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Larissa Hesketh-Rowe

Would you save two strangers or your partner? A review of 'Strangers Drowning'

It all started well. The writing style is very vivid, very intimate. It draws you in. You peer through the window into these people’s lives, they invite you in and you become friends. Together you share in their triumphs and their pain.

Strangers Drowning: Voyages to the Brink of Moral Extremity

 profiles a few extraordinary individuals living lives of extreme ethical commitment. We meet a family that founded a leper colony out in the wilderness in India, despite the risk to their children. We share in the hardships of a couple who adopt twenty children alongside two biological children because they keep finding young people in need. We follow a nurse on an incredible journey of hunger strikes and self-sacrifice to bring about change for her people and protect some of the most vulnerable women during conflicts in Central America. And we get to know people who donate large percentages of their money to the most worthwhile causes.

They push themselves to the brink of their own moral standards. For them, unlike for most of us, there is little discord between their own beliefs and their actions. They are in many ways “more free, because [they] can control [themselves], so [their] intentions aren’t frustrated by weaknesses [they’d] rather not have”.

Yet these people are not heroes. They are “do-gooders”. A term chosen deliberately for its provocative nature. “Ordinary” people do not like do-gooders, there is something provoking about them. 

Is it their holier-than-thou attitude? Is it our guilt at not doing more ourselves?

Heroes are for wartime, we learn. They are ordinary people doing extraordinary things because the situation calls for it. Those people we admire. We imagine we could be them, if disaster ever struck our neighbourhood.

For “do-gooders” it is always wartime.

These people go beyond your average “part-time, normal do-gooder - someone who has a worthy job, or volunteers at a charity, and returns to an ordinary family life in the evenings”. Their work is never done. The people they need to save include not just their family, their community or victims of a particular illness, but all victims of all suffering throughout our entire world.

Between these intimate stories of do-gooders Larissa weaves the history of our conception of do-gooders through developments in psychology, political theory and philosophy.

Why is society so suspicious of do-gooders? Looking at our cultural history suggests some answers. Misreadings of Darwin make only selfishness natural, and thus altruism a form of deviant behaviour. The need for consumerism within Capitalism sets as the norm the egotistical consumer. Even the sacrosanct nature we attribute to human frailty, the love within fiction for the flawed, complex hero battling her own imperfection can lead to an idealisation of the selfish.

It seems society is against our do-gooders. Somehow, they are not to be trusted.

Questions over whether they are truly doing the right thing, the moral thing, the human thing, are left hanging. Larissa seems purposefully quiet in her own book. She makes no argument, only carves a path through history and leads us to extraordinary - if disconcerting - people.

As we dig deeper into their lives our do-gooders’ stories stray into the darker realities of committing your entire existence to a higher calling.

Our caring parents of twenty-two children struggle with children with terminal conditions and are almost torn apart by tragedies under their roof. We find our nurse’s abusive past keeps her too long with a stifling husband and we hear “do-gooders” compared with codependents, interfering in problems and in countries they do not understand for their own moral satisfaction.

Our do-gooders are driven to work without sleep, without comforts and without friends. Many question their every action, feel alone in the world and drive themselves to despair.

The children of the founders of the leper colony survive, but what if they hadn’t? Would one twist of fate have converted them from local celebrities to cruel and terrible parents abandoning their parental duties and putting their children at risk?

This question is asked but never answered in the book. What judgement do we make of these people who seemingly put their own happiness and that of their nearest and dearest at risk for strangers? The reader is left to decide.

Would you save two strangers or your partner?

The title of the book ‘strangers drowning’ links with a question Larissa asks her subjects; would you save two strangers from drowning or your partner? How many strangers would outweigh the life of your partner?

Neither Larissa, nor her subjects, nor the book answers this question.

 in the Globe and Mail does give one answer:

“This dilemma is false. I do not have to choose between my mother and two strangers, and I will not.” Perhaps it’s about saying to the person setting the problem, “Hey, if you jump in with me, maybe we can save all three.”

Despite the inspiration I take from many of these stories, this is what makes me sad about Strangers Drowning: the book does not invite us to jump in and save all three. There is no call to action to changes any of the injustices we see. I feel endlessly beaten by the weight of suffering in the world and yet am not encouraged to fight back. I’ve always felt positive about the giving I do and that it makes a difference. In Stranger’s Drowning you either leave your wife to drown or you do nothing. The middle ground I and so many people I know occupy – who, together, make a huge difference in the world – are dismissed in one sentence at the beginning of the book as every day do-gooders and volunteers.

As I grew more frustrated with a societal narrative that seemed to discourage a truly ethical life and felt more and more sorry for the individuals Larissa profiled I raced towards the end of the book, reaching for the ultimate conclusion.

Would we be happier if we could all shake off this group narrative celebrating selfishness?

If we all took on some more of the burden perhaps the few would not need to drive themselves so far to pick up the slack of the rest of us?

Were we all to become “do-gooders” she states, then the world would be “so utterly different as to be nearly unimaginable.” Whether this would be a good thing or not is left hanging.

Yet without do-gooders “showing what a person can do for strangers if he sets himself to do it fewer would try”.

But with burdens and pasts that seem to make our do-gooders miserable, in a world suspicious of them, Strangers Drowning leaves little inspiration to try.

In Strangers Drowning there is no call for us to leap in and help save strangers from drowning. We are left entirely as we were. We are still “us”, the do-gooders are still “them”. With this divide still intact I am saddened to find we are free to continue our lives just as before.

Perhaps this is precisely why doing good seems like such a burden to many of our do-gooders.

The burden falls unequally on them alone while we are free to sit back. That’s too much weight for a few but if we each lifted a bit more each individual burden would be light.

I am fortunate to have many wonderful friends in the Effective Altruism movement with which to share the load and through which I was able to reach out to Julia Wise. She, along with her husband Jeff, is one of the do-gooders in Strangers Drowning. I asked her if this was really a true portrayal of what giving was like for her.

“It's funny for me now reading back on how things were at the time Larissa MacFarquhar began interviewing us in 2010. At the time I did feel that helping was a struggle, and that I didn't know other people who were really trying. Five years later I feel very differently! Seeing the growth of the effective altruism community, and having friendship and support from that community, has made a world of difference to me. Instead of feeling isolated and downtrodden, I feel invigorated by being part of a worldwide effort to change how we help others. I'm also glad Jeff and I did decide to have children, as I think it's easier to forge ahead whole-heartedly with our work in effective altruism when we feel satisfied that we have the important things in our personal lives.”

 about her experiences, and this feels like a reflection of what giving could be like if we all took on a little more.

We need more stories like Julia’s. Stories of people who do “save all three”, but not through great sacrifice nor unusual achievement but simply by living an ethical life that balances the needs of others with theirs.

We often seem to focus on the most extraordinarily effective givers. People like Bill Gates, Elon Musk or clever graduates who go on to be bankers earning six figures to give away most. Reading Strangers Drowning reinforced in my mind that the voice that is missing from these narratives is that of the ordinary person.

People who give their extra income to buy antimalarial bednets and try to eat less meat. People who run local groups to fundraise for top charities. People who volunteer on promising projects, speak to their MP or simply just try to encourage others.

These role models remind us that we - the ordinary “us” in Strangers Drowning - can also make important positive changes in the world, especially when we act together.

Larissa’s portrayal of the do-gooders moved me, yes. Julia’s story fills me with hope and inspires me to action. I will not leave two strangers, my partner or the do-gooders drowning.

Scott Weathers

Reaching for Greater Impact Through US Legislation

The United States Senate is currently considering 

, a bill that USAID argues could save the lives of 15 million children and 500,000 mothers – Effective Altruists should take note.

At its core, the Reach Act would create a Maternal and Child Health Survival Coordinator position at USAID, who would prioritize spending on the most cost-effective, evidence-based interventions. The Reach Act builds on 

, a report commissioned to identify the most high-impact interventions in maternal and child health.

 gives a benchmark for the impact scaling up maternal mortality interventions could have through 2020.

Raj Shah, the previous administrator at USAID, instituted a number of reforms that has allowed USAID to save more lives. This legislation is about codifying and institutionalizing those reforms through future administrations.

An important distinction that Effective Altruists will notice is that this legislation (at least in the short run) will save lives primarily by prioritizing the best interventions, rather than summoning up new resources for global health. This means that the true number of lives saved by the Reach Act will be the difference between the impact of the interventions USAID funded before and after the reforms are enacted.

USAID does not specify which interventions will be de-prioritized, possibly because this involves upsetting constituencies within USAID. It’s impossible to tell exactly how many lives this legislation could save because this number hinges on decisions that future Maternal and Child Survival Coordinators will make.

USAID’s priorities affect billions of dollars of aid every year.

However it is very clear that USAID’s intentions under Raj Shah align nearly perfectly with EA values. The interventions USAID has prioritized are highly cost-effective – vaccinations, micronutrient supplementation, breastfeeding, and other priority interventions 

 feature prominently in Acting on the Call. Under Raj Shah, USAID has made allocation decisions to prioritize funding within 24 focus countries that have 70% of global maternal and child deaths and scaled up evidence-based and cost-effective interventions.

Ultimately, the Reach Act will also elevate the profile of global health and create favorable conditions that could deliver more overall funding for cost-effective interventions. This will happen through 3 major reforms: the Reach Act will 1) create an inter-agency working group to produce a “whole of government” 10-year plan for ending maternal and child deaths by 2035, 2) obligate the White House to report to Congress on this plan, and 3) establish a public-private partnership to generate more financial resources.

In India, USAID’s focus on several interventions could save tens of thousands of lives.

It is also likely that USAID will be able to demonstrate much greater impact through Reach Act reforms, making the case for increased funding much easier. Together, these reforms would 

generate resources and create accountability mechanisms

 for political actors that are not currently using their power to improve global health as much as they could.

Effective Altruists bemoan the lack of opportunities to effectively do good in the world beyond cost-effective charitable giving. Let’s be clear: giving to GWWC-recommended charities represents the clearest and easiest way to improve the world for individuals in the developed world. But supporting the Reach Act offers the potential to improve millions of lives and refine US efforts to save lives in the developing world.

James Snowden

Explain like I'm five: Essential surgeries

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 

Giving What We Can

A Statement from 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.

Carolina Flores

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

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](

Blog

Would you save two strangers or your partner? A review of 'Strangers Drowning'

Reaching for Greater Impact Through US Legislation

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.