never heard of

Larissa Hesketh-Rowe

Each year more than six million people die from preventable diseases. 

If your average person in the US just donated 10% of their income 

 700 people from malaria for at least three years with mosquito nets or treat 7,100 people for neglected tropical diseases that keep them from work and school.

But what if you could double or triple even those numbers? What if in the future we discover even more helpful ways to donate our money? Would we regret ‘wasting’ our donations on less effective interventions in the past?

Should we donate to charities that tackle extreme poverty now or invest our money and wait for the future when we might understand more which poverty interventions work?

I have chosen to give now to charities that fight extreme poverty. Here’s why.

2015: An important year for eradicating poverty

This year is an important time in our our mission to eliminate extreme poverty.

 funds to top charities. Effective Altruism is growing as a movement with 

 books both out and a record breaking number of people attending the 

In international development more broadly, the Millenium Development Goals end in 2015 having 

 the number of children who did not make it to their fifth birthdays compared to 1990. They will be replaced by the 

), which are more inclusive and far reaching. The Sustainable Development Goals aim for a world free of extreme poverty by 2030.

Only a couple of months ago (on the 24th July) Nigeria marked 

. A small step in completely eradicating this deadly disease from the planet by removing it from the last remaining countries; Nigeria, Pakistan and Afghanistan.

We’re also setting the new climate change targets and as we know it is the world’s poorest that will be 

All of this momentum strengthens my feeling that now is an important time to give. The more success we achieve, the more people can see what is possible and how much of an impact individuals can have. We can seize the opportunity to create a worldwide movement where giving is both normal and clearly effective.

Nearing success on some of the most cost effective interventions

These successes also mean some of the cheap and effective interventions against extreme poverty will soon become superfluous (we hope!). This means there are cost effective giving opportunities now that might not be there if we wait. Yes, we can invest our money now and give more later. But will current interest rates really yield enough extra money to offset the cost effectiveness of current charities?

Not only that, but will the interest gained 

 (the effect of current investments in the receiver’s ability to help others)? Money we donate to, for example, deworming charities keeps people in work and school. These people then contribute to their families, their communities and their society in ways that they otherwise would not have done. These changes then benefit their children and their children’s children.

Are we losing generations of impact the longer we delay?

The age of the randomised controlled trials

One argument for delaying is that in the future we’ll have more information and be able to give even more effectively.

It will likely always be the case that we will know more in the future. Should we therefore always put off giving?

Blog

Explain like I'm five: Essential surgeries

A Statement from Giving What We Can

The scourge of women's health you've never heard of

Why I choose to give now

Action on the refugee crisis and action on global poverty: thoughts, facts and ways to do good better.

Should we give to SCI or fund research into schistosomiasis?

Giving What We Can is Hiring! Director of Growth.

Giving What We Can is Hiring! Research Analyst.

Development, Population Growth and the Mortality-Fertility Link

Smart Legacy Giving