10

Domestic or Global?

Trying to do the most good involves making difficult judgments, not only about which charities are most highly effective but also about the broad areas in which our resources will do the most good. So far I have taken aiding the world’s poorest people as my leading example of a highly effective cause; but is it the most effective possible cause? How does it compare with efforts to stop the infliction of suffering on animals? to mitigate the damage we are doing to the climate of our planet? to save endangered species from extinction? or perhaps to save ourselves, by reducing the risk that we will wipe ourselves out?

The field of philanthropy has, as a whole, been extremely reluctant to tackle these comparative questions. That may be because finding the answers involves not only questions of fact that are difficult to establish but also controversial value judgments. To assume that there is no point in even trying to answer them and that all philanthropic causes are alike is a common error, but one with very serious consequences in terms of missed opportunities to do more good. One large, influential organization that has made this mistake is Rockefeller Philanthropy Advisors. We can take it as an example of the error not because in this respect it is any worse than many other philanthropic advisors but because it is one of the world’s largest philanthropic service organizations. It claims to have advised a total of more than $3 billion in charitable giving and to advise an additional $200 million each year.

The Rockefeller Philanthropy Advisors website features a series of leaflets called “Your Philanthropy Roadmap.” The goal of the series is stated to be helping donors create “thoughtful, effective giving programs.” One leaflet, “Finding Your Focus in Philanthropy,” includes a chart showing various areas in which a philanthropist might give: health and safety, education, arts, culture and heritage, human and civil rights, economic security, and environment.1

Curiously, this set of categories allows no place for animal welfare, although as we shall see in chapter 13 that field offers opportunities for greatly reducing suffering at modest cost. Animal welfare does not fit into the environment category because much of the suffering humans inflict on animals takes place in factory farms, laboratories, puppy mills, zoos, and circuses. Although these places, especially the factory farms, do have a negative environmental impact, that is distinct from their impact on animal suffering.

The way in which Rockefeller Philanthropy Advisors divides up the field of philanthropy also fails to indicate that intending donors living in affluent countries must choose whether to give to an organization that acts domestically or one with a focus beyond their country’s borders. That choice determines whether they will benefit people who are already among the wealthiest one-third of the world or those who are far worse off. In the Rockefeller list, giving to reduce global poverty does not even appear as a category—presumably it is divided among health and safety, economic security, and environment—but one could reasonably see the decision whether to give to health or economic security as less significant than the decision whether to give to projects in the United States or in some of the world’s poorest countries.

Among the various philanthropic projects the leaflet describes are one seeking to improve health care for the global poor and another aimed at improving health care in the United States:

•In 1998 Ted Turner gave a billion dollars, or a third of his wealth, to the UN to scale up proven health programs focused on the world’s biggest killer diseases, which overwhelmingly kill children in developing countries.

This initiative has been highly successful, drawing in and coordinating funds from other non-profits, such as the Gates Foundation. Since 2000, 1.1 billion children have been given a combined vaccine that prevents measles and rubella. The vaccine now reaches 84 percent of the world’s children. Between 2000 and 2012, worldwide deaths from measles have fallen 78 percent, with a total of 13.8 million deaths averted.2 The cost per vaccination is estimated to be $1. If that figure is correct, the estimated cost per life saved would be just under $80.³

•In 1986 Lucile Packard gave a $40 million donation to establish a hospital in Palo Alto, California, and established a foundation to give further ongoing support.

The Lucile Packard Children’s Hospital in Palo Alto has been in the news for its success in achieving difficult separations of conjoined twins. For example, in 2007 the hospital separated two girls from Costa Rica who shared a liver. The operation took nine hours and involved twenty-two people at a cost estimated at somewhere between $1 million and $2 million. One of the girls then needed open heart surgery for a congenital heart defect, and the other also needed another operation to reconstruct her chest cavity. Follow-up operations on each girl were also required. The hospital paid for the operations, and the doctors donated their time, while the family’s travel and stay in the United States—which lasted about six months before the girls were well enough to go back to Costa Rica—was assisted by a charity called Mending Kids International.

In 2012 Palo Alto was ranked by CNN as the third wealthiest town in the United States, with a median family income of $163, 661.4

What Rockefeller Philanthropy Advisors does not say, in describing these two projects, is that the cost of saving a child’s life in an intensive care hospital in the United States is typically thousands of times higher than the cost of saving the life of a child in a developing country. Such disparities are not limited to rare cases like the separation of conjoined twins. Intensive care for a newborn in the United States costs around $3,500 per day, and for a prolonged stay it is not unusual for costs to exceed $1 million.⁵ It doesn’t seem all that difficult to judge that it is better to use a million dollars to save the lives of hundreds of children by protecting them from measles than to use it to separate one pair of conjoined twins or save one extremely premature infant.⁶ Governments arguably have the responsibility to look after their own citizens first, but individuals have no such responsibility.

Toby Ord has given another example of the cost differences between helping people in affluent countries and helping people elsewhere. You may have received appeals for donations from charities in affluent countries that provide blind people with guide dogs. That sounds like a cause worthy of support—until you consider the costs and the alternatives to which you could donate. It costs about $40,000 to supply one person in the United States with a guide dog; most of the expense is incurred in training the dog and the recipient. But the cost of preventing someone from going blind because of trachoma, the most common cause of preventable blindness, is in the range of $20–$100. If you do the math, you will see the choice we face is to provide one person with a guide dog or prevent anywhere between four hundred and two thousand cases of blindness in developing countries.7

When I suggest to audiences in the United States that we should help the world’s poorest people, a very common response is that we should help the poor in our own country first. Poverty in the United States, however, is very different from poverty in developing countries. So different, in fact, that even those who think it defensible to give some degree of priority to helping our compatriots might, when fully informed of the difference, be led to reconsider whether it is right to discount the lives and interests of people beyond the borders of our country so heavily that assisting the poor in an affluent country like the United States should take priority over assisting some of the world’s poorest people. In 2012 the U.S. government poverty threshold for a family of four was $23,850.⁸ That works out to a per person income of $5,963, or $16.34 per person per day. That isn’t a lot, but it is much more than the World Bank’s “extreme poverty” line of $1.25 per day. This figure is in 2005 U.S. dollars, which is equivalent to $1.53 in 2014 dollars, and it is intended to mark the minimum amount on which one can meet one’s basic needs. Globally, more than a billion people are living in extreme poverty, as thus defined, virtually all of them in developing countries. You may be thinking that this figure could be misleading because of the greater purchasing power of money in poorer countries, but that is already taken into account. The World Bank’s figure is at “purchasing power parity”—in other words, it is the amount that, in the local currency in the country in which the person lives, buys the same amount of food and other essentials that one can buy for $1.53 in the United States in 2014.9 If there are any legal residents of the United States living below the World Bank’s extreme poverty line, they must be missing out on benefits to which they are entitled because the Supplemental Nutritional Assistance Program, or SNAP (formerly known as food stamps), provides an average monthly benefit of $125 per person, or $4.00 per day.¹⁰ In 2014 nearly forty-seven million relatively poor Americans were participating in SNAP. All impoverished Americans have access to safe drinking water, free schooling for their children, free health care through Medicaid and, in many cases, subsidized public housing. Should they fall seriously ill, they can go to a hospital emergency room, and the hospital will be legally bound to treat them, irrespective of whether they have health insurance, until it is safe for them to be discharged. Hundreds of millions of people in developing countries lack these benefits.

Those who are poor in the United States are poor relative to the majority of members of a society that is, by historical standards, extraordinarily affluent. Those who are in extreme poverty in developing countries, on the other hand, are poor by an absolute standard that refers to their inability to meet their basic needs. In the United States, food security is officially defined as “access by all people at all times to enough food for an active, healthy life.”¹¹ A family is therefore considered to be food insecure if one member does not, for an unspecified period of time, have access to that level of food.¹² This could happen if, for instance, the adults in the family buy diet sodas with their SNAP entitlements (which is perfectly legal) or if they sell their benefits at a discount for cash to buy drugs or alcohol (which is not legal but does happen). In the United States, if child welfare officials discover children who are severely undernourished, they will place the children in care to ensure they are properly fed. In developing countries, poor families may be short of food for long periods, and their children may be permanently stunted because of malnutrition and undernutrition. Poor women often have to walk for three hours a day to fetch water from a stream and then spend more time gathering firewood to boil it to make it safe to drink. If children get diarrhea, their parents are likely to be unable to get any medical assistance for them. Poor parents may have to watch their children die from easily treatable conditions.

I am not denying that Americans should be deeply concerned about poverty in their own country. Other affluent nations have better social security than the United States, so their poor are, in absolute terms, generally better off than the poor in the United States, but in those countries, too, there are grounds for trying to do better. I have no doubt that being poor in a rich nation makes life extremely difficult and often degrading. My point is only that there is a wide gulf between being poor in the United States and being in extreme poverty as defined by the World Bank. For effective altruists, the most important consequence of this gulf is that their dollars go much further when used to aid those outside the affluent nations. We have already seen this in regard to interventions to protect health. The income figures I have noted make it easy to see that this also holds for other benefits, including direct cash transfers. If a family of four is on the extreme poverty line, its annual income will have the purchasing power equivalent of US$2,234. The charity GiveDirectly makes one-off cash grants of about US$1,000 to African families living in extreme poverty. If the families are on or close to the extreme poverty line, this is equivalent to giving them at least six months’ income, and if they are well below the extreme poverty line, it may be as much as a year’s income. With part of that money, they may buy corrugated iron to replace the leaky thatch on their roof. This keeps the family and its provisions dry when it rains and saves them the cost of replacing the thatch each year. They may use the remainder to start a small business or simply buy more food so the family can eat better. Giving $1,000 to a family living in poverty in the United States might be the equivalent of a month’s income. If they are in public housing and using their SNAP benefits well, they will not need the money for food or shelter. If, on the other hand, they are hungry because they are not using their SNAP benefits to buy nourishing food, then we need to know whether they will use $1,000 in cash any better. For all these reasons it is unlikely that $1,000 will bring a poor family in America the kind of benefits that giving the same sum to an impoverished African family will achieve.13 So whether we prefer to give cash grants or food or health care interventions, we will do more good by donating to organizations working to help people living in extreme poverty in poor nations.

Robert Wiblin has called the difference in what you can get for donations to different charities altruistic arbitrage. In the business world, if two identical products are selling at different prices in different markets and the cost of transporting the products from the lower-priced market to the higher-priced market is less than the price difference, someone will soon buy where the price is lower and sell where the price is higher. That is known as arbitrage, and it tends to smooth out such price differences. If the world of philanthropy were like the business world, then whenever there is an opportunity to do good much more cheaply than most people are doing good, philanthropists would pounce on it, and the opportunity would rapidly disappear. But philanthropy is not as focused on effectiveness as the financial sector is focused on profit. Some causes are less popular than others and so tend to be neglected. That explains why it is possible to do so much more good per dollar donated by helping poor people in poor nations than poor people in rich nations. The rich people in rich nations, either through their government or through domestic charities, are already helping their poorer fellow citizens—perhaps not enough to raise them out of poverty but enough so that the cost of making a lasting, positive difference to the life of a poor American is far higher than the cost of making such a difference to the life of someone who is poor by global standards. Wiblin offers this advice: “Target groups you care about that other people mostly don’t, and take advantage of strategies other people are biased against using.”14