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Jonathan Courtney

Apply for the September Internship!

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!

Michael Peyton Jones

Charity Update I: Development Media International

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.

Our Charities Update Is Coming!

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.

Hauke Hillebrandt

The most cost-effective health intervention? Killing parasitic worms, malaria mosquitos and HIV with one stone. 

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

 for coinfection as well as statistical measures of causality.

For example, the study that was conducted in Senegal was done over a period of time in order to compute the relative risk of malaria infection in the presence of schistosomiasis infection. If you have some quite robust statistical results and some plausible biological mechanisms that are in line with that, you have a good story. The mathematical model brought about a new argument for a causal link. We do not see this as an end to the debate. 

We hope that this will encourage researchers to continue to do field studies along this line, because this is a very important problem that needs to be addressed as soon as possible.

What's the effect size that your model suggests? If you were to do mass drug administration against schistosomiasis, how much would you reduce new malaria infections? Can your model make predictions on that?

 I think that will definitely depend on the setting. It will depend on how prevalent malaria and schistosomiasis are in the location. But according to some calculations we've done, there is a 

potential reduction of 5%, which is definitely a lot.

 And that is just prevalence, which doesn't take into account the fact that a lot of these children will have multiple episodes of malaria during a year. Because we don’t look at severe malaria, our 

study is conservative in the sense that it does not account for potential avoidance of malaria induced deaths.

 Another thing to note is that the reduction in malaria associated with praziquantel administration for schistosomiasis can be even greater if done in combination with artemisinin-based combination therapies (ACT). Some of our findings suggest that the effectiveness of ACT for reducing malaria prevalence and symptomatic malaria episodes is less in areas of co-endemicity with schistosomiasis. So by mass treating against schistosomiasis, you’re also potentially improving the impact of malaria interventions.

 from 2013 published in Proceedings of The National Academy of Sciences (PNAS) about reduction of HIV when you do mass drug administration against schistosomiasis. Can you talk a bit about that too?

 It's a study that we started a few years ago in collaboration with Doctor Kjetland, who initially conducted a cross-sectional study among women in rural areas in Zimbabwe. Doctor Kjetland and collaborators observed that there was a 

very strong correlation between female genital schistosomiasis and HIV infection.

 As with malaria, there was a very strong biological reason why we would believe that there is a causal link, that is, that 

female genital schistosomiasis increases the risk of HIV transmission.

 This is not just because the two diseases overlap in the same regions, but also because women usually get female genital schistosomiasis long before they become sexually active. We know that sexual transmission is the main route for HIV transmission in Africa, so in general women get female genital schistosomiasis before getting HIV. And 

female genital schistosomiasis is a long lasting disease.

 Meaning that when they get it, they can have it even for the next 

 Sometimes, they have it for the rest of their lives.

So even if they are treated, the symptoms of 

female genital schistosomiasis remain even after deworming.

 Yes. That is really the big problem with that. To really turn around this trend 

 them before they start developing the symptoms, 

 Using the data collected from Zimbabwe, we developed a mathematical model without making any assumptions about the direction of the causal relationship. We analyzed the data with the new model, to see if we got a result that agreed with what biology seems to say: that female genital schistosomiasis is an increased risk factor for HIV.

The model showed that. In doing that we brought new information, a new argument from a modelling perspective, to the table, that supports the hypothesis that the presence of schistosomiasis increases the risk of HIV infection among women in Africa.

paper in PLoS neglected tropical diseases

 that talks about the cost effectiveness of this intervention. Your analysis suggests that in terms of HIV reduction, that it's immensely effective to reduce schistosomiasis as compared to traditional HIV interventions. Can you say what is the order of magnitude there? How big is the reduction of new HIV infections?

 First I want to say we look at two things in the PLoS NTD paper, we only look at mass treatment and what effect it has on reducing schistosomiasis and HIV. This 

very, very rare for a lot of public health interventions.

 Basically, by doing these interventions in rural areas in Sub-Saharan Africa, you'll be able to reduce the cost of healthcare in a country, simply because of the large burden of HIV and schistosomiasis that you are going to avert. But in the 

, we look at a much broader community-based intervention approach where we meet mass drug administration with provision of water, sanitation, and also hygiene education.

Can you say a bit more about the water sanitation aspect? Because some people who read this might think, "We give the deworming pill - and then the schistosomiasis vanishes completely." But because of rapid reinfection, we have a baseline burden of schistosomiasis that remains, even after the population is treated, if we don’t work on water sanitation. Is that true? That's what I hear from some schistosomiasis researchers. And is that why it's particularly cost effective to also do water sanitation projects at the same time?

focusing on sustainable development projects to promote hygienic and sanitary behavior would reduce exposure to worms.

 That could include not using local streams or rivers for bathing, and just decreasing exposure to contaminated water.

Are you planning to do a cost-effectiveness analysis on the malaria data too? Is that in the works and going to be the next paper?

 We are considering other projects and exploring some other interaction as well. We are always open to getting new data, getting a better sense of what's happening in local community, and developing more realistic models.

Cost effectiveness analysis on malaria data is one of them?

That's interesting. Here at Giving What we can, two of our top recommended charities try to target NTDs. One being the Against Malaria Foundation, and they distribute insecticide-treated bed nets. Then we also recommend the Schistosomiasis Control Initiative. Do you think the Schistosomiasis Control Initiative would be - in the light of this new data - in a particularly good place to claim they are actually in fact treating malaria in quite a cost-effective way?

becoming more synergistic in the way we're tackling tropical diseases in Africa. It's one of the things that has been highly advocated by 

 We realized, for example, that when we were doing the research for the PNAS paper, one of the things that motivated us was the fact that even for schistosomiasis control you have two different efforts through which this disease can be controlled, but the people involved don't necessarily talk to each other.

On the one hand you have an engineering approach by providing clean water, providing sanitation in different communities, where the main goal is not necessarily the fight against schistosomiasis. But by doing that, they're actually fighting against schistosomiasis, and they're fighting against many of the water-borne diseases - cholera and many others.

On the other hand, you have Mass Drug Administration, which also does a very good job in fighting against the disease. 

But most of the time these two groups don’t talk to each other. An important question is: how can they harmonize their approaches, be more synergistic and get higher benefits for the local population, and better reach their goals?

I think that the same thing should be done with malaria. 

That is one of the reasons why we wrote these papers - to try to get these different agencies to start talking to each other, to start harmonizing their approach

, and to really see the mutual benefit in a more holistic approach in fighting these diseases which are really intertwined one with another.

Lastly, is there anything that people can do to assist with research on NTDs?

 Sometimes it is difficult to get the data that we need. It would be great if 

agencies and researchers could embrace open science and open sharing of data. That would help us a lot with our research.

Blog

Apply for the September Internship!

Charity Update I: Development Media International

Our Charities Update Is Coming!

The most cost-effective health intervention? Killing parasitic worms, malaria mosquitos and HIV with one stone.

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