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Chloe Kane

Inadequacies in the area of water, sanitation and hygiene (known collectively as WASH), are responsible for a huge number of health problems throughout the developing world, including diarrhoea, the leading cause of childhood mortality. As outlined in our WASH 

, research in the WASH sector has often produced conflicting and ambiguous results as to which interventions are effective. However, two world-class research institutions, Innovations for Poverty Action (IPA) and Poverty Action Lab (JPAL), believing that progress could be made in this area, carried out a series of randomized control trials (RCTs) to try and find a solution. The results of these trials provided strong evidence that installing chlorine dispensers next to water sources is a highly effective method of ensuring the chlorination of unsafe water. Convinced of the effectiveness of chlorine by existing research, 

 (DSW) was then launched. Giving What We Can has been researching DSW since September, and believes that on many measures it looks like a highly cost-effective charity with promising opportunity for leverage. Despite this, we hesitate to include DSW among our top charities at this time, because we have lingering concerns about the strength of the existing evidence for the efficacy of water quality interventions.

What makes chlorine dispensers good - four problems, DSW's solutions:

783 million people in the world, or 11% of the global population lack access to safe drinking water. As a result, people are drinking water contaminated with bacteria that lead to diseases such as diarrhoea.

Water can be treated with disinfectants, and some research has shown chlorine to be particularly effective here, suggesting a 29-35% reduction in diarrhoea. This is due in part to its significant residual effect: it keeps water safe from recontamination for the period over which we expect water to be retained (usually only 24 hours).

Even when the health benefits are well-known, chlorine isn't used if people have to pay for it.

The chlorine from dispensers is free. On top of this, instead of the distribution of individual bottles of chlorine as some charities and trials have done, DSW's system is much more cost-effective - only one dispenser is needed for the whole community.

The public nature of the dispensers, and their location next to water sources serve as a reminder. On top of this, DSW uses community education and local promoters to encourage usage. In keeping with their evidence-based practice, they have carried out RCTs in order to ensure that that such promotion has the widest possible impact, and is continued over a long period of time. The outcome of this is a programme that has seen an average adoption rate of 43% in the scaled up programme. This compares to adoption rates in other WASH interventions of 5 -10%.

WASH interventions are often neglected, and end up in disrepair because maintenance is costly.

DSW has been set up with the idea that it provides a service - not just the initial infrastructure. Maintenance costs have not only been factored into the organisation's budget, but they have once again carried out RCTs in order to ensure that they are using the most effective methods for this part of the programme too.

Scaling up - Dispensers for Safe Water and Evidence Action

Given their early successes, DSW is in the process of scaling up their programme with the aim of reaching 25 million people in Africa by the end of 2018. DSW is now part of the larger organisation 

 that also runs another of our recommended charities, 

, though you can continue to donate directly to both projects.

There are several key elements of their scaling up model that give us reason to believe that DSW will continue to be effective:

DSW carries out research and pilots in regions into which it is considering expanding, in order to determine whether it is a suitable destination for the chlorine dispenser system. In addition, it carefully monitors any partner organizations to ensure that best practice continues to be used.

The Kyoto protocol allows organizations to gain carbon credits if they can show that the activity they are carrying out reduces carbon usage. Since using chlorine means that people no longer have to boil their water in attempts to purify it, DSW earns carbon credits which it can then sell in carbon markets such as the European Union Emissions Trading System. Because of this, they are able to cover a large amount of the fixed costs of running the organization, allowing more of the donated money to be spent on chlorine and dispensers.

The DSW scaling model is such that as the programme is expanded, average costs will increasingly fall. This is because chlorine supply chain costs, and maintenance costs will be lower if several can be attended to in one round. This means that even if DSW expands into areas with lower rates of diarrhoea such that potentially fewer lives would be saved for a given amount of money, the reduced costs overall offset this worry, and permit them to expand into more regions.

Because of the carbon credits system they are using, DSW hopes to be financially sustainable by 2018. That is, once they reach a certain scale (the projected 25 million people) the carbon credits system should be raising enough money to sustain the project without need for further donations. However, to reach that point they have a substantial funding gap to make up. Since a large part of their model is based on economies of scale, donations will be increasingly valuable in making it to this goal.

Current internal estimates supplied to us by DSW put the net cost of one DALY averted at $67.5. DSW estimate that one dispenser with a life-time of 5 years averts 3.97 DALYs, relying on estimates of diarrheal reduction due to Fewtrell et al. (2005) and Kremer et al. (2009). The marginal gross cost for a dispenser of this kind installed in 2014 is $671, but the net cost of $268 is significantly lower due to sale of carbon credits.

The internal cost-effectiveness estimate is indicative of a highly cost-effective charity. In addition, two things should be noted. The figure given is a conservative estimate based on the minimum number of diarrhoea-related deaths averted. This figure doesn't take into account the benefits of the prevention of other water-borne diseases that chlorine dispensers help to prevent, and so DSW's programs may well have a larger potential benefit than this estimate indicates. In addition, costs are expected to decline over time due to economies of scale.

In spite of DSW's many positive aspects, we remain cautious about recommending them at this time. This is due to our uncertainty about the current evidence for water treatment interventions. As GiveWell explore in comprehensive detail in their

, despite many randomized control trials that demonstrate efficacy for water treatment interventions in reducing diarrhoeal disease, the small number of blinded trials to date have failed to find evidence of an effect. While the blinded trials are smaller in number, they also represent a higher standard of evidence. Like GiveWell, we don't believe that we have encountered an adequate explanation for this discrepancy that would allow us to entirely discount the null results reported in blinded trials. As a result, whilst DSW looks highly promising, at the moment we cannot recommend them as a top charity. However, we believe that they are likely to be among the most effective WASH charities, and quite possibly the most effective in this area. Furthermore, future research on water interventions may well resolve our lingering concerns regarding the evidence for water treatment interventions.

Dispensers for Safe Water

Giving What We Can

 about foreign aid, and decided to contribute, with three further myths about individual giving. If you've been inspired to help combat extreme poverty, we hope this video can help you to make a big difference with your donations.

Three myths about charity you should be aware of

Krisztina Csortea

 organized a debate on whether ending poverty is possible, and a video recording of the event is now available 

. The deadline for the first set of Millennium Development Goals is coming up in 2015, and new goals are being formulated now. The panelists discussed the progress of MDGs so far and the next set of challenges facing poverty elimination. If you ever wondered how to be smarter about aid and whether China can serve as a model for Africa or about how to get to "zero poverty" and then stay there, this is well worth a watch!

'Can we really end poverty?' an intelligence2 debate

Stephanie Crampin

Myth: We give money to Africa and nothing changes.

This is just one of the false and dangerous ideas that Bill Gates sets out to tackle in his latest campaign against poverty. 

 of the Bill and Melinda Gates Foundation for 2014 sets out three common misconceptions about government aid, and presents arguments to show that they are mistaken. Not only that, these myths actively cause harm by discouraging people from donating, and thereby preventing poor people from making the progress needed to lift themselves out of poverty.

You can see the full series of Gates’ videos on our 

Gates tackles the first myth that ‘poor countries are doomed to stay poor’, by demonstrating that in fact, “the world is better than it has ever been”. In the last fifty years, there has been a significant improvement in infant mortality rates in many countries, and a huge improvement in welfare in countries such as China and Mexico that have moved from ‘developing’ into the ‘middle income’ bracket. The idea that we can’t do anything to help is harmful as it prevents us from investing our own funds in interventions that will greatly improve the lives of many people.

It’s important to combat these myths and, once the facts are in place, to think carefully about individual giving, and about where you personally can have the most impact. This is because it’s not just the Bill and Melinda Gates Foundation that can make a huge difference to people’s lives; by giving as little as 10% of your own income, you can dramatically and realistically improve the lives of thousands of people. Put plainly, the facts are:

We are spending less on aid than we think, and less than we think we should.

We can each make a great difference individually, and together we can end extreme poverty in this lifetime.

Corruption only makes it more important to give to the best charities.

We can help people in developing countries to help themselves, rather than depend on assistance.

The best health interventions are likely to reduce the problem of overpopulation rather than making it worse.

The best way to avoid the potential pitfalls of aid is to carefully consider which charity to give to. Find out which charities can best use your donation on our 

Stop the myth today

Peter Hurford

Jon Behar left a lucrative job at an investment management firm to pursue dreams of running philanthropic projects. Behar runs a startup called 

 which uses a model called "Giving Games". These games are run at colleges and other areas around the world and engage people in discussions about effective giving.

Rob Wiblin and I sat down to interview Jon Behar and learn more about Giving Games. Here's what we learned:

"Giving Games" are a way to get people engaged in discussing effective philanthropy by asking them to chose where to give a pot of money from two pre-selected choices;

These games can be used to experimentally test why people don't give more effectively and find ways to encourage them to give more and give better;

Donating to Giving Games could be an option to leverage an existing donation to a 

Our mission is simple and consistent with the mission of "Giving What We Can" - encouraging people to both give more generously and more effectively than they otherwise would. I aim to accomplish this by running "Giving Games", which is just a very simple way to engage people in conversations about effective giving. We gather people together and have a conversation about which charity they would like to give to from a few pre-selected options. The group is also given real funds to make a real donation, which gives participants a sense of ownership over the decision and also engages them in a conversation that encourages them to take a strategic approach to giving.

So far we've run about 25 Giving Games, most of which have taken place at colleges, though several were online and in other settings.

I see the model as a way to experimentally test why people fail to give effectively and see if we can find any methods to get them onto giving effectively. A Path That's Clear can test these things as hypotheses. Maybe people are afraid of putting up their own money? Well A Path That's Clear provides the money needed to make the decision. Maybe people don't have easy access to high-quality information on effective charities? A Path That's Clear can provide that information. Maybe people just think that "charity begins at home"? We can test that by running a Giving Game with a local non-profit and a non-profit working in the developing world.

What are some of the results of the Giving Games?

Right now, we're looking at the decisions players make to see if they actually give to more effective charities and see if they are thinking more about strategic giving. We do this through post-game surveys that ask players about their experiences and then also by getting feedback from the moderator of the Game.

The actual results of the Games are encouraging - in nearly all the games, the players have selected the more effective charity. But more importantly, players are indicating that their experience in the Game has changed how they think about philanthropy; they resolve to do more research and think about impact the next time they personally give.

We've also taken audio recordings of the Giving Games so I can listen in and the conversation flows freely. One of the driving factors for this is that we're not just getting a random group together, but rather a group with lots of existing social ties (club, sports team, dorm room floor, class) that are already comfortable with each other.

How has the model changed, if at all, in response to these trials?

 against, not another charity, but rather the option of letting players keep the money themselves. In this game, people chose AMF, but this decision was probably too obvious and the discussion was not as deep as we would have hoped. Once we decided to make the conversation about two different effective charities or about testing critical notions like "giving begins at home", we found the conversations started really going somewhere.

What's your plan for scaling this up? Who are you going to target? And what is your plan for making this sustainable?

In the long-term, I'd like to institutionalize this process at as many schools, universities, and workplaces as I can, though our main focus is on colleges and universities. I want to embed this conversation about how one can do the most good and make this part of the college experience.

We ran a Giving Game at Brandeis University with 25 students as part of their orientation process. That could serve as a pilot to hopefully making the Giving Game or this type of discussion part of the welcoming process of all students. I have started to very recently partner with The 

 to run Giving Games under their brand. I also have a few other leads and I'm optimistic we'd be able to get other donors out there. Lastly, I also intend to run an experiment soon with some economists at George Mason University who study giving behaviour. We'll do a Giving Game in a laboratory setting without a social component, because the social component makes it very difficult to control for variables. We're going to try and test some of the really basic assumptions of the model.

What's nice about the model is that anyone can run a Giving Game. Any donor who wants to leverage their giving by running a Giving Game can do so. I want to encourage as many people as possible to take the idea and run with it.

How do you intend to pay this? Including costs of running?

Initially I'd been funding this out of pocket, but I'm excited about this partnership with The Life You Can Save which opens up a lot more resources. I think that the bulk of the cost will be covered by donations, especially once we get up to scale. Luckily, I think there are a lot of people who would potentially donate to Giving Games. Anyone who is already thinking of donating to a GiveWell top charity can accomplish the exact same donation while also funding us, basically for free, leveraging their impact.

Does the amount of money on the table affect things?

Not much. It does need to meet some sort of threshold to get people interested, usually in the $50 to $250 range. However, in an activities fair, for example, even asking people to decide about a dollar was enough to get them to engage.

What would cause you to give up with Giving Games? Do you have an exit strategy?

Ultimately, the hope is that we'll get people to give more and give better. I need to trust the data to see if we actually do that. If we do five experiments and they all indicate that Giving Games turn people into, say, selfish misanthropic people, I need to respect that. I want to be very conscious as we're setting up the impact measuring systems to measure both the potential positive impacts and the potential negative impacts as well. Therefore, I think we need to get better at systematically measuring our actual impact. The surveys we have in place are nice, but then you have to trust self-reports, and our surveys aren't long-term enough. The logistics here are difficult because we're talking about people in their teens and twenties and we care about how people will give over the next 60+ years.

Something I'd like to do is to get some actual donation tracking set-up, but this introduces privacy concerns. The bottom line is that we're going to have to come up with clever ways to get real-time windows into those long-term dynamics. I think this will be a continual process of ramping up and it will really be ongoing, basically have already been started in the past. The experiment at George Mason that I mentioned earlier will be a big step in the right direction and hopefully even this coming academic year we'll have significantly more ability to measure what we're doing.

What do you think is the greatest weakness of the approach?

I think there's a potential for crowding out. There is the problem of people giving better but giving less, which is a consistent finding in the existing literature. My gut feeling is that it is not going to be an issue and crowding out will be quite minimal because you're concerned about crowding out not in the immediate aftermath, but rather over the participants' lifetimes. Given that most participants have a positive reaction to the game, I don't expect it to be a big issue, but it merits closer investigation and hopefully the George Mason experiment will shed light on that.

Have you had any success getting people to become Giving What We Can members or 

we run Giving Games through Giving What We Can chapters

 where the chapter reaches out to random groups of students and asks them to participate. Generally, we've found that this does get those random people interested in participating in their local GWWC Chapter. But we don't have any evidence further than that and we don't know anyone who's taken the 

Can other people get involved in "A Path That's Clear"? If so, how?

. We love to get inquiries and we're eager to talk to folks and get people as involved as we can.

'Giving Games' and Giving What We Can: an Interview with Jon Behar

Roxanne Heston

__A couple of months ago, Typhoon Haiyan devastated thousands of lives in the Philippines, wrecking communities and tearing families apart. These people, unconnected to most of the world prior to the disaster, soon became the centre of our attention, as the rest of us shuddered to envision our own communities and families disappearing from around us.

It is a bittersweet trend that has arisen in recent years in which the suffering of others far away brings us closer to them. The outpouring of funds, volunteers, and goods proves that our compassion can extend beyond physical and social barriers to help those most in need. Schools, congregations, and the like band together to do what they can for the victims - people, we quickly realize, who are in many ways like ourselves. Media images of distraught parents and desperate children poignantly hit home, showing families beside the ruins of houses or amongst what were once their own schools and congregations. For the weeks in which the suffering in the Philippines dominated news headlines, we empathized not with their specific plight, but instead on a more fundamental level: with their need for health, safety, and wellbeing.

Now a couple of months later, other concerns and festivities take up our attention, and the plights inflicted by Typhoon Haiyan have trickled from newscasts and discussions. Thoughts of those in the Philippines have been stowed as a memory of a movement, no longer stirring the compassion and union that spurred a movement initially. Although waning empathy is unfortunate, it is only inevitable that others' struggles slip out-of-mind as they fall out-of-sight.

It is incredibly valuable to remain resolute, in part because it is so easy to assume that our help is no longer needed. It is in the lull between disasters, when popular attention diverts to other matters, that it is most important we stay attuned, to reach out to our global community even when its voice in the media has become quiet. In the far aftermath of devastations, we can still relate to the care we felt for those who suffered and lend a hand to those around the world when few recognize a hand needs lending. With those memorable events in our heads and our hearts, we can reach out to those who could always use our help in obtaining the same simple necessities of health, safety, and wellbeing we afford our own.

What Typhoon Haiyan can teach us about compassion

Carolina Flores

Christmas can inspire giving and sharing with our loved ones. Why not expand our generosity to the neediest people in the planet? Giving to effective causes allows us to make a big difference in the lives of others. To make giving easier this Christmas, we have created a page for Christmas donations, where you can also donate in someone else's name.

Despite the consumerist frenzy it has come to be associated with, there is something beautiful about the spirit of Christmas. Spending time with the ones closest to us, giving and receiving presents, sharing in common cheerfulness - these can all be wonderful displays of love for others. Why not spread this generosity all over the world, and reach out to those who are suffering in extreme poverty?

We are in a position to give so much: we can give health, life, education, and opportunities to thrive to people all over the globe. We can make Christmas an opportunity to make a difference in the lives of people who are suffering.

And how can we make the biggest difference? One of the ways to do so is to donate to effective charities - charities which, according to a large body of research, save the most lives with a donation. In this way, the generosity inspired by Christmas can have a real impact in improving others' lives. There is no better way of expressing compassion, solidarity and love than by giving to those who need it most. This is why no Christmas gift can be better than helping others.

The best gift you'll give this year

Julia Heckenast

Neglected tropical diseases (NTDs) are having a serious impact on some of the world's poorest populations by depressing economic development. In this blog, we examine the economic impact of onchocerciasis, commonly known as river blindness, which is such a disease. Spread by blackflies, the sufferer's body is eventually infested with worms, causing a range of debilitating symptoms, including blindness.[1] The socioeconomic impact of the disease is complex, affecting individuals, village communities and the national workforce, with an estimated 1 million disability-adjusted life-years (DALYs) lost worldwide. Leaders of past successful control programmes declared victory over river blindness, but in reality, millions of people still remain at risk of the disease.[2] However, it is clear that unlike other diseases such as HIV/AIDS, successful elimination of onchocerciasis could be achieved more easily than we think.

The parasitic nematode causing the disease is rife in 27 sub-Saharan African countries, with around 37 million people infected, and 90 million more at risk.[3] The parasite was also imported through the slave trade to six Latin American countries.

To begin to understand the economic burden of NTDs, we searched key repositories of health-related publications including PubMed, the World Health Organisation (WHO) and Cochrane websites combining a variety of disease-related search terms with a selection of economic-related terms. Disease-related search terms included all of the 17 NTDs as defined by the WHO,[4] and economic-related search terms included words such as burden, cost and employment. Diseases with inexpensive treatments that affect the largest populations were prioritised, such as onchocerciasis. The economic burdens of NTDs in developing countries were reported in a total of 282 articles, which we then subdivided by disease area giving 22 articles for onchocerciasis. Of these, we were able to access 16 articles for our review.

The socioeconomic burden of the disease can be felt on several levels. The early symptoms are often disabling, with itchy skin, muscle pain, reduced immune response, and visual impairment that can lead to blindness. We see the most drastic effects in small communities where most people are infected: up to 6.5% of the villages surveyed in Guinea were blinded.[5] After losing his sight, a previously healthy young man whose body was his only means to an income, is unable to work properly, can hardly walk beyond the village and spends the little he earns on health costs. His self-esteem and concentration suffer, and he is unlikely to ever get married or have a family.[5] Even without visual impairment, he would earn significantly lower wages.[6] For a child, the impact on their education damages their future prospects and leads to an estimated 17% drop in future income.[7] Whole villages are abandoned for fear of the disease, leaving acres of fertile land deserted, which has a knock-on effect on the wider economy.

This extensive impact of onchocerciasis is responsible for 1 million DALYs worldwide, which is a measure of healthy life-years lost due to disability and mortality.[2] This impact is three times that of the effect of asthma in the UK.[8] To counter this, several control strategies have tried to bring an end to the debilitating effects of the disease. Historically, both anti-vectorial and anti-parasitic measures have been used with some success. In 1974, the WHO started the Onchocerciasis Control Programme (OCP), poisoning blackfly breeding grounds in West Africa to try to interrupt parasite transmission. In some areas, children born after the initiation of the programme were no longer at risk.[2] A similar international programme, the African Programme for Onchocerciasis Control (APOC) was also established in 1989, with the help of pharmaceutical giant Merck, to begin mass distribution of the anti-parasite agent invermectin. By the end of 2005, over 40 million people living in 90,000 African villages affected by onchocerciasis had been treated. The cost of this programme was estimated to be only $0.74 per person, making this a highly cost-effective approach.[2]

The success of these programmes has consigned onchocerciasis to the bottom of the public health agenda at a time when consolidating these achievements and ensuring long-term success would be critical. It is clear from our research that control of onchocerciasis needs to be extended to wider areas, and that elimination is feasible. For example, one study estimates that three NTDs, including onchocerciasis, could be eliminated from Latin America and the Caribbean by 2020 for $128 million. In Nigeria, which has the highest rate of infection in the world, onchocerciasis could be eliminated in just a few years for an annual cost of less than $1 per person. Having said that, new programmes need to be designed to be sustainable and supported by communities in order to make onchocerciasis a disease of the past.

By Julia Heckenast, working pro bono on behalf of Costello Medical Consulting, with a wider team at Costello Medical Consulting

1. Jamison D, Breman J, Measham A, et al. Priorities in Health. The World Bank, 2006.

2. Basanez MG, Pion SD, Churcher TS, et al. River blindness: a success story under threat? PLoS Med 2006;3:e371.

3. African Programme for Onchocerciasis Control [APOC]. Final communiqué of the 11th session of the Joint Action Forum (JAF) of APOC, Paris, France, 6-9 December 2005. Ouagadougou (Burkina Faso): APOC. 2005.

4. Souery D, Papakostas GI, Trivedi MH. Treatment-resistant depression. Journal of Clinical Psychiatry 2006;67:16.

5. Evans TG. Socioeconomic consequences of blinding onchocerciasis in west Africa. Bull World Health Organ 1995;73:495-506.

6. Workneh W, Fletcher M, Olwit G. Onchocerciasis in field workers at Baya Farm, Teppi Coffee Plantation Project, southwestern Ethiopia: prevalence and impact on productivity. Acta Trop 1993;54:89-97.

7. Martin G, Grant A, D'Agostino M. Global health funding and economic development. Globalization and health 2012;8:8.

8. Murray J. UK health performance: findings of the Global Burden of Disease Study 2010. The Lancet 2013.

Should we be blind to the (economic) burden of onchocerciasis?

Costello Medical

In this blog we take a look at the economic impact of a parasitic worm infection responsible for a large proportion of epilepsy cases in the developing world. The disabling nature of the disease translates into a huge economic burden on both a personal scale for the sufferer and for the countries where the disease is prevalent. By demonstrating the value to be gained from disease elimination we hope to demonstrate the importance of investment in appropriately funded and designed control and eradication programmes.

 (NTD) identified by the WHO and is caused by the larval stages of the tapeworm species Taenia solium, which affects both man and pigs. [1, 2] The disease remains a big issue in many developing countries, mostly affecting the health and livelihoods of the poorest populations within a country.[3] The fact that the disease is entirely preventable, makes its impact on health and economy even more devastating. Epileptic seizures, chronic headaches and memory loss are all common symptoms of infection that contribute to the morbidity of the disease.[4] The disabling nature of these symptoms translates into a huge economic burden to the sufferer in the form of expenses needed for treatment and productivity losses,[4] making disease control essential yet desperately lacking.

For people living in developing countries around the world, one of their only economic productivity assets is often their body. The economic shock of a debilitating illness, like cysticercosis, can drive a sufferer into abject poverty.[5] Although data on the global disease burden of cysticercosis is limited, it is estimated that there are approximately 50 million people in the world living with the infection and that epileptic seizures occur in 50-70% of all symptomatic cysticercosis cases.[4]

To begin to develop a better picture of the economic burden of cysticercosis across the globe, we searched key repositories of health-related publications including PubMed, the World Health Organisation (WHO) and Cochrane websites combining a variety of disease-related search terms with a selection of economic-related terms. Disease-related search terms included all of the 17 NTDs as defined by the WHO, and economic-related search terms included words such as burden, cost and employment. Diseases, like cysticercosis, with inexpensive treatments that affect the largest populations were prioritised. A total of 282 articles met our inclusion criteria, which we then subdivided by disease area giving a total of [9] articles for cysticercosis. Of these, we were able to access 8 articles for our review. The locations of these studies included East Asia, South Africa, West Cameroon, Mexico and Peru.