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
bang 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 HIV 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
HIV/AIDS, HIV 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 HIV
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 HIV 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 HIV.
And that's a very targeted
intervention, because you can
target it at pregnant
women who have HIV.
And so that reduces the costs,
because you don't have to
treat everyone else.
And it avoids an entire lifetime
of HIV, 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 HIV.
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 condom
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 HIV 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 Homo
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.
