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TOBY ORD: I'm Toby Ord.
And I'm here today from Oxford University, where I'm a
research fellow in philosophy.
And also I'm the president of an organization called Giving
What We Can.
And I'll be talking about these types of things.
I should say as well that I haven't always been a
philosopher.
I used to be a computer scientist beforehand.
But I decided I was interested in logic and things like this,
which at my university the Philosophy Department was
mainly in charge of.
I spent more and more time over there.
And I was also very interested in a lot of ethical questions
and ended up being sucked away from computer science to the
world of philosophy.
But hopefully, you'll see that I've got an approach to some
of these philosophical or ethical questions, which is
perhaps more quantitative than you're used to seeing from
people who look at these things.
So let's start.
I have always been interested in charity and
helping other people.
And in particular, when I was an undergraduate, I used to
get into conversations through the night with my friends.
And they would say to me, in some heated political debates,
something like, well, if you think that, why don't you send
all your money to help people starving in Africa, or some
other cliche like this.
But this was meant to be a reductio of my position, that
you can't possibly think that, because you'd have to spend a
lot of your time and effort helping these other people.
But I started to treat it more like, well, maybe I should be
doing this.
Maybe I should be thinking about what I'm doing with my
income and maybe actually that is the logical conclusion.
If you think all people are equal and that you can help
people in poor countries for less, maybe I should be doing
something like that.
Maybe I should investigate it.
And I noticed a couple of philosophers
have written on this.
Peter Singer has some very good papers on this, "Famine,
Affluence, and Morality," for anyone who wants
to look that up.
And there are some very strong arguments.
And I took these seriously and started to think about what I
could do in my life if I really wanted to, to help
people who are less fortunate than myself.
So when I was thinking about this, I divided the different
ways I could think of helping up into these four categories.
One was voluntary work.
One was my career.
So what good could come through my career.
Another one was the personal relationships I have.
And another was donations.
And I thought that that's something that a lot of people
neglect as a way that they can have a lot of
impact in the world.
There's was also the thing that was
most amenable to analysis.
So I decided I wanted to work out, well, what in terms of
donations could I do?
If I really wanted to, what could I achieve?
And that's the topic of this talk, really.
So I worked out that over my career, I'd be able to earn
about one and a half million pounds.
And I encourage all of you to try to work out what you'll
earn over your career.
I think this is an informative thing to do, particularly as
you can work out then what you could achieve if you
really wanted to.
And it's nice to know that--
through donations.
It might be that you can achieve even more
through your career.
I worked out that I only really needed about 500,000
pounds over my life if I kind of kept on my current
lifestyle, which is very good.
At that point, I was a graduate student and I had
pretty much all the things I really needed in my life.
I have a lovely wife, and great friends, and have
wonderful conversations, and can see beautiful places and
travel to Europe once or twice a year on that.
Living in the UK is a nice advantage there, but I could
take some--
a bit more expensive, but I could take some travel and
listen to the best music ever recorded.
And the things that I can do would rival a lot of the
things that a king could do a century earlier.
We've got it pretty good in the world today.
And so I thought, actually, I have a lot of these things
which are of a lot of value.
And if I spent this extra million pounds on myself, it
wouldn't actually make my life all that much better, because
I get-- the things which are of highest value or the best
*** for your buck in your life, you get first.
And then you get less and less effective
things added on later.
And so I thought, actually, I could probably do that if I
really wanted to, and carry on living a slightly kind of
grad-student-plus kind of lifestyle and donate about a
million pounds.
And so I thought, well, what could I do with that?
And once you start to get a big number like this, it's
worth putting more effort.
What can I do with a million pounds as opposed to, is this
10 pounds I'm donating for this fun
run, is that effective?
Or is this other thing effective?
If it's on that kind of level--
dollars perhaps I should use.
I'll try.
A pound is one and a half dollars.
So I tried to think about these things.
And if it is just these very small sums, it's not really
worth doing the analysis as to what's going on.
But if you realize that over your life you can do a lot at
about a million pounds.
I mean, if you were spending a million pounds on a house or
something, you would put in some time doing some research
on that, because you might be able to get, say, a house
that's 10% better.
It's a good deal.
You spend 900,000 pounds for a house that would be worth a
million pounds or something like that.
So I want to think about that kind of thing when it comes to
charity and trying to get a good deal.
There's many ways that I could help people with my money, for
example, education, empowerment of disempowered
groups such as women in poor countries, or promoting peace.
I mean, the list is very long.
I'm going to focus on health in this talk, because there's
some really good evidence about health.
And so you can get quantitative and get into the
nitty-gritty.
And I also think it's plausible that health in poor
countries is one of the best ways that we can help people
with our money.
And if you think that actually one of these other things is
even better than health, that's great, because it means
this is a lower bound for how much you can
achieve in your life.
So by looking at health, maybe we can do
even better than that.
So the first question here is, what metric should you use to
try to work out what you can achieve with a
certain amount of money?
So one common thing that's talked about is the percentage
spent on overheads and administration.
And so you often hear something where they say that
only 10% of this organization's budget is spent
on administration.
I don't think that that's a very useful metric, because
what a charity does is much more important than how much
it spends on these.
So there's a lot of variety between charities in terms of
what they fund.
And I think the key question instead is for a given
donation, how much benefit do people receive?
So it could be, for example, that if an organization spends
its money on program evaluation, which is checking
to see after they try something.
So suppose they build some wells in Kenya.
And if they spend some money to go back and find out
whether those wells are being used or whether they're still
working 10 years later, try to find out the lifespan of the
well to work out how good a project it was to compare it
with other projects, that counts as overheads.
But it's also the exact type of thing that organizations
should be doing.
So there's this issue that the overheads money's not wasted.
And even if it were wasted, the difference of 10% or 20%
or something like that between charities you'll see later in
this talk is actually very small.
The differences get much bigger than that.
And so this would be a relatively bad way of
assessing things.
There's a lot of research that can help us answer this
question of for a given donation how much benefit do
people receive?
But most people aren't aware of it.
And the greatest difference here comes from the type of
intervention performed.
So, for example, whether you distribute malaria nets to
help prevent children getting malaria, or whether you
distribute some medication to limit the effect of *** on
your system, or whether you distribute condoms to try to
avoid new people getting this, or whether you build wells, or
whether you provide sanitation systems such
as toilets and sewers.
So there's a whole lot of these different things you
could be doing with money.
And some of them are much more effective than
others, as we'll see.
Just as an example to motivate this that's quite easy to
understand, if you're providing someone with a guide
dog to try to combat the bad effects of blindness, this
costs about $40,000.
In contrast, it costs about $20 to completely cure someone
of blindness caused by trachoma.
So for example, if you wanted to donate $40,000 in order to
fight blindness, you could either provide a single guide
dog or you could completely cure 2,000 people.
So there's a very big difference there, because
presumably also having a guide dog is less good while being
blind is less good than having your blindness cured as well.
So it seems like in that case there's something of a factor
of 2,000 or so between these different types of
interventions.
And this type of thing does come up quite a lot.
This is not just an aberrant case.
But you might wonder, how can we take this idea further and
look at cases where--
this is very much an apples-to-apples comparison.
But in many cases, you won't be able to do that.
It would be, say, curing blindness versus saving
someone from dying of AIDS.
And they're quite different, and it's hard to compare them.
So we want some way to broaden the universe of interventions
which can be compared with each other in order to work
out what's most effective within that universe of
possibilities.
So how can we compare apples and oranges?
So here are a couple of ways you might try to do that.
The first one you might think of as how many
lives can we save?
And that was the subtitle, I think, of this talk.
And that's the type of question which is interesting,
because I think most people don't ask that.
They might hear something like it only costs $1,000 to save a
life with our charity.
And they might respond to that by saying,
well, OK, here's $1,000.
But they don't tend to say, well, hang on a second.
If you can actually save someone's life, literally, for
$1,000, maybe I should give you another
$1,000 and another $1,000.
I mean, if there was someone on the street who you met who
was dying, you would take this more seriously
in a certain way.
So what I'm trying to think of is trying to take these ideas
about what we can do more seriously to look at the hard
figures for it and then to try to take them seriously.
Now, a big problem with using how many lives can we save as
a metric is that there's this truism in public health that
no one's ever saved a life, because the person tends to
die later, right?
Unless you were to become immortal, that would really be
saving someone's life in that sense.
And that would be pretty good.
Actually, I would recommend funding that
if that was an option.
But what you're more talking about is having someone--
they'll still die.
It's just they die at a different time.
And it's not just at a different time, right?
Because it means that you have more life.
The distance between your birth and your death is
longer, and you get more years of life in which to do things
that are good for you.
So that's the first issue, is that we can extend lives and
that's what we're really talking about.
And so you might replace that with a question and say how
many life-years can we save?
And I think that's a much better question.
But there's still this bit about what's the
quality of that life?
And you might imagine a case where, say, you're in
hospital, and you've been diagnosed
with a form of cancer.
And you're given an option of a treatment for that cancer,
which would mean that you will live longer, but that the
quality of the life will be much lower.
Maybe it's a very invasive chemotherapy.
And it's not obvious that you should take that.
I mean, if you had 10 years of life at low quality versus 9
years at higher quality, quite possibly the 9
years would be better.
So there's cases where you want to trade off between
quality and quantity.
And it would be foolish to just use the quantity here.
And there's also cases where you want to compare
non-life-extending treatments.
For example, if you cure someone of blindness--
actually, that does have a bit of an impact on
how long they live.
They live a bit longer if they're cured of blindness.
But if we abstract that away, you can see that also a lot of
the benefit comes from turning normal years where you're
blind into years where you're sighted.
And that's a lot of the benefit.
So you want to be able to capture both of those things.
And the way that people in public health and health
economics and practical ethics tend to think about this is in
terms of Quality-Adjusted Life Years.
So this takes into account both the quality and the
quantity, and is also known as QALYs, so I'm going to use
that term a bit, Quality-Adjusted
Life Years, or QALYs.
Now to explain exactly what that is, I've got a slide here
where this is a schematic of someone's life, the
health-related components of their life.
And you can see here that it starts at
100% quality of life.
I mean, it could start lower than that.
It's just sketching something.
And you can see that their life maybe
goes down in quality.
They perhaps become sick during the early part.
And then they recover.
And then there's a sickness in middle age, which is also
recovered from.
And then various stages of gradual decline towards death
at about 75 years old.
And you could imagine a curve like this for someone.
Maybe actually it would fluctuate a lot more.
You know, you get up in the morning, you stub your toe
while you're getting into the shower, and you drop to zero
quality of life or something, or maybe negative.
And then you bounce back up again and various things.
You can think about your overall quality of life.
This is just meant to be your
health-related quality of life.
But you get the basic idea.
It's a measure of how well you're doing.
And maybe 100% is a bit arbitrary as well.
Maybe you could get above that.
But in terms of health-related quality of life, we tend to
think 100% is someone who's perfectly
healthy at that time.
And zero is someone who their health-related quality is
equivalent to being dead.
So maybe that would be indifferent between being at
that quality or being dead.
Maybe being in a coma is a good example of zero or maybe
being at a level of pain which is so intense.
Maybe there are levels of pain so intense they're below zero,
and there are some levels such that they're a bit above that,
and they're at zero.
So that's the basic idea.
And then you can see that to apply it in practice, you
could imagine a kind of stylized version of this
question, where we have two lives here which I think both
live to 60 years at 70% quality.
And here's two different ways you can improve that life,
maybe two different health interventions.
The first one improves the quality of
that life up to 90%.
And the second one improves the length of the
life up to 70 years.
And then what you do to compare which one is the
greater benefit is you just look at the area of them.
So it's just taking the integral is the idea.
That's the value of a life, the area under the curve.
And this, you'll be perhaps happy to know, is the standard
approach used in public health.
It's reasonably quantitative.
And they allow us to compare apples and oranges within
health, which is the real kind of key benefit
of using this approach.
It's important to say, though, that they're
only a rough measure.
So you might have been thinking, I understand how you
would measure this quantity of life, because you can measure
when someone is born and you can measure
which day they die.
But I don't really understand how you could measure the
quality of the life.
It seems very hard.
There are surveys which are designed to elicit
responses to this.
For example, you ask questions such as, if you could either
live for 10 years in this health state, perhaps being
blind, or you could live for 7 years in full health, which
would you prefer?
And then you can start moving those numbers around and you
keep asking the question.
And then you can use that to elicit a quality.
That's called a time trade-off.
There's other ways as well, where you imagine a chance
you'll die.
You can either be perfectly healthy with a chance to die,
or you can have this health state.
How much chance to die would you be prepared to put up with
to avoid that health state?
So there are different ways like this.
And they have slightly different
methodologies and so on.
And they elicit answers to these questions.
But even then, they're probably still often going to
be out by up to a factor of two.
You might think that's a pretty bad metric.
If I had like a yard ruler which was so inaccurate that
it often got out by a factor of two, you might think that
was a very bad measure.
But it turns out that in the universe of interventions that
we're considering, a factor of two is enough to make quite a
lot of progress.
And I think it would often be less than a factor of two.
But I just wanted to flag that.
It is an inherently rough measure.
And what's in some ways is just surprising is that with
such a rough measure you can make so much progress.
So the first question here is, what is a QALY worth?
A Quality-Adjusted Life Year, what's one of them worth?
Well, here's something.
In Britain, where you have the National Health Service,
they're prepared to spend 20,000 pounds for a
Quality-Adjusted Life Year.
If a new drug comes on the market which costs less than
20,000 pounds, so $30,000, they'll fund it for each
Quality-Adjusted Life Year.
If it costs more than 30,000 pounds, or $45,000,
they won't fund it.
And if it's in between, they'll look at extra
considerations.
But they have an approach like this.
And now, there is 8,760 hours in a year.
So this comes to about 2 pounds 30 per hour, or about
$3.50 for an hour of healthy life.
And I don't know what you think an hour of healthy life
is worth for yourself.
But for me, I would definitely think that this is
a pretty good deal.
If someone came into this room and was selling hours of
healthy life and was a reputable and trustworthy
distributor of quality-adjusted health hours,
then I would be using all the money than I had available to
buy them and also get some more money from
the bank and so forth.
I think that's a pretty good deal.
We often go to the cinema, for example, and spend much more
than $3.50 to upgrade a normal, perfectly healthy hour
of our life into an hour where you're also at the cinema.
And it seems this is a lot less good than creating entire
new hours of your life in which you could do other
activities and so on.
And so I would think, actually, we should be willing
to spend quite a lot more than that per hour of our life.
So maybe the NHS should try to get more funding so that they
can increase that limit.
If actually all the individuals in society would
be prepared to pay more out of their own pocket for it, than
maybe the government should as well.
That's a separate question.
This is just trying to get an idea of what
you think it's worth.
Another question is, would you spend 20,000 pounds to get a
whole year?
That's a bit harder, because it's a very
large lump of life.
It's not just fine-grained.
I think if you're prepared to spend 2 pounds 30 for an hour,
then you should be probably prepared to spend 20,000
pounds for a year.
It's just like buying a lot of hours.
But maybe you don't have that amount of money in the bank,
so it's hard to think in those terms.
But is another way to think about it is would you prefer
to have a salary of 20,000 pounds per annum or a salary
of 30,000 pounds per annum but be blind, one of those for the
rest of your life?
Or you could bump those numbers up.
You could say 120,000 pounds versus 130,000 pounds but be
blind, or something like that.
And for me, I would definitely think that this money is just
not worth that much to me compared to my health.
And I would definitely choose the ones on the left-hand side
unless it got really, really low.
So I think that I would also be prepared to spend 20,000
pounds per year.
So let's move on, though.
So that's what it's worth.
It's worth at least that amount of money to us.
Now, what does it cost, which is a different question.
Often things cost less than they're worth, which
is why we buy them.
If they cost more than they're worth, we should not buy them.
So spending 20,000 pounds on a QALY is a pretty good deal.
Can we get one for less than that?
Well, let's look at a question of preventing or curing
***/AIDS, *** being the virus, AIDS being the syndrome which
you get if your viral load gets high enough and is a kind
of late stage, where you're immuno-compromised.
We all know it's a major cause of death and disability in
developing countries.
And there are many different approaches to dealing with it.
And so let's look at a few of them in turn.
So here's a comparison between two different health
interventions.
The first is treatment of Kaposi's sarcoma, which is a
particular AIDS-defining illness.
It's a skin condition, which you only get if you're really
immuno-compromised, so it's one of the ways that people
decide whether to say that *** has progressed to be AIDS.
And the second one is antiretroviral therapy, which
is paying for drugs which fight the viral load and help
prevent *** turning into AIDS.
As you can see, the second one is much more effective than
the first one.
This is just a longer bars are better type graph.
And they're better in proportion to the length.
And what we've measured in here is how many
Quality-Adjusted Life Years per 1,000 pounds per $1,500.
And what I've drawn there is a line which is the level it
would need to be.
It would need to be at least as long as that to be as
effective as we thought the NHS use, which was just a
yardstick that we had beforehand.
And the NHS actually fund treatment of Kaposi's sarcoma.
And it's funded in the US as well.
It's considered to be kind of on the line, but to be
effective enough in a rich world context.
But you can see there's a very large discrepancy there in how
much benefit you can produce for a
given amount of donation.
But it's even more interesting if we zoom out and then
consider another intervention, prevention of transmission
during pregnancy.
So this is giving drugs to the mother, well, to the would-be
mother, during the stages of pregnancy so that the new
child doesn't get ***.
And that's a very targeted intervention, because you can
target it at pregnant women who have ***.
And so that reduces the costs, because you don't have to
treat everyone else.
And it avoids an entire lifetime of ***, which is
really good.
And so the effectiveness of this is
quite a lot more effective.
I should say that these figures come from a report
called "Disease Control Priorities," second edition,
which is a big aggregation of a whole lot of the
cost-effectiveness figures.
There is a literature on this stuff, where people try to
estimate how cost effective these different things are.
They do different types of trials, including randomized
controlled trials.
And some of it they have less information, so they have to
do more modeling, and it becomes a bit more tentative.
But this is the estimate for this.
But we can zoom out again and see more interventions.
So we zoom out here.
We can compare it to--
distribution of condoms is a lot more effective again, as
it's very cheap to distribute them, and you can avoid a lot
of cases of ***.
And you can only just--
I was going to say you can only just see this
cost-effectiveness threshold.
Actually, we've moved it a little bit so you can actually
see it. it would just be invisible at this point.
And these things are just extremely cost-effective.
And if we zoom out one more time,
we can look at something.
In this case, it's not an AIDS-related intervention.
But the distribution of bed nets to prevent malaria is
even more cost effective again.
And at this point actually, if we hadn't slightly enlarged
it, you wouldn't be able to see the bar for treatment of
Kaposi's sarcoma.
This new option is about 1,000 times more effective.
So you can do 1,000 times more health gain for a given size
of donation.
Oh, and to look at the actual number, you can see it's
nearing 60 years of healthy life for every 1,000 pounds,
which is very effective.
So let's just pause for a moment and say what we can
learn from this?
So one thing is that health programs in developing
countries can be amazingly cost-effective, about 1,000
times more so than we're willing to spend in our
countries on health and about 1,000 times more effective
than is needed to be a good deal, according to what we
judged earlier when we said how much health you need to
get for 1,000 pounds to be a good deal and so on.
Another thing is that our money's worth much more than
we might have thought.
Every 5 pounds to 30 pounds, or $7.50 to $45, that's the
kind of estimate range for that most effective one, is
worth a year of healthy life.
Well, worth is the wrong word.
I'd used this term before, but it's enough to buy a year of
healthy life.
So that's quite interesting, because you might not have
thought that you were carrying around enough money in your
pocket today that it's like a whole year of healthy life for
someone else.
But you can only get these types of benefits with your
money if it's used on the best programs.
And also, only if it's used on other people.
So your money's worth a lot more than you might have
thought, if it's used for others.
That's the catch.
Otherwise, it would be great, because I would be telling you
how to get 1,000 times more value for your money for
yourselves, which would be a roaring success of a talk.
But this is instead a talk as to how to get 1,000 times as
much value for your money for other people, which is a bit
less of a roaring success, but I hope it's still at least
interesting.
So these things I've talked about are mainly focused on by
policymakers.
And this report was aimed at policymakers, people who are
ministers of health in poor countries and also people who
run aid programs and so forth.
But they're also of interest to all of us when it comes to
charity and trying to work out how we can help people most
with the money that we decide to give to charity.
And maybe it will also make us think more about how much we
should be giving, once we realize that
it can be so effective.
So when we try to donate money, we're trying to help
people, and to help them as much as we can.
If we had some option, we've got two programs and the
second program helps people less, we
wouldn't do that, right?
It seems like we are trying to help people a lot.
And so suppose we wanted to donate money
to help fight AIDS.
It really matters, actually, whether that money's used to
fund treatment of Kaposi's sarcoma or to fund ***
distribution, for example.
There's a huge difference in effectiveness between these
different options.
And it's not actually enough to just know that the
organization is trying to fight AIDS.
You'd actually want to know more, because some of the ways
of doing that are a hundredth as effective as other ways.
And you might think that actually the organizations
would be the experts on this and would know and would be
doing the most effective one.
But often they're not.
One of the reasons for that is because they don't do as much
program evaluation as we would like, because they're trying
to keep their overheads ratio really good so that people
will donate to them who've been kind of sucked in by the
idea of the overhead ratio, which is a sad, sad fact.
But also they just generally aren't aware of these figures.
There's been not enough of a movement to really make people
aware of these figures and to be aware of how good these
things can be.
Often if you talk to someone who's, say, funding a less
effective treatment, they'll say that they're a very
efficient organization, because there's no way that
they could fund that treatment more effectively than what
they're doing.
But that's a different question to, hang on, if we're
really actually just trying to fight AIDS, maybe there are
other ways to fight AIDS which would be more effective for
those people.
We don't have to always use the same intervention.
And so it's relatively rare that people think of stepping
to a different intervention.
It's even rarer that they think of stepping to a
different cause.
Maybe they would think, what we're really trying to do is
make people healthier and avoid, let's say, premature
death or disability, in which case, maybe we should be
focusing on malaria instead of AIDS and close down our AIDS
arm and start up a malaria net distribution charity.
I've never heard of any charity doing that.
But there's a kind of mindset you get into it.
And if you're not familiar with these numbers, you think,
well, this is where expertise is and so on.
We must be really good at doing this.
But it turns out some of the things, even if you're an
expert at them and 20% better at doing them than anyone
else, that there's something else you could be doing that
even if you were average at it would be 10 times more
effective, 1,000% better, which I think is really
interesting.
It's kind of the main point of this talk.
So here's a few more summaries about what does this all mean.
I think one headline figure is that where to give can be even
more important than whether to give.
So suppose you had three options.
One is that you don't donate anything.
The second option is that you donate enough to save 100
Quality-Adjusted Life Years by funding *** transmission
prevention, which we saw was one of the middle-level
effectiveness.
Or alternatively you save 700 Quality-Adjusted Life Years by
funding malaria net distribution.
Well, interestingly, the difference in absolute terms
between 2 and 3 is much bigger than the difference
between 1 and 2.
That's what I mean by saying where to give.
That second question can be even more important than the
first question about whether to give at all.
Also, we can see that we can do pretty amazing things that
we might not have thought of.
So while you might have thought that in order to
really help people, you'd have to go to another country, away
from your friends and family, do a different career, not the
thing that you're passionate about, and that you wouldn't
be able to live the kind of affluent lifestyle
that you're used to.
But it's interesting to see that if you were to stay in
your home country, do whatever job you wanted to do, with
your friends and family, and donate 10% of your future
income, which would still leave you very affluent by
world standards, that you could save at least 3,000
Quality-Adjusted Life Years during your career, which is
three millennia of life at perfect health, or 30
millennia of life improving their health by 10% or some
equivalent.
And I think that's pretty interesting.
These options are there for all of us, if we
want to take them.
It's not just a radical choice with a
huge amount of sacrifice.
There are options with very little sacrifice which would
actually help a lot.
So you can consider this question, how much good could
we achieve if we really wanted to?
I mean, I consider these options for me.
Spend the one and a half million pounds on myself, have
my great kind of grad-student-plus life, or
grad-student-plus-plus in this case, the grad-student-plus
life, with also some extra--
a better car or something, and bigger house and whatever.
Or I could have my grad-student-plus life and
also donate a million pounds to others.
And I chose to do the second thing, because I had trouble
actually after thinking about this getting all that
motivated about getting the extra plus there.
It just wouldn't actually improve my life all that much.
So I chose the second path.
And I still have a great quality of life and can save
at least at 30,000 QALYs, which is equivalent to saving
300 centuries of perfectly healthy life, which is pretty
cool, right?
It's a pretty exciting thing to be able to do, I think.
So I want to just stop for a moment, because you might be
thinking, how can this be right?
These numbers must be wrong.
How can people in our shoes do that much to help people.
And I think that this helps to make it clear.
And this graph is the world income distribution.
And I think it's the most important chart in economics,
because it's the best kind of summary of the state of the
world today.
What we have here, it's slightly complicated.
So what we have on the y-axis is income
per household member.
So that's a measure, you look at how big the household is.
You look at the household income.
You divide by the number of people in the household, so
that children count on this as well.
And a child in a poor family counts different to a child in
a rich family, whereas if you use a more naive measure, that
doesn't work properly, because it turns out that they've got
no income because they don't work a job, and so it doesn't
really come out right.
But it's household income per member, and it's measured in
US dollars adjusted for Purchasing Power Parity.
So PPP means that you take into account the fact that
money goes further in poorer countries.
For example, it goes about four times further in India
than it does in Main Street, USA.
So what they do is they effectively multiply someone's
actual income in India by four for this graph.
If you didn't do that, this effect would
be even more extreme.
But they've taken that into account already.
And then what we've done is we've lined everyone in the
world up, all 7 billion people, from the poorest to
the richest.
And we look at how much income they have.
And you can see that there's this extreme spike at the
right-hand side.
And if you're looking at this on a large projection screen,
then on that screen, which is only itself about a yard and a
half tall, at that scale you can see that there is an
ellipsis there, that I haven't been able to fit in the
entirety of this curve.
So this is something where if you had fit in this entire
curve, it would be taller than Mount Everest at this scale.
So it's a pretty extreme, skewed distribution.
And it's a power law for people who are into
that kind of stuff.
What's particularly interesting about it is if you
actually look at it, you might do what I did, which is to
look at this and think, oh, yeah, I'm somewhere in that
bit where it curves around.
I'm rich, but I'm not like the truly wealthy.
And I won't be.
There's these annoying people who earn squillions of dollars
per annum and isn't that unfair?
And I'm quite wealthy compared to these other people.
But then if you actually look at these numbers, you realize
that at the moment, particularly if you're a young
person without children or later on in your life when
children leave home, you're going to be probably pretty
wealthy on this.
And probably a lot of the people watching this are in
the richest 1% of the world's population or will soon be in
the richest 1% of the world's population.
So they're in this area here.
This is the richest 2% I've shaded.
So what's kind of interesting is that actually we are in
this spike, typically.
And there's been a lot of interest recently in America
and Britain, other rich countries, about the 1% and
the 99% on a national scale.
But it's interesting that in the global
scale, we are the 1%.
And we often don't pay enough attention to that.
But that's what's going on here.
That's why the stuff that's in your pocket can buy years of
healthy life, is because the stuff that's in your pocket is
worth a crazy amount of money, because we're all really rich.
It's just that we tend to compare ourselves to our
peers, and so we don't notice that as much.
So I'll just talk a little bit, before questions, about
the organization that I've set up, which tries to take these
ideas and put them into practice.
And it's called Giving What We Can.
So it's a community of people who feel strongly about
improving the lives of those people
in developing countries.
And it's a group where each member of the group has made a
pledge to donate at least 10% of their income to wherever it
is that they think can do the most to help
people in poor countries.
And we also run a website that collects and shares
information on the most cost-effective charities to
help our members and to also help the general public.
So even if one thinks 10%, maybe that's a bit much for
me, but I'd really love to find out more about this.
How do I do more effective giving?
Which charities are they that actually implement some of
these most effective interventions that we've done
extra due diligence on and so forth?
Well, you can go to our website and check that out.
If you just search for Giving What We Can, you'll find it.
It's givingwhatwecan.org.
And there's two aims that we have in this organization.
And they fit in with what I've been talking
about in this talk.
So the first aim is getting people to give more.
So this square represents something like what people
were giving previously on average in the US.
And firstly, I want to try to convince people that they
could give a lot more than they do.
It's actually not that much of a sacrifice, because most of
the things that are really important in our lives are
actually very cheap.
People say this all the time.
It turns out they're right.
It's true.
And you can get a lot of the value of your life on not much
of the money of it.
So getting people to give 10% in this case.
And the second aim is getting people to give to more
effective organizations, which works out something like this.
And so together, we massively increase the total impact.
And it's very plausible that anyone who's hearing this talk
could actually improve the impact they're going to have
through charitable donations over their life by a factor of
100, quite possibly by more than that actually.
But because you've got these two different dimensions and
it's not additive, it's multiplicative, it leads to a
really big benefit if you're doing both of
these things right.
We have 292 members, I think, or maybe it's slightly more
now, who've pledged to donate at least 10% of their income.
This comes to more than $100 million of income that's
pledged over their lives, which was enough to fund
between 2 and 11 million Quality-Adjusted Life Years.
To put that into some kind of context, 5 million years is
the period of time since humans and chimpanzees
diverged evolutionarily.
Or 200,000 years is the amount of time ***
sapiens has been around.
So this is quite a large amount of life.
And we've got local chapters to try to discuss these ideas
and get people interested in various places including
Oxford, Cambridge, London, Princeton, Harvard, Rutgers,
San Diego, Canberra.
Some of them are at universities.
Some of them are towns.
And we try to get people involved in talking about
these ideas.
And that's the web address.
So just to conclude, we're exceptionally wealthy, living
in rich countries in comparison to people in the
poor countries.
And our money can do hundreds of times more for them than it
can for us.
In fact, I gave a pretty good argument, I think, that it
could do 1,000 times as much good, because we think that if
we spent the money on some of these health interventions,
just where I had that barrier, that that would be better than
how we spend our money.
And then we realized that that would produce an amount of
health which is one thousandth as much as we could produce
for other people.
So that's a pretty good argument that therefore we can
do at least 1,000 times as much to help other people.
But maybe you think some of these
numbers are a bit uncertain.
And let's be safe and say just 100 times as much good.
However, it can only achieve this if it's given wisely.
So we really want to spend a lot of time thinking about
where to give or at least just spend a very small amount of
time checking the website of people who do spend a large
amount of time, probably more than hundreds of hours, maybe
thousands of hours now, thinking about where that is
and looking at the research on this and trying to work out
the best approaches to this idea that where to give is
even more important than whether to give.
And finally, the world is an unfair place with a great deal
of suffering, as I'm sure you all knew before you
came into the room.
But we can each do a tremendous amount to
help make it better.
And let's do so.
Thank you.
[APPLAUSE]
TOBY ORD: Now I believe if people have had some
questions, then I'm going to get a laptop up here with some
moderated questions.
MALE SPEAKER: They're-- not yet with Moderation.
TOBY ORD: OK.
So if you're just tuning now, and you're in
Google, that's go/ord--
O-R-D, my surname--
hyphen dory, D-O-R-Y. But for now, let's take
this question here.
AUDIENCE: Yeah.
Your example of blindness, in particular, got me thinking
about all these cognitive biases that people have, and
how they originally overestimate what they think
is going to be an impact of like disabilities in their
life, and how in reality, we're much more on a hedonic
treadmill, and we adapt really quickly after losing a limb or
becoming blind or something like that.
How do you think we should adjust these quality figures
for that sot of cognitive bias?
TOBY ORD: Yeah.
That's a great question.
Actually, people in public health, including here at
Harvard, are looking at these types of questions.
And it turns out if you elicit these quality weightings by a
group of healthy people, let's say in the case of blindness,
they say that a year of blindness is
at about half quality.
They'd be indifferent between two years of blind life versus
one year of perfectly healthy life.
However, if you ask people who've been blind,
particularly--
not just in the first six months or so.
The first six months or so probably is really bad,
adjusting to that.
After that, they tend to say it's less bad than that.
Although interestingly, it turns out that if they then
regain sight, they then say it was actually worse than they
were saying when they were blind.
So there's an extra effect to that cognitive biases thing,
that there is this extra aspect where it partly depends
on the state they're in.
And I think we often like to think the state we're in is
particularly good compared to other states so we can feel
happy about our lives.
But it's difficult to know exactly how to take that into
account, because it seems to keep fluctuating.
But I would think that maybe just taking the average of a
group of sighted people and a group of blind people would at
least be a good first step on that.
If you did that, then maybe it would say that instead of
being half as good and having a quality weight of 0.5, the
quality weight should actually be 0.6 or 0.7 or something.
It won't change the numbers I'm using very much, though,
but it is the type of thing that if we could get more
fine-grained than this and try to work out some more
nitty-gritty questions, that it would be really useful to--
I mean, an improvement of the accuracy of an estimate by 20%
is certainly worth having.
So it's a good question.
Do we have any other questions?
AUDIENCE: Question from Mountain View.
TOBY ORD: OK.
AUDIENCE: So I have two questions to this.
One is could you address the next hurdle that
people have to giving?
So the first hurdle is, will it make difference?
And this talk addresses that.
The next question is, is this the difference
that I want to make?
So let's say that it turned out-- just let's pretend that
the most effective way was to give food to people who are
starving in some location.
And you could feed them, and let's say this was the
cheapest thing that could be done, and it would give the
most Quality-Adjusted Life Years.
But then the thing is that some people might feel that
doing this just means that there's going to be extra
millions of people who are going to starve the next year.
So many people won't give because this may be the most
effective way, is to prevent people from dying by giving
them mosquito nets and so on, but it's just a bigger problem
for another day.
So that's my first question.
The second question is, if we really take this argument all
the way to its extreme, one might say that--
let's just say the US government within the US
borders, then we don't have to deal with the issue of helping
people in other countries, but everything that's done could
be in some sense put on this utilitarian scale.
If I build a new bridge, we could talk about how that
helps people.
Actually, that's not a good example.
But there are other kinds of things like this were we could
say that, well, there's other things that we do that improve
people's lives.
And if we just determine that there are two things, let's
say, that are the most effective at improving
people's lives, why doesn't government do only those two
things and stop doing almost anything else that's not
necessary right?
So like cut all the welfare programs, cut everything else,
cut anything for special needs children or whatever, because
these two programs that we've determined are the only ones
that are going to give us the most effective results.
So could you address those two concerns?
TOBY ORD: Wow.
They're both big questions.
So I'll take, I guess, the second one first.
So if you look at these things-- so one thing to say
is the government in the US actually does do this.
But they use a different methodology.
The one I'm talking about is called
cost-effectiveness analysis.
The one the US government use is called benefit-cost
analysis, or cost-benefit analysis.
And that's an approach where you measure the benefits in
terms of dollars and you measure the
costs in terms of dollars.
So they actually do use this in order to work out--
they try to kind of pool together benefits based on how
much people would be willing to pay in order
to get those benefits.
So they do think about this in the US and measure things like
this, although that methodology, I think, has
quite a lot more flaws in it.
It's got a lot more room for ethical problems to arise than
the one I'm talking about.
But anyway, the thing is that if you really did want to help
people as much as possible, then going with a
sophisticated version of this approach is
the way to do that.
It's just defined to be the way that helps people as much
as possible.
And so therefore, I think it is a pretty
good idea to go with.
In your particular case, it will turn out that if there
are just a couple of interventions, that they will
end up with diminishing marginal returns.
So what we've tried to get here is estimates as to how
effective it is on the margin.
So if you're going to save one more life from malaria, with
the current amount of malaria mosquito net distribution, how
much would that cost?
But if you roll that out to, say, 80% of the population,
and then you're trying to get the last 20% covered, then
that can be much more costly.
So sometimes there are issues where that will change.
And so what you want to think of is, for each of these
interventions, you want to think of it as cost curve
would be the more sophisticated way to do it.
But also, even then, you'll saturate these things.
So, for example, mosquito net distribution, the number of
people dying from malaria per year is uncertain.
It's somewhere between about 700,000 per annum and 2
million per annum.
Let's say it's a 1 and 1/2 million per annum.
And the amount it costs to save a life due to malaria, on
average, by distributing nets is about $2,300.
So now I've set up a multiplication problem for me.
But there's something around about $3 billion worth of
money that would be needed to totally cover that, which is
actually very small compared to, say, the US budget.
So with some cases like this that are very effective, it
turns out that you can actually
completely saturate them.
And it won't be the case there's just two things that
end up getting done.
The really effective things will get done.
And then they'll get to move on to the next most effective
and the next most effective.
And they'll get quite far down the list.
So it is actually pretty valuable.
In fact, in terms of these interventions, I've got a nice
chart which I didn't present.
But if you look at all the interventions that the DCP2
looked at and you do a chart of all of them, you can find
that they're log normally distributed, and that the most
effective 20%, if you were to fund them all equally, 80% of
the benefits would come from the most effective 20%.
So if you do work your way down from the top, you
actually cover a huge amount of benefit.
So also, the first question was about additional issues.
I definitely think that QALYs and cost-effectiveness
analysis at this kind of level is not the be all and end all
about this.
I'm trying to just get these ideas onto the table in terms
of how you can think about this with the
kind of simple examples.
And obviously, you could have more and more hours of making
it more sophisticated and trying to get
better data and so on.
But in the particular case of overpopulation, that's not
another thing that you'd want to think about.
As to the effects of that, you'd ideally want to take
that into account.
Now, I can say that it turns out that there's a couple of
big points you can make there.
One of them is that it turns out that saving infant lives
probably actually helps with overpopulation.
It actually reduces the expected number of people on
the planet, because it turns out that there's a process
called demographic transition, where once people get
wealthier, they and their children start surviving
better, they have fewer children.
And it's more than proportional, so it
compensates.
And this is what has happened in rich countries.
And it seems to be happening in some of the poor countries.
So it looks like if you get actually child survival to be
improved, it actually would fight overpopulation rather
than exacerbate it.
The other thing I could say is, even if you didn't believe
that, you could try to find some organizations.
And we recommend a couple on a website, which don't save
lives, but just improve quality of life.
And so that would be a way to do it that where that other
argument wouldn't come up.
And then a third thing to say is that if you really thought
that overpopulation was so bad that you were willing to just
let a whole lot of people die because of the overpopulation,
the badness of the overpopulation of helping was
going to be bigger than the goodness of helping those
people, then you must think that overpopulation is really,
really bad.
It's so bad that even if we could spend 15 pounds to save
a year of life, that the overpopulation effect is even
bigger, in which case you should just donate money to
fight overpopulation.
That would be logical conclusion.
The conclusion wouldn't be, there's this absolutely
terrible thing that's so horrific that it overwhelms
these amazingly big benefits.
Therefore, I won't do anything.
But therefore, I'll donate money to a group that, say,
distributes condoms or educates people about family
planning and so on.
There's plenty of those groups as well.
So I think that style of response ends up not quite
blocking the course of this argument, I think.
But I hope I've answered your questions.
AUDIENCE: Yeah.
I think you have.
I think that in the same way that a year of life extended
can be adjusted to be a quality-adjusted year of life
extended, I'd like to see this analysis.
I'd be really happy to see if this analysis could be further
extended one more thing about whether it is also generating
or getting rid of a problem.
In other words, one more adjustment that would be more
convincing to people I think than that, yes, if I donate to
this, I'm not only giving extra Quality-Adjusted Life
Years, but I'm also diminishing and not increasing
the problem for tomorrow.
TOBY ORD: Yeah.
I agree.
There's definitely potential additional considerations and
we want to take them into account.
I'm totally on board with that.
AUDIENCE: Thank you.
TOBY ORD: So here are a couple of questions
that have come in.
One of them is, you showed how giving effectively is much,
much better than giving ineffectively.
Have you considered the other ways of giving, volunteering,
personal relationships, et cetera?
Work was the other one.
Maybe they can be even more effective for some of us than
giving money.
Yeah.
I think that's a great question.
And it's plausible.
I think personal relationships is one that occurs to a lot of
people when they're thinking about this.
It's like, how can I be a good person in terms of my family
and friends.
But it seems that once you get to these scales, it's hard to
see that really the best things that you can achieve
overall, in some kind of neutral, impartial sense, are
going to be through that.
But the other areas, volunteering is potentially
very valuable, as is work, depending on what you do.
So for example, it could be the case that--
I mean, I have, in my spare time, set up this
organization, which has done a lot of good.
And so probably I've done more good through my volunteering
than I will achieve, actually, through all of my donations
over my life, which is pretty cool.
And similarly, if you can find some really high-impact
volunteering approaches, then you can do a lot of good.
It is definitely hard through volunteering things in rich
countries to have as much impact as we've seen.
Often, in fact, one could have even more impact if one worked
a few extra hours and then donated the money.
That might seem surprising.
But if you remember from economics that we have a
comparative advantage in some kind of fields, and that's the
field where we get the most money.
And so if we go into that field and earn money, then it
is very effective, because then we can pay someone who
does the thing that we're interested in.
So we get, for example, an expert in computing to,
instead of donating their computing services to a poor
person, use that to get money to pay the person that the
poor person needs, and to pay someone who's actually an
expert in those things, as opposed to someone who is more
of a dilettante
But it does depend.
But volunteering could potentially be even more
important if you get really high leverage on it.
And work could be really important as well.
It's hard to know in terms of improving technology.
Obviously, there's been a lot of technology spillovers for
poor countries which have been very useful.
For example, allowing them to leapfrog landlines and to go
straight into mobile phones in order to get connected, I
think a lot of people would have thought that would take a
lot longer before that would be useful.
So there are potentially a lot of approaches there.
And also, maybe doing your job has various other effects.
Obviously, it depends on what it is.
But I don't know exactly how to assess these things.
They're quite a lot harder to assess.
So I'm not claiming they're less valuable, really, so much
as there's at least quite a high bar to beat.
But maybe they could be more valuable than that.
And I think that people should think about those
things quiet seriously.
Another question is the following.
It seems that core to the high-quality cost
effectiveness is the fact that the donated dollars are used
in developing countries.
What are the implications for those who want to give
locally, for example in developed countries?
It's a good question.
So there are various implications.
So one implication is that you might think within your local
area, whether that's your country or your community,
that you also want to take these ideas in light and to
try to give effectively within those areas.
I don't have particularly good data on that.
But you probably want to start thinking about it a bit,
because once you see that there are several orders of
magnitude separating the best and worst interventions in
poor country settings, you might think that there
actually could be quite a lot of discrepancy between the
interventions in rich country settings.
And in fact, there are, in terms of health, at least, a
similar kind of curve for health
interventions in rich countries.
So that's something where maybe also in other forms of
volunteering or donation that you could get that happening.
And you'd start to see this lesson, choosing where to
give, it could be worth maybe let's say spending half the
time you would spend earning to donate the money just doing
research on this problem, and then donating half the money
to something that's more than twice as effective.
That's quite plausible, so at least to spend, say, 10% of
the time or whatever on the question about where.
Another question, though, I think would be to really think
about why it is that you want to help
locally instead of globally.
I've had a nice advantage on this, which is that I was born
in Australia.
And so my local thing would have been to help Australians.
And I wouldn't care about helping British people over,
say, Kenyan people, because I didn't know any British people
or Kenyan people, and so it seemed fairly obvious that if
I can help more people in Kenya than I could in Britain,
that that would be the better thing to do.
Otherwise, I'd be kind of unduly privileging British
people for some reason.
Now that I've moved to Britain, I still kind of am in
this situation.
And I also kind of feel, why would I help Australians
rather than helping more people somewhere else, or
helping them in better ways?
So it's helped to kind of break some of that partiality
from me in terms of this type of donation.
Obviously, I'm still very partial in my personal
relationships.
But I think that I can kind of help the world
more in these ways.
And so one would also want to think that it's often very
difficult to help in such extreme ways and to spend some
time thinking about the ratios that you would end up with.
Is it the case that for the most effective way you can
help people locally, you could help 100 times
as many people globally?
If so, then you might think, can I really justify a 100 to
1 ratio in terms of that?
Maybe if I had chocolate cake, I would give it to my friends
rather than to a stranger, other things
being equal or something.
But if there was a case that I had to stop 100 strangers
having their chocolate cakes in order to give one to my
friend, maybe I wouldn't do that.
So it could be interesting thinking quantitatively about
some of those things as well.
But there's a lot of people who think that it could be,
but they're not swayed by these reasons and so on.
If so, that's fine.
I'm just trying to give some arguments.
There's only two minutes left.
Is there time for another question?
There's one.
Anyone locally, or globally?
AUDIENCE: Here's a quick question.
TOBY ORD: Thanks.
AUDIENCE: It's actually locally.
TOBY ORD: Oh, sorry.
AUDIENCE: What is your opinion of GiveWell's recommendations?
Why don't you just outsource all of your donations to them,
because they seem to looking for very similar things?
TOBY ORD: They're great.
So for those people who aren't aware, GiveWell is a charity
evaluator, formerly operating from New York, I think now
from San Francisco.
And they are assessing, doing this kind of thing, trying to
look at different charities and where you can kind of help
people the most for your donations.
And I think that they're great and have done
good research on this.
When they started up, they managed to launch a couple
years before Give What We Can, as I had to finish my PhD.
But we kind of were thinking about these things in a
similar time and were in contact with each other.
And we're both really frustrated by the fact that
there's a lot of really good research being done that's not
been shared with the public.
So foundations, say, the Gates Foundation, I'm sure they do a
lot of really fantastic research on where to give.
And then they use up those opportunities as well, and
they don't kind of share this information more broadly.
And I think it was great to share it.
And that was GiveWell's approach, to
share that really publicly.
I think that's their real big advantage.
And so we at Give What We Can take
their advice very seriously.
It's one of the several inputs that we take.
We also talk to people at the World Health Organization, The
World Bank, Oxfam, lots of places, and try to find out
what's going on and what we think about different
interventions.
And sometimes we come up with different
conclusions to Give Well.
But they're probably, of all of those kind of inputs to our
decision-making process, they're probably the largest.
And so we take them very seriously.
So definitely do a search for GiveWell as well and have a
look at what they say.
Thank you.