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Olivia Goldin

In 2012, an estimated 9 million people were newly diagnosed with active TB [1], and 1.5 million people died of TB [2]. Despite this, the vast majority of TB is fully curable [3].

Up until January 2012, Giving What We Can recommended the 

 as a top charity. This recommendation was withdrawn due to concerns about their capacity to use additional funds to effectively deliver cheap and effective antibiotic treatments - though this does not mean that they are not doing fantastic work.

This blog post provides a summary of our report (forthcoming), which gives an update on whether cost-effective interventions for TB still exist.

Tuberculosis (TB) is a disease caused by bacteria of the Mycobacterium Tuberculosis complex [4]. It is airborne and primarily spread by inhaling microscopic droplets through another person’s coughing or sneezing [5].

In approximately a third of the world’s population TB is latent (i.e. not yet manifesting symptoms or causing harm to the patient, and not contagious). In 2013 there were approximately 

 (i.e. harmful, symptomatic and contagious) 

 (Disability Adjusted Life Years) are lost 

: the average adult suffering from TB loses 3-4 months of work time, resulting in a loss of 20-30% of annual household income. The families of people who die from the disease lose about 15 years of income, on average. TB costs approximately 

$12 billion to the global economy annually

 or families, even once they have been cured. Women in particular may be more vulnerable given that they are less likely to earn money in developing countries and be more dependent on their husbands or male relatives. [10]

There are several factors that increase the incidence of TB. These include:

, such as prisons. TB is rendered inactive by UV light which comes from the sun, so lack of light facilitates its spreading. [11]

, which may be due to the correlation with other risk factors such as the likelihood of living in slums or being incarcerated. [12]

, as it makes the body more vulnerable to TB by weakening the immune system. [13]

Factors that increase the likelihood of death from the active stage are often of a social nature. They include a 

disbelief in the population in the benefits of TB medical treatment

 the disease, or indirectly target prevalence through 

The most cost-effective direct intervention appears to be treatment of drug-susceptible TB through short-course chemotherapy, a standard treatment regimen that forms part of the WHO's 

) strategy. In DCP2, the authors estimate that it 

 (2001 USD) to treat non-drug-resistant TB, where the patient is HIV-negative. [20]

We also recommend that charities focus direct interventions in 

areas where there is a high concentration of TB sufferers and high-risk groups

, in order to minimise extra costs, such as transportation.

There are other interventions besides direct medical treatment that may help combat TB and be cost effective. Worthy of note is that the World Bank rates the intervention of 

 [21] suggesting that there are interventions that reduce indoor air pollution that may be highly cost-effective.

Excitingly, there are several charities working in these areas that appear to be highly cost-effective. Although exact figures are not currently available, 

 appears to be averting DALYs at a cost of less than $50 per DALY. A calculation of this figure, along with discussion of other promising organisations, is included in the report, but it is important to note that our analysis of these organisations is very preliminary and so this estimate may be subject to substantial revision as we learn more about Target TB.

 as promising initiatives working to alleviate the risk factor of indoor air pollution.

Much more research is needed in this area. However, some TB interventions appear very promising, and we look forward to seeing further exploration of these.

US Center for Disease Control: Education Resources on TB

US Center for Disease Control: fact sheet on TB

Governmental report on TB control in India in 2011

Perception and social consequences of tuberculosis: a focus group study of tuberculosis patients in Sialkot, Pakistan

WHO and UN: Policy guidelines for collaborative TB and HIV services for injecting and other drug users

Linking TB and the environment: an overlooked mitigation strategy

Stop TB Partnership: World TB day brochure

Friends for International Tuberculosis Relief: Treatment Default

World Bank: indoor air pollution at a glance

Tuberculosis: The Potential for Cost-Effective Intervention

Charlie Satow

Corruption exists in developing countries. Transparency International’s 

 indicates that in a list of 23 countries, including those among the world’s poorest such as the Democratic Republic of the Congo and Ethiopia, 

almost every second person reported paying a bribe for a public service

. In two of these, Sierra Leone and Liberia, this figure was over 75%, while 

This gives rise to justifiable concerns when donating to charities working in developing countries where reported corruption is high, and governance and institutions are weak. Won’t our money, or the goods it buys, just be stolen? Faced with this challenge, how should a prospective donor respond?

Corruption is common in many countries across the world. Source: Transparency International Global Corruption Barometer 2013

First, what do we mean by corruption, and why don’t we like it? Here I’m not referring to ‘grand corruption’, large-scale looting by those taking advantage of their position in public office (e.g. 

 and others); what’s most relevant for Giving What We Can is 

theft of inputs or money designated for improving the lives of the poor

This is clearly a bad thing: the poorest are totally deprived of the benefits of an intervention, and the donation that funds it is wasted. This sort of graft can also undermine confidence in the organisation concerned, and, on a macro level, the “psyche and moral fiber” of local society, according to 

Corruption deprives the poorest of the benefits of an intervention. Credit: futureatlas.com

One response might be to avoiding donating altogether, which certainly ensures zero corruption in the use of your donations. But it also ensures zero impact; ideally we want to find some way of giving responsibly and still contributing to the alleviation of poverty.

Alternatively, you might demand a ‘zero tolerance’ approach to corruption from organisations you support. In fact, this has been the attitude of World Bank president Jim Kim, who in December 2013 

 corruption to be “public enemy number one,” adding, “we will never tolerate corruption, and I pledge to do all in our power to build upon our strong fight against it.”

Certainly, from a practical point of view, it’s a good idea to ensure that the charity you are giving to is aware of the risks of theft and corruption and has processes in place to avoid them. For example, the 

 and places a high priority on ensuring nets are indeed distributed to beneficiaries through 

. It also claims to work only with reputable distribution partners.

all transfers are checked and accounted for

 against a budget agreed jointly with the local Ministry of Health, regularly commissions 

 with those with whom they work in country (as well as having the advantage of distributing a drug with little to no market value). These sorts of procedures, in line with MANGO’s 

 to financial management for NGOs, can help to give a donor confidence in the integrity of a charity’s operations.

a ‘zero tolerance’ attitude is misguided

you can never be certain of eliminating corruption

. If corruption is actually an unfortunate fact of life in all societies to a certain extent (witness ample examples of corruption in ‘developed’ countries like 

, where the cost of corruption may be up to £99bn), then it is fruitless to try to avoid it entirely.

, corruption is not going away anytime soon. In this context, a genuine ‘zero tolerance’ attitude is impractical: the standards would be so high as to render any work on the ground impossible.

 of the Center for Global Development (whose argument is about public sector corruption but is still relevant for our purposes) you recognise that corruption is “almost always a symptom of a broader problem of weak systems of control, entrenched patronage, insider rents and privileges,” then it follows that stringent formal reporting requirements imposed from outside aren’t likely to be totally successful in avoiding the problem.

a single-minded focus on corruption potentially overstates the threat it poses, and is itself a waste of resources

. Above I mentioned that corruption is present in all societies. But that does not mean it is always present: because corruption stories in nonprofits make a good story, they often garner disproportionate press attention, giving the false sense that all charities inevitably suffer immense losses from corruption.

, arguing that, given our ignorance of how representative corruption cases are, stories of corruption in aid organisations are more likely to reflect better reporting of allegations than an actual greater fraud or corruption risk. Likewise but more generally, Olken and Pande, in 

, find that “estimated levels of corruption are remarkably heterogeneous [in low-income countries]”.

Given this uncertainty, Professor Alan Fenwick, director of the Schistosomiasis Control Initiative, 

 “prejudices and fears of corruption and wastage” as a distraction and obstacle to SCI’s work. Corruption is a key concern when working in certain societies, but some organisations may find it less of a problem than others. Witness the Against Malaria Foundation, which, fortunately, has experienced 

no material loss of nets through theft”

This leads to an alternative point of view: as Savedoff 

, ‘how much money is wasted?’ might not even be the right question when we think about aid interventions. Rather, if our aim is to improve school attendance through deworming, for example, 

the first question should be ‘does the money that gets through have the desired impact?’

 This chimes with the increasing interest in 

 approaches to aid in larger-scale bilateral programs, where payment is made by funders to a recipient government or organisation only after there has been confirmed progress towards an agreed-upon goal.

Translating this philosophy to charitable giving at the individual level, it means 

we should look at the good done by an organisation as the principal measure of whether we should support them

working to minimise corruption in practice

; if we make our donations conditional on an organisation’s achieving certain outcomes, then there is less scope for diverting money away from beneficiaries as this will result in reduced achievement of these outcomes. In essence, 

minimising corruption follows on from an emphasis on results

Recognising that, when donating to charities, effectiveness comes first is not to say corruption should not also be tackled head on separately. And here, 

it is to developed country governments and companies that we must direct our attention

for each $1 developing nations receive in foreign aid, $7 in illicit money flows abroad

, depriving millions of public services. 

 suggests, further, that about 45% of illicit flows end up in offshore financial centres, and 55% in developed countries, demonstrating rich countries’ complicity in this. No matter how much effort is put into making aid as effective as possible, without simultaneously addressing this crippling outflow of resources the net effect of rich countries on poor countries will continue to be negative. For those concerned about corruption, then, organisations working to combat it through increased financial transparency like 

 are good places to start informing yourself.

Each year a huge amount of money flows out of developing countries illegally. Credit: Global Financial Integrity

Returning, then, to the issue of corruption and charitable giving, what can we conclude? When faced with corruption, 

credible mechanisms in place to avoid corruption

, and, more importantly, which can demonstrate the biggest ‘bang for the buck’ – which are 

most effective at alleviating poverty according to rigorous evidence

, such as the charities Giving What We Can 

. Meanwhile for those who are particularly concerned about corruption, a promising start to an intervention is investigating illicit outflows from developing countries.

Donating in the face of corruption

Sebastian Roing

How can we accomplish as much good as possible? How can we broaden our outlook on giving so we don’t get stuck with causes where the returns are easily identifiable (such as insecticide-treated bed nets)? What are the returns to investing in cancer research? What are the returns to investing in climate change research? What are the gains to investing in research into near-Earth asteroids? GiveWell has teamed up with Good Ventures to set up the 

. In the spirit of effective altruism, this projects tries to find answers to the questions above, with the aim of finding out how donors can accomplish as much good as possible.

Overview of the Open Philanthropy Project

GiveWell was founded by a team of co-workers in the hedge fund industry who wanted to explore cost-effective giving. The organisation grew, produced a lot of research and can in some ways be compared with Giving What We Can. However, there are differences, in the charities recommended by the separate organisations, their undertakings and their methodology. We have previously written about GiveWell 

One central focus of both organisations has been global health charities. Why? Because charities with a good track record in this area often offer quantifiable, measurable and accountable returns. As we explain in 

Our research on this so far has consistently shown health interventions to be the most effective at improving people’s lives. As a result, although we still investigate other areas, health interventions are our primary focus.

Examples of interventions in other areas which may be really effective include (re-)communicating research from organisations such as WHO-CHOICE and GiveWell, and funding research about climate change. Part of Giving What We Can’s research is into ways to compare these different types of improvements. But for now, we simply don’t know if many of these areas offer opportunities for effective giving.

With this question in mind, GiveWell set up GiveWell Labs, which later developed into the Open Philanthropy Project (OPP). The OPP takes a step away from the rigour of GiveWell’s traditional charity evaluations, and explores a broad range of issues in four categories:

In doing so they initially ask the following questions:

 In particular, how many people does it affect, and how deeply does it affect them?

**What are the possible solutions?**Are there opportunities to make tangible progress?

 All else equal, the OPP expects to have more impact where there is less existing philanthropy.

Clearly, it is at present impossible to produce reliable estimates of the return in DALY/$ (disability-adjusted life years per dollar) to donations within such areas as preventing global catastrophic risk or scientific research. But these are important issues. The OPP has produced dozens of shallow investigations and a handful of medium-depth investigations into causes within the four categories. A comprehensive table summarizing the results of these investigations is at the bottom of this post. All the results have been taken from 

The investigations should be seen for what they are - shallow investigations - but they serve as very good introductions to these issues for philanthropists. Another benefit of this work is the range of topics covered: the 28 investigations cover topics from criminal justice reform in the US to the risks of geomagnetic storms.

 and the OPP in that they have both investigated tobacco control and traffic safety in low- and middle-income countries. WHO-CHOICE came to 

 that there exists a number of “highly cost effective” interventions in this area (under $int2000/DALY). Note that the organisations have different benchmarks and methodologies.

Linking the research back to the questions asked by the OPP we notice that the OPP has 

mainly investigated issues which affect millions of people

, such as climate change and aid to fragile and conflict-affected states. In some cases, it is unclear whether a solution exists. For example, we cannot prevent a large volcanic eruption at present and more research could at best help us predict the next one. In other cases, however, more concrete solutions exist. For example, regulation could help to drive down broadband prices in the US.

Relating to who else is working on the problems, in most of the OPP’s investigations, there exist private organisations which fund research, advocacy or lobbying. In some cases, such as aid to fragile and conflict-affected states, private efforts are completely dwarfed by official aid. This is also the case for anthropogenic (human-caused) climate change, where the US government spent £8bn per year in technology to reduce emissions. One area which looks relatively promising is geo-engineering research, for which funding appears to be limited whilst interventions could potentially have a large impact.

Relatively few final conclusions are reached in OPP research, and the reports primarily serve as introductions to different issues. In one sense, the purpose of this blogpost is to make the OPP research more widely known, so as to diffuse knowledge and prevent repetition. Naturally, future in-depth research needs to be checked and questioned in an academic way, but the OPP reports serve as good introductions to the issues at hand. They can help 

direct future in-depth research to the most promising areas

The OPP is hoping to give another big-picture update on where their work stands within the next few weeks. Additionally, they are hoping to conduct shallow investigations of nanotechnology, synthetic biology governance and emerging technology governance.

Overall, it is well worth paying attention to the research that the Open Philanthropy Project publishes, especially as a guide as to what causes are worth exploring in more depth. This may well lead to finding very cost-effective areas for giving or political advocacy.

Please note that this table contains reproduced material from the Open Philanthropy Project. If you find a particular investigation interesting, you should consult their website with the full reports 

Blog

Tuberculosis: The Potential for Cost-Effective Intervention

Donating in the face of corruption

Open Philanthropy Project: looking at hard questions on how to do good

Female Genital Mutilation: what is the problem and what can be done?

Eight ways you can use your time to improve the world

WHO-CHOICE: a look at the effectiveness of different health interventions

How to make the most of tax deductibility in the US

Can schistosomiasis be eliminated? Lessons from Coca-Cola and other stories.

The World's Hidden and Deadly Hunger

Against Malaria Foundation: August - September Update