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Hauke Hillebrandt

This is the second of our series of charity updates. You can read the first one, on Development Media International, 

 for several years now. Our colleagues at Givewell have published an 

 on SCI recently that was generally very positive and SCI continues to rank among Givewell’s top charities.

In this blog post, we give you an update on their efforts that complements Givewell’s report. You can find more general information about SCI on our 

SCI continues to be one of the most effective charities in the world

Recent scientific findings related to SCI’s effectiveness

 on new research indicating that treating 

schistosomiasis might reduce - with great effectiveness [1] - both malaria [2] and HIV [3] infections

 (due to reduced immunodeficiency and reduced female genital schistosomiasis). Even though such disease interaction had long been speculated about [4, 5], evidence for a causal connection and a cost effectiveness analysis had been lacking. In the light of this new evidence, we have increased confidence in recommending SCI, even though more research is needed on the topic.

It has also been suggested that schistosomiasis might interact with Tuberculosis [6], Hepatitis [7], and Appendicitis [8], all of which make up a substantial amount of the global burden of disease, and we are currently doing more research to look into these links. We are also re-investigating in how far schistosomiasis parasites contribute to undernutrition and lack of micronutrients.

However, some recent studies hint at a potential decrease in SCI’s effectiveness. A recent report [9] shows that climate change will make temperatures more suitable for schistosomiasis transmission over the next 20 years, not only in terms of spread to other currently non-endemic countries, but also in terms of increasing the intensities of the disease in countries currently affected. The authors suggest that this increase in infection and reinfection intensity may reduce the impact of control and elimination programmes such as those undertaken by SCI. On the other hand, the resulting increase in need and thus scalability of SCI’s programs might increase their effectiveness.

Furthermore, researchers continue to be worried about the development of drug resistance to praziquantel, as it is the only drug currently recommended by the World Health Organization for the treatment and control of human schistosomiasis, which is also used by SCI [10]. Some signs of resistance of schistosomes against praziquantel have been observed in the laboratory, but in the field only isolated cases of decreased effectiveness of praziquantel have been observed so far [10, 11]. However, these are not issues that decrease SCI’s effectiveness in the near future, as resistance is localized and limited.

SCI has room for $3.8-8.3 million of additional funding over the next few years

. However, as the number of people targeted to receive deworming rises (see Figure 1), SCI could probably scale up and strengthen its efforts in the countries where they currently operate and expand to new countries.

A recent report by the World Health Organisation estimates that the overall costs for all kinds of preventive chemotherapy (i.e. mass deworming, not chemotherapy used as cancer treatment) in the coming year are in the hundreds of millions (see Figure 2). The investment target for preventive chemotherapy against schistosomiasis (for delivery only- medicines are donated by the pharmaceutical companies) during 2015–2020 is estimated to be about US$ 59 million (US$ 51–67 million) per year (see Figure 3). This already takes into account that countries such as Brazil and India completely covered the cost of distributing the donated medicines using their own resources.

In poorer countries such as the DRC, Senegal and Niger [12], costs of distributions are shared among the local Ministries of Health and SCI, as well as other organisations such as the USAID, END Fund, CNTD, and APOC. But poor countries are not in a position to execute these programs by themselves and bigger aid givers such USAID are also do not completely fund such programs. Thus, SCI, with their unique expertise, might play a substantial part implementing such future deworming programs and thus require substantially more funds. This could change in case bigger agencies such as USAID recognize the cost effectiveness of interventions targeting NTDs and star investing more in this area.

Fig. 1: Number of people targeted for coverage with integrated preventive chemotherapy, selected NTDs (from recent WHO report on NTDs [13])

Figure notes: school-age children; STH, soil-transmitted helminthiases.

Notes: The dots indicate the number of people treated in 2012; the solid lines are targets not forecasts. Targets assume integrated delivery of preventive chemotherapy for LF and onchocerciasis in Africa, schistosomiasis and STH among school-age children, and LF and STH outside Africa. Pending further evidence, they do not yet assume further integration of LF and onchocerciasis in Africa with schistosomiasis and STH.

![](https://lh3.googleusercontent.com/Q2Y3FDavEwPBDbhwIIrR9xJWsH-fY6_y_6dT_ygAithzHydbfDsD9Hl7t-z626mMb5ZGC0tSUhqcJkiWq49i24F1WqN2iN4h1lwOcrITDqjL8ZDVS1EY43ezcQ15Q5TR42-o_VM)

Fig. 2: Figure showing the overall projected costs of all preventive chemotherapy (i.e. mass drug administration against NTDs including schistosomiasis and soil transmitted helminths) in the coming years. This excludes medicine prices, which are donated by the pharmaceutical companies. Figure adapted from (Fig. 2.4 Investment targets for universal coverage against NTDs from recent WHO report on NTDs [13]).

![](https://lh4.googleusercontent.com/U2t2t3_M3RsHJk8MINgLn2OPwxlxPvuGWkcxN31sIAzd4IuqiS-G6iixq1AVwMeF6gMKeGODlGuyVza0QxiUB829vA67jPCzCwrRSiEW_5QPyUDpmKjJPWQVWoLopV8L07kJ2c0)![](https://lh4.googleusercontent.com/HIKeaxz0bZOSuCrXc1O78GzI6jfKLP2HqIn5tVo-oTAJyCnXeCTsvr12JLF0iWP4Lyz_Wt6qJNyU4_HspB5USD_KBho_FBB4vgXlKg1CbmrmBo5NbiqEfsLPv_nNVAUuYoS5J8A)

Fig. 3: Figure showing the projected costs of preventive chemotherapy against schistosomiasis (upper panel) and soil transmitted helminths (lower panel) in the coming years. This excludes medicine prices, which are donated by the pharmaceutical companies. Figure adapted from a recent WHO report on NTDs [13].

Notes: Shaded areas reflect the range determined by low and high values of the unit cost benchmarks; they do not reflect uncertainty about future rates of scale-up and scale-down of interventions. The dots in 2012 are actual numbers reported (when available) multiplied by the unit cost benchmarks, which is the approximate cost of delivering one treatment; these are not actual expenditures, but can be thought of as a benchmark for actual expenditures. All numbers expressed in US$ are constant (real) US$, adjusted to reflect purchasing power in the United States of America in 2015.

very successful at starting partnerships and receiving funding from governmental and 

. However, based on their effectiveness, reputation, and room for additional funding, one might have expected then to have received more funding from private foundations and private donors in recent years. Based on conversations with SCI, they are currently working closely with the Imperial College Development Office team on increasing their efforts to attract grants from private foundations and philanthropists. They are also in the process of hiring additional staff for their Fundraising and Advocacy team. At Giving what we can we 

 and not exclusively based on overhead costs, so we think using resources to attract more funding can potentially be a very good idea.

Recently, SCI has hired more staff for their operations. The five new hires have graduate degrees and among them are a 

, who has published in peer reviewed journals, and an expert on the link between schistosomiasis and HIV infections (an important topic on which we have 

). We believe that it reflects well on SCI that they continue to 

expand their team with the needed expertise

Updates on SCI’s Plans and Activities from November 2014 to March 2015

In most of the 16 countries that SCI operates in, 

the deworming programs are going according to plan

, according to SCI [14]. However, there were problems with deworming programs in three countries. In Liberia, due to the Ebola epidemic, all deworming operations have been suspended. In Yemen, due to political tension, a staff member had to be temporarily evacuated last year, but has now resumed work. In Zambia, drug delivery seems to be a continuing problem: SCI reported in April 2014 [15] that, due to delays during 2013, treatment scheduled across 6 provinces only took place between January - March 2014. The remaining 4 provinces were scheduled to receive MDA during July 2014. However, then in December 2014, SCI reported that only “piecemeal treatments” – about 60,000 – were successfully delivered.

Overall, we feel that, since there were only 3 out of 16 countries in which operations had problems, and some were due to reasons that were hard to predict, SCI’s operations seem to run very well.

In sum, SCI continues to be one of the most effective charities in the world. Its operations are very well executed and this is likely to continue as SCI has recently hired new, highly qualified staff. Recent scientific findings suggest that treating schistosomiasis might reduce - with great effectiveness - both malaria and HIV infections, which might make SCI even more effective than we previously thought. Finally, both in the short, but especially in the long-term, we believe that there is room for millions of dollars of additional funding and therefore 

we strongly recommend SCI as a charity to donate to

Mbah, Martial L Ndeffo et al. "Potential cost-effectiveness of schistosomiasis treatment for reducing HIV transmission in Africa–the case of Zimbabwean women." PLoS neglected tropical diseases 7.8 (2013): e2346.

Mbah, Martial L Ndeffo et al. "Impact of Schistosoma mansoni on Malaria Transmission in Sub-Saharan Africa." PLoS neglected tropical diseases 8.10 (2014): e3234.

Mbah, Martial L Ndeffo et al. "Cost-effectiveness of a community-based intervention for reducing the transmission of Schistosoma haematobium and HIV in Africa." Proceedings of the National Academy of Sciences 110.19 (2013): 7952-7957.

Morrow, Richard H, Robert L Colebunders, and James Chin. "Interactions of HIV infection with endemic tropical diseases." AIDS 3.1 (1989): S79-88.

Feldmeier, H, I Krantz, and G Poggensee. "Female genital schistosomiasis as a risk-factor for the transmission of HIV." International journal of STD & AIDS 5.5 (1994): 368-372.

Li, Xin-Xu, and Xiao-Nong Zhou. "Co-infection of tuberculosis and parasitic diseases in humans: a systematic review." Parasit Vectors 6.1 (2013): 79.

Gasim, Gasim I, Abdelhaleem Bella, and Ishag Adam. "Schistosomiasis, hepatitis B and hepatitis C co-infection." Virology Journal 12.1 (2015): 19.

Botes, SN et al. "Schistosoma Prevalence in Appendicitis." World Journal of Surgery (2015): 1-4.

McCreesh, Nicky, Grigory Nikulin, and Mark Booth. "Predicting the effects of climate change on Schistosoma mansoni transmission in eastern Africa." Parasites & vectors 8.1 (2015): 4.

Neves, Bruno J, Carolina H Andrade, and Pedro VL Cravo. "Natural Products as Leads in Schistosome Drug Discovery." Molecules 20.2 (2015): 1872-1903.

Kasinathan, Ravi S, William M Morgan, and Robert M Greenberg. "Genetic knockdown and pharmacological inhibition of parasite multidrug resistance transporters disrupts egg production in Schistosoma mansoni." PLoS neglected tropical diseases 5.12 (2011): e1425.

Daumerie, Denis, and Lorenzo Savioli. Working to overcome the global impact of neglected tropical diseases: first WHO report on neglected tropical diseases. David William Thomasson Crompton & Patricia Peters. World Health Organization, 2010.

Investing to overcome the global impact of neglected tropical diseases 2015.

Charity Update II: Schistosomiasis Control Initiative (SCI)

Jonathan Courtney

Are you a student or recent graduate who is interested at interning at Giving What We Can? Are you free from the 14th to the 25th of September? If you answered yes to both of these questions you are in luck, Giving What We Can is running our September Internship program again this year and we are looking for applicants.

The internship involves working at the Centre for Effective Altruism's offices in Oxford for two weeks. Successful applicants will get to work alongside 10 to 15 other interns, networking and working on exciting projects focused on the growth and improvement of Giving What We Can. Projects include working on Giving What We Can’s outreach strategy, improving our social media presence, doing research for our blog and improving on the research we use for our recommendations. If you want the chance to meet other EAs and spend two weeks gaining skills and working in a prominent EA organisation, I encourage you to apply! Note that this is an unpaid internship, and we won't be able to provide accommodation (although I can help you find something if you need help!)

We will be closing applications at the end of next week (April 2nd 2015), so be sure to apply soon! If you are interested, follow the link 

 to apply. If you know anyone else who might be free and interested do pass the message along!

Apply for the September Internship!

Michael Peyton Jones

This is the first of a series of blog posts on charities we’re re-evaluating this year.

 is an organization we’ve had our eye on for some time. Back in 2013 we 

 their Head of Public Engagement, Will Snell, and in May last year we 

To recap what we already know, DMI is an organization focussed on a health intervention that is potentially very effective, but difficult to assess: mass-media campaigns. Their main technique is short, targeted radio spots of 60 seconds or less. These provide small pieces of health information in a memorable form, and the hope is that if people actually respond with behavioural change, then we may see a substantial drop in child mortality.

The big question is how much of an effect DMI’s efforts actually have. Their starting point is a statistical model which they developed in conjunction with the 

London School of Hygiene and Tropical Medicine

. This estimates a reduction in child mortality of 

. Such a high effectiveness is consistent with previous analyses, such as the 

 that ranked media campaigns very highly as a means for combatting HIV/AIDS. That’s a good starting point, but what really excites us is that they’ve been following this up with a large-scale randomized-controlled trial across Burkina Faso (see the 

The RCT is a long-running procedure: it started in 2012, and the full, end-line results are not expected until the end of this year. But DMI have recently released the midline survey results, which give us 

The midline results come in the form of survey results measuring various self-reported metrics across the treatment and control groups. Overall, they look promising, showing a consistent improvement in the treatment group. Even after discounting their estimates significantly, GiveWell give their current estimate as $5,236 to save a child life. That’s within a factor of two of some of our other recommended charities (GiveWell 

 that AMF, one of our top charities, saves a child’s life for $3,340), and DMI’s own estimate is much lower.

However, we do have some concerns about the interpretation of these results. GiveWell provides a comprehensive list, but we’d like to highlight just three points here:

The results come from self-reported survey data. This means they are always going to be less reliable than assessment of objective measures, such as mortality data.

Lack of blinding. Both the participants and the surveyors may have been aware of which group the participant was in - the survey itself contained questions on whether they had heard the radio spots.

Asymmetries between the control and treatment groups. There were some relevant health differences before the treatment began, and there were other health programmes running simultaneously with the RCT.

The self-reporting and blinding problems will not persist to the endline data - for that, DMI are going to measure mortality statistics. However, they do present problems for the midline data. The lack of blinding is the most worrying: lack of blinding can lead to 

, and its effects are hard to account for in retrospect. However, DMI have confirmed that the questions which specifically relate to their programmes appear in the last section of the questionnaire. That should mean that the interviewees will only be unblinded for the last section at worst, although the interviewers are still unblinded. While not ideal, this is much better than having a full lack of blinding.

The problem with asymmetries between groups will remain even for the endline results. GiveWell highlights three prominent health programmes that might have had some effect on child mortality during the running of the trial. By and large, it seems likely that the effects were present in both groups, and the independent evaluators at the LSHTM plan to adjust for such baseline imbalances between the control and intervention arms in their analyses.

Finally, we have some worries about the portability of DMI’s programmes. Unlike many other health interventions, which have a biological pathway of action that we can expect to work consistently across humans, DMI’s radio spots rely on culturally changing behaviour. As such, they may run into communication barriers that are hard to discover - in one country an older female voice might be regarded as authoritative, whereas in another the reverse might be true. However, DMI have extensive experience in developing these programmes, and perform a great deal of formative research and testing for efficacy. If the RCT provides an endorsement of the overall methodology, then we are fairly confident that cultural hurdles can be overcome.

Overall, we broadly agree with GiveWell that DMI is an excellent organization with plenty of room for funding, and that the midline RCT results are promising. DMI’s approach of spreading simple, but effective, health information is very scalable, and there are a wealth of possible extensions to the programmes (for example, further simple improvements in 

). With that in mind, we consider DMI to be a promising charity, and if the endline results from the RCT prove good, we are likely to consider them one of our top charities.

Thanks to DMI for clarifying several points with us directly, and to GiveWell for an excellent baseline report.

Charity Update I: Development Media International

It’s that time of year - we’re re-evaluating our 

Over the next weeks we’re going to release a series of blog posts for a few charities we’re currently considering recommending. This will include several charities we haven’t recommended before, as well as some that we already do. We won’t be discussing all our current top charities, however, as in most cases the relevant facts have not changed much.

Once we’ve released all the blog posts we’ll update the 

 page. This is of particular interest to anyone who gives via the 

 - a change in our top charities will result in a change in how we distribute funds from the Trust.

The first post will be up in the next couple of days.

Our Charities Update Is Coming!

An interview with Dr. Martial Ndeffo Mbah and Laura Skrip from Yale University about how mass drug administration against Schistosomiasis might help reduce Malaria and HIV infections

This is part I of a series of updates on the effectiveness of our recommended charities. This week: the 

Today, we’ll be talking about some exciting new research that has the potential to change our charity recommendations.

You probably know that two of most effective charities are the 

, which distributes insecticide-treated bed nets to prevent malaria, and the 

, which delivers Mass Drug administration to deworm people. Not only are these organisations among our recommended charities, but they also consistently come out on top of the charity rankings by 

One of the reasons why stopping malaria is so important and effective is that, every year, there are more than 200 million cases and roughly 660,000 associated deaths. According to the Global Burden of Disease study [1], this translates to more than 80 million years of otherwise healthy life being lost to malaria (see our 

post on Disability adjusted Life years or DALYs

). In comparison, even though schistosomiasis can be treated at a very low cost by means of mass drug administration (MDA), its associated DALY burden is comparatively small (about 25 times less than the years of life lost to malaria), at an estimated 3 million years of lost healthy life [2] (though a recent commentary argues that, in fact, it may be twice as high [3]).

But now a series of recent papers by Dr. Ndeffo Mbah, Laura Skrip, and colleagues from the School of Public Health at Yale University and Baylor College of Medicine suggest that mass drug administration to reduce schistosomiasis has some impressive side effects. After executing a computational modeling tour de force, they found that 

treating schistosomiasis might reduce - with great effectiveness [4] - both malaria [5] and HIV [6] infections

 (due to reduced immunodeficiency and reduced female genital schistosomiasis).

Their analysis suggests that (depending on MDA efficacy) averting one HIV case through treating schistosomiasis costs as little as US$51.68–259.31. If we assume that 20 DALYs are lost per infected adult [7], this translates to US$2.58-12.97 per DALY averted (our calculation, uniformly weighted with a 3 percent discount rate as per DCP convention). The cost of treating schistosomiasis with a combination of albendazole and praziquantel is already among the most cost-effective interventions out there ($177 per DALY averted) [8]; adding the benefit of reduced HIV infections makes it even more impressive. Moreover, a recent Cochrane review [9] suggests that there is evidence of benefit in terms of slower disease progression for deworming HIV co-infected adults.

If you are looking for yet another reason to donate to SCI, it turns out that treating schistosomiasis also has the potential to fight malaria. In another paper, the same authors suggest that (depending on context) MDA reduces prevalence of Malaria by as much as an impressive 5%.

Since schistosomiasis, HIV/AIDS, and malaria are particularly prevalent in Sub-Saharan Africa and many people are co-infected, this has the potential to catapult mass schistosomiasis treatment to the top of all health interventions, especially when combined with water sanitation efforts.

We sat down with Martial and Laura to talk about their research, how you can infer causality without randomized controlled trials, the need for synergistic approaches to combat neglected tropical diseases and the importance of data sharing.

Martial Ndeffo Mbah holds a PhD from the University of Cambridge and is currently an Associate Research Scientist in Epidemiology (Microbial Diseases) at the 

Center for Infectious Disease Modeling and Analysis

School of Public Health at Yale University

. His primary research interest is computational modelling of neglected tropical diseases.

 at the School of Public Health at Yale University. Her main research interest is dynamic transmission modelling of neglected tropical diseases.

Your lab has published a few papers on the positive side effects of mass drug administration against schistosomiasis. 

Your most recent paper in PLoS Neglected Tropical Diseases

 suggests that if you give people drugs against schistosomiasis, this may actually reduce the prevalence of malaria. Can you tell us a bit more?

 The idea for the paper came from a number of conversations that we've had with Peter Hotez at Baylor College of Medicine in Texas, one of the coauthors on that paper, along with with some other collaborators at Yale. We were talking about the co-infections that you have with a lot of Helminth diseases [infections by parasitic worms], and malaria especially. Looking at this, and also taking into account the fact that these 

co-infections, and comorbidity are highly prevalent in many African settings

, one of the things that really drove us to do this research was the fact that 

so little work has been done on that very interesting problem either from the fieldwork perspective or especially from a modelling perspective.

When we started looking into the literature, the only field study that we were able to find that was addressing the interaction that you have, especially causal interaction between schistosomiasis, schistosoma mansoni and malaria, in particular falciparum, was a 

study that was done in Senegal some years ago

. Looking at that study and our previous experience modelling interactions between schistosomiasis, female genital schistosomiasis and HIV, we decided that it was really appropriate to do a study on this to 

raise the profile and to raise awareness about the fact that schistosomiasis

 (especially schistosoma mansoni, which is widely spread in Africa), 

has been observed to have a strong correlation with an increased risk of malaria, especially among children.

Regarding the causal relationship: there's a very strong overlap in Sub-Saharan Africa between locations with lots of schistosomiasis and lots of malaria and so one might think this is just a correlation. But you write about how, if you are infected with schistosomiasis, then certain parts of your immune system might be very prone to malaria and also you're the first to create a mathematical model that suggests that it's indeed causal, that schistosomiasis exacerbates malaria infection. Is that correct?

 Yes. First of all, I'd like to say that there are quite a number of biologically plausible reasons why we believe that it's really a causal relationship, especially among children who have a very high burden of infections. 

Other researchers have studied some of the biological reasons

Blog

Charity Update II: Schistosomiasis Control Initiative (SCI)

Apply for the September Internship!

Charity Update I: Development Media International

Our Charities Update Is Coming!

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