Global Health and Development

Introduction

In 2013 nearly 800 million people were living under the international poverty line.¹ This has a huge negative impact on health² - each year, millions of these people die from preventable diseases such as malaria, tuberculosis, and diarrhoea.³

This immense suffering is easily preventable, but is nevertheless neglected - as of 2019, members of OECD's Development Assistance Committee spend on average just 0.30% of their GNI on foreign aid.

This profile sets out why you might want to focus on problems in global health and development - and why you might not. This area looks most promising if you are sceptical of our ability to influence the longer-term future of the world, if you think that animal suffering is not as significant as human wellbeing, or if you think we need strong evidence of impact to justify interventions.

The case for global health and development as an important cause area

How can you tell where your resources will do the most good?

• Heuristics: We can use rules of thumb to focus our attention. In particular, we might look for important problems that are being neglected by others, and interventions for which there is lots of evidence, and/or where learning more would be very valuable.
• Quantitative estimates: We might look at studies which estimate the cost-effectiveness of interventions, based on empirical data from randomised controlled trials (RCTs).

Global poverty causes a great deal of suffering for a huge number of people

In 2013, 10.7% of the global population lived below the global poverty line of $1.90 per day - that’s nearly 800 million people.⁴  This line is intended to represent the minimum level of income needed to fulfil basic needs: food, clothing, healthcare and shelter. Arguably the biggest negative impact of poverty is the cost to health:⁵ millions of people die each year of diseases such as malaria or tuberculosis that are easily preventable or treatable in the developed world.⁶ It is estimated that the damage done by these diseases in the least developed countries plus India is between 200 and 500 million DALYs (disability-adjusted life years, a measure of a year of healthy life) per year.⁷

There are well-evidenced ways of reducing poverty

Although it is a huge problem, global poverty seems to be relatively tractable - especially if we focus on the immediate costs to health and quality of life.⁸ In particular, we know how to prevent and treat the most common diseases, and the cures are often relatively cheap. For example:

• malaria can be prevented by giving people insecticide-treated bednets,⁹
• tuberculosis can be treated with a course of drugs over 6 to 9 months,¹⁰
• diarrhoea can be prevented through better sanitation¹¹ and treated with oral rehydration therapy,¹²
• parasitic diseases can be cured with a pill that costs under $1.¹³

(We discuss the cost-effectiveness of these kinds of approaches in more detail in the next section.) Over the last 60 years, millions of lives have been saved using these techniques, suggesting a very clear way to make progress.¹⁴ 

Additional resources could do a great deal more in this area

Global poverty does receive a lot of attention from individuals and organisations. However, the total funding going towards poverty alleviation is small relative to the funding for many other priorities in developed countries. The UK government spends roughly 0.7% of national income on foreign aid each year ($12.1 billion in 2015) - but spends nearly three times as much (around 2% of national income) on defence.¹⁵ Most other countries in the world spend a similar or even smaller percentage on foreign aid.¹⁶

Individual donations to overseas aid are also relatively small. In the UK in 2015, people donated more to each of medical research, hospitals and hospices, religious charities, and charities for children and young people, than they did to overseas aid and disaster relief,¹⁷ and there are similar results from the US.¹⁸ The charities currently implementing the most effective global health interventions seem to have a clear need for more funds. For example, as of August 2018, GiveWell evaluates that the Against Malaria Foundation would need $50 million to fund all of its currently intended distributions.

We have stronger evidence for interventions in this area than almost anything else

There is a robust record of success in global health and development, and the relevant outcomes are somewhat measurable. If, for example, you donate to the Against Malaria Foundation, you can be reasonably certain that you are paying for the distribution of bednets that will prevent at-risk people from contracting malaria. 

Though there may be larger potential gains in other cause areas, there is also generally less certainty about what the actual benefit will be. There is a tricky tradeoff here - between a more definite impact, and a less certain but potentially larger impact - which we will discuss in more detail later.

Together, the above analysis provides a compelling initial case for global health and development as an important cause area: it is large in scale, apparently tractable and relatively neglected, and is backed up by strong evidence.

Cost-effectiveness analyses and RCTs

Cost-effectiveness analyses attempt to quantify how much good can be done with a given amount of money.¹⁹ Although these analyses require us to make a number of simplifying assumptions, we believe they form an important part of assessing the impact that can be had in a given cause area.²⁰ 

It is sometimes possible to save lives via health interventions in the developing world at very low cost. The eradication of smallpox, for example, is estimated to have cost around $1.6 billion.²¹ If we conservatively estimate that this saved 60 million lives,²² then it cost about $25 per life saved.

This is ridiculously effective when we consider that the UK’s National Health Service will spend tens of thousands of pounds to save just a year of healthy life.²³ 

The best health interventions currently available may not be quite this effective, but are still extremely promising. GiveWell’s latest cost-effectiveness analyses use “saving the life of an individual under 5” as their benchmark, and their estimates suggest that their recommended charities can do the equivalent of this for between $900 and $7,000, depending on the charity.²⁴ This still seems like an exceptionally good deal compared to the cost of saving lives in the developed world.

These cost-effectiveness estimates rely on some subjective inputs, but they are based on the results of high-quality randomised controlled trials (RCTs). RCTs involve giving a treatment (e.g. insecticide-treated bednets) to half of a population, randomly selected, while the other half are given no treatment (or a placebo/control). We can then measure differences in outcomes between the two groups, where any differences should be due to the treatment alone. These RCTs should therefore give unbiased estimates of the impact of the treatment.

Interventions in global health and development appear to be backed up by more RCTs than we have seen with any other cause area. The distribution of insecticide-treated bednets to prevent malaria, for example, has been studied extensively, and assessed in two Cochrane reviews.²⁵ Lengeler’s (2004) review, which considers more studies and looks at a broader range of outcomes, finds a statistically significant effect on child mortality, summarised as “5.53 deaths averted per 1000 children treated per year.”²⁶

Another RCT looked at the impact of GiveDirectly’s unconditional cash transfers on developing countries.²⁷ It found that recipients increased the value of their assets, and also saw increases in food security, revenue, psychological well-being, and female empowerment.

To summarise, we believe that it is possible to have a large impact in global health and development because:

• The problem of global poverty is large in scale, affecting hundreds of millions of people and severely reducing their quality of life;
• Many of the problems associated with poverty, particularly the impact it has on health, are highly tractable, since we can treat many of the worst diseases easily and cheaply, and just need to scale up known approaches;
• The problem is relatively neglected given its scale;
• The evidence in this area is particularly strong compared to interventions in other cause areas, and suggests these interventions are cost-effective.

Some concerns about prioritising global health as a cause area

Here we summarise and respond to a number of common concerns about prioritising global health and development as a cause area:²⁸ 

Does foreign aid really work?

A common concern is that developed nations’ attempts to help those in poverty are wasted effort and money.

However, this simply does not match the facts: when we look at what aid has achieved over the past sixty years, there’s a lot of good to show for it. Though some aid may do little or no good, there’s a convincing argument that the average dollar spent on aid has been well worth it. As mentioned above, the lives saved by money spent on the eradication of smallpox work out at ~$25 per life saved, using conservative estimates. Even if we assume that all other aid spending has been completely useless, we could still easily justify the total money spent on the grounds of smallpox eradication alone. If we assume an upper bound of $4 trillion spent on aid, smallpox eradication alone would still give us a figure of around $67,000 per life saved, approximately one hundredth of the statistical value of a life for various US agencies.

In addition, it’s clear that other things beyond smallpox have had a positive effect on poverty. Using nets, indoor spraying, and medicine, we’ve seen a significant decrease in annual deaths from malaria between 2010 and 2015.²⁹ Oral rehydration therapy has cut annual diarrhoeal deaths from 4.6 million in 1980 to about 0.5 million today.³⁰ Undoubtedly, not all aid works, but this isn’t an argument against working to improve health and living standards in the developing world. Instead, it’s an argument for demanding higher standards of evidence of effectiveness before we channel significant effort and funds into it.

Charity “begins at home”

Some people think that we should first focus on helping people close to us geographically. Only once problems close to us are resolved should we help the global poor.

However, there are strong reasons to think that additional resources can do a lot more good in the developing world than they can in richer countries. Simply put, an additional dollar is worth more when you have less money. Precisely because the developing world lacks resources, their biggest problems are ones that we have already figured out how to solve in richer economies, which have a much higher level of health and education. Preventing someone from getting a deadly or debilitating disease improves their life a huge amount, and it’s much harder to give someone a similar boost when their basic needs are already met.

In Doing Good Better, William MacAskill suggests that a dollar is worth about 100 times more to someone living in poverty than to the average person in a rich country. This is based on the fact that the annual consumption of someone on a median US income is about 100x that of people living in the most extreme poverty, and the importance of additional money seems to decline with income.³¹

Given how much more effective the same money can be if given to poorer people, it seems hard to justify focusing on those close to us. If Macaskill is right, you would have to think that people close to you are somehow a hundred times more valuable than poorer people overseas. This seems unjustifiable, especially given that many philosophers think that there are no reasons to discriminate against people based on their location or nationality.³²

Who are we to say what poor people need?

Another concern is that we cannot help people in developing countries without an intimate understanding of their situations and needs.

There are two important points to make in responding to this view. First, global health and development interventions aren’t necessarily paternalistic. Recently research has begun to look at the potential benefits of direct and unconditional cash transfers to very poor people, with promising results, and these certainly provide a good baseline against which to compare more targeted interventions.³³ Second, concerns about paternalism seem less well-founded when people have clear needs, such as the prevention of severe malnutrition or suffering. If people are dying of known preventable diseases, it seems hard to imagine how we could be “wrong” about the need to prevent this. There may well be other things that they need beyond surviving, but sorting this out first seems fairly uncontroversial.

Why might you not choose to prioritise this cause area?

Global health and poverty seems to be a promising cause area. But there are also a number of reasons why you might be unconvinced by this analysis, or why you might think that a different cause area is likely to hold even greater opportunities to do good.

You might think that there are better ways to improve the lives of people living today

You might believe that focusing on global health and development is simply not the best way to improve the lives of people living today. There might be other problems that people face today which are larger in scale, more neglected, or more clearly tractable - for example, a case could be made that mental health problems create more suffering overall than even poverty does. Or it might be that investing in broader cause areas - such as improving collective decision making, or certain forms of political advocacy - could improve our ability to solve all the problems facing humanity, and so be more effective.

One consideration here is how much importance we should put on having a strong evidence base and track record when prioritising cause areas. We discussed earlier how the strength of evidence is a substantial point in favour of global poverty interventions. However, care is needed to avoid the “streetlight fallacy”. We want to look for the best solutions, not just those that are easiest to see or measure. There may be other opportunities to help the world today which have less robust evidence behind them, but have higher expected value because they would do so much more good if successful, and where learning more could be incredibly valuable.

You might think that we should prioritise reducing the suffering of non-human animals

Each year, it is estimated that over 50 billion animals globally live in conditions of extreme suffering before being slaughtered in factory farms.³⁴ As we discuss in our animal welfare profile, this issue has even less money spent on it than global poverty.

This suggests that animal welfare could plausibly be even larger in scale, and more neglected, than global poverty. Comparing the two turns on the following judgement calls:

1. The significance of animal suffering relative to human suffering

Though it seems likely that animals have the capacity to suffer and feel pain,³⁵ you might believe that humans’ greater cognitive complexity means that their capacity to suffer is greater or more significant. Or you might think that other reasons make it worse that humans live in poverty than that animals are kept in cages. Perhaps freedom and dignity are more important for humans than they are for animals, for example.

2. The indirect effects of poverty interventions versus animal interventions

Human societies are capable of development in a way that animal societies are not, and so we might think that the indirect effects of human-focused interventions will be greater. However, improving attitudes towards animals might increase empathy generally, which could itself have positive indirect effects.³⁶

3. The importance of a strong evidence base

As mentioned above, global health interventions tend to have much more evidence behind them than animal welfare interventions. If you think that a strong evidence base is important, this might be a reason to prefer global poverty interventions to animal welfare interventions.

You might think that we should prioritise the long-run future of humanity

There could be many more people in the future than are alive today.  So if we think we can affect the long-term future, this might be higher impact than focusing on more immediate problems.

This comparison turns on a number of judgement calls:

1. How much moral weight should we give “future people”?

We generally feel an intuitive obligation to treat future, not-yet-existent people in roughly the same way as existent people. However, some philosophers have questioned whether we should give the same degree of moral consideration to future people. On “person-affecting views”, an action is only good or bad if it is good or bad for someone - and so the value of an action depends only on how it affects people who are either already alive, or who will come into existence regardless of our actions. One implication of this view is that human extinction, while bad for the people who die, causes no longer-term harms: there is no harm in people failing to come into existence.

A related issue is the non-identity problem, arising from the fact that sometimes future people may owe their very existence to choices made today. For example, which policies a government chooses to enact will affect which people have certain jobs, affecting which people meet and marry, and therefore causing different people to be born in future. Those very policies might also affect how good the lives of future people are - if the government chooses to prioritise policies that increase short-term economic productivity over mitigating climate change in the longer-term, say, this could have a negative impact on future generations. But if the very policies that appear to have made future people’s lives “worse off” also ensured that those exact people were born at all, can those people really be said to have been harmed by those policies? If not, then this may be reason to prioritise the welfare of people who already exist, or whose existence does not depend on our actions.

However, the non-identity problem might also be taken as a reason to reject person-affecting views. The implication, that choosing policies that will make future generations lives worse off is not causing those future people any harm, seems highly counterintuitive. We could instead adopt impersonal principles for evaluating the moral value of actions.³⁷ This means that we would judge not based on how they affect specific people, but based on how good they are from the perspective of the world as a whole.³⁸

2. Can our actions today have any real impact on the far future?

Even if the future of humanity is incredibly important, you may still believe that there is very little we can do to reliably shape it. The very far future is an area for which we do not have - and cannot have - robust randomised controlled trials and cost-effectiveness estimates.

However, we do think there are reasons to be optimistic here. Small changes in the values of a civilisation could last a very long time, since people tend to try to pass their values onto their descendants. And in the past, relatively small actions have essentially averted global catastrophes: for example, Stanislav Petrov, a lieutenant in the Soviet Air Defence Forces, may have prevented a nuclear war when he judged that reports that the US had launched a nuclear missile were false (which they were).³⁹

In addition, we don’t need to be highly confident that our actions will have the desired impact, if the potential gains are large enough. Working on the world’s largest problems will always be difficult and involve some risk, but that doesn’t mean that we should always focus on easier, smaller-scale issues.

3. How should we trade off fixing immediate problems against thinking about the longer-term?

Even if you believe that the long-run future is ultimately what’s most important, you might still think that fixing the world’s most immediate problems is the best way to influence our trajectory.

If you think that the world is on a positive trajectory, then it makes sense to focus your efforts more on ensuring that humanity survives to enjoy that future.  But it might be that there is a serious risk of us getting “stuck” in certain negative patterns, including inequality. In that case, it’s possible that one of the best ways to ensure improvements in the longer term is to invest a lot of resources in solving the problems we face right now, to ensure they don’t continue to affect future generations.

You might think that we need to focus more on “systemic change”

A final objection to the case outlined above is that it only tackles the symptoms of poverty, not the root causes, and neglects the importance of systemic change. It’s not clear whether focusing on the most immediately obvious problems will help us to eradicate poverty altogether. Instead, we may need to better understand the systems in the world that perpetuate poverty and inequality, and think about longer-term strategies for changing these systems.

It is uncertain whether there is a limit to the benefits of focusing on concrete, tractable things like reducing disease, without also focusing efforts on more systemic change. On the one hand, perhaps by helping the worst off in tractable ways, we can get everyone to the level at which they can fulfil their own basic needs, which could naturally lead to economic growth and more productive societies.⁴⁰

On the other hand, it might be that inequality is perpetuated by more fundamental things, such as the politics of developing countries. If this were the case, we might need to address politics more directly. However, it might also be true that while we do need to consider the bigger picture and conduct research to better understand systemic issues, current marginal resources are still more effectively spent directly helping the very poorest people.⁴¹

We’ve given some examples in this profile of the kinds of interventions that currently seem most promising for tackling global poverty - but this isn’t to suggest these are the only ones worth focusing on. Accounting for less immediate, tangible impacts may be needed to have more of an impact on poverty in the long-run, and things like political action could be very valuable. Evidence for interventions in this space is currently lacking, but more research on opportunities in this area could be very valuable as it enables us to learn more.

Summary

• Global poverty causes a huge amount of suffering across the globe, with over 800 million people affected. One of the worse consequences of this is the widespread existence of diseases which would be easily prevented or treated, and which cause between 200 and 500 million DALYs of harm each year.
• There are a number of interventions which we know to be highly effective in preventing and treating these diseases. These include using bednets to prevent malaria, and distributing treatments to prevent parasitic diseases. There is still plenty of scope for further funding to increase the impact of these interventions further.
• We have stronger evidence for effective interventions in this area than in most other areas.
• In light of this, the objection that foreign aid doesn’t work appears to be false. On average, aid does work. It would be even more effective if we focused on the most effective interventions.
• Similarly, since interventions in the developing world can do so much more good than interventions focused on developed countries, it is hard to justify working closer to home.
• It is plausible that we should further systemic change in order to solve these problems. However, systemic change might be best furthered by short-term work which puts people in a position to improve their own futures.
• Whether you believe this to be the most important cause depends on: whether you believe there to be other (perhaps less tested) ways to improve human lives, how much value you give to reducing animal suffering, and whether you believe it to be more urgent to focus on the long-term future of humanity.