Reducing suffering. The philosophical argument for an effective philanthropy

There is a philosophical argument that underpins the moral attitude of helping others. This argument explains WHY we ought to help others and provides insights into HOW we ought to do so. For this reason it has become the Rosetta stone of the movement known as Effective Altruism. The argument was famously developed by Peter Singer, an Australian philosophy professor based at the University of Princeton, and begins with a hypothetical situation: 

• Imagine you are walking to a job interview wearing your brand-new suit and shoes. Suddenly you realize that there is a young boy struggling to lift his head above the water, he has fallen into a pond. You look around and his parents do not seem to be anywhere near. No one else is around. If you do not jump into the pond and help the boy, he will certainly drown. But jumping into the pond will mean that your new suit and shoes will be ruined, and you will miss the interview, most probably failing to get the job. What would you do? 
• The majority of people, across cultures, gender, socio-economic situation, and religion, agree that the morally correct thing to do is to jump into the pond and save the child. 

The direct implication of this thought experiment is very important: if you find yourself in a situation where you can save a life, the categorical imperative, the thing to do, is to save that life, above all other costs. 

This reasoning has influenced the way we think about charities and giving to others. And this is for two reasons. First, we have realized that millions of people die every year from conditions that can be easily and inexpensively averted. As easy as pulling out a child from a pond. The existence of evidence-based high impact charities, working in some of the most deprived places on Earth, means that we find ourselves in the position of saving a life. By donating to those charities we can have a proven impact on reducing human suffering. 

Second, this moral stance does not end with the inclination to help, it extends to the responsibility of finding the way to maximize the impact of our altruistic drive. In other words, our altruistic input (time, money) should aim for maximum results (highest number of people reached in a fulfilling manner). As Will Macaskill puts it “when it comes to helping others, being unreflective often means being ineffective” (2016, p12). 

So we work to reduce human suffering and we do this by implementing cost-effective operations. Endowed with this call and this craft, we are now obliged to decide which human challenges to tackle first. 

As Colombians we were nourished to address our perennial peace-building conundrums. Our recurring day and night dreams were once related to device a political agreement between contesting armed groups, one that would end the bloodshed and set the ground for institutional reforms in the agrarian, health and education systems. Later in life we were loured to think about development. After being introduced to the experience of the East Asian developmental states, suddenly we began asking ourselves: what does it take to be a tiger? We studied top-down structural reforms; we were captivated by the economic push driven by state-sponsored conglomerates; and wondered about the political-economy conditions for elites and non-elites to converge in coordinated economic efforts. 

Pondering around peace and development has been fascinating. However, social change has not been as tangible as we had wished for. In the last 6 years we failed to implement a peace process and set forth even the most conservative egalitarian reforms; and the lockdown due to Covid evaporated at least 10 years of heralded improvements in poverty relief. This has led us to a simple conclusion. It is not a pessimistic one, on the contrary, it identifies a window of opportunity for advancing positive change in Colombia. 

We have realized that there is a myriad of people whose lives we can improve drastically. Just not through the effects sought by vouching for peace, or through promoting redistributive economic reforms. With time we have come to realize that there is one problem that has survived the highs and lows of peace and development dreams, it is related to the quality and quantity of healthy life. 

We had not realized the magnitude of suffering caused by NEGLECTED TROPICAL DISEASES (NTD) or by other infectious diseases in general. However, these conditions tend to produce the most human suffering as measured by years of life lost due to premature death or poor health. And the existence of this public health burden is a major determinant for low economic performance in the future, which in turn diminishes the number of people that can engage in activities that enhance the quality of democracy and wellbeing in a society. Graph 1 shows the World disease burden by cause.  

Graph 1. World burden of disease by cause, 2017

Source: IHME, Global Burden of Disease. OurWorldinData.

Two questions arise. Why did we miss this burden for so many years? And why are we talking about NTDs if according to Graph 1 cardiovascular disease, cancer and neonatal disorders create the most burden of disease? 

Well… public health is not a common topic among social science faculties or among development agencies in Colombia or the world (hence the neglect). We discovered that applying an empirical approach to picking the most pressing human challenges takes the focus away from the politics and economics of peace and development and puts it into the logistical challenges of serving the most deprived communities with inexpensive medical treatment and sanitation. 

On the other hand, we ARE taking care of the most burdensome conditions in LOW-INCOME contexts. The last 50 years have seen a steady decline in the burden of communicable diseases in middle and high-income countries, and this has been attributed to sustained improvements in public infrastructure, education and access to vaccines, antimicrobials and sanitation. And the result of this is seen in Graph1. But Graph 2 illustrates this has not happened in the most deprived areas (the bottom billion) of the world.  

Graph 2. Sub-Saharan Africa burden of disease by cause, 2017

Source: IHME, Global Burden of Disease. OurWorldinData.

After more than 10 years of work the experience of some of the most cost-effective charities conveys some pristine conclusions. First, NTDs cause the most human suffering in low-income contexts, mainly in sub-Saharan Africa and south Asia. For a number of historical, institutional and geographical reasons, these countries tend to have states with limited capabilities to provide basic public goods, as well as weakly coordinated societies to push for reforms. As a result, poor water and sanitation facilities, limited distribution of vaccines, difficult access to primary health care centres, risky living and working conditions in tropical and subtropical areas, among others, derive in burdensome health conditions that have long been eliminated from middle and high-income countries. Second, it is much more difficult/expensive to reduce/prevent/eliminate non-communicable diseases such as heart conditions or cancer, or political distress such as gender inequality and education gaps, than neglected tropical diseases. Moreover, a great deal of political and socio-economic disparities can be traced back to health disparities. 

Now, subnational territories across the global south have equally or even worse prevalence of infectious diseases than Africa and Asia. For example in a small municipality next to the big touristy city of Cartagena (Colombia), the prevalence of helminthic infections (parasites) is as high as 90% (of total population in the municipality). And this has remained constant for at least 10 years. This prevalence is much higher than those reported by charities like Evidence Action and The END Fund (both recommended by GiveWell) in Pakistan, India and Kenya. 

Aware of all the above, onceonce has committed to fight the burden of neglected tropical diseases and other infectious diseases in Colombia and Latin America. We believe that the statistical bias that results from comparing national-level data has left our region in oblivion from the work of evidence-based charities. Therefore, filling this void is a humanitarian obligation. 

Neglected Tropical Disease

Neglected Tropical Diseases are pathologies that share a series of conditions. First, they develop mainly in tropical and subtropical areas of the world, . Map 1 shows countries that demand treatments for NTD. Second, they are easily and inexpensively treatable. Not only treatments to reduce these diseases tend to be cheap, but economic analysis has shown there are huge economic benefits derived from world-wide prevention and eradication campaigns (Polio eradication being the paradigmatic example, but HIV following close). And third, they are called “neglected” for two reasons. One, because they develop in some of the most deprived places in the world, where there is very little access to public infrastructure. Places that seem in oblivion from state and market forces. And two, because more attention is given to killer diseases (cancer, HIV, human violence), despite NTDs producing equally important burdens of disease.

NTD are estimated to affect 1.7 billion people yearly. Mortality rates due to NTDs tend to be very low, but morbidity rates are high. When unattended, these diseases tend to have long-lasting impacts on individuals: limiting for life their cognitive capabilities, increasing school absenteeism, which in turn has a negative effect on adult income, and has considerable health costs. In sum NTDs unleash the typical chain of events (negative feedbacks) that are referred to as poverty traps. 

The World Health Organization has identified 17 NTD, 12 of which are present in virtually every country in Latin America: 

In February 2021 the World Health Organization launched the 2021-2030 roadmap to address Infected Tropical disease, disclosing global agreements on prevention, control and elimination targets. Regarding soil transmitted helminths the WHO has set the target of 97 countries have eradicated STH as a public health problem, and for doing so it has established three critical actions: i) increase political commitment to ensure domestic financing, ii) develop more effective drugs, iii) develop comprehensive surveillance and mapping systems to target treatment and monitor drug resistance (p16). Moreover, the WHO recommends a more integrated intervention. First, by jointly delivering NTDs treatments that are common to several diseases; second, by mainstreaming the line of work against NTDs health ministries; and third, by coordinating actions among the ecosystem of stakeholders. 

Disability adjusted life years (DALYs) is a composite measure first designed by the World Bank in the Global Burden of Disease studies (1990, 2001). This effort has continued under the purview of the Institute for Health Metrics and Evaluation of the University of Washington (2010, 2015, 2016, 2017, 2019) with the financial support of the Gates foundation. 

DALY is a numerical expression that adds the years of life lost due to premature mortality (YLL) and the years lost to disability (YLD). Every disease is attributed a YLL (mortality burden) and YLD (morbidity burden) in every country, and when added to create a measurement of DALYs they provide an estimate of the burden of disease in that specific country. This methodology has allowed the comparison of health profiles of countries across time and pathologies. Although is a perfectible methodology (see GiveWell, Global Priorities Project), this is the most accurate and widely used metric to compare the burden of disease and it has become the golden standard for health debates. 

Technically one DALY is equivalent to one year of life lost due to the combined estimated burden caused by premature mortality and disability. Conflict, terrorism and interpersonal violence caused an estimated 36 million DALYs in the World in 2017. This is significantly less than the 62 million DALYs caused by malaria and neglected tropical diseases (47 million of which are caused in Sub-Saharan Africa and 1.2 million in Latin America). This confirms that communicable diseases have a much higher burden than many of the usual pathologies normally addressed by charities and development organizations. 

“Schistosomiasis and STH infections are diseases of poverty. These infections give rise to much suffering and death; in addition, they contribute to the perpetuation of poverty by impairing the physical and intellectual growth of children, and by diminishing the work capacity and productivity of adults.” (WHO, 2011)

Parasitic diseases are among the most prevalent neglected tropical diseases. According to the World Health Organization, parasitic worm-infections (also referred as helminthic infections) affect more than 1.5 billion people, which is almost ¼ of the World’s population. These infections affect people mainly in tropical and subtropical areas in sub-Saharan Africa, the Americas, China and East Asia, where extreme poverty, poor sanitation and scarce access to primary health care are common determinants of health. 

Table 2. Facts about helminthic infection

Source: PAHO, Pautas operativas para la puesta en marcha de actividades integradas de desparasitación. pg4.

The WHO estimates that “over 267 million preschool-age children and over 568 million school-age children live in areas where these parasites are intensively transmitted”. This is of special concern because this infectious disease affects growth, nutrition and cognitive capabilities, producing long term impacts. When there is a prevalence of helminths higher than 20% in a community, it is considered a public health problem, and massive deworming interventions are recommended to at least 75% of the total population (infected or not).  The most affected population groups are in the following order: children between 5 and 14 years; children between 1 and 4 years; and pregnant women. 

Contagion entails an anal-oral transmission. This means that infected people excrete helminthic eggs. These excretes contaminate food, water sources, hands and once the eggs have become larva, they can also enter into the body via bare foots (Ochoa Vásquez 2019, 48). 

Table 3. Six 2030 global targets for soil-transmitted helminthiases

Source: World Health Organization Global Targets on Soil-transmitted helminth infections

The Neglected Tropical Disease Network describes the two types of worm-infections. Soil-transmitted helminthes (STH), which are “transmitted by eggs present in human faeces which in turn contaminate soil in areas where sanitation is poor”; and schistosomiasis, that is caused by larva that penetrates human skin and cause damage when they remain in the body. These types of worm infections account for most of the global helminth disease burden. 

Table 1. Parasite species in Schistosomes and Soil-transmitted helminths

Source: WHO (2011), helminth control in school-age children

Table 2. Effects of schistosomiasis and soil-transmitted helminth infections in humans

Source: Who (2011) helminth control in school-age children

COMPARATIVA will concentrate on soil transmitted helminths, as they are of especially high incidence in Latin America, in contrast to schistosomiasis that is mainly present in Africa, as shown by maps 1 and 2. 

Map 1. Global distribution of schistosomiasis. Map 2: Global distribution of Soil-transmitted helminth infections.

Source: WHO (2011), helminth control in school-age children                            Source: WHO (2011), helminth control in school-age children

Infant mortality due to STH is around 155.000 per year, which is much less from that due to diarrhoea and pneumonia, which add up to 2 million children. However, it is morbidity what concerns global health specialist. If not treated, parasites can induce anaemia, malnutrition (especially lack of vitamin A), dysentery, growth and cognitive problems. “In addition to the prevalence of STH in Latin America and the Caribbean, it is known from scientific evidence that helminthiases contribute to exacerbate transmission and severity of malaria, tuberculosis and AIDS diseases, that are public health problems in these countries.” (PAHO). Moreover, this morbidity generally creates other development problems like reduced income, diminishing school attendance and poverty. As the latest Nobel prize in economics, Michael Kremer, claims, parasites are the underlying reason for much of the school absenteeism reported in Kenya.

In Colombia

Colombia has reported the existence of 9 of the 17 neglected tropical diseases identified. The burden of helminthic infections in Colombia is recognized but insufficiently addressed. The World Health Organization estimates that 30% of children before and after school age are requiring preventive chemotherapy, this adds up to 3.2 million children. However, only 1.3 million (40%) are receiving treatment. 

The National Plan for the prevention, control and elimination of neglected tropical diseases (2013-2017) established that the Colombian government would focus its limited resources in the prevention and control of soil-transmitted helminths, river blindness and trachoma. This is good news. Presumably, as part of this plan, in 2015 the government published the national survey on parasitism in school population for the years 2012-2014. This study became a base line upon which a national strategy for prevention and control could be designed. 

What were some of the findings of this survey? Just in the pilot survey that took place in several municipalities of Antioquia, Choco, Sucre and Vaupés the results were astonishing: 91% of the 1,016 children (7 to 10 years) surveyed were infected by at least one parasite (44% Trichuris trichiura, 34% Ascaris lumbricoides, 25% Uncinarias). The survey divided the country in 8 biodiversity regions, finding that 4 of them had helminth infection prevalence above 45% and 3 of them had prevalence above 57%, which is considered to produce high risk of contagion and requires immediate massive deworming programs. The main academic paper derived from this survey concluded worm infections remain a public health problem, and massive anti-helminthic chemotherapy should be followed in prioritized high risk-areas.  

Interestingly, the distribution of the different STH is different in Colombia from the rest of the World. In Colombia Whipworms are the most prevalent parasites, as opposed to Roundworms, which are, on average, the most prevalent in the world. 

Graph 4. Types of helminths in Colombia vs. World

Source: National Survey for Parasitism 2012-2014 (Colombia); WHO (2002) Helminth Control in school age children (World)

Moreover, the risk of getting infected from helminths was directly proportional to the distance to the centre of the country, as shown in Map 4. The regions with the highest prevalence contain municipalities in the Amazon, the Pacific, the Caribbean and the eastern borders of the country. Similar findings had been discovered previously and since then. A 2015 study in the indigenous resguardo (collective land) of the Nasa community in Cauca (pacific coast) found that 95% of children had soil-transmitted helminthes, 21% had anemia and 35% chronic malnutrition. Similar results were found in 2015 in the resguardo Wiwa at the Sierra Nevada de Santa Marta. A previous 1999 study found that after 6 months of implementing a massive deworming program, reinfection rates want back to pre-intervention levels or even higher. Another 2013 study found that the 84% of children surveyed had more than one and up to 4 different parasites. A systematic review of literature published between 1990 and 2017 estimates an overall 65% prevalence and 38% multi-helminthic infection in Colombia. 

Map 4. Risk of contagion from infectious disease

Source: National Survey of Parasitosis 2012-2014

Almost all literature consulted embarks in small-n studies of children in school age. They are not representative studies of a region or the country. But in the aggregate they all recall prevalence between 65 and 90%. This numbers are much higher than those found by evidence-based charities in Africa and Asia. 

Further research shows evidence of the aggravating consequences of STH on school performance, attention spam and compliance with duties. What are the social determinants of this condition? All studies tend to point towards water, hygiene and sanitation deprivations, which are then coupled with path dependence conditions such as low education attainment from parents and structural poverty. For example, this study in Cundinamarca found strong positive correlations between helminths and dirt floors, lack of sewerage and absence of sanitary infrastructure. 

The latest report published claims that the Colombian government reported deworming programs in only 5% of the required territory, which is 4 times less than the Latin American average. This is most probably a data collection problem, as many deworming interventions are led directly by subnational governments. Still, it is symptomatic of the weakness of the health system and its capacity to address this disease. 

Targeting

The communities targeted for a deworming strategy will be located in the regions with the highest levels of multidimensional poverty. These regions are Vaupes, Vichada Chocó, Guainía and La Guajira. 

Table 3. Regions (Departamentos) with the highest levels of multidimensional poverty. Source. DANE 2021. 

These territories are selected because they share very poor development indicators and equally low state capacity metrics. In these territories market and state forces work poorly to provide basic public goods, this means that the opportunity cost of not receiving deworming treatment for any individual is very high, as neither the state or the market can provide for them. This is different for some communities in Cundinamarca or Antioquia, where the prevalence of infection from soil-transmitted helminths is high but they have close access to public and private services that provide public goods.  

Now, provided that the national survey on parasitism is not updated, the way to identify municipal targets is by looking at local studies, regional and municipal health situation analysis (ASIS, in Spanish), risk index of water quality (IRCA, in Spanish), subnational deworming yearly reports (Health Ministry), and the housing conditions dimension of the multidimensional poverty survey (National Statistics Agency). According to the guidelines of the Colombian government, when the prevalence measurements are not updated, it is technically correct to target based on socio-economic surveys that show that water and hygiene conditions are inadequate.  

Given the transmission mechanism described above (anal-oral, water-source and food contamination), Ochoa Vásquez (2019) claims that individual stool analyses are much less effective than a simple survey to determine the prevalence of the disease on the community level and therefore to determine the need to engage in mass deworming on a regular basis. 

The following tables show a ranking of municipalities with i) the highest multidimensional poverty and ii) the lowest housing conditions according to the multidimensional poverty housing component. 

Table 4. Ranking of municipalities with highest multidimensional poverty levels. Source: DANE 2021

Table 5. Ranking of municipalities with lowest housing conditions in the multidimensional poverty metric. Source: DANE 2021.