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Emma Howard

If you’re anything like me, when reading the paper or the news online you may be drawn to sensationalist headlines concerned with aid expenditure, international aid being delivered at the expense of local needs and the plight of the taxpayer. These headlines can provoke public outrage at the perceived cost of foreign aid to the taxpayer, often resulting in the formation of a generally negative (though often ill-informed) consensus about the value and repute of aid and international development initiatives. As a consequence, one may come to believe that by virtue of paying taxes they are doing their “fair share”.

Some of the world’s wealthiest make claims tantamount to asserting that paying taxes and making charitable donations or gifts are pretty much the same thing (examples to follow). Those who earn the most are taxed the most, so it is easy to see how this deduction is made. However, the argument I am going to lay out outlines why I don’t believe that paying taxes and giving to charity are the same thing. I will present it using three myths.

Myth 1: If people were taxed less they would give more

This myth concerns the demand for greater governmental disclosure and accountability for where exactly taxpayer dollars are being spent, and the belief that the public's money would be better spent on altruistic causes if left in their own hands.

 that paying tax and charity are essentially interchangeable crops up in the news from time to time. An 

 of this is when Mitt Romney tacked his charitable contributions onto his tax returns when stating the percentage of his income reported and paid on his 2010 return. He used this same tactic 

 when defending his record regarding his previous refusal to release past tax returns.

 has been to lower tax rates in the US in order to free up more money for individual charitable spending. His reasoning is that individuals can make better decisions about where to give and what society’s needs are than the government. An example of this viewpoint might go something like this “I know my own community better, and I am therefore more sensitive to where my money would be better spent than some far-removed government bureaucrat”. The problem with this logic is that although it may hold some truth, it does not apply to everybody. 

 conducted in the US shows that people from more economically diverse communities are more likely to give to pro-social causes than those living in homogeneously affluent areas. People in affluent areas tend to adopt a more insular perspective, with donations predominantly going into non-profit organizations that serve a direct benefit to themselves or their direct community. As such, donations from the very wealthy tend to be channeled into elite colleges and universities, arts organisations and museums.

When challenged on the disproportionate amount of voluntary giving compared to the wealth of a given individual or family, people often respond with the claim that they would give more (and better) if they were taxed less. Although research on this phenomenon is limited, some US studies report that when taxes go down, people actually 

”, and it means that when the price of giving goes up, the value of the tax deduction per donated dollar is less. Whilst reducing taxes would certainly increase the amount of discretionary money available to the very wealthy, it is unfortunately not a reality that this money would go into charitable causes, it tends to just 

 the individual lays claim to. Therefore, although lowering taxes may seem like an attractive proposition to increase charitable giving, this would be unlikely to translate into any real behaviour change. It is simply not the case that taxes provide the biggest barrier to giving, it’s the philosophy behind giving that matters most.

Myth 2: A large proportion of my taxes are being spent on the developing world:

The gross overestimation of foreign aid expenditure appears to be one of the most pervasive and challenging beliefs to dispel in public opinion. One research study revealed that the average American believes that as much as 

 of the public budget is spent on foreign aid, and believed that the appropriate amount of foreign aid would reside in the region of 

. In fact, the actual federal budgetary allocation for poverty-focused development aid in the US is less than 

. Even at its highest estimation the entire international development budget only sits at 

To give you an idea of what this works out to per American taxpayer, the amount of tax dollars spent in 2012 on the developing world was 

. One might still argue that this seems a lot. In response, I think the following illustration proves useful:

If I asked the average person “what matters most to you? Chocolate or a starving child?”, I expect that most people would agree that a starving child is more important. If I then took that question one step further and asked “Given the choice, how much would you spend on chocolate per year compared to helping that child in need?” I would predict that even the biggest chocoholics amongst us (myself included) would prioritise the hungry child above a love for chocolate. However, if we were to compare the 

 on “candy” per year per american in 2012, it far exceeded expenditure on foreign aid, with candy expenditure estimated at a cost of $101.76 per person. A further $126.02 was spent on lawn care and $204.78 on soft drinks in the same year.

By comparison, the UK is the world’s third biggest donor, with the Prime Minister pledging to commit to 0.7% of the national budget into foreign aid in line with the 

. With a British population of approximately 62.6 million, the 0.7% target would equate to an eventual annual cost of 

 per British taxpayer. According to current British overseas spending, this works out as 

 per taxpayer. When asked in a recent poll, 59% of Britons surveyed voted for a total decrease in international aid expenditure by the British government. However, if we go back to the chocolate example, annual British spending on chocolate and confectionary was 

 per person in 2011, which works out as more than twice the foreign aid contribution per taxpayer for that year. As a society, what does it say about us that we would favour giving even less to help the world’s neediest than we would spend on chocolate in a given year?

To me this expenditure gap represents a massive judgement lapse in the prioritisation of need, and I believe we 

 be doing better for the developing world than this. I will go as far as to say that according to candy/ lawn care or soft drink expenditure, it would appear that most of us in the developed world still have space in our personal spending budgets to help those in need without much sacrifice to ourselves, and the moral case for making that small sacrifice appears strong.

Bill Gates recently addressed the impact foreign aid spending has in a 

. Compiling aid spending on health since 1980 divided by the number of children’s deaths prevented in the same time, he arrived at a ball-park figure of approximately $5,000 USD per child’s life saved. Bear in mind this figure didn’t include resulting health improvements to improve quality of life, so impact is even greater than this figure suggests. Although $5000 may seem expensive, it is important to keep in mind that the U.S. government 

 an American life at several million dollars. Additionally, Gates notes that healthy children do more than simply survive. Given the opportunity, surviving children can get an education, find employment, help economic growth and become self-sufficient in their communities. By employing this perspective, one could argue that aid is a bargain buy.

Myth 3: Charity starts at home: taxes to the developing world are being delivered at the expense of local needs

A common misconception exists that asserts that any international aid efforts divert resources away from local communities in need. In times of domestic economic austerity, many people believe that local governments and charities should be channeling all their funds into meeting local needs instead of the “far away” problems of another land. However, Tanner makes a convincing 

 to the contrary responding to calls to axe international aid saying “

Whatever way you look at it, it is wrong on at least three fronts. Firstly, it assumes the aid budget is too big. Secondly, it suggests that dealing with suffering in Britain can only be done by compounding suffering elsewhere, and thirdly, it ignores the realities of government

In the UK, with a 0.7% foreign expenditure allocation and at least 99% of the remaining budget being spent locally, the idea that international aid takes away from the notion of “charity starts at home” is unfounded and damaging to aid efforts. For the relatively small amount of money the UK designates to international aid, the difference that is made is substantial compared to the potential difference that money could make locally. For example, Britain currently sends 

 of the world’s poorest children to school in developing countries for only 

 of the cost of sending the same number of children to school in the UK. The time has come for us to evaluate why the 99% of fiscal inland spending is not effective enough, rather than calling for the 0.7% foreign aid budget to be reallocated domestically. The point I am not making is that aid is perfect, but rather that it does not present as sizeable a drain on resources as one might think.

Furthermore, it is often the case that domestic aid efforts and expenditure fly under the radar of the public eye, and the media attention that international aid garners can sway public opinion without substantive evidence. 

 recently responded to claims that they do not mobilise enough resources towards tackling local problems. They 

 claiming that although local rescue efforts may not attract as much press attention or occupy the center of their public media campaigns, local expenditure still exceeded foreign expenditure at £28.1 million vs. £25.1 million last year.

Moreover, the idea that “home” (wherever that is) exists as an isolated entity independent of any overarching global problems is short sighted. For example, it is predicted that the energy-related 

 will exceed those of developed countries by 127% by 2040. Therefore, the neglect of global issues or people via political or cultural labelling could have potentially devastating effects on a global scale. This is not merely limited to climate change, but impacts population control, immigration, global disease burden, water and environmental and economic sustainability. We are all equal stakeholders in the welfare of our shared planet, and the current reality is that some of us have more financial means than others to address these problems. It would be wrong to assume that the benefit is exclusively one sided, so we need to start thinking of aid less as a rescue and more as an investment.

, all those in favour of a common good need to challenge the notion that private avarice is a substitute for both public and moral responsibility towards serving that good. The answer to global poverty is unlikely to lie in the diversion of tax money into millionaire’s pockets, the axing of foreign aid or a libertarian state. So, instead of citing tax-induced poverty or that we’re doing “our fair share”, let’s start spending less on chocolate and more on 

Doing your fair share: why paying taxes is not giving to charity

Stephanie Crampin

Giving What We Can gives its support to the Against Malaria Foundation, and the intervention of combating malaria more broadly, as one of the most effective ways to fight poverty today. Malaria is estimated to cost Africa $12 billion a year through healthcare and loss of work and education. It accounts for almost one million deaths a year, being a significant contributor to child mortality.

As malaria is intimately related with poverty, eradication of malaria would be a huge step in improving the welfare of lives in developing countries. Smallpox eradication saved more than twice the number of people in the 20th century world peace would have achieved, and saved over $8 billion annually. At a cost of just $1.5 billion, this is one of the most effective aid efforts in history. Eradicating malaria would also have large and far reaching consequences, but innovation and work has been and will be needed.

Despite the current use of insecticide treated bednets and malaria drugs, it is likely that reaching malaria eradication will not be possible without the existence of a vaccine. Vaccines against malaria have been in development for many decades, and receive a huge amount of funding and media coverage. However, to date there is no vaccine available for parasitic infections, such as malaria, and the task is proving to be a huge challenge with many already failed attempts.

Malaria vaccines have received a significant amount of press coverage in the last few months as one vaccine in development by GlaxoSmithKline is showing promising results. The 

 of a large 18 month phase 3 trial last week: The trial was to detect the effect of the vaccine on 15,000 infants and children in 7 African countries. The trial revealed that malaria cases were reduced by 46% in children, and reduced by 27% in infants. The vaccine has been in development for three decades, and a request for global approval has now been submitted by GSK to the European Medicine’s Authority.

The vaccine used is RTS,S (or Mosquirix as it is known commercially), engineered using genes from the outer protein of Plasmodium falciparum, the malaria parasite, and a portion of the hepatitis B virus, as well as a chemical adjuvant to boost the immune system response. It is the most recently developed recombinant vaccine against malaria, and has proved the most effective to date.

The big players in the efforts to bring a malaria vaccine into use include GlaxoSmithKline, who are already active with the Global Alliance to Eliminate Lymphatic Filariasis, and endorse the London Declaration on Neglected Tropical Diseases, donating 400 million albendazole tablets each year to fight NTDs. The PATH Malaria Vaccine Initiative supports several malaria vaccine candidates, as well as including a drug development programme, currently advancing a synthetic form of the malaria drug artemisinin. The Bill and Melinda Gates Foundation is also a key funder in the development of the vaccine.

The progress towards a vaccine against malaria is very exciting and we anticipate that when an effective vaccine appears, it has the potential to be a very high impact intervention in poverty reduction. Due to the profile such a vaccine would receive, it is likely that it will also be very well funded. Were an eradication effort to be made against malaria, it is anticipated that a strategic combination of bednets, drugs and vaccines will be what is needed to eradicate the disease. As a result, malaria bednet distribution charities look to be one of the most promising areas for individual donors in the next few years. We look forward to seeing more progress in this area, and anticipate the day when malaria eradication is a feasible possibility.

Promising news for malaria vaccination

Benjamin Hilton

For more information on this topic, see our 

Whenever a disaster happens, whether it’s an earthquake, a tsunami, or some new human conflict, we all feel that urge to reach into our pockets and give a little to help. We know that, in an emergency, there is a huge amount of suffering, whether that is through deaths, injuries or loss of property and livelihoods. And we think that, when someone has nothing, every little will help. And so we donate, knowing that when the worst comes, victims of a disaster will need all the help they can get. But is emergency aid really that effective? Should we instead hold ourselves back, and give to one of the recommended charities instead?

In 2006, the Disease Control Priorities Project released a damning report of humanitarian interventions in natural disasters, saying that “the highly emotional and sensationalized climate of disaster response has long prevented the adoption of a cost-effectiveness approach in decision making.”[1] The need for rapid response times and improvisation means that it is difficult to ensure cost-effectiveness. Even worse, the international community spends millions on short-term responses to disasters, but there is often not enough funding to ensure even the mid-term survival of victims. And the prevalence of coordination and congestion problems, as well as situations that are outside charities’ control, means that the success of response operations are often limited by factors other than funding, so that there is often very little room for more funding for emergency responses.

On 12th January 2010, a magnitude 7.0 earthquake shook Haiti. The epicentre of the earthquake was just 17km from Haiti’s capital and largest city, Port-au-Prince, with a population of approximately 2 million. A huge number of buildings collapsed, including hospitals and other critical infrastructure. The drinking water and sewer systems were almost completely destroyed.[3]

After the earthquake, there were an estimated 250,000 injured victims suffering a wide range of injuries. In the first few hours, first-aid and triage stations were vital. Within a few days, operations such as wound debridement and amputations were needed. And in the following weeks, surgical needs actually increased as more patients (often with infected wounds) sought medical care. In the weeks to months after the earthquake, non-trauma surgical needs such as maternity services increasingly needed to be provided by NGOs as the pre-earthquake health system collapsed.

The earthquake in Haiti produced a huge humanitarian response. However, the NGOs involved experienced a huge range of different problems that reduced the effectiveness of their operations. Notably, there were supply delays, a lack of appropriately experienced health professionals, and challenges in coordinating between government, military and non-governmental organisations.

Very few of the over 600 health agencies who responded to the Haiti earthquake had the relevant experience or competence to provide appropriate surgical care, and they often lacked the capacity to build emergency surgical infrastructure. A lack of coordination led to too many agencies trying to provide the same care in the same area, while other sections of Port-au-Prince (Haiti’s capital and largest and worst affected city) were left with no access to emergency care. After a few weeks, many military and humanitarian groups left, leaving behind thousands of post-operative patients. The lack of referral systems or any good communication between NGOs caused problems when patients stopped going to hospitals from groups that had left and moved to other NGOs’ hospitals.

Experienced agencies often have a shortlist of hotspot regions (such as central Africa for conflicts or central America for natural disasters). They then preposition materials at major airfields so that their proximity ensures a rapid response. However, prepositioning requires substantial maintenance costs and a high risk of waste as medical and food supplies expire. What’s more, proximity does not necessarily reduce response times. In the case of Haiti, airport congestion led to large delays getting through the medical equipment that was urgently needed to treat the quarter of a million injured victims of the earthquake. The US military-controlled Port-au-Prince airport gave dignitaries and high-profile media priority, while planes carrying humanitarian supplies were diverted to Santo Domingo (the capital of the neighbouring Dominican Republic), and transported the 200 miles to Port-au-Prince by land.

Finally, specialists (surgeons, anaesthesiologists, traumatologists, emergency medicine doctors) who are experienced in treating war-wounded as well as working in resource-limited settings are very rare. Inexperience in emergency settings can be a hindrance rather than a help. The American College of Surgeons listed hundreds of surgeons to go to Haiti, but agencies did not accept their help due to their inexperience.

These problems are indicative of issues encountered in the majority of emergency aid efforts. For example, poor coordination was criticised in response to the Rwandan genocide[4] and the 2004 Indian Ocean tsunami[5]. In the case of emergency aid it is also quite likely that uncontrollable (from an NGO’s perspective) events will occur that significantly hinder the response - in the case of Haiti it was the airport congestion, but in other cases it could be military blockades or overcrowding. Financial aid would not help in these situations, reducing the room for more funding for aid organisations.

Search and rescue teams are needed in the first 48 hours following a disaster involving the collapse of buildings. Very few developing countries have the expertise to conduct search and rescue missions in collapsed multi-storey buildings, so they are often sent at high cost from industrial nations. However, if not executed immediately, the value of search and rescue drastically decreases, as people who are trapped die quickly without treatment. As it also takes a long time for teams from other nations to reach the disaster zone, the large amount of money this requires is very inefficiently spent. Investing in local search and rescue teams is most likely to be an effective use of resources.

Field hospitals are a common but very expensive way of treating casualties. They often arrive too late to treat the emergency casualties before they die or are treated by local hospitals. Field hospitals that stay longer than the first two to three weeks can be effective, although there is little data to suggest how effective compared with how local services would have taken immediate action. In the 2003 Bam earthquake, around $10.5 million was spent on about 10 mobile hospitals, but the cost of rebuilding the entire health infrastructure in the area was only $10.75 million!

Preventing and controlling the spread of disease can be effective if effective methods (such as the use of insecticide-treated malaria nets or encouraging hand-washing with soap) are used. Another way of increasing the cost-effectiveness is by strengthening already-existing programs rather than starting new ones.

Creating shelters is an important method of ensuring survival. However, tent cities, being easy to set up, are the most common method of doing this. Tent cities are difficult to sustain and nearly impossible to end. They rarely have effective sanitation and living conditions are poor. Distributing construction material or cash subsidies is more cost-effective, as they have greater positive effects in the long-term.

Cash assistance is a plausibly effective method to aid with long-term recovery of a disaster. It cannot really be used to meet immediate life saving needs. in most disaster-affected countries, those with the largest income will more easily gain access to the services and goods they need, whether that be shelter, medical, food, or anything else. This suggests that income availability is often a limiting factor in long-term recovery, and that therefore cash assistance could speed up this recovery.

Donating in-kind, for example by sending clothing or tinned food, whether to NGOs or from NGOs to countries, is of limited use, and, according to the Disease Control Priorities report, “often cause serious logistic, economic, and political problems in the recipient country”. They can divert humanitarian funds from more effective uses to warehousing supplies and building facilities for the safe disposal of pharmaceutical donations.

In 2004, the Indian Ocean earthquake and tsunami sparked a huge number of donations, with 81% of UK adults donating to the campaign, and a total of £392 million being donated.[7] 25% of personal overseas charitable donations in 2004/2005 were to the tsunami appeal, and 20% of those were diverted from other causes.[8] If we assume that these donations would have also been on overseas aid, 5% of the total personal donations budget on overseas aid from the UK was diverted away from other causes to the already over-funded tsunami appeal. In 2010, 48% of UK adults donated to the Haiti earthquake appeal, with a total of £107 million donated:[9] 5% of overseas aid donations the Haiti appeal. Almost all major organisations, including the Red Cross, Médecins Sans Frontières, Oxfam, Save the Children and UNICEF raised significantly more than they spent in the first year after the earthquake, indicating the vast overspend and a lack of room for more funding in the Haiti appeal.[10]

With smaller events, the numbers are less staggering, though still surprising. With the 2008 Burma Cyclone, 23% of UK adults donated a total of £19.5m, and in the 2009 Asia-Pacific disasters, 23% of UK adults donated a total of £9.3m. In 2011, for the East Africa drought appeal, 18% of UK adults donated a total of £72m. It is clear that donations to crises are disproportionately large, lending credence to the idea that there is little room for more funding in emergency aid appeals.

I still want to donate! Where should my money go?

The effectiveness of emergency aid varies massively depending on the disaster. However, out of the 5 charities involved in emergency aid that we evaluated, there are clearly some more effective places to donate: if they are active in the area, Médecins Sans Frontières (Doctors Without Borders), and if they are not, to the local Red Cross or Red Crescent society of the area where the event has taken place or the International Federation of Red Cross and Red Crescent societies. The charities on which we have focused has been guided in part by GiveWell’s prior work in this area.[11]

Médecins Sans Frontières were the most impressive emergency aid charity evaluated. They recognise that emergency aid operations are overfunded, closing appeals early[12] or even not raising any money at all for some operations.[13] To minimise response times (one of DCP2’s biggest criticisms of emergency aid), MSF has staff in 60 countries at all times.[14] They do not end an operation after only a few weeks, but only when: the situation has stabilised (e.g. in a conflict zone), or has deteriorated so much that it is now unsafe for its staff; other organisations have the capacity and motivation to restore a medical system that meets people’s needs; or the most urgent needs of victims of a disaster have been met and relief operations are no longer needed.[15] They carry out impressive evaluations of their actions. For example, one paper analysed the cost-effectiveness of two MSF surgical trauma centres: Teme Hospital, Nigeria at $172/DALY averted and La Trinité Hospital, Haiti, at $223/DALY averted.[16] They also wrote the paper on which the above case study on Haiti was based, actively critiquing their own work.

The International Red Cross and Red Crescent Movement consists of 189 National Red Cross and Red Crescent Societies run by 13 million volunteers and coordinated by the International Federation of Red Cross and Red Crescent Societies (IFRC).[17] The IFRC’s Disaster Relief Emergency Fund (DREF) is used to ensure that there is immediate financial support available for National Societies for emergency response to events.[18] The IFRC’s response to events seems very dependent on the national society: their proximity can mean excellent response times and organised relief, but they vary, and there can also be a lack of coordination or even very slow response times in some cases. Overall, the movement’s system of response and comprehensive evaluations are impressive, as is their leading role in the international humanitarian responses to disasters, although we would recommend MSF over the Red Cross/Crescent movement for larger disasters.

The cost-effectiveness of emergency aid in is difficult to assess: the wide range of different situations makes the effectiveness of the interventions vary massively depending on the event, and the lack of research in the area does not help the situation. But some generalisations can be drawn from the evidence we have. Emergency aid is likely to be rushed and improvised, and organisations often arrive too late to help with the short-term problems and leave too early to help with mid- to long-term problems. Lack of coordination between organisations, as well as other problems such as congestion, overcrowding and blockades are prevalent in emergency responses. These problems cannot easily be overcome with more funding, and emergency responses often receive far more than is spent, meaning that there is little room for more funding. If you still want to give, give cash not other objects, and give to charities that act more effectively with their money such as the ones mentioned here.

Disease Control Priorities in Developing Countries, Second Edition (DCP2), The World Bank, Chapter 61

, Natural Disaster Mitigation and Relief, Claude de Ville de Goyet, Ricardo Zapata Marti and Claudio Osorio, 2006,

This section is a summary of the first two pages of "

Improving Effective Surgical Delivery in Humanitarian Disasters: Lessons from Haiti

" by Kathryn Chu, Christopher Stokes, Miguel Trelles, and Nathan Ford. PLOS Medicine, April 2011,

Public health risk assessment and interventions: Earthquake, Haiti, January 2010, World Health Organization

Address by Mr. Cornelio Sommaruga, President of the ICRC, at the United Nations General Assembly 49th session, 23 November 1994

Coordination of international humanitarian assistance in tsunami-affected countries, Tsunami Evaluation Coalition, Jon Bennett, WIlliam Bertrand, Clare Harkin, Stanley Smarasinghe, Hemantha Wickramatillake July 2006

CAF Disaster Monitor, A survey of the UK general public’s donations to overseas disaster appeals, Summary of trends, Liz Lipscomb, December 2011

UK Giving 2004/05, Results of the 2004/5 survey of individual charitable giving in the UK, Cathy Pharoah, Catherine Walker, Charities Aid Foundation; Karl Wilding, Susan Wainwright, National Council for Voluntary Organisations

Ratings of Disaster relief charities one year after the Haiti earthquake | Givewell, February 2011

Disaster relief charities | GiveWell, 2011

Japan: A note on Funding and Donations | Doctors Without Borders, March 14 2011

Closing a programme | Médecins Sans Frontières (MSF) International

Comparative Cost-Effectiveness Analysis of Two MSF Surgical Trauma Centers, Word Journal of Surgery, Richard A. Gosselin., Andreu Maldonado, Greg Elder, 2009

Heart vs mind: a review of emergency aid

Olga Kuznetsova

Parasitic worm infections are endemic in large parts of the world. Eradication of these worms (deworming) has long been considered a simple and cheap intervention that brings substantial health and education benefits to millions of children worldwide. Many organisations such as the Bill and Melinda Gates Foundation, the World Health Organisation (WHO), and Deworm The World support deworming programs. However in recent years, more data have emerged that cast doubts on the effectiveness of such programmes. Most of these studies have already been discussed by Giving What We Can in 2012, with a focus primarily on the cost-effectiveness of treating worm infections [1]. Here, I will mention the most recent findings, and why we believe that deworming is still a worthwhile cause to support.

Soil-transmitted worm infections are prevalent in the world’s poorest communities and cause symptoms such as anaemia, diarrhoea, abdominal pain, and weakness. The three main types of intestinal worms are roundworms, whipworms (as pictured below) and hookworms, and their eggs pass into the soil through human faeces in regions with poor sanitation. Infection is transmitted when the eggs are ingested via contaminated vegetables or utensils, and hatch in the intestine [2]. According to the WHO, worm infection in children can cause organ damage that exacerbates with age, as well as less direct effects such as reduced productivity, fatigue, and as a result, lower school attendance. It might also worsen other conditions such as tuberculosis and HIV/AIDS [3].

Although deaths from worm infections are rare, worm treatment has long been regarded a cheap and effective health intervention in the developing world. The earliest example of successful deworming was carried out in the early 20th century in the southern states of the USA. After observing that 40% of children suffered from hookworm infections, John D. Rockefeller’s Sanitary Commission sponsored an eradication campaign, which included treatment with thymol and education about good hygiene. The benefits extended beyond health, with improvements seen in school attendance, enrolment, and literacy [4]. Similar observations were made more recently in Kenya, where mass deworming of schoolchildren led to reduced absence from class [5]. Looking at even more long-term benefits, two unpublished studies reported the results of a Primary School Deworming Program in Kenya, which started in 1998. Besides an improvement in height and weight, children treated for worms worked more hours in adulthood due to improved health and earned 20% more than those not treated [6]. However, the fact that the studies have not yet been published has raised concerns about publication bias [7], while the positive studies were treated with significant reservations by the charity evaluator GiveWell, who argue that the results are not necessarily representative of other regions with a lower worm burden [8].

As always, when there are doubts about the efficacy of a treatment, a meta-analysis of published studies can reveal the true effect. The most recent version of the Cochrane review (2012) assessed 42 randomised controlled trials of deworming. In several studies, children were pre-screened for worm infection before treatment, and showed some increase in weight and haemoglobin levels. However, in the trials where the entire community was treated without pre-screening, there was little or no effect on health parameters, growth, cognitive ability, or school attendance. The exception were two trials showing a large positive increase in weight, however both were conducted over 15 years ago in an area with a high worm burden and may not reflect the situation elsewhere [9].

Overall, the Cochrane review has sparked criticism, notably from Innovations for Poverty Action (IPA). In their blog, IPA argues that the review left out three studies showing a positive effect of deworming (one - the early 20th century study and two unpublished). In addition, if deworming following pre-screening improved certain health parameters, the same effects should be seen in infected individuals during mass deworming projects, even if the data from the whole population do not show statistically-significant benefits. On the other hand, GiveWell, while agreeing that the evidence for the benefits of deworming is low, mentioned that the Cochrane review did not include studies on combination treatment for soil-transmitted worms and schistosomiasis (infections of the urinary tract and intestines by the Schistosoma worm). They maintain that combination treatment leads to improvements in health and development, and, like Giving What We Can, continue to recommend the Schistosomiasis Control Initiative (SCI) as a highly effective charity [8, 10, 11].

The largest trial to date, conducted in North India, was published in 2013 eight years after it was completed. It studied one million children who were treated with deworming drugs twice a year over a five-year period. A trial this size was an opportunity to test whether treating worm infections would reduce child mortality (in parallel, the authors examined the effects of Vitamin A supplements on mortality). The results were clear and disappointing: long-term deworming had no significant impact on mortality, weight, height, or haemoglobin levels [12]. However, the validity of the methods and results has been controversial. GiveWell raised the question of why a trial this size was not published for eight years since its completion date, suggesting publication bias [10]. Furthermore, a response published in the Lancet journal claimed that coverage of Vitamin A programme was far lower than the 96% reported in the trial, with less than 10% of children reporting to have received a vitamin tablet within the last 6 months of the study. There were also claims of poor monitoring, reporting bias, and little training and incentive given to the Indian workers who administered the drugs [13]. All these issues raise significant doubts as to whether the Vitamin A (and by extension, deworming) study has been properly planned and executed, and the results are not given much weight in the scientific community.

To conclude, although some recent studies have shown no improvements to health and education after deworming, the data are not always reliable and the studies not always well-executed. The mixed results of the studies in the Cochrane review highlight how trial design and monitoring can affect the conclusion, even when the same drugs are used to treat the disease. Furthermore, the current interventions are very cost-effective even considering the recent adjustment of DCP2’s estimate (see the 2012 GWWC post). Overall, it appears that there can be short-term and long-term health benefits to deworming, especially when schistosomiasis is treated together with soil-transmitted worm infections. As a result, both GiveWell and Giving What We Can continue to recommend deworming and schistosomiasis treatment programs such as SCI and Deworm The World Initiative.

Neglected Tropical Diseases – Are they Cost-Effective to Treat?

Preventive chemotherapy in human helminthiasis

Bleakley H. Disease and Development: Evidence from Hookworm Eradication in the American South. The Quarterly Journal of Economics. 2007;122(1):73-117

Miguel E and Kremer M. Worms: Identifying Impacts on Education and Health in the Presence of Treatment Externalities. Econometrica. 2004;72(1):159-217

Worms at Work: Long-Run Impacts of Child Health Gains.

Hawkes N. Deworming Debunked. BMJ. 2013;345, e8558. doi:10.1136/bmj.e8558

Combination Deworming (Mass Drug Administration Targeting Both Schistosomiasis and Soil-transmitted Helminths).

Taylor-Robinson DC, Maayan N, Soares-Weiser K et al. Deworming Drugs for Soil-Transmitted Intestinal Worms in Children: Effects on Nutritional Indicators, Haemoglobin and School Performance. Cochrane Database Syst Rev. 2012; doi:10.1002/14651858.CD000371.pub5

New Cochrane Review of the Effectiveness of Deworming.

Cochrane’s Incomplete and Misleading Summary of the Evidence of Deworming.

Awasthi S, Peto R, Read S et al. Population Deworming Every 6 Months with Albendazole in 1 Million Pre-school Children in North India: DEVTA, a Cluster-Randomised Trial. The Lancet. 2013;381:1478-1486

Sommer A, West Jr K et al. Vitamin A Supplementation in Indian Children. The Lancet. 2013;382(9892):591

The evidence for deworming

David Goll

: We think our top charities do fantastic work, but we are always interested in other methods for helping the world’s poor. The Copenhagen Consensus and other authors have highlighted the potential of agricultural R&D as a high-leverage opportunity. This was enough to get us interested in understanding the area better, so we asked David Goll, a Giving What We Can member and a professional economist, to investigate how it compares to our existing recommendations.

Owen Cotton-Barratt, Director of Research for Giving What We Can

Around one in every eight people suffers from chronic hunger, according to the Food and Agricultural Organisation’s most recent estimates (FAO, 2013). Two billion suffer from micronutrient deficiencies. One quarter of children are stunted. Increasing agricultural yields and therefore availability of food will be essential in tackling these problems, which are likely to get worse as population and income growth place ever greater pressure on supply. To some extent, yield growth can be achieved through improved use of existing technologies. Access to and use of irrigation, fertilizer and agricultural machinery remains limited in some developing countries. However, targeted research and development will also be required to generate new technologies (seeds, animal vaccines and so on) that allow burgeoning food demand to be met.

Agricultural research and development encompasses an extremely broad range of activities and potential innovations. A 2008 paper issued by Consultative Group on International Agricultural Research (von Braun et al., 2008), an international organization that funds and coordinates agricultural research, identifies 14 ‘best bets’. These include developing hybrid and inbred seeds with improved yield potential, better resistance to wheat rust, increased drought tolerance and added nutritional value, but also encompasses the development new animal vaccines, better fertilizer use and improved processing and management techniques for fisheries.

Notable successes in seed development seem to have generated immense social benefit. The high-yielding varieties that spread through the ‘Green Revolution’ are often credited with driving a doubling of rice and wheat yields in Asia from the late 60s to the 90s, saving hundreds of millions of people people from famine (see, for instance, Economist, 2014). Given the prevalence of hunger and the high proportion of the extremely poor that work as farmers, agricultural research and development seems to offer a potential opportunity for effective altruism.

Existing benefit-cost estimates are promising, though not spectacular. The Copenhagen Consensus project ranked R&D to increase yield enhancements as the sixth most valuable social investment available, behind deworming and micronutrient interventions but ahead of popular programmes such as conditional cash transfers for education (Copenhagen Consensus, 2012).

The calculations that fed into this decision were based on two main categories of benefit. First, higher yield seeds allow production of larger quantities of agricultural output at a lower cost, bolstering the income of farmers. Around 70 per cent of the African labour-force work in agriculture, many in smallholdings that generate little income above subsistence (IFPRI, 2012). Boosting gains from agriculture could clearly provide large benefits for many of the worst off. Second, decreased costs of production lead to lower prices for food, allowing consumers to purchase more or freeing up their income to be spent elsewhere.

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The evidence for deworming

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