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Kat Steiner

Why I finally took the pledge

I recently made the commitment to donate 10% of my pre-tax income to the most effective charities in combating extreme poverty, from now until I retire. It was something I’ve been considering for several years, but it was a big decision and not one I take lightly. Giving What We Can has shaped my opinions on charitable giving, altruism, and effective charities for nearly five years, and I wanted to share a little of my journey to finally Pledging.

When I first heard about Giving What We Can, I was a student, living with some people involved with it. There were Centre of Effective Altruism meetings in my living room, late-night discussions about the latest 

 report, debates over the problems with deworming figures. I remember attending a talk by Toby Ord and Peter Singer in the Exam Schools in Oxford, and loving the positive, quantifiable numbers they were quoting about how much has been done and can be done to fight extreme poverty. I am proud to have introduced some family and friends to 

 both as a charity and as a really effective charity, and I’ve been delighted by their responses to my sporadic fundraising efforts.

 before now? Many of my friends did so as students, but I held back. I was cautious about making a commitment to give money when I didn’t know how much I would have in the future. I was still a student, had never had a proper job, had never had to support myself on its income. I was worried about failing further down the line when I found I had more immediate needs for my money: children, emergencies, end-of-life care, travelling the world. I decided to take another look when I had been in employment for a while, and see how things stood.

Around the start of this year, Giving What We Can had revamped their website and set up 

, a way of tracking your donations without signing the pledge outright. Now in steady employment in Oxford, I gave it a go. It’s nearly the end of the year, so I took stock, and was surprised. I’d been topping up my donations each month to the 10% mark, when I’d got my paycheque and paid my rent, and I hadn’t had to change my behaviour or spending to accommodate it. All that I had was a deep satisfaction each month that my money was winging its way to charities that are making a real, personal difference to people’s lives.

Having been on the periphery of Giving What We Can for ages, I know the great community they’ve fostered. When I started Try Giving, I felt more involved in the Oxford chapter, but still on the outside looking in. I couldn’t feel like a fully paid-up member until I’d pledged. You can’t really say you’re committed to a group like Giving What We Can until you’re committed to giving in accordance with your beliefs. And my experiences with fundraising and learning about effective altruism make me keen to do more or at least see what life on the other side of the fence was like.

So when Ravi Patel in Cambridge created a 

 inviting people who were thinking of Pledging this holiday to take a picture of themselves and share it, this felt like the perfect time. I was being invited to join what I knew was a very special community. And there were lots of pictures of people doing the same. So I went for it. I’m delighted to hear that Ravi’s event has been instrumental in getting more pledges in December than any other month – over 40 at least! That’s a serious amount of money earmarked for the most effective charities.

I would definitely recommend anyone thinking of pledging but feeling cautious to check out Try Giving. You may be surprised how much you can give without any negative effects (and lots of positive ones!) And there’s absolutely no pressure to keep going – times are hard for a huge number of people in the UK right now and I don’t feel happy telling anyone what to do with their money. I just want to take responsibility for mine, and join an awesome, welcoming community of people doing the same, all over the world. Thanks for reading.

James Snowden

Médecins Sans Frontières: a brief review

Doctors without Borders (Médecins Sans Frontières, MSF) is an international medical and humanitarian organisation which “provides assistance to populations in distress, to victims of natural or man-made disasters and to victims of armed conflict.” (Activity Report 2013)

Last month I considered switching my regular pledge donation to MSF. The ebola outbreak in West Africa has put medical volunteers in the spotlight and MSF seemed to be at the forefront of the response[1]. Reading accounts written by medical volunteers,[2] I was struck by just how awesome they are. MSF’s own cautionary notes about working overseas[3] demonstrate the high level of sacrifice involved, and incidents in the Central African Republic[4] and Somalia[5] remind us that the risk is very real.

MSF seems a bit like a global emergency response team. An ambulance service on a massive scale. If I was President of the World and choosing how to spend my budget I’d definitely have an ambulance service. So MSF is a good thing. But is it the best thing I could do with my donation? I felt compelled to donate, but first I did some research.

This article is meant to outline some of the factors I considered and hopefully provide some helpful information for others making a similar decision. It should not be taken as either a positive or negative rating of MSF.

MSF is a large organisation, currently operating in around 60 countries worldwide

In 2013, the three largest country programmes were in Democratic Republic of Congo, South Sudan, and Haiti

MSF runs short term health programmes in response to armed conflicts, epidemics, famines and natural disasters

It also runs longer term health programmes, targeted at ongoing health crises

MSF doctors treat a diverse range of problems, including malaria, HIV, mental health and cholera

Much of MSF’s work is in response to natural or man-made disasters. A 2006 report by the Disease Control Priorities Project concluded that “the highly emotional and sensationalized climate of disaster response has long prevented the adoption of a cost-effectiveness approach in decision making.”[11] The effectiveness of disaster relief efforts is difficult to evaluate but it seems likely that it is less effective on objective measures than other modes of intervention. You can read an excellent blog post on disaster relief here.[12]

MSF works in a number of areas which have been identified as particularly cost-effective and scalable. This includes mass vaccination programmes[7] and bednet distribution.[8] They were also instrumental in founding the Drugs for Neglected Tropical Diseases Initiative (DNDI) which has a very high potential upside[9].

MSF also works across a broader range of equally worthy but less well understood or less cost-effective interventions, including HIV treatment and mental health. For this reason, Givewell decided to deprioritise them as a ‘top charity’.[10]

As MSF undertakes such a variety of programmes it is difficult to evaluate the effectiveness of the charity as a whole. However, it seems safe to say that MSF enjoy a good reputation in their field. The British Medical Journal praised MSF for “leading the world’s response to Ebola” and chose MSF for their winter charity appeal in 2014.[13] Their global presence means they are often in a good position to respond to disasters quickly.[14] Both Givewell[15] and Giving What We Can[16] have recommended MSF as a top charity for disaster relief.

90% of MSF funding comes from private individuals[17]. Non-affiliation with governments allows MSF to work in politically sensitive conflict zones such as Afghanistan and DRC. It also insures independence from political goals, meaning programmes are prioritised based on need alone.

MSF undertakes regular critical evaluations of their programmes and have published a number of negative conclusions of their own programmes. These reports are freely available here[20]. Givewell concludes that while MSF is “more transparent than the vast majority of charities we have considered, it is not as transparent as the most transparent charities we have found.”[21]

In 2013, MSF held slightly over €600m in cash and equivalents[18]. This should not necessarily be interpreted as no room for more funding as the nature of MSF’s work means the flexibility to start programmes without delay is crucial. MSF has a good track record of making sure funds are used in the most efficient way, closing their 2004 tsunami appeal after just 6 days as it was sufficiently funded.[19]

In the end, I concluded that the reason I found MSF particularly compelling was as much because of my admiration for the doctors and nurses, as the effectiveness of their work. While MSF didn’t seem to be as effective as the Giving What We Can recommended charities, they are doing good work in a way which I find personally inspiring and a donation seemed appropriate.

I therefore decided not to switch my regular pledge donation from the 

 but to make a small regular donation to MSF in addition to my pledge.

Voa News: Ebola Crisis Puts Doctors Without Borders in the Spotlight

Africa is a Country: MSF doctor writes about experiences working in Ebola zone in Sierra Leone

MSF: Three MSF Staff Among 16 Civilians Killed at Central African Republic Hospital

The Guardian: MSF to pull out of Somalia after 22 years

MSF: Sierra Leone: MSF Targets Hundreds of Thousands in Mass Vaccinations for Yellow Fever

MSF Field Research: valuation of a mass distribution programme for fine-mesh impregnated bednets against visceral leishmaniasis in eastern Sudan.

DCP: Natural Disaster Mitigation and Relief

Giving What We Can blog: Heart vs Mind in Emergency Aid

British Medical Journal: MSF: how a humanitarian charity found itself leading the world’s response to Ebola

Giving What We Can: Research report on Emergency Aid

MSF: International activity report 2013: facts and figures

Humanitarian Practice Network: Tsunamis, Accountability, and the Humanitarian Circus

Sebastian Roing

What values do we need to keep in mind about the DALY? Part I

Should we value the life of a 25 year-old more than that of a 65 year-old simply because they have different social roles? Should we discount future health benefits because it is uncertain whether they will arise or not? Should we think differently about the individual burden of a disease when a whole community is affected instead of just one individual?

This post gives a brief history of the health statistic known as the DALY – Disability Adjusted Life Year. The DALY has come to influence many decisions in global health over the last 20 years. I raise a few problems with the statistic,and emphasise its benefits as a statistic that is comparable across causes.

The DALY is an attempt to merge data on morbidity and mortality into one statistic, and make it comparable across different diseases and causes. It assigns a numerical value between 0 and 1 to health outcomes, where death, the worst possible case, is assigned the value 1. Thus, it allows for simple addition of different health outcomes. This enables agencies such as the WHO to calculate the disease burden of a particular region, accounting for all the different diseases prevalent in that region.

Moreover, the DALY can also be used to guide resource allocation, by allocating resources to the intervention that saves the most DALYs per dollar. So how do we construct the DALY and put a numerical value on health outcomes? Well, at face value it’s a simple formula:

**DALY = YLL (Years of life lost) + YLD (Years of life lost due to disability)**

Suppose a young adult of 25 years is living in a remote area where there is little access to health care. Tragically, this individual has contracted AIDS, and receives no antiretroviral treatment. Nonetheless, the 25-year-old survives for a year, but then dies of an infection.

This scenario can be converted into DALYs. First, we need to account for the year lived with AIDS without receiving antiretroviral treatment. The 

 on this health outcome is 0.547. These weights are numbers between 0 and 1 and they signify how bad a particular health outcome is compared to death. 0 represents a state of full health, whereas 1 represents death. The figure below lists a few common causes and their disability weights. The full list of disability weights is available 

To get the YLD for the 25-year-old we therefore multiply the number of years lived with AIDS by the disability weights (1 * 0.547 = 0.547). The other component, the YLL, is simply the years of life lost relative to the agreed standard life expectancy (87.8 – 26 = 61.8). The DALYs lost and the total burden of the disease for the 25-year-old is 62.347.

**DALY = YLL (standard life expectancy – age at death) + YLD (years lived with disability * disability weight)**

But wait. Aren’t there at a hundred ethical problems with this method? Well, there are a few. I will describe the four issues I think are most important in this post. Two of these issues have been resolved in the latest update of the Global Burden of Disease study from 2010.

History of the DALY and two (resolved) issues

The original DALY was developed at the Harvard School of Public Health in the late 1980’s. Other measures, such as YLL (Years of Life Lost) and QALY (Quality Adjusted Life Years) were already popular, but they offered no standardised way of measuring morbidity and mortality.

The DALY was subsequently adopted by the Global Burden of Disease 1990 study of the WHO (GBD 1990); a huge project which estimated the total, global disease burden by using DALY methods. The GBD series was later updated in 2004 and most recently in 2010. Over these 25 years, the DALY statistic changed significantly following a lively debate about, chiefly, two ethical issues inherent in the DALY; age-weighting and time discounting.

Reasonably, we might ask ourselves – Is it worse if a 25-year-old suffers from AIDS than if a 75-year-old suffers from AIDS? What about infants? Is the death of an infant as bad as the death of a 25-year-old? The original DALY envisaged the weighting of age according to social roles played by people of different ages. C. J. Murray explains the technical basis of the DALY in his 1994 article 

Quantifying the burden of disease: the technical basis for disability-adjusted life years

. The weighting of age in the original DALY followed the function in the figure below.

The weighting peaks at around 25 years, and decreases as age increases. Furthermore, the weighting starts at 0 at birth and increases quickly until the age of 25. This implies that the death of an infant, at birth, is weighted as 0 DALYs (nothing). So the death of an infant is definitely not regarded as bad as the death of a 25-year-old. And the weighting of age is linear. This implies that, in terms of DALYs, one 25-year-old suffering from AIDS for one year is approximately as bad as two 75-year-olds suffering from AIDS for one year.

Murray did not justify age-weighting by some differential intrinsic valuation of life. Rather, age-weighting was an attempt to capture different social roles at different ages. The young and the elderly depend on young adults for care, emotional and financial support. Sickness and death among this group of individuals is therefore particularly serious.

But if we open up for the possibility of weighting according to social roles, shouldn’t we also weight individuals across professions and income? What about doctors and nurses? Since people depend on them for care shouldn’t they also be given a higher weight? It turns out this kind of weighting is quite problematic. By weighting people according to their age we open up many other issues that would have to be considered before we could justify the application of age-weights. Furthermore, numerous critics voiced concerns about the universalism of a human life. The practise of age-weighting was consequently 

A related issue is time discounting, a constantly relevant problem in cost-benefit analysis. Toby Ord and Robert Wiblin have written extensively on this issue in our section on 

. Discounting is the practise of applying higher weights to benefits that arise in the present relative to the future. For example, most people would prefer getting a piece of chocolate today than tomorrow (see, for example, 

 experiment on present-bias). And I wouldn’t exchange $100 this year for $100 next year, chiefly because I could take the $100 today and invest them such that my return would give me more than $100 next year. We usually model this phenomenon using geometric discounting.

However, the practise of discounting is not as intuitive when it comes to health benefits. Is it better to cure an individual of tuberculosis today rather than next year? Not really. But could this cured individual contribute to society in such a way that we are able to cure more people of tuberculosis next year? Well, maybe, but Ord and Wiblin suspect that most benefits 

Time discounting was originally used in the DALY statistic for technical reasons. Suppose we let DALY estimates guide our resource allocation. What would be the benefits of investing in a research program that produces a vaccine for HIV? If the time horizon is infinite, then the benefits would be infinite, because we would prevent an infinite number of people from contracting HIV. Consequently, if we don’t discount benefits in the future, all resources should be invested in vaccination programs.

What is the problem with this reasoning? As pointed out by Ord and Wiblin, it is not appropriate to assume that no one would ever think of a vaccine against HIV if it weren’t done by one research program in particular. It is not the appropriate counterfactual. It is better to construct an explicit model that assumes that someone else would think of a vaccine in x years. Furthermore, discounting the DALY creates a lot of intergenerational inequality that is quite arbitrary. Originally, the DALY used a discount rate of 3%. This gives a weight of approximately 0.22 to DALYs that arise in 50 years. Is it fair to consider 5 deaths in 50 years as serious as 1 death today?

The most serious implication of age-weighting and time discounting, as noted by 

 was that no one could get rid of these practises without re-doing the entire analysis. Once a disease burden had been calculated for a particular setting it was more or less impossible to exclude time discounting and age-weighting without going back to the original data. This was a serious obstacle to transparency and transferability of results in the global health debate. I join the crowd of positive supporters of the WHO decision to ignore time discounting and age-weighting in the latest Global Burden of Disease study.

In the next post in this series, I will look at the DALY and its role as a measure of disease burden that is transferable across different conditions and illnesses. I will also discuss the future of the DALY, its limitations as an indicator of resource allocation, and an additional method that could include community effects into the DALY.

What values do we need to keep in mind about the DALY? Part II

 in this series, I introduced the DALY and discussed two resolved issues: age-weighting and temporal discussion. In this post, I will look at the DALY and its role as a measure of disease burden that is transferable across different conditions and illnesses. I will also discuss the future of the DALY, its limitations as an indicator of resource allocation, and an additional method that could include community effects into the DALY.

The DALY as a transferrable measure of disease burden

The DALY is meant to transcend illnesses and causes. We should be able to study the circumstances in a region and estimate the total burden of disease, in DALYs, by aggregating the lives lost and disability inflicted by all diseases in that region. Furthermore, if, for example, diarrhoea is the foremost cause of DALYs lost in that region, and there are ways in which diarrhoea can be mitigated at a low cost, then we should naturally allocate resources to this cause. This is where the DALY is really powerful. It gives a very clear indication of 

where resources are put to their best use

But what if I don’t agree with the disability weights used by the WHO? This is in fact a very real concern and something that has been debated since the conception of the DALY. How do we agree on disability weights for different health outcomes? In 1990 a panel of experts set all the disability weights. This was criticised and the 

 set disability weights using public surveys and expert consultation.

Still, suppose I have two interventions available. One distributes malaria nets and averts 0.2 DALYs per dollar. The other distributes antiretrovirals to people with HIV and averts 0.15 DALYs per dollar. Clearly, the net benefit of investing in the intervention that distributes malaria nets is higher.

However, I may reasonably argue that living with HIV/AIDS deserves a much higher disability weight than 0.547. This would change the cost-effectiveness estimate above. Maybe it would even make the DALYs averted higher than 0.2 per dollar. This example illustrates that 

we can never agree about the cost-effectiveness of different health interventions if we don’t agree on the relevant disability weights

, who also cited a few other disagreements. Some people think certain conditions such as fistula worse than death, but many people disagree. Some people would rather bring a person to full health than save the life of an infant. Some people emphatically disagree.

Where does this leave us? Well, we shouldn’t forget that a lot of time and effort actually has gone into making the disability weights as representative as possible. I myself feel that I am in no position to question most of the disability weights worked out for the GBD 2010. So should we trust the experts and the public surveys? In most cases, I think we should. But this does not imply that we should give up the chance of critical review.

In fact, all the hard work put into the development of the disability weights and the DALY constitutes a tremendous resource. The hard work has, amongst other things, gone into assembling evidence on different health outcomes. Even if one doesn’t agree with the final disability weights, the information provided is still valuable.

For example, the latest update, GBD 2010, includes many non-communicable diseases that account for an increasing share of global DALYs. Diabetes, musculoskeletal disorders and mental and behavioural disorders is inflicting a much higher disease burden globally than in 1990, and will create new challenges to health care systems in the future. Only this result is very important, as it implies we should do more research into cost-effective interventions that combat these conditions. Since the scale of the GBD 2010 is so extensive, it has ample opportunity to find many issues that we need to put more focus on. In combination with efforts to make global health data more transparent, accessible and reliable, this can only be an asset to the cause of effective altruism.

Another concern I had with the DALY initially was that it would obscure important subtleties that vary across issues and regions. An analogy of this would be the credit rating of financial instruments prior to the US sub-prime crisis. The credit ratings didn’t account for the composition of these financial instruments. (Apologies for the analogy to finance). In the case of the DALY, it is equally important that we don’t forget that the DALY is not a measure of everything - it doesn’t measure the risk of contagion, for example. Averting 200 DALYs in community A may in fact be inferior to averting 150 DALYs in community B if community B is struck with a particularly contagious disease.

Naturally, no indicators account for all aspects of a situation. In many ways, it might not be a very serious concern, since rigorous analysis will always supplement the DALY with other methods and practises. Giving What We Can performs charity evaluations using a range of indicators and data - see for example 

our latest evaluation of Water, Sanitation & Hygiene

. Nevertheless, one should take care and question cost-effectiveness statistics in the form of DALYs averted per dollar if they are referred to hastily. And don’t forget to think about the transferability of positive results – just because an intervention worked in one setting doesn’t mean it will work in another. A 

 covered some really interesting issues on the topic of results transferability[10].

We may reasonably expect DALY estimation to be an influential method in guiding resource allocation decisions in the future. But are there any other methodological problems that we need to consider?

When it comes to resource allocation there is one problem with the DALY that stands out. It was noted in this 

While we may determine disability weights for particular diseases and conditions, the welfare of the individuals suffering from these conditions will invariably depend on their own individual circumstances. For example, autism has a disability weight of 0.259. But we would expect the burden of autism to vary depending on income; country and place; and social attitudes. In fact, the burden of many conditions may vary so much as to make a universal disability weight meaningless.

A friend read my research for this post over my shoulder. He jokingly said: “What’s the disability weight for gluten intolerance?” (He is himself gluten intolerant but doesn’t suffer greatly from the condition since there are dietary alternatives available at a relatively low cost in Sweden). I immediately thought about how serious his gluten intolerance would be in a low-resource setting. Herein lies a challenge for the DALY. How do we account for circumstances such as income that changes the burden of a disease across individuals? How many more parameters do we include? Where to draw the line in this respect is a question for the future.

Another problem, which relates back to the social roles used to justify 

. Should we apply higher weights to contagious diseases that strike whole communities? Or are the disability weights attributed to such diseases high enough already? I think one could at least consider introducing some systematic (higher) weighting to diseases that are very contagious and thus disrupt social roles and groups.

For clarity, consider the following example. We have estimated the total disease burden for a large geographical area. Amongst the prevalent conditions are tuberculosis (disability weight: 0.331) and uncontrolled asthma (disability weight: 0.132). The total amount of YLDs (years of life lost due to disability = disability weight * total years lived with condition across population) caused by each condition in our geographical area is approximately the same. Remember that YLD is the second component of the DALY.

However, tuberculosis is prevalent in three communities only, whereas uncontrolled asthma is uniformly distributed across the entire population. Social roles in the small communities hit by tuberculosis are disrupting, since young children and young adults are particularly susceptible to tuberculosis. This systemic effect increases the burden of the disease both economically and socially.

Asthma, however, which is uniformly distributed, cannot be said to upset social roles in any systematic way. (I’m assuming that asthma is not generating any ostracization etc. - please take this as an idealised example). With reference to the burden of the diseases, it would then make sense to apply a weight to the YLDs in the communities struck by tuberculosis. This weight would not be applied to a lone victim of tuberculosis, but only to the three communities where the disease is disrupting social roles. Nor would the weight be applied to victims of asthma.

I think we must ask ourselves these systemic questions particularly if we want to use the DALY for resource allocation. To me, there is a value in a community, separate from the sum of the individuals, which should be relevant for the burden of a disease. This community effect should therefore also be relevant to cost-effectiveness analysis, and to the cause of effective altruism.

However, including such community effects would open up for the same kind of criticism that was levied against the age-weighting of the original DALY. For one, if we weight not only YLDs but DALYs according to community effects, then we are effectively going against the universalism of human life. Why? Because then the DALYs of 10 individuals living in a community would be weighted higher than the DALYs of 10 individuals living separately.

Community weighting could also introduce further problems - “should we give higher weights to certain communities which are of particular importance such as doctors?” “What is a community and where do you draw the line between communities and individuals?”. In fact, maybe it is easier to keep the DALY in its “pure” form and use other forms of analysis to assess community effects. However, this implies that reports such as the GBD 2010 might mislead future research and interventions by not acknowledging community effects. And community effects would at least capture my intuitive aversion of very contagious diseases.

The DALY is a fantastic effort to improve our understanding of the disease burden across causes and different regions of the world. But keep in mind:

Your own personal values: do you give the authority to the people behind the GDB 2010 to set disability weights?

The transferability of results: a success in one setting does not guarantee a success in another.

Other systemic problems such as community effects.

The disability weights are not adjusted to individual circumstances such as income and do not represent welfare: the burden of a disease may be much worse in one setting than another.

Jessica Costello

Evidence Action in the last quarter of 2014

In the first of this series for this year, we recap on Evidence Action’s activities in the last quarter of 2014.

September: ‘Dispensers for Safe Water’ delivers the goods

 developed by South Pole Carbon, which provides a snapshot of the benefits reaped from the ‘Dispensers for Safe Water’ program in Uganda.

More than 1500 chlorine dispensers have been set up in Uganda, with plans for thousands more to be installed by Evidence Action in future. The water purification system requires only a few drops of chlorine solution per filling of water in order to eliminate 99% bacteria, and is delivered by motorbike from central storage points. When approximately a quarter of all Ugandan children under 5 years are regularly affected by diarrhoea, and resulting malnutrition, stunting, cognitive impairment and early mortality, such a simple yet effective system is a valuable solution to the health challenges faced by Ugandan families.

A number of people living in rural Ugandan areas described the positive impact such a water system has had on their lives. For example, a mother from the Luwanga village now saves money on the firewood she would have burned to boil three pots of water daily, and she can now use this time to undertake other domestic activities.

Notably, the ‘Dispensers for Safe Water’ program has reduced the inefficient and unsustainable deforestation of firewood, thereby preventing 60,000 tons of carbon entering the atmosphere annually.

A local promoter, assigned to take care of dispensers and educate families on its use, describes his duties. In addition to checking and refilling the dispenser, he is responsible for maintaining the water point (e.g. weeding around the borehole), recording the number of users, encouraging users to be hygienic, and visiting families in their homes to ensure they are drinking safe water. Close collaboration with local authorities and trained local staff means the effective promotion, monitoring and refilling of dispensers.

Blog

Why I finally took the pledge

Médecins Sans Frontières: a brief review

What values do we need to keep in mind about the DALY? Part I

What values do we need to keep in mind about the DALY? Part II

Evidence Action in the last quarter of 2014

Tips on starting warm winter conversations about effective giving

Why community matters in thinking about social problems

How to combat mistrust of Western health workers?

New Year's Resolutions and Giving

Giving What We Can 2014 Year in Review