Episode 3: What

Transcript

Stephanie Tam: So, some of you have probably been approached, at some point in your life, by a charity worker with a clipboard on the street.

Sam Deere: Yeah, I think that probably happens most of the time I go down Cornmarket Street.

Stephanie Tam: Right, and when that happens, I usually end up wondering, well, it all sounds pretty good, but is this the best use of my time and money? In our last episode, we wrestled with tricky questions around how to help: how we can test good intentions and ideas about how to solve problems like high crime rates, the kind of evidence we should be considering, and the risks that we should weigh.

Sam Deere: In this series, we explore the idea of effective altruism. It’s a way of combining the empathy and compassion that motivate us to do good things, with the evidence and reasoning that helps us do those good things more effectively.

Stephanie Tam: Over three episodes, we take questions that keep us up at night, like — why should we care for distant strangers at the cost of ourselves and our own communities? Or, how can we make sure our donations are doing the most good? — and wrestle with just how hard it is to help in the face of suffering and uncertainty, and enlist experts — from philosophers and statisticians to social workers and practitioners — to find a way forward.

Sam Deere: In our final episode, we take a look at what. What’s actually working out there, right now? What are some programs to which can I donate my money and be confident that they’re saving lives or doing a lot of good? What do solutions that are global in scope, cost-effective, and scientific look like? And is charity the only way to make a difference? What else is possible?

Stephanie Tam: We’ll start with a major problem in public health that many in the effective altruism community care about because of its importance, cost-effective solutions, and neglectedness: the life-and-death stakes of malaria and its surprisingly tight relationship with global poverty …

Sonia Shah: And when I started digging into that question in various ways as a science journalist, it became clear to me that malaria alone could explain a lot of why some societies are poor and some societies are wealthy.

… the good work that is already being done to fight malaria, and how we can help out …

Rob Mather: So long-lasting insecticidal nets are accepted by all of us, really, involved in the campaign against and the fight against malaria, as the first line of defense because it's not only a mechanical barrier, it's also a chemical barrier, and it works very very well.

… and the tricky debate about direct interventions, foreign aid, and investing in sustainable development and technologies.

Sonia Shah: I think our whole mentality about how we help people needs to shift. You know, we shouldn't think of it as: well, what's easy for us to do, what makes us feel good? So we need to be listening to people on the ground and hearing what they want help on! You know, and I think it behooves us as people who actually do — really do want to help, to listen to that.

Sam Deere: You’re listening to Doing Good Better, a production from the Centre for Effective Altruism. It’s a podcast that explores how to combine head and heart to wrestle with how to, well, do good …

Stephanie Tam: … better.

Sam Deere: I’m Sam Deere.

Stephanie Tam: And I’m Stephanie Tam.

Rob Mather: So, malaria is a parasite that — in fact there are five types of malaria parasite — and they are transmitted by the bite of a mosquito, so that’s how we as humans become infected with malaria. It’s a particularly debilitating disease, and of course it is one that can kill.

Stephanie Tam: This is Rob Mather, who makes a case for malaria as a killer we should care about.

Rob Mather: I set up and run the Against Malaria Foundation and we fund bed nets to protect people from malaria, particularly in sub-Saharan Africa. And if we look at some of the numbers around malaria, between half a million and a million people die from malaria each year, depending upon which numbers we focus on. Gathering data in Africa can be challenging at times. However we look at it, it's a very large number of people.

Sam Deere: In 2015 alone, it’s estimated that around 214 million people fell sick from malaria.

Rob Mather: So by any measure it is a humanitarian issue. It perhaps becomes even more emotive when we look at the particular individuals who are affected, and some seventy percent of the deaths are children under five.

Sam Deere: Pregnant women are also especially vulnerable to malaria.

Rob Mather: So it is a humanitarian issue and it is also an economic issue, because if we look at what happens when people fall sick with malaria, they can't teach, they can’t farm, they can't drive, they can't function. And that has a very significant effect on the domestic output — the productivity — often referred to as the gross domestic product — the GDP — of a country, indeed of a continent. So if we would all like to assist Africa in improving its GDP circumstances and how it prospers, then malaria is towards the top of the list in terms of something that we need to fix.

Sonia Shah: If you're poor you're more likely to get malaria, of course.

Stephanie Tam: This is Sonia Shah.

Sonia Shah: I’m a science journalist and author of a book called The Fever, How Malaria Has Ruled Humankind for Five Hundred Thousand Years. I'm interested in, actually, inequality between populations and within societies, and it seemed to me that, you know, health was a major sort of defining factor of that difference. And when I started digging into that question in various ways as a science journalist, it became clear to me that malaria alone could explain a lot of why some societies are poor and some societies are wealthy.

Stephanie Tam: That’s really interesting. So effective altruism is really interested in alleviating global poverty. What’s the relationship between poverty and malaria?

Sonia Shah: Well, I mean, there’s the obvious one, which is that if you're poor, you’re more likely to get malaria, of course — because if you're poor you’re more likely to live in a home that doesn't have window screens, that doesn't have regular electricity, so you might be outside a lot more. You probably live in marginal lands that are poorly drained. There might be standing water around, the roads might be rutted, etc. All these things contribute to the way poverty makes you more vulnerable to getting malaria.

Sam Deere: However, it also works the other way around.

Sonia Shah: But what we also now know is that having malaria itself can cause poverty, can lead to poverty. You know, just having malaria, of course, it's an economic burden. You know, in rural areas it strikes most often during harvest time. So exactly when families need to be out in the fields, reaping the harvest of all the investment they've made all year, they’re home, sick, in bed with a fever.

Sam Deere: So, the malaria-poverty relationship becomes something of a vicious cycle.

Sonia Shah: But it also, you know, malaria strikes pregnant women and children hardest. And so societies that have a lot of malaria tend not to invest as much in those sectors of society, those parts of the demographic, and that has kind of long-term, follow-on effects, so that economists like Jeff Sachs have actually figured out that just by having malaria in your society depresses GDP growth by 1.3% every year. And if you think of that compounding, you know, year after year after year after year, you think some of these societies have had malaria for centuries and longer than that, you know, so that's a pretty heavy toll over time.

Stephanie Tam: And how do economists come to these kinds of conclusions?

Sonia Shah: There are studies done early on in the early twentieth century. This was done in Central Africa by a mining company, where they went in there and, you know, of course, there's tons of malaria and tons of other diseases as well, and that was really impeding their ability to just function — you know, just have this mine functioning — because their workforce was so sick all the time. Anyway, they were able to engineer the landscape so that they didn't have malaria anymore. You know, they kind of graded the area, got rid of the standing water, stuff like that. They still had all the other things that make people sick. They still had bad food, unsafe water, not enough health care, all that other stuff;  but they took malaria out of the equation, and what they found is that mortality from everything — so, all cause mortality — went down. Just by getting rid of malaria, you get this drop in deaths from everything else. So it’s this sort of underlying kind of contributory factor.

Stephanie Tam: All of which makes Sonia’s hypothesis — that malaria alone could explain a fair bit of global health and poverty — pretty compelling.

Rob Mather: I think one of the numbers I would offer you is that for every million dollars we spend on fighting malaria effectively, it is often quoted that it improves the GDP of the continent of Africa by twelve million dollars.

Stephanie Tam: That’s Rob Mather again.

Rob Mather: Now if we were to go to a series of investment professionals and say — “We're not going to focus on the humanitarian issue, we're not going to focus on people dying and people falling sick, and we're not going to invoke in our minds what would happen if our children were to go to sleep at night with the risk of not an itchy bump if they were bitten by a mosquito, but potentially a death sentence. We're not going to invoke any of that. We're just going to focus on the investment return if we put these quantities of money into effectively and efficiently fighting malaria, particularly in Africa, look at this return!” — many investment professionals would say, “I want to beat a path to your door.” So I think there's a humanitarian and there's an economic argument to say that malaria is something that should be right at the top of our lists.

Stephanie Tam: So, having heard all of that — the scope of malaria, which kills a vast number of people, and its many other knock-on effects in terms of poverty — let’s talk about solutions: what we can do, and what is being done already to fight malaria within one of the charities recommended by the Centre for Effective Altruism, which is — you guessed it, AMF.

Rob Mather: So we have a very simple approach. We have people that raise money through us through sponsored activities, and of course there are others who simply donate money at AMF. We then take all of the public's money — so a hundred percent of the money that's given to us by the public — and we buy long-lasting insecticidal nets (LLINs). Because what we have on our side is that the pregnant female, who needs a blood meal to reproduce, tends to bite between ten o'clock at night and two o'clock in the morning.

Sam Deere: In other words, when people are sleeping.

Rob Mather: So if we can protect people when they're sleeping with a mechanical barrier — a bed net — but one that is also impregnated or covered with insecticide, then when the mosquito lands on the net, it picks up a little bit of insecticide on its feet and it causes what we call knock-down, which is a polite way of saying that it kills the mosquito. Now the insecticide is safe for anybody that is inside, so even a very small baby inside is not going to suffer any negative effects. And the particular value of these nets is that, as you might imagine, they are distributed in some very challenging environments, and so nets can become damaged and torn and one of the wonderful things, if you like, about the long lasting insecticidal net, is that even when you have tears and holes — which gives an entry point, potentially, to the mosquito — but because the mosquito doesn't do a small aeroplane aerobatics maneuver through a hole; it lands on the net and then migrates to the hole. So it’s not only a mechanical barrier, it's also a chemical barrier and it works very, very well.

Stephanie Tam: And how much do these nets cost to distribute?

Rob Mather: Well, the nets cost two and a half dollars each, on average. And then on top of that you're adding typically another dollar and a half. So that would be for the shipping, and the pre-distribution, and the distribution, and the follow-up. So we’re looking at something like four dollars a net. And that those nets protect two people on average, and they last for somewhere around three years.

Stephanie Tam: Can you talk to me a little bit about that monitoring and evaluation?

Rob Mather: So there are two things that we would focus on. The first is to ensure that the nets actually get to beneficiaries, to populations, as intended. So for us what that involves is focusing on data, and it particularly involves visiting every single household, in a distribution area, that is going to receive a net.

Sam Deere: For instance, health workers would visit households to learn how many people sleep there,  so they can account for how many nets are needed for each household.

Rob Mather: That data is put into electronic form — it’s put into a database — so it’s highly visible, so it can be part of a very accountable and transparent set of preparations for distribution. And in our particular case, we report on that in great detail, for those who wish to look at the details, but also in summary form for those who wish to look at the summary.

Sam Deere: So that’s the first part.

Rob Mather: What we then focus on is what we call post-distribution monitoring. So we track every six months by visiting five percent of the households that receive nets. They’re randomly selected, they’re visited unannounced, and that's the best way of gaining statistically significant information in an unbiased fashion, to allow us to understand: what is the coverage level off to six months and twelve months and eighteen months? And we do this for two and a half years. And what is the state of those nets? What is the condition they're in?

Stephanie Tam: Right. And what are the kind of coverage rates we’re talking about?

Rob Mather: If you look at a mass campaign, you would hope to achieve somewhere in the region of ninety-five percent of sleeping spaces covered, on day one. And you typically find that after a year — after twelve months — you would hope to find coverage levels still in the sort of eighty-five percent and above range; and then after two years you would hope to be somewhere around the eighty percent range; and then after three years, when a re-coverage campaign would take place, you may well have dropped towards sixty percent or something like that.

Sam Deere: In other words, some of these nets degrade over time in the kind of tough environments they’re distributed in.

Rob Mather: So that's the reality, so what we hope to do is to work to achieve at least eighty percent coverage over the majority of the three year period, because that will ensure that we don't allow malaria back in when we’re shutting it out through the distribution of these nets.

Stephanie Tam: That makes sense. And is that about the goal you’ve actually been meeting?

Rob Mather: We have in Malawi, we have not in DRC. Time will tell in some of the other locations where the post-distribution checkups — as we call them — are at early stages.

Stephanie Tam: And what kind of evidence is there to prove that bed nets are actually effective at preventing malaria?

Rob Mather: Well, the first studies were done — I think — as long ago as about thirty years ago. And a number of randomised controlled trials have taken place.

Sam Deere: So, to recap from Episode 2 — which you should definitely go back and listen to if you haven’t already — a randomised controlled trial is an experimental method that gives us a really good standard of evidence that something works. The idea is that you take a group of people, randomly sort them into two groups — so that the groups are more or less the same — and then you give one of the groups a treatment. In this case, the treatment is malaria nets. The other group, known as the control group, gets no treatment. So when you compare the outcomes for the two groups, because the only difference between them — at least in theory — is that one of them received the malaria nets and one didn’t, you can conclude that malaria nets are responsible for the different outcomes.

Rob Mather: There's a wealth of evidence, I suppose, that's very much on our side when we have looked at the value of distributing bed nets. There are a number of studies of studies that have taken place that have also drawn that information together to really investigate, in great detail: how sure are we that nets work?  And I think, going back a number of years now — probably fifteen to twenty years — the evidence started to be put in place that indicated, at a very significant level, that nets are very effective indeed.

Stephanie Tam:  And how much does it actually cost, so — if someone were wanting to donate to save a child from malaria — how much would that cost, to save a life?

Rob Mather: The simple answer, if I was to give one number, would be about three thousand dollars. There is an organization — there are a number of organizations in fact — that have looked at this calculation, and said, let's take the cost of a net and the cost of distributing it, and the number of nets we would have to deploy statistically, given the studies that have been done, that equate to one life being saved — or perhaps more correctly, one death averted. But that number, the direct answer to your question, is about three thousand dollars.

Stephanie Tam: So how how does that three thousand number get calculated, given that nets cost about two and a half dollars, and then, you know, a few additional dollars for distribution?

Rob Mather: Okay. So if you were to — obviously, if you and I were to go to a village in Africa, and there were five hundred people and we were to deploy 250, we wouldn't be able to say that two hundred fifty lives had been saved.

Sam Deere: That’s because not all of those 250 people receiving the nets would necessarily have died from malaria in the first place. Remember, malaria only kills a small fraction of the vast number of people who fall sick.

Rob Mather: But statistically what we would find, is that if we were to distribute ten thousand nets over here, and protect twenty thousand people and if we were to not distribute ten thousand nets over here, and not protect twenty thousand people — if we were to come back a year later and look at the mortality numbers and see what had happened in those populations that were equally affected by malaria, what we would find is that if we took the total cost we had spent on the nets in the distributing and the monitoring, and we looked at how many fewer people had died in the environment where nets had been distributed, and we perform that calculation, we would find that effectively, the deployment of the nets had led to about two to three thousand dollars being required for every life that we saved.

Sam Deere: Another way of thinking about the cost of saving a life is in terms of a unit called a DALY, which stands for Disability Adjusted Life Years.

Rob Mather: Now the disability adjusted life year is, in a sense, a measure of overall health impact or disease burden. In a sense what it's doing is saying: let's look at how many years of life are lost because of this disease, let’s say, and also how many years are lived with either disability or reduced function, if you like, and to try and combine those two and say: as a result of this disease, it is affecting somebody's life and removing this number of years, because it’s causing early death, if you like, and there are a number of years of their life that are being lived less fully.

Sam Deere: Then there’s the Quality-Adjusted Life Year, or QALY.

Rob Mather: The other way you can look at it — the other way around, if you like — is a quality adjusted life year which in a sense is: how much does it cost to give somebody an additional year of life? So we can actually give somebody a healthy year of life, one year of healthy life, for x dollars. And that's another way of looking at this economic decision making that has to be made when it comes to health interventions.

Sam Deere: So, by using a measure like a DALY, you can start to make some rough comparisons between different ways of making people healthier. The lower the cost per DALY, the more health that you can create for a fixed amount of money.

Rob Mather: You're looking about the very low numbers of a few thousand dollars, and when you think that — I think in the UK, and it's probably very similar in America and Australia and Canada and many other countries in the world —I think in the UK our National Health Service is prepared to spend thirty thousand pounds on extending a person's life by a year.

Stephanie Tam: All of which goes back to Leah Libresco’s point in our first episode, about the exciting opportunity these charities provide to save lives, because our money can go much farther in so-called developing countries. But there’s also another debate, when it comes to how to help: that we should not only be focusing on direct interventions like bed nets, which might be regarded as band-aid solutions, but also investing in developing technology or long-term policies that will eradicate the problem altogether.

Sonia Shah: The thing that we don't know how to do yet, or that is very very difficult to do, is to bring it down to zero. And once you bring it down to zero, then it's not coming back.

Stephanie Tam: Science journalist Sonia Shah again.

Sonia Shah: Because this is a living system, right? We're talking about mosquitoes and parasites that have been around for a long, long time. They have a lot of defenses to fight back when we try to control them. And one of the ways they do that is of course by evolving resistance to our chemicals, and that usually takes anywhere from three to seven years, if you use it enough. You know, the more you use it, the faster it's going to become useless. So it's sort of this catch-twenty-two. So we have to keep coming up with newer and newer tools — like, okay, we use this one for a while, it stops working, let's keep developing a new one so then we roll out the next one, and then the next one and the next… And you know, it's become sort of a cold war kind of situation.

Stephanie Tam: Yeah, and I mean, I guess one of the big problems or concerns, in the aid community, is that we are actually potentially speeding up resistance of mosquitoes. But I mean, that also doesn't seem like it's something that can be helped, and maybe it's just a problem with every vaccine and every antibiotic ever.

Sonia Shah: I mean, yes and no. I think there are kind of innovative ways to get around that problem. You know, if we actually accept the fact that these are living creatures that want to survive and have their own strategies for doing that, so it's not just about killing them with like the biggest gun we can get. But what about using evolution on our side? And there's actually a few interesting ideas about controlling mosquitoes when they're older, for example. Now, young mosquito is not going to ever make you sick, right? Because it takes time for a mosquito to a) get infected with malaria, and then it has to develop; the malaria parasite has developed inside the mosquito’s body for anywhere from — you know, it could take five to seven days. So by the time the malaria mosquito is infective to another person, it is a very, very old mosquito. That's pretty much at the end of their lifespan, because a typical mosquito only survives about a week. So we're talking about grandmothers, right?

Stephanie Tam: Oh my God. That’s such a weird concept, too. The dangerous mosquitoes are the grannies, actually!

Sonia Shah: Yeah! Yeah, it’s the granny mosquitoes. The old mosquitoes are going to get you. But that's really useful fact for us, because, you know, you don't necessarily have to depress the entire mosquito population. You need to breed and have babies and live to maturity and all that. We just want to shorten their lives a little bit.

Sam Deere: So, as it turns out, there’s actually a lot of work being done in this area — controlling malaria by genetically modifying mosquitoes using a gene-editing technique called CRISPR. These techniques are still in their infancy, and it’s hard to say whether they’ll work. But if they did, in the long run, maybe this would be more cost-effective than using bednets.

Stephanie Tam: I know there’s some excitement around this new CRISPR technology so that they’re incapable of transmitting malaria to humans. Do you think that's a good solution for eradicating malaria?

Rob Mather: Well, I mean, as the science progresses, time will tell but I mean — I suppose my comment would be — I hope so! Because if I look at the number of people that are affected by malaria and that die from malaria and the economic impact, we've really got to sort it out. If a vaccine can be found and it means that nets are no longer needed — terrific. If a genetically modified solution can be found and the scientific community, and all of us who ultimately engage with us as well, believe that that is the way to go, terrific. In the meantime, our aim is to do the most we can to cover people with nets.

Sonia Shah: I think there's a lot more that could be done that's way better. Way better. I mean, we know what works. There's parts of the world that had a lot of malaria and now they don't. What happened? They developed. They developed, they got more prosperous, people got better homes, people got better roads, people got better healthcare systems so that they could go to the doctor when they're sick and get medicines right away, you know. All that stuff happened and we got rid of malaria in lots of places in the world. So that's what we need to do, and that's what — places where there is a lot of malaria — that's what they want, too!

Stephanie Tam: Hm. Yeah. So essentially it’s actually, the solution is partly infrastructure and just improving the overall lifestyle standard of living?

Sonia Shah: Yes. It's overall development and health care infrastructure. All of that, you know, is just putting into process a system of development that continues, that's sustainable, that keeps going. There are also immediate things that can be done that, in my view, could be a lot more sustainable over time. For example, there’s efforts to train community health workers. You know, community health workers who could look at a certain community and see: okay, well, in this community the malaria mosquitoes are all breeding in this ditch because it's blocked with garbage. So why don't we hire a bunch of kids and clear all this garbage out? And now suddenly we have far fewer mosquitoes and we have less malaria too. And that’s something that people in their own communities, if they're empowered to learn about malaria, learn about the malaria ecology and come up with a local solutions that will only work in that one place. I mean, that's not something you can scale up, that everyone can do it everywhere.

Stephanie Tam: Yeah. That's a really interesting solution and I sort of wish that there were ways to test that on a standardized thing. But I agree that that’s part of what makes it perhaps local and sustainable. Do you know if that's actually been done in any areas?

Sonia Shah: Yeah, there's definitely examples of places where local science has figured out local solutions that work locally, and it's little things — little parts of environmental management where you can actually really bring down the malaria rate. It’s been done in Mexico, it’s been done in China, it’s been done in parts of Africa as well.

Stephanie Tam: Which brings us to the question of foreign aid, which can sometimes be contentious among those working in development.

Stephanie Tam: So okay, in terms of foreign aid — good thing? Not good thing? A way to contribute to even, say, these kind of, like, local development efforts?

Sonia Shah: Sure. I mean I think it could. I mean, I haven't seen it doing that so much but I think you could, absolutely. I mean, I think our whole mentality about how we help people needs to shift. You know, we shouldn't think of it as: well, what's easy for us to do, what makes us feel good? What satisfies our funding cycle and our ability to keep getting more money to do this thing that makes us feel good? That's to me, that’s sort of the ethos in a lot of aid work, and that needs to change. So we need to be listening to people on the ground and hearing what they, what they want help on! And I think in a lot of cases with malaria, they might say: we don't want help with that. We want help with getting jobs, we want help with better homes, we want help with, you know, telecommunications — better cell service. That might be what they want, you know. And I think it behooves us as people who really do want to help to listen to that.

Rob Mather: Now there are some very valid and sometimes complicated arguments that become political about foreign aid, and funding. Our focus is that as we wish to cover people with nets we want to be alive and aware to the issues, some of the complicated issues that surround foreign aid going into different countries. But we cannot ignore the fact that we we need to protect many people from malaria, and it is a very large team effort.

Stephanie Tam: And in that sense, it sounds like the local economies aren’t able to meet that challenge on their own?

Rob Mather: No. I think the simple answer is no. Again, we get into political discussion, potentially, in some countries in Africa. The level of governance comes under significant scrutiny, which is probably the polite way of putting it. And, you know, I think there is a really valid discussion about where funds are being allocated, and should countries be funding this sort of thing, and it not being funded by international aid. But these are not simple issues. And while somebody might say, “Surely country X can find ten million dollars to fund four million nets going into its country,” remember, you know, malaria isn’t the only problem. Malaria, AIDS, TB, fresh water, roads. I mean, we're talking about very challenged economies, and I do have some views on not just the health environment — but governance and transparency and accountability in countries and judicial systems and so on — but I think that’s not a discussion that I would focus on initially. When we at AMF look at: here is a circumstance where, through a lot of discussions and due diligence regarding, this country needs this many nets. Are there any other funders? If there aren’t any other funders, is the reality —as has occurred and does occur — millions of people are going to be left unprotected at night? If my four children were in that environment where I were putting them to bed at night — and as I mentioned earlier, the bite of a mosquito can be a death sentence rather than an inconvenient, itchy bump — I know that I would want them under a net. And just because those children are not my children, and they’re in a different country, that makes no difference to me. I wish to have them protected, and I and my colleagues and the many supporters we have, I think, feel the same — that we want to try and do our bit to assist. Because we know that if we get nets over heads and beds, versus them not having nets, we will have a fairly significant impact on a lot of people's health.

Stephanie Tam: I think the concern that the people who are anxious about foreign aid tend to have is whether it’s not just who should be funding bed nets and healthcare and things like that, but whether foreign aid in some way enables governments to not do so.

Rob Mather: And I think it's an important one to continue to address, because I think, I think that I would suspect that there are circumstances in which that is the case, in that it helps governments avoid their obligations, to a degree. One of the things that I think those involved in international aid can do, is to ensure that the work that is done is very well thought through. There are soundings taken from many different parties, and when assistance is brought to bear, it comes with capacity building; in other words, skills and capacity building in-country, so that it's not as though it is an in-and-out intervention. We’re assisting those communities in which we operate to better help themselves as the months and the years roll by. Because I don't think that aid should be forever. I think that in some ways aid is a — in certain circumstances has a terrific role to play, but it always, in my view, must keep an eye on trying not to be there, as soon as possible.

Stephanie Tam: Yeah! I agree with that one.

Sam Deere: So while the task of finding the most effective ways of making a difference remains incredibly complex, if you're looking for something good to do — right now — you could do a lot worse than putting your donations towards buying some bednets.

Sam Deere: One of the important things, I think, to remember is: what differentiates something like malaria is, it's not just big in scale, and it's not just a tractable problem — that is, a problem where we can see a solution — but then also, malaria is something where there's a big gap between the amount of mosquito nets that should be out there and the amount of mosquito nets that are out there.

Stephanie Tam: Yeah, and I think maybe this would be a helpful way to summarize some of those ideas: importance, tractability, and neglectedness.

Sam Deere: Yeah. So one framework that we sometimes use is called ITN, or, importance, tractability, neglectedness. So importance, or impact, is basically the scale of the problem — so a really big problem is probably more pressing than a really small problem. Tractability is that, you know, how hard is the problem to solve? And then you've got neglectedness, which is, how many people are currently working on the problem? Something that scores highly on all of those areas — you're going to be more likely to solve the problem in a cost-effective way, and help more people, than something that doesn't.

Stephanie Tam: Sure, yeah. And so the way that would kind of map onto malaria would be that it's one of the biggest killers of children under five — that goes to importance. Then in terms of tractability, we have this solution — in bed nets — that is fairly easy to implement and that is not costing a massive amount, so you can donate more and get more bang for your buck, so to speak. And then neglectedness, suggesting that…

Sam Deere: If you look at the projections between what it would take to get full coverage of malaria endemic areas in Africa, there's a big gap between the amount of mosquito nets that should be out there and the amount of mosquito nets that are out there.

Stephanie Tam: Hm, yeah. Part of the idea is, there are certainly other things that may be as big, in terms of global burden, but perhaps less easy to fix, at least in a donation sense.

Sam Deere: Yeah. Either less easy to fix, or they already have lots of people working on them. So climate change is obviously an incredibly important issue, but it's very, very hard to solve, because it's a massive coordination problem between all the countries in the world, and, you know, requires this huge amount of international coordination and cooperation. There's lots of vested interests working against it, and also there are lots and lots of climate activists, because it is obviously such an important problem.

Stephanie Tam: I mean, I think part of this is getting at the idea that the recommendations that might be on EA charities aren't universal mandates. So obviously, you want some people working on climate change, and part of the reason that the Centre for Effective Altruism doesn't focus on climate change is also because a lot of other people are focusing on it.

Sam Deere: Yeah, yeah, absolutely. You're not trying to say, everyone should follow this exact path. What you're trying to do is say, let's not make judgements about what we should do in a vacuum. Let's look what other people are already doing because there might be an important field out there, but it might also be a crowded field, and so being the next person in a crowded space doesn't really do that much. Being the next person in a space that's really neglected could actually move the needle a whole bunch.

Stephanie Tam: Sonia mentioned this idea that it's easy for us to donate to bed nets, and to spend that kind of money just because we don't want to deal with it in the way that is actually more complicated.

Sam Deere: Yeah, so there's two things there. I think that's a really important point. But I would turn that question on its head: in many ways, that's actually what we should be doing. I'm not a political activist in, you know, west Africa. So for me to make claims about that political environment or to call for a particular change of government, without having all the facts and without being a local activist, seems very presumptuous. But I can help by distributing anti-malarial bed nets. It feels much riskier, certainly for small donors and people who are not subject-matter experts and in-country experts, to be the people who are kind of making the decisions about which, you know, which roads to fund.

Stephanie Tam: Yeah.

Sam Deere: That seems really fraught. Again it goes to this idea of neglectedness. If a local government is more likely to invest in the road, then you shouldn't invest in a road. Because that's exactly the problem that you could raise: the outside donors supplanting the local capacity of the local government to do their job. They're both good approaches to this, and we should be not just investing in sort of short-term, safe solutions; we also need to be investing in risky, long-term solutions that have these high payoffs. We just need to do that as advisedly as possible.

Stephanie Tam: Yeah. So, we've been exploring how to help, how to help the most people, what doing good looks like in various contexts. I'm thinking about how we want to end this series.

Sam Deere: Yeah?

Stephanie Tam: Is there something that you really want people to take away?

Sam Deere: Yeah. I really hope people go away feeling excited about what they might be able to do. That making a difference is really possible, and that helping other people doesn't have to come at a cost to yourself. That altruism is something you can do; you can be excited about it, and by being deliberate about it —consciously seek out those opportunities which help the most people — you can actually make a tangible difference in your lifetime, and not just for people living now, but for people in the future as well. And, I don't know, I — that really inspires and motivates me, and I hope that that's inspiring and motivating to other people.

Stephanie Tam: Well, as someone fairly new to the ideas of effective altruism, and who often wonders how to do good better, it's been an interesting, thought-provoking adventure. And I hope it's been for you as well.

Sam Deere: This has been Doing Good Better, a production of the Centre for Effective Altruism. If you're interested in learning more about some of the charities or causes that might have the greatest potential to help others, or anything else about effective altruism, check out effectivealtruism.org. You'll find resources on these topics and many more.

Stephanie Tam: Thanks for listening. That's all for now!

Doing Good Better is a podcast series co-hosted by Sam Deere and Stephanie Tam, exploring the why, how, and what of effective altruism.

Our producer is Stephanie Tam and our sound engineer is Dominic Apa; our production assistants are Sandrine Chausson, Jhansi Hoare, and Kiran Lloyd; with help from Sam Deere, Irene Tortajada, and Nikita Patel.