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Rob Wiblin

We are excited to announce that for the first time in a while, Giving What We Can is changing its recommendations! Below we describe what is happening and answer some natural questions that flow from that.

What is happening with our recommendations?

We are splitting our recommendations into two different categories, and adding a new one to the list - 

AMF and SCI will become our ‘High-confidence recommendations’. They have been vetted extensively by GiveWell, and have a high probability of achieving a lot of good with your money.

Project Healthy Children and Deworm the World will be classified as ‘Opportunities for leverage’. There are two reasons to separate them in this way: their projects have not been scrutinised in the same level of detail as AMF and SCI, and by its nature their approach - influencing health policies in developing countries - is harder to concretely evaluate. If successful, both might achieve more good per dollar than AMF and SCI. However, it is hard to know how likely they are to do so.

We are also going to list other organisations such as

We regard this as a very promising opportunity and more information will be forthcoming in the near future.

We are writing a short report on AidGrade, and will likely have more to say about them in future as their project matures.

We are at an early stage, collecting information on the fundamental cost effectiveness of their work.

Those we have looked at in the past, and a brief assessment of where we stopped 

Global Network for Neglected Tropical Diseases

Project Healthy Children sends experts to low-income countries, now exclusively in sub-Saharan Africa, to hasten and increase the quality of mandatory micronutrient fortification of staple foods such as wheat and maize flour, sugar and oil. They place advisors within recipient governments to offer encouragement, coordination across agencies and technical assistance, depending on what is required to push fortification standards forwards.

A significant fraction of people in recipient countries experience worse health due to insufficient intake of iron, vitamin A, iodine, zinc and folic acid. These deficiencies cause the greatest harm in children and pregnant mothers. Ensuring that commonly-consumed foods contain these nutrients should improve population health.

What are some promising things about Project Healthy Children?

They are promoting an approach - micronutrient fortification of staple foods - that costs very little per person reached, typically under $0.30 per year for ongoing fortification with the most important nutrients. Micronutrient intake is regarded as a top priority health issue for the developing world by the 

Increased micronutrient consumption is highly likely to reduce the severity of deficiency.

They have operated, and probably will continue to operate, in countries with high levels of micronutrient deficiency.

They operate on a tight budget. A single member of staff lives in each country for 3-6 years and is paid a modest income. This individual, with support from two central staff members in the US, can run a full country program to completion for only a few hundred thousand US dollars.

If they achieved a comprehensive national mandatory fortification scheme in any given country, this would affect millions of people. The cost to PHC per person reached with fortified foods per year would be in the order of 1 cent.

We have spoken with four contacts in affected countries who have had dealings with PHC. Their names were provided by a technical fortification expert recommended by PHC. All had a positive view of the competence of PHC staff, felt they were filling a useful gap not filled by other organisations, and were respected and appreciated by recipient governments.

We have heard that some of the countries PHC has operated in, or are considering opening new offices is, are not yet making progress on food fortification.

Our qualitative impression from dealing with them is one of overall competence.

They have described learning from mistakes made in Honduras in the early days of the organisation, and have dramatically shifted approach in response.

They claim to put a lot of research into deciding in which countries to open offices, weighing up the chances of success and the number of people assisted, among other characteristics. Documents they have sent us appear to back this up.

As a result of all of the above, their approach could generate big health gains for each dollar they spend. A ‘naive’ cost effectiveness calculation might be as follow:   

The country has a population of 10 million

They have a one in three probability of the program successfully leading to comprehensive iron fortification to combat anemia

If they succeed, they will bring forward the initiation of fortification by six years

Iron fortification would on average improve health by 0.3% for each person in the country (

), considering both the level of harm caused by anaemia and its prevalence.

This leads to an estimated ~$7 per DALY averted, or ~140 DALYs for each $1000. If this were correct, it would be a higher expected impact than AMF or SCI, and obviously be extremely exciting.

While this is a plausible calculation, I expect that it will turn out to be over-optimistic. Experience shows that the more you learn about an intervention the more likely it is to 

, and be less impressive than you initially thought. The question is how much we should adjust back estimates such as this to account for our remaining uncertainty. This is in large part a judgement call, which is why we are putting forward this information so that donors can make their own judgement.

What are your most significant remaining questions about PHC?

We have not yet scrutinised the literature on how much ill-health is caused by anaemia. GiveWell have suggested that the evidence on this used by the WHO and other groups may not be comprehensive or reliable.

There are conflicting reports regarding the impact of vitamin A and zinc deficiencies on child health. These may be subject to the ‘decline effect’ where high initial estimates are not replicated in future research. For instance, 

. Furthermore, progress has been made on vitamin A supplementation and salt iodisation in recent years, so rates of deficiencies may not be as high today as in the past.

We do not have a clear record of their apparent impact across all of the countries in which they have operated. As such, the positive stories we have heard in Rwanda and Malawi may not be representative. We expect to receive further information about this issue in the near future.

Larger organisations such as UNICEF, USAID, Hellen Keller and GAIN also work on micronutrient nutrition. Previous successes that appear to be caused by PHC may be in part due to the work of other organisations. However, I would note that PHC has given compelling responses to questions about their overlap with other groups.  

They claim that UNICEF does not do their style of fortification policy work.

USAID provides funding for programs, but also does not do work on fortification policy with governments.

GAIN and Helen Keller run more similar projects, but PHC is careful not to open offices where they already have matters covered. GAIN usually focusses on the largest countries, which creates a niche for PHC in providing experts for small, challenging or otherwise neglected countries in need of fortification.

Note that even where a country would otherwise achieve fortification, PHC can still have impact by increasing the number of nutrients used, the share of the population covered, and the enforcement of the policy.

We hope to speak with representatives from these organisations in the near future to confirm all of these claims.

Would you personally give to Project Healthy Children on the information we have?

I will be making a donation to PHC for two reasons. One is that I am optimistic they are having a large impact on people’s health. The second is that I hope it will encourage their further involvement with our research. The value of the information we hope to get from them is significant. If they pass further scrutiny they could be a target for large donations from both us and other effectiveness-focussed donors, which would allow them to operate in many more countries which would benefit from fortification.

What should influence my decision about whether to give to a low or moderate risk recommendation?

If you prefer a high probability of some impact, or are naturally skeptical about organisations claiming to have a large impact by influencing government policy, then our ‘low-risk recommendations’ will be more appealing to you. If you are particularly persuaded by the material available about PHC and DtW, inclined to give them the benefit of the doubt, and comfortable with variable results, then you will be more inclined to give to those groups.

As described above we are collecting information which will give us a more comprehensive view of PHC’s record of success, will aim to speak with other organisations working on micronutrients, and will scrutinise the evidence used to support high benefit to cost ratios of fortification. Further research could both lead us to endorse PHC with greater confidence, or drop it from our list. Those who would like to know more, or offer relevant information, can reach us at research [at] givingwhatwecan [dot] org.

What is GiveWell’s attitude to Project Healthy Children and Deworm the World?

We asked GiveWell about its views on these organizations. GiveWell responded as follows:

"Both Deworm the World and Project Healthy Children are near the top of the list of organizations we would be interested in considering were they interested in working with us. In both cases, we think there are significant unanswered questions about the organizations' track records that lead us to expect higher impact per dollar from our 

 (AMF, GiveDirectly and SCI) relative to these 2.

We would be interested in evaluating both PHC and DTW if they were ready to go through our 

. (In fact, we reached out to both organizations earlier this year suggesting that they engage with us.) In addition, in the case of DTW, we've done considerable work on the 

 and feel comfortable in our assessment of the evidence. We have only done minimal work on the evidence for the types of nutrition programs that PHC implements and, based on our past experience, we feel that this in-depth assessment of the independent evidence for program effectiveness would also be an important step in any assessment we would make.

We agree that both organizations have the potential for leveraged impact, but we think it's worth noting that there are many other organizations in many different categories about which the same could be said. Within developing-world health, there are many other organizations that seek to leverage government resources (examples include 

, and many more) and there are also many organizations that seek to pioneer fundamentally new approaches to old problems, which if adopted widely could have extremely magnified effects (some examples can be found on the 

 website). We also believe that our top charities have their own opportunities for magnified/leveraged impact (see the section just below the "strengths/weaknesses table" of our 

). More broadly, there are many organizations in many causes that work on policy advocacy, scientific research aimed at technological breakthroughs, field research aimed at better informing aid, systems change, culture change, and other interventions that could have enormous effects from a cost-per-DALY perspective. Donors seeking higher-risk, higher-reward charities have many options."

Preferring more strictly vetted charities is a defensible position. Whether you think DtW or PHC can outperform other organisations will be affected by how strongly you assume a charity of this kind doesn’t work until comprehensively proven otherwise. However, given the potential to increase our impact several-fold relative to AMF, I think we should take their approach very seriously both in our further research, and when considering where to give. The risk that PHC turns out to be worse than the alternative has to be balanced against the fact that it could be much better.

While I agree with GiveWell that it is possible that the other organisations listed offer even larger leverage, the research we have done gives us greater confidence in PHC at this point than any of the others listed. The probable existence of other, better, as-yet-unidentified options isn’t relevant for someone deciding between AMF or PHC today.

Project Healthy Children: a promising opportunity for leverage

, one big idea in development that is slowly building momentum as a concept, if not as a reality, is a focus on the movement of people to better places to live and work. One of our research volunteers, Shaun Raviv, recently took leave from Giving What We Can to work on 

 on how migration could reduce poverty which was just published in The Atlantic.

"A very large percentage of people who have gone from extreme poverty to relative financial stability have done so by moving across borders. So why don't we just let more people move?" It does not sound very sexy, but here’s why it is sexy: According to one economist, it is "the biggest arbitrage opportunity in the world” and its upside is “the rapid elimination of absolute poverty on earth."

"To prove the economic power of open borders, supporters often turn to the work of Michael Clemens, a development economist and one of the strongest voices for loosening border restrictions. Clemens is not an open borders advocate, but his research and writings make it very clear that movement of people across international borders should be a much higher priority than it is now. He is, he told me, "in favor of a vastly more sensible way of regulating movement," if not "a utopia of completely free movement." Based out of the Center for Global Development, a think tank in D.C., he has spent much of the past half-decade compiling international labor mobility statistics that are, as he says, "gasp-inducing."

"Barriers to emigration may--according to Clemens's paper--"place one of the fattest of all wedges between humankind's current welfare and its potential welfare." Though he affirms that the research on migration's effects is far from complete, what Clemens has found "suggests that the gains from reducing emigration restrictions are likely to be enormous, measured in tens of trillions of dollars." Remove all remaining barriers to trade, says Clemens, and all remaining barriers to capital flow, and it still wouldn't compensate for the inefficiencies created by current global labor mobility restrictions. His research indicates that allowing free movement of all people across international borders could double world GDP."

"According to Clemens, we are all victims of an epic intuition fail. "Development is about people, not places," he has said many times over, and often the best way to make a person richer is by allowing them to move to another place. We don't really care about helping poverty-stricken Liberia, we care about helping poverty-stricken Liberians. It sounds almost too simple at first: A very large percentage of people who have gone from extreme poverty to relative financial stability have done so by moving across borders. So why don't we just let more people move?"

I recommend reading the whole thing. Now that Shaun has finished working in his article he is continuing to write for us, including looking at the work of 

 which helps poor Mexicans work temporarily as farm workers in the USA, where they receive much higher wages.

 which clearly raises many of the most popular criticisms of open, or at least more porous, borders:

"Restricting immigration is necessary to avert the destruction of the high-capital-to-worker society which is uniquely conducive to technological progress. Even if mass immigration may please some poor immigrants in the short run, it is 'eating the seed corn.' As commenters have pointed out to you before, virtually all the world population growth in the last two centuries has been enabled by the diffusion of technology from advanced countries to poor ones (and one reason most formerly-poor countries are still poor is that they put nearly all their economic growth into population growth rather than capital accumulation, so they stayed near the Malthusian limit!). Transforming all the advanced countries into poor countries by mass immigration will kill the goose that lays the golden eggs."

"Also, there are diminishing marginal returns to immigration. The first few poor immigrants may enjoy big wage gains over their home-country wages (though higher cost of living in rich countries will mitigate those gains) but as more immigrants arrive to compete down wages and fill all the jobs enabled by the available industrial capital, each new immigrant gains less and less over staying home."

We will have to deal with potential downsides like this as we continue to investigate whether migration promotion can compete with our top recommended charities.

GiveWell also recently published a 'shallow' 

 of the potential benefits of migration, though only seasonal migration within poor countries. They offer this cautious summary:

 Domestic seasonal migration may carry large benefits for migrants and their families, but some people who might benefit from migration may not be taking part."

 A funder might support or expand the micro-credit or conditional cash transfer migration support programs that have been studied in Bangladesh, or fund more studies of the impact of such programs in different settings to help address the question of generalizability."

 The authors of the one randomized study to date are planning replications in other countries. It is unclear whether the partner organization from the study will be expanding the program studied to other parts of Bangladesh."

Far larger wage and welfare differences for a given person are found between countries than within them, so I expect we will focus almost exclusively on opportunities for international migration.

Moving people rather than money

Jess Whittlestone

On Saturday morning, I met a friend for breakfast at G&Ds. I had a large cappuccino and a blueberry muffin, which in total cost me £4.50, just 50p less than the budget I'd been living on for 

This was the first "unrestricted" food I'd eaten since finishing the "live below the line" challenge, and whilst I'm not going to deny that I enjoyed eating something that wasn't rice or spaghetti, it also made me feel slightly uncomfortable. I became very aware that for those that live below the poverty line, or in worse conditions in reality, there is no such "Phew, I'm glad that's over and I can go back to my normal diet" moment. Celebrating such a moment suddenly felt pretty distasteful.

Thousands of people over the world have been participating in this challenge, and I imagine many have been blogging about their experiences: what they ate, what the hardest parts were, what they learned. But before getting onto all of that, I wanted to reflect briefly on my reasons for taking the challenge.

Of course, these reasons might seem pretty obvious. 1.4 billion people today still live in extreme poverty. To put this in perspective, the campaign website points out that this is 20 times the total UK population, which I find pretty staggering. By taking this challenge, we're raising awareness, and more importantly, fundraising to bring about change. The Giving What We Can team are still top of the teams leaderboard, now having raised over £16,000 for SCI.

At the same time, I think it's important to realise that what we're not doing by taking this challenge is "simulating poverty" or getting any insight into what it's like to live below the poverty line in reality. On day two, someone shared with me 

, which is quite strongly critical of the challenge for just this reason. The author points out that living on a pound a day for 5 days no more gives you a sense of what it's like to live in poverty day in day out "than you could empathise with the plight of a wrongly convicted death row inmate by spending 24 hours alone in a room. In your house. With the door unlocked." Whilst I think he's overly aggressive in his message (read the rest of the article and you'll see what I mean), and misses the bigger point of raising funds and awareness, I think there is an important message to take away here. We're not doing this to get any sense of what it's like to live in extreme poverty. What it does give us, though, is a sense of extreme appreciation for our own situation - and so hopefully, a strengthened motivation to help those less fortunate.

Porridge. Rice. Spaghetti. Tomatoes. Lentils. A few beans, a few precious teabags.

Pretty much all my meals looked like this:

A little monotonous, but really not bad all things considered. I thought I might get hungry, but actually with big enough portion sizes and the fact that Tesco Everyday Value rice and spaghetti are astonishingly cheap (40p for 1kg rice, 19p for 500g spaghetti), I got by just fine.

Given the point I just made about not even getting close to simulating poverty, I'll first say that relatively speaking the challenge was a stroll in the park. At the same time, it was certainly difficult at times comparad to the way most of us live normally, so I'll share with you some of my hardest moments:

Being invited out for dinner with friends after a talk on Monday evening, and having to say no.

 I mean, I could have gone and not eaten, but by this point I was getting pretty hungry and had my 33p meal waiting at home. Much of my social life revolves around food, and having a limited budget means missing out on things. The "chilli" and rice I'd pre-cooked the previous night tasted surprisingly good, though.

Having a HUGE chocolate cake sat right in front of my nose in the office on Tuesday afternoon when I was just starting to get hungry

.... this was pretty unbearable. The smell wafting in my direction was just so tempting. Why is it that this is the first time we've 

Going out to a chinese restaurant for lunch on Friday and watching everyone eat yummy looking food whilst sipping water

. Unlike Monday's dinner, it was harder just to avoid with Peter Singer there... fortunately the conversation was interesting enough that I just about managed to distract myself from my rumbling stomach!

What did I miss the most? Fresh coffee, without a doubt.

That we pay a huge amount for convenience. It's much easier to go and grab a quick bite after work with friends than to go home and cook, but the former probably costs at least 5 times more. I don't think I'd quite appreciated this before, or how much money I could save if I planned ahead and was prepared to make that little extra effort.

It also just reinforced for me how much eating is a part of my social life, and eating out incredibly ingrained in our culture. Most of the ways we socialise involve spending some money on food or drink - going for dinner, grabbing coffee, meeting for a beer.

On a more positive note, I learned that planning ahead can save you huge amounts of money, and you can really live very cheaply if you stick to a budget, buy food and cook in bulk. I feel I've learned some useful strategies for making the most of my money which I'll use to spend less on food in the future.

Going to the pub on Friday evening after work and meeting Alan Fenwick, director of SCI, the charity I've been doing all this to raise money for. So far I've raised enough money to deworm almost 3000 children, which is well worth missing out on a piece of chocolate cake for!

What a £5 coffee break taught me about living below the line

Stephanie Crampin

It's Live Below the Line week! To find out why I'm living on a pound a day, see 

. I and the rest of the team have been 'living below the line' for two days now, and are very grateful to all our wonderful sponsors, who have managed to put the GWWC team at the top of the team leaderboard, with over £15,000 raised and being donated to SCI, to help them continue treating neglected tropical diseases in the poorest countries, and in one of the most cost-effective ways.

I planned my meals out before going shopping, making sure that I bought enough to avoid hunger pangs. Interestingly, I found out that if I voided the big bunch of bananas I had scanned and put them through separately, I was actually able to afford more!

I started off with a 45 minute run (quickly deciding that keeping this up all week might be a bad idea), followed by banana cooked into porridge, made with water. Oddly this was better than the cereal I'm used to.

Lunch was jam sandwiches and a banana, taking me right back to school packed lunches.

Getting peckish and cold during the day, I managed to consume a can of rice pudding and a fair amount of diet cola too. A coffee meeting in the afternoon became a meeting where I sat and politely sipped water- I think that this sort of thing will prove the most annoyingly restrictive part of the week.

Dinner was the most entertaining meal of the day, and surprisingly tasty due to the lack of fresh ingredients. I don't know if I can call it chili, but I made a stew out of kidney beans, mushy peas, passata, tomatoes and brown sauce.

I realised too late that value canned products come without easy-to-open lids, and, lacking a proper can opener, managed to prize them open with an attachment to a corkscrew that my dad had shown me how to use four years ago. I never thought I would need to use that information. I made enough dinner to last me all week, and with 100g of spaghetti the meal cost 32p. At the end of day one I didn't feel hungry at all, and was fairly confident that the week would go smoothly.

A pattern has emerged in my diet: porridge, sandwich, chili. Fortunately, I enjoy it.

So far I am halfway through and on track for completing the week as planned.

Blog

Project Healthy Children: a promising opportunity for leverage

Moving people rather than money

What a £5 coffee break taught me about living below the line

Halfway through Living Below the Line

Opportunity to intern with Giving What We Can

Dan Pallotta: the Way We Think About Charity is Dead Wrong

What We've Been Reading

Why I Give: Lee Bishop

Should we fund nutrient fortification for kids in the developing world? Part 2

Why give now