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Are mass deworming programs valuable? Giving What We Can’s position on the recent Cochrane Review.

Updated 26/07/2015: We made some changes to this blog post based on feedback

an excellent and detailed analysis of on the new deworming

 and concluded “Our current view is that these new papers do not change our overall assessment of the evidence on deworming, and we continue to recommend the Schistosomiasis Control Initiative and the Deworm the World Initiative”.

A recent Cochrane review paper by Taylor-Robinson and colleagues 

 has called into question the effectiveness of mass deworming programmes. Specifically, it suggests that there is not good evidence that mass deworming contributes significantly to overall childhood health and nutrition, educational attainment, or school attendance.

This has implications for Giving What We Can, because two of our charities focus on delivering mass deworming programmes. We wanted to update our members on the current state of play.

Health benefits of treating populations with schistosomiasis are not questioned by the review

An important takeaway from this is that the conclusions of the review specifically focuses on soil-transmitted helminths (STH) — these include whipworm (Trichuris), roundworm (Ascaris), and hookworm. The conclusions of the review on health outcomes do not relate to schistosomiasis.

Schistosomiasis is associated with more severe ill-health than STH 

 . Consequently, the disease burden is higher, and treating it might be more cost-effective than treating STH 

 . Even the Cochrane review agrees that there is benefit of treating populations with schistosomiasis:

“The evidence for the benefit of treating populations with schistosomiasis is fairly clear, as the infection has a very substantive effect on health. (Danso-Appiah 2008 as cited in the Cochrane Review by Taylor-Robinson et al. 2015 1)” 

To this end, this review does not substantially affect 

our overall conclusion on the health benefits of population deworming for schistosomiasis as done by the Schistosomiasis Control Initiative

, even though SCI also treats both Schistosomiasis and STH (‘combination deworming’).

our recommendation of the Deworm the World Initiative

, but at this stage we have not significantly changed our position on them.

 took into account an earlier version of this Cochrane Review, which reached similar conclusions about the small effects observed on overall health and educational outcomes. However we chose to continue to recommend Deworm the World, for a number of reasons.

Firstly, a paper that suggested more positive outcomes from treating STH infections was not considered by the Cochrane Review based on their predefined exclusion criteria (even though the paper makes a good case for showing a causal relationship, it was excluded, because it was ‘Not a comparison of deworming with placebo or no treatment.’). 

We considered this paper in our recent report

, and a subsequent analysis of its data by GiveWell:

Another recent paper looked at deworming spillovers during early childhood and suggests that there are improvements in cognitive performance equivalent to between 0.5 and 0.8 years of schooling. However, this paper looked at combination deworming. Givewell conducted a reanalysis of this data looking at the effects of STH by excluding all the schools that received praziquantel against schistosomiasis. They find that not all but many of the results still hold, which means that DtWI’s case of only deworming for STHs in India is still strong with regards to improvement of school performance.

Secondly, even if the health effects of deworming are small, the low cost of the intervention means that it may extremely cost-effective. Not only is mass drug administration cheap to deliver, DtWI provides technical assistance to the Indian government rather than distributing drugs themselves, which enables them to cause more children to be dewormed for a certain donation. Given the low cost of treatment, it is plausible that DtWI is still extremely cost-effective.

Thirdly, while the Cochrane Review does not support mass deworming programs (such as those that DtWI is helping to coordinate in India), it also makes the point that “children with worms should be dewormed”. However, as it is time-consuming and expensive to individually screen children for worms, and the deworming medications do not have harmful side-effects, the most cost-effective ways to treat infected individuals is through mass drug administration. As we noted in 

In the light of this cost-benefit analysis for screening versus mass treatment, the case for mass deworming is still strong, but one might suggest that it is better to focus more on more heavily infected populations and improve trials. Because DtWI provides technical assistance and evaluation of whether an area should be dewormed based among other whether the local worm burden is sufficiently high, they have probably improved the effectiveness of mass deworming programmes in the more recent past.

If it is the case that we should deworm children, then it follows that we should do so using the most effective process — namely, mass drug administration. A recent paper suggests that treating all children at risk for worm infection would cost approximately 300 million dollars a year, but the cost of treating them via screened programs might be 2 billion dollars or more per year 

Deworm the World has a number of programs. Its program in Kenya and Ethiopia treats both STH infections and schistosomiasis and they have plans to move to other African countries where schistosomiasis is present. Given the higher disease burden of schistosomiasis, this particular program is likely to be preventing a significant amount of ill-health irrespective of the value of concurrently treating STH infections.

It’s important to note that one of the Cochrane Review contributors caveats the conclusions of the Review by saying that they should be taken in the context of a world that is different to that of 20 years ago — specifically, with a lower overall worm burden:

“So deworming may have helped in these exceptional, heavily infected, untreated populations from another decade, but this is scarcely a solid base for contemporary policy: public health nutrition has changed, worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies. 

This suggests that there is still value in treating STH infections in areas of high worm burden. Recent studies in Bihar state in India indicate that worm burdens are still very high 

 and therefore that mass deworming of children — at least in this particular case — might be justified.

Finally, DtWI is using their donations to conduct research into deworming and its effectiveness — something that in the light of the recent papers seems to be very much needed.

One of the most controversial components of the Cochrane Review are two papers that revisit a well-publicised study that links deworming to improved school attendance.

 have sensationalised some of the findings of the recent papers. We think this unfairly represents their implications. What’s actually going on?

recent re-analysis of the original Miguel and Kremer study

 has recently been published by researchers working at the London School of Hygiene and Tropical Medicine (Davey et. al.). This re-analysis was made possible because Miguel and Kremer released their original data, along with the statistical modelling software that they used to produce their results. This is admirable — very few authors provide this level of transparency and ability for proper peer review, and Giving What We Can commends them for it.

There were two components to the re-analysis. 

The first set out to simply replicate the original study’s results.

 The authors corrected some minor errors in the data (rounding errors etc.) and an error in the original computer code. The replication study reproduced the majority of the results of the original, but called into question the improvements in school attendance.

 set out to compare the results obtained from the original methodology (drawing on conventions in development economics) with those obtained from an epidemiological methodology. As the authors of the re-analysis state:

Our interest in replicating M&K came not from an interest in school-based deworming but in evaluation methodology ... We replicated M&K to learn more about the techniques used in economist-led trials, by re-analysing and presenting this famous trial in a format familiar to epidemiologists.

The re-analysis found that the evidence for improved attendance at schools where treatment was given was weaker than the original claimed, and the authors highlighted concerns that, because of limitations in the data, that the results could be susceptible to bias.

The conclusion drawn from the re-analysis of the data and the updated Cochrane Review are controversial. 

 that their main conclusions regarding school participation gains are robust 

 , and that the results fit in with other studies on deworming that suggest positive impact on labour productivity and education 

 also finds the re-analysis unconvincing and concludes that the results from the original study hold 

 . Givewell has also recently responded to these papers and argues that the evidence still seems to suggest that deworming increases labour productivity. Givewell estimates that:

“Deworming generates a net present value of $55.26, against an average cost of $1.07, i.e. that deworming is ~50 times more effective than cash transfers” 

Obviously the re-analysis suggests that deworming may provide less of an overall benefit in the form of improved educational outcomes, but at this stage, the robustness of these results with regard to school attendance is unclear. Both sets of authors have made decisions regarding methodology that reflects their particular academic discipline (i.e. development economics vs. epidemiology).

However, from Giving What We Can’s perspective, these results are only a small fraction of the whole picture. 

 is not substantially based on the school attendance results of the Miguel and Kremer paper, and so we do not feel that the re-analysis — even if it does prove to be the correct interpretation of the data — significantly updates our position.

Part of Giving What We Can's purpose is to use the best available evidence to inform our charity recommendations. We will be taking some time to incorporate these findings into our recommendation of Deworm the World, and attempt to get in touch with relevant parties to clarify a number of our concerns. However, it’s important to note that the evidence that we based our 

 on has not changed significantly since we made it. At this stage we will continue to list the Deworm the World Initiative as one of our ‘Promising Charities’, while investigating the implications of this Review further.

http://www.cochrane.org/CD000371/INFECTN_deworming-school-children-developing-countries

Reanalysis of Miguel and Kremer deworming study by Davey et al

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv127.full

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv128.full

Miguel and Kremer's response to Davey et al 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv129.full

Davey et al's counter-response to Miguel and Kremer's response 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv130.full

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv131.full

http://www.evidenceaction.org/blog-full/worms-win-kids-lose-our-statement

http://blog.givewell.org/2015/07/24/new-deworming-reanalyses-and-cochrane-review/

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000371.pub6/abstract

 Colley, DG. "Human schistosomiasis - The Lancet." 2014. < 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61949-2/abstract

 "PLOS Neglected Tropical Diseases: The Global Burden of ..." 2015. 25 Jul. 2015 < 

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002865

 Kjetland, Eyrun F, Peter DC Leutscher, and Patricia D Ndhlovu. "A review of female genital schistosomiasis." Trends in parasitology 28.2 (2012): 58-65.

 "Cost-Effectiveness in $/DALY for Deworming ... - GiveWell." 2011. 26 Jul. 2015 < 

http://www.givewell.org/international/technical/programs/deworming/cost-effectiveness

 Note that the cited paper does not say much about the health benefits of deworming for schistosomiasis, and is more to illustrate that even the authors of the Cochrane review agree that Schistosomiasis population deworming is indicated

 Ahuja, A. "When Should Governments Subsidize Health? The Case of ..." 2015. < 

 Greenland, K. "The Epidemiology of Soil-Transmitted Helminths in Bihar ..." 2015. < 

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003790

 "Re-analysis of health and educational impacts of a school ..." 2015. 23 Jul. 2015 < 

http://ije.oxfordjournals.org/content/early/2015/07/21/ije.dyv127.abstract

 "Full Text - International Journal of Epidemiology - Oxford ..." 2015. 23 Jul. 2015 < 

 "Worm Wars: A Review of the Reanalysis of Miguel and ..." 2015. 23 Jul. 2015 < 

http://blogs.worldbank.org/impactevaluations/worm-wars-review-reanalysis-miguel-and-kremer-s-deworming-study

 "New deworming reanalyses and Cochrane review | The ..." 2015. 26 Jul. 2015 < 

Is deworming really effective? A response to recent deworming studies

Daniel Selwyn

What do you want to be when you’re older?

It’s probably one of the first questions we can remember our response to. Back then our vivid imaginations could transport us from being astronauts on spaceships to princesses in beautiful dresses with an entourage of seven dwarves (only one of those was an actual childhood dream of mine).

The unbounded nature of childhood dreams is surely universal, innate to every child.

It should thus both deeply sadden and anger us that so many children across the world die before they even reach the age of five. Nine million a year, one every four seconds.

 at the hands of preventable diseases that rob families, communities and continents of the prosperity and livelihood that it is so easy to take for granted.

The fact that where you are born determines to such a cruel extent the scope of your response to that age-old question about the future is strikingly unjust. The globe is polarized between those who are allowed to dream and those who can only live in nightmares.

The perennial nature of extreme poverty is precisely the reason why it so often escapes the headlines. It also contributes to a perception that the reasons for its persistence are inevitably structural and insurmountable, beyond the comprehension or capacities of ordinary people.

effective altruism, especially for a student armed with nothing more than a government loan and a desire to do something purposeful, is both shocking and inspiring.

Rigorous research and extensive evidence can demonstrate just how conceivable the eradication of poverty really is - when our charitable giving is used in the right way.

For the price of a pint we could deworm fifty children, keeping them healthy enough to attend school and exercise their right to an education of their own. Mosquito nets could protect the beds of almost thirty people for around three to four years for the same amount as a weekly shop. (If you would like to check, use this 

This does not mean that you have to either starve yourself or be a recluse at university in order to truly help others. Such a degree of self-sacrifice is neither necessary nor desirable.

But it does raise a fundamental question: 

if students were aware of just how far even a small amount of money can go - making a tangible difference to such a significant number of people’s lives -, would we continue to spend it on ourselves?

Judging by the success with which the effective altruism movement has been embraced at university campuses across the globe, the answer to that question from the student body appears at best to be a resounding no, at worst, a ‘probably not as often’.

If an entire generation of millennials changed their spending patterns for a lifetime to include the most effective charities we would see astonishing results.

But such bold claims are all well and good coming from a privileged group of society, of whom many don’t even know what it’s like not having a three-month summer holiday, let alone working a full-time job.

What’s to stop a student with high-minded ideals reneging on them once they have to pay their taxes, bills and rent and find that they have very little left over?

This is a legitimate question. But, for me, there are three reasons to pledge as a student that stand out.

Firstly, taking the Giving What We Can pledge itself was a 

public announcement of my determination to be part of the fight against extreme poverty and also a growing community of people doing the same thing. It’s a commitment with which I can hold myself accountable.

It may, in fact, be particularly beneficial for students to take the pledge before we’ve started earning. This is because it 

avoids the potential difficulties of having to adjust at a later stage.

 How can you miss something that wasn’t there in the first place?

I know that from day one of my first job until the last, 10% of my earnings are accounted for. I will have to work around that from the very beginning, which could make it far easier in the long run.

even after donating 10% of our salaries to the most effective causes, we are still likely to be in a position of immense fortune.

It’s hard to think of ourselves as part of the world’s super-rich; most of us are far from oligarchs or sheiks! But reality tells a different story: 

the average starting salary for a graduate (£21,702) makes them richer than 96% of the world, earning a staggering 21.1 times the global average.

Even after deducting 10% from that starting salary they would still be part of the richest 4.9% of the world’s population. But in this scenario, they would also be able to distribute 523 mosquito nets, or treat 2,679 people for neglected tropical diseases- 

the equivalent to saving one life every year.

it will make me happier knowing that a significant part of my earnings will be going towards saving and transforming other people’s lives.

 By spending it exclusively on myself, the increase in quality of life and happiness I might be able to expect would be comparably insignificant.

It’s important that we don’t overestimate the importance of that 10% to our lives or underestimate how much good we could do with it and how much happier that could make us.

So, as a student approaching the final year of my time at university, the question of what I want to do when I’m older has never seemed so daunting and exciting.

This is not just because I have sadly outgrown my Snow White gown. Rather, it is because 

I am increasingly aware of how privileged I am to even be able to choose what I want to do, as well as how empowered our generation is, more than any before it, to make a difference.

How your student loan can save lives

Alison Woodman

Giving What We Can now has over 1000 members, representing many different walks of life and nearly 50 countries. As Director of Community, one of my aims is to get to know as many of these people as possible. I want to learn about how and why they came to join Giving What We Can, and see what our staff can do to support them in their extraordinary commitments. I took on the role in February, and since then I have had the pleasure of speaking with over 100 recently signed up members. A couple of weeks ago I booked a few days off from Skyping with members and used the time to look back over the conversations I’d had so far. I’d like to share with you some of the things I found!

We’re naturally interested in why people choose to donate a significant amount of their income to others, and our blog has highlighted individual stories in the 

’. One of the most interesting things I’ve been learning about is this: why do members choose to take a pledge, rather than make a private commitment to give 10%? I found that, in nearly all cases, people gave one or more of the three following answers:

“Taking the pledge acts as a commitment device”

: this was the most common explanation I heard. Choosing to give 10% of your lifetime income is a long term commitment, and many people find that it’s easy to forget internal goals as time goes on. By joining Giving What We Can, you make a public commitment, and have more accountability, so you’re more likely to stay on track.

Blog

Is deworming really effective? A response to recent deworming studies

How your student loan can save lives

What I learnt from talking to over 100 Giving What We Can members

Tell All Your Friends!

Want to be a good altruist? Check your biases.

The Economics of Morality

What kind of fundraiser are you?

Giving Is Receiving

When is systemic change a good idea?

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