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William MacAskill

Living on $1.25 a day - what does that mean? 

1.4 billion people live on less than $1.25 per day. What does that mean?

What it doesn't mean is that these people are living on what $1.25 could buy in, say, Kenya. If you thought that, then you might think that $1.25 isn't so bad, because money goes much further in developing countries.

Unfortunately, the fact that the money goes further in such countries has already been taken into account. What "$1.25 per day" means is: people living on this amount consume the goods equivalent of what $1.25 could buy in the US in 2005. That is to say, the figure is purchasing power parity (PPP) adjusted. That means we can work out how much, in actual money, people in Kenya live on below this line. In 2005, the purchasing power parity conversion factor was US$1 to 29.5 Kenyan Shillings. So $1.25 is about 37 Kenyan Shillings. At market exchange rate (today's rate, so again this is only a rough estimate), that's 44¢.

Because that's still talking about 2005 money, we want to adjust for inflation, so, assuming 3% inflation per year (again, keeping it rough), that's 56¢. So, in my view more accurately, we should say that the global poor, in Kenya at least - though other countries at an equivalent level of economic development have similar PPP conversion factors - live on 56¢ per day. Jeez.

However, the story doesn't end there, because "$1.25/day" doesn't refer to income. It is based on measurements of consumption. So when a person gather sticks from the forest for their own use - that counts as 'consumption'. Similarly, as far as I understand it, any free services provided by the government count in this as well.

So I think a more intuitive way to think about extreme poverty is: if you gave a Kenyan living below that poverty line 56¢, you'd have doubled what they can consume in a day.

A lot of people who know this about the $1.25 a day line subsequently refuse to believe it. I really struggle to believe it. Surely, if someone lived in the US on $1.25 a day, they would die! (I heard this argued in a conference on poverty by an academic who'd written several articles on poverty.)

If we're referring to income, I think that's simply not true. With an income of $1.25 a day you could have a much better quality of life than the extremely poor. You can dumpster dive and live off the excess of the affluent country; they have free access to roads and lighting, a good legal system and police protection, and medical assistance if they get sick. I know someone who lived on $1000 per year for a couple of years - several times more than the extreme poor, but he had a really pretty reasonable quality of life.

However, if you're thinking about consumption rather than income (as you should), there is a difference which does make the comparison to "$1.25 living in the US" misleading: in the US you just can't buy the sort of low-quality goods that you can in developing countries. Markets just don't exist for those goods. Even the most basic lentils and rice sold at Walmart in the US would be regarded as a luxury item for people living on $1.25 a day.

Eliz Kilich

Hilleman Laboratories: A potential answer to the inequity in vaccine need and vaccine supply?

Vaccines have delivered enormous health gains by eradicating some of the worst diseases confronted by humanity. As a result Giving What We Can has been looking into biomedical research projects as potentially high-leverage opportunities for donors. As part of our investigation we spoke with Hilleman Laboratories, a research group operating in new Delhi, India that tries to adapt vaccines to make them suitable for widespread use in the developing world. We concluded that thanks to seed capital from some large pharmaceutical companies they did not have any need for additional funding from our members. However, Dr Davinder Gill, Hilleman Laboratory's Chief Executive Officer kindly made time to talk to Eliz Kilich of Giving What We Can about their research and what 'funding gaps' remain in vaccine research.

What is necessary for a biomedical project to be worthwhile?

I think there are three essential components to a project being worthwhile. Firstly, there must be a public health need. Secondly, it is essential that the appropriate resources and networks are available and can be utilised effectively. The project needs to be financially viable. The third component to a successful project is organisation. The skills, competency, experience and potential outreach of the organisation are critical. There must be a clear goal – a point of completion.

Why have we struggled to produce some vaccines in the past despite substantial investment?

Investment has mostly taken place in the developed world. This does not reflect the areas where the burden of diseases such as TB, malaria and HIV are highest. Therefore vaccines have been developed largely for the needs of the developed world. The issues of access and affordability have not been addressed. There is a clear difference in equity in the developed world and developing world.

In terms of why investment has not directly yielded results is largely because the research is inherently “risky.” There is no real guarantee of success. HIV, malaria, TB are extremely complex diseases meaning we are still unsure which strategy to use when developing vaccines.

Which diseases or approaches are currently neglected?

This includes some of the world’s tropical diseases such as Dengue, Chagas Disease and Leishmaniasis. Respiratory and diarrhoeal diseases are also a major health burden in the developing world with few affordable vaccines available. This will include pneumococci, rotavirus and other gastroenteritis-causing organisms.

In terms of approaches that are neglected, I would say the technical aspects, such as altering the formulation, packaging and delivery method, have been overlooked in the past. The current methods are not optimized for the developing world. For instance, Rotavirus Vaccine licenced in 2006 is in liquid form and needs to be refrigerated in order to thermostabilise the vaccine. If delivery methods can be improved the costs could be kept very low.

What are the main goals of Hilleman Laboratories and what makes it such a good project?

Our goal is to bridge the translational gap between research and development of vaccines to suit the needs of the developing world. We have a unique and strong 50:50 partnership between the Welcome Trust and Merck. Also, by being based in India we have a strong infrastructure to leverage, because the country has a long tradition of actually making vaccines. At the moment we are still in preclinical research but aim to test our products in clinical trials by next year.

What benefit would the vaccines you plan to develop offer?

The main obstacle to the access of vaccines in the developing world is pricing. The vaccines for such diseases (as mentioned above) cannot be afforded by the developing world. Despite organisations such as GAVI subsidising the prices from $50 to about $5 a dose, this is still unaffordable for the broader needs of the developing world. Hopefully, the optimised vaccine will reduce the cost to $1 a dose or less. This saved procurement cost would be added to the saved distribution cost of vaccines by reducing wastage.

Vaccines need to be kept cold otherwise their effectiveness can be reduced a lot and their shelf life is shortened. Vaccines cannot be adequately stored in the cold in tropical climates where transport is difficult. Therefore a thermostable vaccine would impact to reduce the cost dramatically. These reduced expenses for delivery and disposal would reflect in the price of the vaccine. By being manufactured in the developing world the operational cost would also be kept low, allowing the price of the vaccine to be affordable.

What are the pitfalls such research can fall into?

The obstacles include timing. It is important that stakeholders, that will be crucial in the implementation of the vaccine, are brought into the development and conversations early on. Not being fast enough to deal with local agencies, government and distribution could hinder progress. This is because we would be in a situation where technically the problem of vaccine design is solved but we would have no one to take on the vaccine to adapt and implement it.

What is the future for Hilleman Laboratories?

Hilleman Laboratories has a strong and committed mission to address the major needs in global health. As a strong partnership and as a global company we are well-connected to global health policy makers and agencies. Our collaborative model, network and technical innovation provides us with the resources to make our long term goals successful.

Rob Wiblin

Project Healthy Children: a promising opportunity for leverage

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.

Moving people rather than money

, 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.

Jess Whittlestone

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

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:

Blog

Living on $1.25 a day - what does that mean?

Hilleman Laboratories: A potential answer to the inequity in vaccine need and vaccine supply?

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