Can we help individual people cost-effectively? Our trial with three sick kids

By NickLaing @ 2024-02-20T09:43 (+396)

TLDR: My wife and I tried to help three children with severe illness cost-effectively. We paid for their medical care, followed up on what happened and reflected on the process.

"Hearing about her death hurt badly – as it should. But not only had I done what I could, it made sense. Those 300 dollars gave her a chance of not only surviving, but living a long and happy life."

My wife and I live in Gulu, Northern Uganda, where I operate OneDay Health, a social enterprise which provides cost-effective health care in remote rural areas – but this post isn’t about that.

We naturally encounter many situations where we feel compelled to help those around us, We sometimes help with school fees, medical bills and sometimes just cash bailouts. Many of these might not be very cost effective and fall into the “fuzzy giving” category, but by virtue of living in Uganda I suspect these contributions may often hit the unusual jackpot of both feeling good and being cost-effective, earning both “fuzzys” and “utilons” at the same time (sorry Yudkowsky, we mix them).

Which got me thinking, could we target some of our support in a more cost-effective way? As a medical guy in Uganda, I figured we might be in a decent position to try, so we embarked on a mini-experiment to see if we could find a few medical cases which could be super cost-effective to treat, on par with top GiveWell charities. 
 

Our Cost-Effectiveness Bar

We kept it simple here, and deferred to GiveWell’s top-charity bar of  $5500 per life saved. ^[1] I estimated cost effectiveness by dividing the money we would spend on  medical care  by a series of discount multipliers based on loosely estimated counterfactuals (see calculations below). My approach is deeply flawed as it fails to account for many variables, but allowed me to make a reasonable estimate in about 15 minutes. Feel free to criticize and discuss the method, I'm sure there more accurate and easier ways  (@NunoSempere @Vasco Grilo). I didn’t attempt a cost-effectiveness range as it would take longer. 

But where to find these sick people who might be cost-effectively helped? We planned to identify poor rural farmers who had life-threatening treatable illnesses, who were unlikely to be treated unless we paid for it. So I asked a couple of our OneDay Health managers to be on the lookout for sick people who presented to our  Health Centers, while I also kept an eye out in the health center where I work as a doctor - people who could die without treatment that they couldn’t afford. 

Finding people to "cost-effectively" help turned out to be harder than expected. Over a 2 month period we identified three young girls to help, while we decided not to help in another 5 or so cases. These are the stories people we tried to help– feel free to skip the BOTEC sections if you aren’t into that!

Lamunu – age 9

Even for a hardened doctor, Lamunu’s photo was tough to look at. She showed up in our Health center with about 30% of her body burned after falling into a fire. She had spent 10 days in an ill-equipped government hospital and she continued deteriorate. Her father ran out of money and took her home, before arriving one of our health centers (which can't treat burns) as perhaps desperate last-ditch effort. Her burns were infected, she was malnourished and everybody involved knew that she probably wasn’t long for this world.

I happen to live 500 meters away from the best burns unit in Northern Uganda at St. Mary’s hospital Lacor so I thought we might be able to help. We paid for her with herfather to take a 5 hour bus ride to Lacor hospital, and supported the family with hospital fees and some food.

Cost effectiveness BOTEC?

Chance of help without us?
10%. – I couldn’t really conceive how this would have happened, given my specific connection to the burns unit and the poor village she came from

Long term quality of life compared to the average person if survives?
70% - This is very hard to judge, but with the disfiguration and scarring, she would have a hard time socially and she would have moderate physical disability 

Chance of survival without help?
10% - Probably conservative, its hard to imagine a scenario where she survived at home, given how quickly she was deteriorating

Chance of survival with help?
25% - Although the situation looked dire, she had already survived a couple of weeks and the condition was treatable. She would need nutritional support, fantastic wound care and skin grafts. In a high-income country hospital with all the resources in the world, I would predict her chance of survival at over 70%. In retrospect her chances were probably better than 25% - the Lacor hospital care was even better than I expected.

Cost of treatment
$600 – Of this we paid only 300 dollars (transport from Soroti, hospital bill, some food). The other half is the estimated cost of her treatment bourne by the wonderful Lacor Hospital which looked after her. This hospital is over 50% donor funded, so this 300 dollars reflects their contribution.^[2]

The calculation...

$600
____________
0.9 x 0.7 x (0.25-0.10)  =            $6349 estimated to save a life ^[3]

The result
Over the first couple of weeks she recovered surprisingly well, while still remaining very sick. Her wounds were dressed multiple times daily, she was started on a high protein diet and the skin infections cleared. She started to eat more and talk a little. After she stabilized, she was booked for a skin graft surgery which could solve her underlying problem. On the day of surgery she was wheeled into the operating theatre where they discovered she had high fever and so delayed the surgery until her infection cleared.

The infection never cleared, and she tragically died two days later. Hearing about her death hurt badly – as it should. But not only had I done what I could, it made sense. Those 300 extra dollars gave her a chance of not only surviving, but living a long and happy life – at least that’s what I told myself…

Sunday^[4]- Age 9 months

Sunday had it tough from the start. Her mother struggled to breastfeed her (surprisingly rare here in Uganda) and she had been feeding her a mixture of what little mil her mother managed, plus cows milk to supplement. This didn’t help at all. Sunday had severe malnutrition, the worst I have seen with a nasty chest infection to boot. Her mother knew she was in a bad state, but didn’t comprehend just how sick she was. Fortunately there was an NGO malnutrition treatment center in nearby Soroti town, which had a good reputation. The mother was so poor that she didn’t even have the money to transport the kid to the center. To my surprise though the malnutrition center was completely free, and recommended they keep the kid for a minimum of 6 weeks until she improved.

Cost-Effectiveness BOTEC

Chance of getting help without us
50% - This is a hard one, as if her mother had realized that she could just go into Soroti town and drop the kid off at the treatment center, she might have managed to raise the transport money eventually, but it seems very unlikely given she hadn’t already for many months.

Survival chance without treatment
60% - In good treatment centers here, severe malnutrition mortality rates are 10-20%, but I doubled this worst case as she was at home, not In a malnutrition center. In retrospect given how dire the situation was, this seems too conservative and maybe 40-50% would have been a better estimate

Survival chance after treatment
80%. - As this was one of the worst cases of malnutrition I’ve seen, I put this probability at the worse end of mortality in malnutrition centers

Quality of life after successful treatment
75% of normal - Although she likely will have some form of developmental delay, most kids with severe malnutrition do surprisingly well long term after successful treatment

Cost
Only $300. Of this we contributed $100 to the mother for transport to and from the malnutrition facility a few times and, then made a $100 donation to the treatment center. I’ve estimated the cost of treatment at the center at around $200 in total

The Calculation...

$300
_____________

0.5 x (0.8-0.6) x 0.75 =        Estimated $4000 to save a life

The result
The treatment center did an amazing job and to cut a long story short she gained weight, got healthier and went home. A few months later she is still growing well and thriving, a great result. Given that malnutrition treatment is already a GiveWell target, this likely being the most cost-effective intervention shouldn’t be a surprise.
 

Angel – Age 7

Angel didn’t tick the boxes the same way the first two girls did. From minute one she pulled on my heart strings from the moment she walked into my consultation office and if I’m honest I would probably have helped her regardless, cost effectiveness be damned. A bright eyed seven year old girl, born with a 99.99% perfect body. But the tiny defect was a disaster, a mere 5 millimeter membrane which was enough to block her aortic valve in her heart.

Enough to make her heart not work properly
Enough to stunt her growth so she was only 15kg at age 7
Enough to ruin a full and fulfilling life

Five years ago in Uganda there was no heart surgery available, so the rich politicians and business people would fly their kids to India to get operations while everyone else had no option.

I was struck by the injustice of it all – in my birth country of New Zealand the operation would have been done 5 years ago. And enraged by the absurdity of the situation – a physical membrane of just a few millimeters standing between a girl and her happy and fulfilling life. At first the Mulago heart institute quoted $4,500 US dollars for the operation, before we bargained them down to $2800 on the basis of Angel’s extreme poverty. This is as close as I’ve ever come to literally bargaining for someone’s life. 
 

My (probably biased) BOTEC

Chance of getting operation without us
10% (probably optimistic)

Probability of survival within 10 years without operation
10% - Her heart failure is worsening, and I’m worried about a timeline of months rather than years.

Chance of operation success and a normal-ish life expectancy afterwards
60% - About 20% of aortic membranes recur after surgery in high income countries, which I arbitrarily increased to 40% given likely poorer outcomes in this case She doesn’t however have many features which increase risk or recurrence. If this operation failed there would be the possibility of another, but I kept the math simple.
Her current re-modelled, possibly permanently damaged heart may mean she will have a lower life expectancy and possibly lower quality of life even after a successful operation, but this is very hard to predict and many children have normal lives after operation.

Cost 
$2800 for the operation, plus $300 for pre-tests and follow up

The claculation..
3100
_________   = $6888 estimated to save a life. Not <$5000, but close enough.
0.9 x (0.6-0.1)  

BUT

The operation hasn’t happened yet. Apparently there’s only one cardiopulmonary bypass machine for kids in Uganda – you can't do heart operations without it and it was broken for 3 months. They’ve just fixed it, but have a huge backlog of kids waiting for surgery, so it might be another 1 to 3 months before Angel gets hers. I hope its soon enough.
 

My reflections and mixed feelings

This whole exercise felt absurd and uncomfortable. Even discussing my experience feels off, given the immense suffering of all the sick kids and their families. Despite the obvious emotional roller coaster, the process was probably net-“fuzzy”-positive overall while coupled with enormous discomfort. What right do I have to make these kind of decisions? Why did I do 100x better than these wonderful people in the lottery of life? Also the reality of valuing of one real, hurting, living, desperate. beautiful, hurting, precious, human at only $5500 seemed not just morally wrong but almost abhorrent. I don’t think many would disagree with me that a human life should be or even “is” objectively worth far, far more. Its also  easier to be two or three steps removed from a donation. And also easier to switch our donations from World Vision to mosquito nets, than to deny someone you talked to potentially life saving treatment just because the theoretical cost is $10,000 not $5500. 
 

Complexity, problems and downsides

• I didn’t account for the value of my time or emotional energy into any of these calculations. Although gained energy and a sharpened sense of purpose through this experiment, if I’m honest there was probably a small net drain on my overall time and energy 
• Risk of “Savior Complex"^[5] formation, where I feel proud or superior to others because of these “good works”. Its interesting that this dangerous mind-state may well be more likely to form helping individuals in a less cost-effective way than it would giving money to highly effective charities
  
  Alternatively there's the chance of negative external perception where I’m accused of being a lone-ranger White Savior. For deciding from my privileged and literally white Ivory tower who might live and die, without consulting local people on what they think about this whole initiative. I’m aware there is a pretty reasonable “Playing God” critique here with a couple of people making important decisions about who to help based on deeply flawed and loosely calculated BOTECs…
• Feeling Guilty and Overwhelmed at times – almost the opposite of the Savior Complex. Guilt from denying people help that didn’t meet our bar, and a litle overwhelmed by the pressure and responsibility.
• Bad decision making ,due to bias from personal connections – see Angel… Its almost impossible to stay objective when dealing with real people in real time and sometimes in person.
• I was surprised how few cases emerged that seemed likely to be super cost-effective. This made this trial take a bit longer than I had hoped and made me less positive about similar projects being viable in the long term.
   

A Charity which cost-effectively helps individual sick people?

As well as our intention to make our own close-to-home donations more cost-effective, I had a vague idea that helping individuals sick people cost-effectively could become an effective charity. Perhaps it could be a bit like Kiva loans for effective altruists, where those who donated would know who they donated to and even the potential cost-effectiveness of each individual donation. There are many charities which pay directly for cost-effective medical care, for example fistula treatment or cataract surgery, but they are systematic entities which only treat one condition. This approach could pick up on any condition that might be cost-effective to treat, which in theory could increase the pool of people able to be helped.

After trying this on a small scale though, I’m less enthusiastic. First finding cases where the life-saving cost might meet the GiveWell bar was harder than I expected. This shouldn’t be too much of a surprise given that most charities which meet the GiveWell bar focus on prevention, which is usually more cost-effective than cure. Because identifying suitable people is tricky, the admin costs of a large scale charity might be so high as to make the work not cost-effective. Also there is a high risk of a charity along these lines being accused of “Playing God” and of “White Saviorism” given that we would deny most sick kids potentially life-saving treatment. I think this criticisms doesn’t hold much weight as we “Play God” in a similar way every time we choose a coffee over a mosquito net, but the negative perception risk remains.

On the other hand, this was a tiny side project over a couple months in one location and as a tiny trial there's no optimisation of any aspect. There might still be a way to run a cost-effective charity which helps individuals with life-saving care. 

There’s no avoiding the strange juxtaposition between helping people we’re connected to, and funding/operating cost-effective organisations. The $3100 we're using to help Angel might save an estimated 0.5 lives, while for the same amount we could treat over 1800 patients at a OneDay Health center and save perhaps a couple of lives. So on one level funding Angel’s heart operation might not make logical sense, but on another level it connects us with our community, helps us love and mourn better and reminds us of the messy injustices in this strange world we're a part of. I hope I'm a better person after this wee endeavour.

We’ll probably keep doing some more cost-effective life-saving giving on a slower, less intentional rolling basis. It might just be MoreGood than not doing it all.

1. ^{^}

   There are decent arguments for a higher or lower bar, and I’m keen to hear suggestions. 

2. ^{^}

   You could argue against including all of this cost bourne by the hospital, but I decided to keep the calculation pretty conservative

3. ^{^}

   At the time, I calculated this lower at around $4000 and just corrected it now after I realised my mistake, so it seemed more clearly cost-effectiv at the time. However we would probably have helped regardless as it was close enough to the bar.

4. ^{^}

   All names changed for anonymity

5. ^{^}

   "Savior Complex" is a Highly recommended HBO 3 part miniseries, raising great questions about the risks of white people trying to help in low income countries. Also interesting from thinking about net positive/net negative in what we do.