A drowning child is hard to find

Stories such as Peter Singer's "drowning child" hypothetical frequently imply that there is a major funding gap for health interventions in poor countries, such that there is a moral imperative for people in rich-countries to give a large portion of their income to charity. There are simply not enough excess deaths for these claims to be plausible.

Much of this is a restatement of part of my series on GiveWell and the problem of partial funding, so if you read that carefully and in detail, this may not be new to you, but it's important enough to have its own concise post.

People still make the funding gap claim

In his 1997 essay The Drowning Child and the Expanding Circle, Peter Singer laid out the basic argument for a moral obligation to give much more than most to, for the good of poor foreigners:

To challenge my students to think about the ethics of what we owe to people in need, I ask them to imagine that their route to the university takes them past a shallow pond. One morning, I say to them, you notice a child has fallen in and appears to be drowning. To wade in and pull the child out would be easy but it will mean that you get your clothes wet and muddy, and by the time you go home and change you will have missed your first class.

I then ask the students: do you have any obligation to rescue the child? Unanimously, the students say they do. The importance of saving a child so far outweighs the cost of getting one’s clothes muddy and missing a class, that they refuse to consider it any kind of excuse for not saving the child. Does it make a difference, I ask, that there are other people walking past the pond who would equally be able to rescue the child but are not doing so? No, the students reply, the fact that others are not doing what they ought to do is no reason why I should not do what I ought to do.

Once we are all clear about our obligations to rescue the drowning child in front of us, I ask: would it make any difference if the child were far away, in another country perhaps, but similarly in danger of death, and equally within your means to save, at no great cost – and absolutely no danger – to yourself? Virtually all agree that distance and nationality make no moral difference to the situation. I then point out that we are all in that situation of the person passing the shallow pond: we can all save lives of people, both children and adults, who would otherwise die, and we can do so at a very small cost to us: the cost of a new CD, a shirt or a night out at a restaurant or concert, can mean the difference between life and death to more than one person somewhere in the world – and overseas aid agencies like Oxfam overcome the problem of acting at a distance.

Singer no longer consistently endorses cost-effectiveness estimates that are so low, but still endorses the basic argument. Nor is this limited to him. As of 2019, GiveWell claims that its top charities can avert a death for a few thousand dollars, and the Center for Effective Altruism claims that someone with a typical American income can save dozens of lives over their lifetime by donating 10% of their income to the Against Malaria Foundation, which is in line with this claim. The 2014 Slate Star Codex post Infinite Debt describes the Giving What We Can pledge as effectively a negotiated compromise between the perceived moral imperative to give literally everything you can to alleviate Bottomless Pits of Suffering, and the understandable desire to still have some nice things.

How many excess deaths can developing-world interventions plausibly avert?

According to the 2017 Global Burden of Disease report, around 10 million people die per year, globally, of "Communicable, maternal, neonatal, and nutritional diseases.”* This is roughly the category that the low cost-per-life-saved interventions target. If we assume that all of this is treatable at current cost per life saved numbers - the most generous possible assumption for the claim that there's a funding gap - then at $5,000 per life saved (substantially higher than GiveWell's current estimates), that would cost about $50 Billion to avert.

This is already well within the capacity of funds available to the Gates Foundation alone, and the Open Philanthropy Project / GiveWell is the main advisor of another multi-billion-dollar foundation, Good Ventures. The true number is almost certainly much smaller because many communicable, maternal, neonatal, and nutritional diseases do not admit of the kinds of cheap mass-administered cures that justify current cost-effectiveness numbers.

Of course, that’s an annual number, not a total number. But if we think that there is a present, rather than a future, funding gap of that size, that would have to mean that it’s within the power of the Gates Foundation alone to wipe out all fatal communicable diseases immediately, a couple times over - in which case the progress really would be permanent, or at least quite lasting. And infections are the major target of current mass-market donor recommendations.

[ETA: Zero is also a special number for other reasons. GiveWell's stated reason for not bothering to monitor statistical data on outcomes (such as e.g. malaria incidence and mortality, in the case of AMF) is that the data are too noisy. A global (or even regional) zero (even for one disease) would be very noticeable, and therefore ought to make filling the next year's funding gap much more appealing to other potential donors. (And if the intervention doesn't do what we thought, then potential donors are less motivated to step in - but that's good, because it doesn't work!)]

What does this mean?

Either charities like the Gates Foundation and Good Ventures are hoarding money at the price of millions of preventable deaths, or the low cost-per-life-saved numbers are wildly exaggerated. My former employer GiveWell in particular stands out as a problem here, since it publishes such cost-per-life-saved numbers, and yet recommended to Good Ventures that it not fully fund GiveWell's top charities; they were worried that this would be an unfair way to save lives. Either scenario clearly implies that these estimates are severely distorted and have to be interpreted as marketing copy designed to control your behavior, not unbiased estimates designed to improve the quality of your decisionmaking process.

We should be more skeptical, not less, of vague claims by the same parties to even more spectacular returns on investment for speculative, hard to evaluate interventions, especially ones that promise to do the opposite of what the argument justifying the intervention recommends.

If you give based on mass-marketed high-cost-effectiveness representations, you're buying mass-marketed high-cost-effectiveness representations, not lives saved. Doing a little good is better than buying a symbolic representation of a large amount of good. There's no substitute for developing and acting on your own models of the world.

As far as I can see, this pretty much destroys the generic utilitarian imperative to live like a monk and give all your excess money to the global poor or something even more urgent. Insofar as there's a way to fix these problems as a low-info donor, there's already enough money. Claims to the contrary are either obvious nonsense, or marketing copy by the same people who brought you the obvious nonsense. Spend money on taking care of yourself and your friends and the people around you and your community and trying specific concrete things that might have specific concrete benefits. And try to fix the underlying systems problems that got you so confused in the first place.

 

* A previous version of this post erroneously read a decadal rate of decline as an annual rate of decline, which implied a stronger conclusion than is warranted. Thanks to Alexander Gordon-Brown to pointing out the error.

33 thoughts on “A drowning child is hard to find

  1. Tbu

    Really interesting, thanks again. Writing on my phone on a short lunch break at work, please forgive typos lack of clarity etc.

    1) maybe in advising gates foundation givewell did the same math you did and realized that the easily averted by donation deaths would soon be averted by random donations, and that the gates foundation As one serious intelligent ambitious agent controlling a large sum of money could attempt projects that would be more difficult to accomplish by a small charity relying on uncertain random donations so counseled the gates foundation not to pick the low hanging fruit, leaving it to us to pick.

    2a) suppose the same person and jacket from ainger’s thought experiment was passing a homeless person with no jacket in the winter, he can get another jacket the homeless man can’t. Does he have an obligation to give him the jacket?
    B) suppose you lived in a town where you frequently passed poor people drowning (poor are forced to be fishermen on shoddy boats?), how much force would Singer’s argument lose?

    I apologize if I’m being obvious

    Reply
    1. Benquo Post author

      On (1), the story "the funding gap is not that big, but there just hasn't been an org set up to fund things of this size) is very different from the story "the funding gap is too large for even a multi-billion-dollar foundation to cover". I think the first story is implausible for a bunch of reasons, among which is that no one is saying that's their reason for doing anything.

      2 is sufficiently out of scope for this post that I think this is not the right place for that discussion.

      Reply
  2. Alexander Gordon-Brown

    I left some replies on your facebook, but this particular issue seems possibly-significant enough that I want to put it here as well. You say "According to the 2017 Global Burden of Disease report, around 10 million people die per year, globally, of "Communicable, maternal, neonatal, and nutritional diseases", declining at a rate of 30% per year."

    Where in your linked report do you see this? I see the following, suggesting that approximate level of decline has been observed over a decade, not a year.

    "Both the number of deaths and death
    rates from CMNN causes decreased from 2007 to 2017, by
    22·2% (20·0–24·0) in terms of total deaths and by 31·8%
    (30·1–33·3) in terms of mortality rate."

    Reply
      1. Alexander Gordon-Brown

        Thanks for modifying. Now I think your argument just doesn't work though? What is intrinsically special about a year that makes it appropriate to compare an annual number of $50bn to the total resources available to a foundation or foundations (would make sense if you were comparing to their annual giving).

        So for example, couldn't I equally say that there are around 100 million CMNN deaths per decade, and at a cost of $5000 each to avert (not a good assumption, as I noted on facebook, but not my focus in this comment..) this would cost $500bn, which is well beyond the resources of the foundations you mention? Or couldn't I use a month rather than a decade, in order to make the problem appear smaller rather than larger?

        Before you were comparing a total to a total. Now you are comparing an annual to a total, or a stock to a flow*. You acknowledge this disconnect in your post, but I don't see how you've resolved it.

        *https://en.wikipedia.org/wiki/Stock_and_flow#Comparing_stocks_and_flows

        Reply
        1. Benquo Post author

          I’m specifically saying the claim that current resources are small relative to the # of savable lives at current “prices” is nonsense. Either GF could suddenly eradicate or nearly eradicate *communicable disease* as a category several times over if it wanted to, or the current amount of funding will be adequate for all high-value opportunities of this type for quite a long time.

          Reply
          1. Alexander Gordon-Brown

            How exactly? Google tells me GF gives a few billion dollars each year. Good Ventures gives an order of magnitude less than this. You suggest that tens of billions of dollars per year is needed. This seems way beyond the resources of those foundations alone as things stand.

            So I have to assume your suggestion is more like 'if GF decided to dramatically ramp up their giving spend down the entire foundation in 2-3 years, they could plug this gap for a while'. This would leave them unable to pick up any low-hanging fruit that appears in say 2025, so it doesn't seem like an optimal strategy. But in any case we now we run into the issue from the other thread that you've created the $50bn number by assuming the marginal estimates can be extrapolated linearly with zero diminishing returns. In the real world I would guess that literally eradicating (e.g.) malaria permanently via such a push would cost far more per person than the cost of treating the easiest cases of malaria, though I'm willing to be shown evidence to the contrary.

      2. Alexander Gordon-Brown

        (Here raising the thing that I specified as not my focus in the other comment.)

        "According to the 2017 Global Burden of Disease report, around 10 million people die per year, globally, of "Communicable, maternal, neonatal, and nutritional diseases.”* This is roughly the category that the low cost-per-life-saved interventions target. If we assume that all of this is treatable at current cost per life saved numbers - the most generous possible assumption for the claim that there's a funding gap - then at $5,000 per life saved (substantially higher than GiveWell's current estimates), that would cost about $50 Billion to avert....The true number is almost certainly much smaller because many communicable, maternal, neonatal, and nutritional diseases do not admit of the kinds of cheap mass-administered cures that justify current cost-effectiveness numbers."

        As already noted on facebook, I don't understand how the last sentence follows. If many CMNN diseases are harder to treat than the cheap cures that justify $5000-per-life-type numbers, they will cost more than $5000 per life saved, potentially much more. This would make the true total required larger than $50bn, not smaller.

        Reply
        1. Benquo Post author

          In that case the current marginal CPLS numbers aren’t very informative, and there’s no “infinite pit of suffering” to justify “infinite debt,” but a pretty limited funding gap at the widely advertised CPLS levels, plus a negotiation over who gets to hold onto surplus capital.

          Reply
          1. Alexander Gordon-Brown

            Back up a sec. I'm not even trying to work out if your bottom line holds right now, I'm just addressing what seem to me like errors of facts and/or logic, so that eventually I have a coherent sense in my head of what exactly it is you are trying to argue. Do you agree the sentence you wrote should read 'almost certainly larger' not 'almost certainly much smaller', for exactly the reason you gave in that very sentence? If not, why not?

          2. Benquo Post author

            Do you agree the sentence you wrote should read 'almost certainly larger' not 'almost certainly much smaller', for exactly the reason you gave in that very sentence? If not, why not?

            No. The number of deaths avertable at widely advertised cost per life saved numbers is much smaller than 10 million, so the amount of money needed to fund all opportunities to prevent such deaths is much smaller than $50 billion.

            Thanks for trying to drill down to the crux here.

        2. Benquo Post author

          I wrote this in response to comments like this one which assume that the “altruists should have utility linear in money” claim is literally true of large donors.

          Reply
          1. Alexander Gordon-Brown

            Thanks for fixing. I also disagree with the comment you highlight, though for different reasons. I continue to be puzzled by parts of your logic as outlined above, and my current best guess is that your bottom line conclusion is wrong on at least a personal level for reasons I don't want to get into in detail right now*, though I may change my mind on this if and when I understand your argument for it. I am highly confident that your description of the contrary claim as 'obvious nonsense' is either wrong or using very slippery definitions of 'obvious' and 'nonsense'.

            *In brief, the utilitarian imperative for me to give away (most of) my money doesn't need a specific number of $5000 per year or a specific quantity of CMNN deaths. It only requires that there are people significantly worse off than me, who would extract greater utility from my money than I would if I spent it on myself. Since I personally am very well off by any reasonable standard, this is almost trivially true. Obviously, YMMV.

  3. Avret

    Question about the following:
    ```According to the 2017 Global Burden of Disease report, around 10 million people die per year, globally, of "Communicable, maternal, neonatal, and nutritional diseases.”* This is roughly the category that the low cost-per-life-saved interventions target. If we assume that all of this is treatable at current cost per life saved numbers - the most generous possible assumption for the claim that there's a funding gap - then at $5,000 per life saved (substantially higher than GiveWell's current estimates), that would cost about $50 Billion to avert.```
    Shouldn't this read '50 Billion Annually'? it's no longer a total number -- moreover, 50 billion annually is a crazy high sum, even assuming constant cost to save a life.

    Reply
    1. Anonymous

      Are the communicable disease rates just gonna shoot back up to the trendline in the next year? How would that happen?

      Reply
  4. Jeff Kaufman

    (crossposting from fb)

    "As far as I can see, this pretty much destroys the generic utilitarian imperative to live like a monk and give all your excess money to the global poor or something even more urgent. Insofar as there's a way to fix these problems as a low-info donor, there's already enough money. Claims to the contrary are either obvious nonsense, or marketing copy by the same people who brought you the obvious nonsense. Spend money on taking care of yourself and your friends and the people around you and your community and trying specific concrete things that might have specific concrete benefits."

    Imagine that the best intervention out there was just direct cash transfers to globally poor people. The room for more funding there is enormous, over $1T (imagine giving $1k to the world's poorest billion). This is very far from "more than enough money". The simple fact that there are extremely poor people who can do far more with my money than I can is enough for me to give.

    There are almost certainly other ways to spend money altruistically that beat directly giving poor people money, but that only strengthens the argument that we should be trying to help.

    Talking care of yourself and the people around you is also good, but if that's all you do then people who don't happen to live near globally rich people are going to continue to lack basic human necessities.

    Reply
  5. Michael

    (crosspost from https://forum.effectivealtruism.org/posts/tXbekheMj9d636MmM/there-s-lots-more-to-do)

    I think the post is more fundamentally flawed; there is a substantial funding gap under Benjamin's assumptions, even if we were to ignore GiveDirectly and other cause areas, and even if we were unwilling to save a life for any more than $5,000.

    According to the 2017 Global Burden of Disease report, around 10 million people die per year, globally, of "Communicable, maternal, neonatal, and nutritional diseases.”* This is roughly the category that the low cost-per-life-saved interventions target. If we assume that all of this is treatable at current cost per life saved numbers - the most generous possible assumption for the claim that there's a funding gap - then at $5,000 per life saved (substantially higher than GiveWell's current estimates), that would cost about $50 Billion to avert.

    This is already well within the capacity of funds available to the Gates Foundation alone, and the Open Philanthropy Project / GiveWell is the main advisor of another multi-billion-dollar foundation, Good Ventures. The true number is almost certainly much smaller because many communicable, maternal, neonatal, and nutritional diseases do not admit of the kinds of cheap mass-administered cures that justify current cost-effectiveness numbers.

    Of course, that’s an annual number, not a total number. But if we think that there is a present, rather than a future, funding gap of that size, that would have to mean that it’s within the power of the Gates Foundation alone to wipe out all fatal communicable diseases immediately, a couple times over - in which case the progress really would be permanent, or at least quite lasting. And infections are the major target of current mass-market donor recommendations.

    The Open Philanthropy Project started out with $8.3 billion in 2011, and presumably has less now. The Gates Foundation has an endowment of $50.7 billion as of 2017. They wouldn't be able to sustain $50 billion of annual donations for very long. As such, I think the first and second paragraphs are essentially invalid.

    It sounds dubious that we could wipe out communicable diseases in a few years and have that be permanent without any further investment. The 2017 Global Burden of Disease lists some communicable diseases as follows: HIV/AIDS, syphilis, chlamydia, gonococcal infection, tuberculosis, other respiratory infections, diarrheal disease, typhoid, salmonella, malaria, schistosomiasis, dengue, rabies, other neglected tropical diseases, ebola, zika, meningitis, measles, hepatitis, tetanus, and so on.

    My understanding is that rather few of these have been permanently eliminated, even in high income countries. Distributing condoms and PrEP for a few years isn't going to permanently eliminate HIV. Bed nets and seasonal chemoprevention aren't going to eliminate malaria. Measles needs ongoing vaccinations. Etc.

    There are of course more permanent solutions that we can use, but these are probably much more expensive and it's unclear whether the two foundations would be able to fully fund them. In the late 1940s, the US substantially reduced malaria by draining swamps and spraying mosquito spray.¹ There's gene drives of course, but we probably need more research at this point before we can safely try to eliminate mosquitoes with that. Ending worms, diarrheal disease, or typhoid would probably require incredible improvements to the water supply. Still, HIV and respiratory infections would probably not be possible to eliminate without substantial improvements in medicine.

    Also, the Gates Foundation is not particularly EA, and we should not expect it to put all its money into global health. (Nor would we assume Open Phil to do so, because it also cares about other cause areas.) In any case, even if they could fill the gap, that's not a relevant counterfactual unless they would fill the gap.

    All of the above is using Benjamin's charitable, optimistic assumption that we can save a life for $5,000 up to $50 billion per year. If we consider just the room for more funding of all the top GiveWell charities better than GiveDirectly, is that low enough that Open Phil and the Gates Foundation can completely fill it? Possibly, in which case I will defer to the argument Jeff Kaufman's post.

    Reply
    1. Benquo

      Gonna repeat my comment above:

      Are the communicable disease rates just gonna shoot back up to the trendline in the next year? How would that happen?

      Reply
      1. Kelsey

        Yes, when all spending on prevention and treatment suddenly stops, disease rates typically bounce back very fast. Eradication efforts (which Gates is funding up to the point where they're not funding constrained) require continual monitoring of large populations for a number of years in order to avoid immediately losing nearly all the ground you gained. If your argument here is based on the assumption that by spending $50 billion in one year you'd eradicate all diseases and need no money the following year, then I think that needs to be telegraphed very clearly in the piece - I felt egregiously misled when I realized that $50billion was an annual number, not an overall number, and if your argument here is that the annual number is all that matters since you'd only need one year of disease treatment then that needs to be explicitly spelled out.

        Reply
        1. Kelsey

          For just one example, in 2017 global measles cases jumped by 30% including outbreaks in a lot of areas considered near eradication: https://www.who.int/news-room/detail/29-11-2018-measles-cases-spike-globally-due-to-gaps-in-vaccination-coverage because there were gaps in vaccine coverage. That's an example where there were shortcomings in global health coverage that was meant to be close to adequate, vastly different than what we'd see if global health funders spent all their money in one year and then called it quits entirely in the next.

          Reply
          1. Benquo Post author

            A large spike relative to a rate that's been radically reduced due to a long history of interventions is not at all the same thing as a return to the pre-intervention baseline.

          2. Kelsey

            Right, there are no examples of a major funder doing a one-year push and then ceasing all efforts because there's so much disease transmission bounce-back from much smaller interruptions of services that it seems like a reasonable assumption that would be disastrous.

            I continue to feel like the original post was incredibly misleading if a key premise is that a one-year push would permanently reduce disease burden even after all services subsequently ceased. Am I reading you wrong, or is that in fact a key premise of your argument here?

          3. Benquo Post author

            I continue to feel like the original post was incredibly misleading if a key premise is that a one-year push would permanently reduce disease burden even after all services subsequently ceased. Am I reading you wrong, or is that in fact a key premise of your argument here?

            There are several ways in which it's better to save lives now than later, and in which zero is a special number. I've added a paragraph to make that a bit more clear.

            I'd hoped readers would take a moment to imagine what that world would be like instead of just evaluating the syllogism.

      2. Anonymous

        If you just blow all the money in a single year scaling up these interventions, you can't expect the effect to be permanent. It depends on the intervention, but I'd expect them to jump back up to 80% of where they otherwise have been otherwise over a few years.

        Malaria chemoprevention drugs will be used that year, then there won't be any more to treat people with malaria the next year.

        The HIV antiretrovirals will be used that year, but without more funding they won't be there the next year and people will go back to dying of HIV.

        The condoms will be used, then there won't be any more. Many people will have their chlamydia treated, but it will gradually spread and go back to its previous equilibrium level determined by infection and cure rates. Likewise with diarrhoea.

        Insecticide treated bednets bought to cover everyone that year will last 3-5 years but then they'll be gone, and in the meantime there won't be new ones to cover population growth. There'll still be some people with malaria, and it will spread from them back to its equilibrium level.

        New sanitations systems might last longer, but they'll often break down without follow-up and maintenance, which is likely if they're built all over the place in a great rush.

        Cash transfers only have medium-sized ongoing effects, so they get spent and basically stop helping people after a few years.

        I could go on, but I think this helps to explain people's intuitions that communicable disease rates would indeed shoot back up and the problems are not solved.

        Furthermore, the idea of spending huge endowments in a big splurge is impractical and would greatly drive up the marginal cost per life saved, as the foundation has to accept worse and worse projects to get the money out the door within a year or two.

        Treating the hardest to reach 5% of people with HIV or malaria or tuberculosis or chlamydia is going to be very expensive if it can be done at any price. We've only managed to eliminate one disease so far, and that one had a bunch of characteristics that made it unusually easy to do so.

        Reply
        1. Benquo Post author

          The sorts of interventions about which people claim cost per life saved numbers below $5000 are things like malaria bednets and drugs to purge people of schistosomiasis (even though the latter doesn't really prevent many deaths per se). Both are about reducing infection rates rather than treating the ill, so in both cases we should expect substantial long-run network effects from universal coverage, if that were achievable.

          Nutritional interventions are a different sort of thing, of course. And in practice - which is my whole point - you can't actually scale those interventions up radically at the advertised cost per life saved numbers, so the true room for funding at that efficiency level is much, much lower.

          Reply
          1. Avret

            Malarial bednets seem like a prototypical case of something _without_ network effects -- seeing as the mosquitoes will likely still live off animal blood etc.

            Also, if your whole point is 'you can't scale up at those numbers', then citing financial numbers for 'obviously these can't be effective' which use those numbers as _scalable fact_ feels ridiculously disingenuous.

          2. Ashwin

            Suppose that 10 million avertable death-equivalents per year are evenly distributed between the following cost buckets: $3k-30k to prevent, $30k-300k, and $300k-$3m If our threshold for things worth preventing is "GiveDirectly" or "more effective in direct benefits than improving my own first-world life", I don' t think such a distribution changes the sense of the scale of room for more funding much? If anything it might increase it, since $3-30k clearly beats the first threshold and all three buckets probably beat the last threshold.

            If the argument is really "marginal cost to prevent decreases as things get funded, so the $5k figure has too much visceral weight"...that's not a very compelling point to me, because you can save a life for much more than $5k and have it easily meet a reasonable worthwhileness threshold. And empirically, decent amounts of funding from GW and Gates haven't decreased the marginal cost-effectiveness by very much--low thousands to mid thousands doesn't really change my feeling of worthwhileness at all.

  6. Holly Elmore

    You know, you can just focus on you and your friends and family having concrete good in their lives *without* the utilitarian imperative to give until it hurts being false. If I take your post at face value, and I buy that funding gaps are not a real problem, my next thought is that now it's more important that I pick the right career, not that I should just stop worrying and make my own life good.

    As long as there are people suffering or not living their potential in the world, the suggestion that those with more should be using their excess to help them before helping themselves will always be compelling. So calling into question any particular avenue of helping others does not, as I see it, lead to the conclusion that we should just focus on ourselves and our loved ones.

    We are free people here. If you don't really believe in EA style giving, then you don't have to do it. You definitely don't have to disprove our ideas in order to be allowed to live as you see fit. Utilitarians can have a point of view that's hard to contradict on its own terms, and you can have your own point of view about what's good for you and others that is more compelling to you than utilitarianism.

    Reply

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