When Doing Good Goes Wrong: Reimagining Effective Altruism Using Equity- and Justice-based Approaches in Global Health and Development Aid

Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness.

– Martin Luther King Jr. (1957).

The younger generations have grown up watching the extraordinary impact of scientific technologies from pocket-sized smartphones to the expedited development of the COVID-19 vaccine. Many of us have been empowered to be dreamers, idealists, and visionaries – challenging unjust systems and developing solutions to our world’s problems. The question becomes less of whether to do good, but rather how to do good properly. Effective altruists emphasize the use of empirical evidence to drive decisions on which populations and interventions to prioritize for humanitarian, development, and foreign aid. This article challenges the current conceptualization of effective altruism, and argues for the importance of bringing equity and justice to the forefront of evidence-based policies on aid.

Defining effective altruism: What is the buzz about?

Effective altruism started in the 2000s as a philosophical and social movement that focuses on doing the most good for the highest number of people in an impartial manner. The movement has since given rise to popular non-profit organizations (NPOs) such as GiveWell and influenced content of online news channels such as Vox. Effective altruists argue that despite the hundreds of billions of dollars donated to charitable organizations and foreign aid, the majority of humanitarian interventions are not effective. Leaders of effective altruism (i.e. Dr. Peter Singer, Dr. William MacAskill, and Dr. Toby Orbs) challenge the following current concepts of aid distribution:

  • Localism: Most charitable donors and volunteers are limited to causes within their local areas, restricting the potential capability of doing the most good. By contrast prioritizing aid in developing countries makes more sense because our dollar will go much further there than in North America.
  • Biased giving: Many individuals have preconceived notions on which social issues they are interested in, neglecting high-priority issues. A classic example would be a well-intentioned PhD student pledging a lifetime career in cancer research because their family members have been affected by cancer, despite the already crowded research area.
  • Disparity of effectiveness: Interventions within a specific global issue have large disparities in terms of cost-effectiveness. For example, for interventions against HIV/AIDS in low-to-middle income countries, educating high-risk groups is much more cost-effective than surgical treatment for Kaposi’s sarcoma. Furthermore, nearly 80% of social intervention projects are not effective.

Effective altruism aims to:

  1. Identify the best global problems to focus on, based on the magnitude of effect on human wellbeing, the neglectedness of the topic, and how practical or solvable the issue is. They encourage cause-neutrality (i.e. detachment of personal interests with a certain issue) and follow whichever path the evidence decides as the ‘most worthy cause’.
  2. Identify the best charities through evaluation of interventions by cost-effectiveness (i.e. cost per disability-adjusted life years, $/DALY). For example, the GiveWell program highly endorses insecticide-treated nets for malaria, vitamin A supplementation, and cash transfer for poor individuals.

In theory, effective altruism is attractive to busy graduate students and young professionals who are looking to change the world. These concepts exploit our desires for simple quantifiable outcomes (e.g. number of malaria infections prevented), promise evidence-driven policies to do the most good, and allow for a detachment of responsibility to fully immerse in a global issue. In practice, this approach risks promoting a reductionistic mindset that understates the complexity of local context and social determinants to health. The promotion of Western-centric and top-down intervention programs could end up doing more harm than good.

The white knight in shining amour: Cautionary tales of top-down approaches to aid

The detached altruistic god, who would only be distracted by sustained face-to-face encounters, need never experience directly what it has truly wrought.

– William Schambra, Philanthropy Daily, 2014

Development work has been tainted by a colonialist history of patronizing top-down approaches where “Westerners” arrive in a less developed country to ‘modernize’ people with ‘backward cultures’. Even with the best intentions, most development programs have failed to collaborate with local communities and instead rely solely on bio- pharmaceutical, technological, or economic solutions.

Smallpox Eradication in South Asia (1973-1975)

The World Health Organization (WHO) initiated large-scale smallpox vaccination campaign in 1967 and successfully eradicated the disease by 1977. Although campaigns were successful in short-term containment of smallpox, the use of intimidation and coercive measures by American physicians in India, Bangladesh, and Ethiopia left resentment in rural communities. These incidences of abuse fostered mistrust in public health efforts and will continue to hamper vaccination campaigns for current (e.g. COVID-19) and future outbreaks.

Thaba Tseka Development Project, Lesotho (1975–1984)

Development professionals sought to solve problems of poverty in Lesotho through Western concepts of commercialization. Their attempts to introduce livestock markets, bring in improved western cattle breeds, and privatize farmlands were met by resistance from locals. These professionals failed to understand the socio-cultural-political context where the men of Lesotho had no intention of farming in the first place. Many of these men were mine workers waiting for reemployment in South Africa and used their cattle for social status and insurance policies.

Effective altruists’ insistence of discouraging emotional investments of social issues (i.e. cause-neutrality) perpetuates a toxic culture of treating the ‘benefactory’ of aid as ‘the others’ and ignores what the real issues on-the-ground are. In contrast to anthropologists and workers from NPOs who spend decades on-the-ground building trust in the communities, effective altruists remain in their ‘ivory tower’ offices to determine where monetary donations should be allocated to. Clinical trials and cost-effectiveness measures are the essential toolkits for effective altruists in determining which interventions to fund. Clinical trials are often lacking adequate data in rural and resource-poor settings, leading to common practices in extrapolating results from one area to another. This becomes problematic because local cultural, socioeconomic, and political factors, which are instrumental in an intervention’s implementation success, are often ignored. Effective altruist should prioritize funding organizations that work closely with local communities to identify real issues on-the-ground, adapt implementation of interventions according to context, and promote bottom-up programs to empower local communities.

The problem of the parachute: building capacity for sustainability and independence

The World Bank reported that most development interventions have been unable to create sustained change in the communities after external aid organizations have left. The term ‘parachuting’ has been used to describe NPOs that enter and leave with short-term band-aid solutions without addressing larger structural problems. This can create dependencies in the community for external aid, hindering self-sustainability and long-term changes. Effective altruists tend to prioritize interventions with clear and objective outcomes (e.g. vaccinations, mosquito nets, and deworming drugs). Interventions with less evidence, but larger potential for long-term change are often ignored (e.g. knowledge building, strengthening health infrastructures, political advocacy).

Community participation, according to the World Bank, is a “process through which stakeholders influence and share control over development initiatives and the decisions and resources which affect them”. A survey of 25 World Bank agricultural projects 5-10 years after completion noted that community participation was essential for the effectiveness and sustainability of its projects. In one example, the National Irrigation Administration Program in the Philippines transformed from a top-down government approach to a community-participation approach over 10 years. Community participation increased irrigation yields by a staggering 10-22%, and water usage was drastically more efficient. Additional ways to enhance sustainability is to support pre-existing grassroots organizations and empower individuals within the local community to create change. Effective altruists should consider the extent of community participation and capacity building in its evaluation of which intervention programs to fund.

Community Health Workers

To address the deficits of medical professionals in rural areas, many countries have adapted a community health workers (CHW) program. CHWs are local individuals without traditional physician or nursing degrees who provide preventative, diagnostics, or medical procedures in rural communities. CHWs have been instrumental in both primary and specialized care for individuals with geographical and financial barriers who cannot access urban medical facilities. The success of the CHW program largely stems from its foundation in community participation: (a) CHWs understand cultural perception of disease by their community, (b) CHWs foster trust and act as a bridge between government, NPOs, and medical professionals with the community, and (c) training and building health infrastructure within communities contribute to empowerment and sustainability.

More than meets the eye: the social determinants of health

Health outcomes are inherently intertwined with cultural, socioeconomic, political, and historical factors that should not be ignored in global health and development aid. Effective altruists are biased towards funding global health issues that have clear and singular technological solution. They often ignore interventions that address social determinants of health or induce structural change because those solutions often lack adequate evidence. Similar to effective altruists, NPOs of the past have avoided global health crises that are ‘too complicated’ and intertwined with socioeconomic factors. For example, the Rockefeller Foundation avoided treating tuberculosis (TB) during the 1930s because of its links with poverty, and the WHO abandoned its malaria eradication program because of the effects of agricultural traditions and labor migration on the spread of malaria. By only funding global issues that are the ‘most solvable’, we risk perpetuating cycles of systemic inequality where populations that need help the most will be neglected.

The promotion of equity should be at the forefront of all stages of development aid (e.g. aid allocation, funding prioritization, implementation). Effective altruists should learn from success stories like the directly observed therapy (DOT) plus program by WHO in 1997-2004 to target multi-drug resistant TB in Lima, Peru. Researchers found that treatment outcome of TB is largely determined by socioeconomic and psychosocial factors, rather than biological. Socioeconomic interventions (e.g. financial assistance, food security, subsidized housing cost for homeless patients, and psychiatric counselling) drastically enhanced TB cure rate. Effective altruists should aim to (a) invest in disadvantaged or vulnerable groups to address differences in capabilities, and (b) ensure organizations they fund are taking steps to narrow gaps of accessibility to interventions. More specifically, factors that influence health (e.g. socioeconomic status, political empowerment, discrimination, geographic accessibility, etc.) should be at the forefront of (a) deciding which communities to prioritize aid, and (b) determining which interventions were successful.

What does this mean for graduate students and young professionals who want to make a difference in this world? Despite its flaws and potential ethical dangers, effective altruism is a great first step towards pushing for evidence-based policies in humanitarian pursuits. However, I argue that the current standards of effective altruism (i.e. cause-neutrality, top-down approach, and avoidance in addressing social determinants of health) is ineffective, short-termed, and unjust. I believe that to create effective change in this world, we need to build trust and involve local communities, build capacity through bottom-up approaches, and address systemic inequalities and injustice. These principles also apply to local initiatives here in North America for which you may be organizing or volunteering. Whether you are distributing food to reduce child hunger from the COVID-19 pandemic, or designing apps to remind elderly to take the right medication – how do we ensure equitable accessibility? Are we understanding what the people actually need? Is our intervention sustainable? Evidence, research, and technology in itself are not the answers to the world’s problems. What matters more is how we use these tools to promote a more equitable and just society.


References:

“Global Health And Development”. 2017. Effective Altruism. https://www.effectivealtruism.org/articles/cause-profile-global-health-and-development/.

“Introduction To Effective Altruism”. 2020. Effective Altruism. https://www.effectivealtruism.org/articles/introduction-to-effective-altruism/.

“Our Top Charities | Givewell”. 2020. Givewell. https://www.givewell.org/charities/top-charities.

“Pitfalls In Global Health Work”. 2021. Uniteforsight.Org. Accessed May 12. https://www.uniteforsight.org/pitfalls-in-development/pitfalls-in-global-health#_ftn3.

Arshad-Ayaz, Adeela, M. Ayaz Naseem, and Dania Mohamad. “Engineering and humanitarian intervention: learning from failure.” Journal of International Humanitarian Action 5, no. 1 (2020): 1-14.

Buekens, Pierre, Gerald Keusch, Jose Belizan, and Zulfiqar Ahmed Bhutta. “Evidence-based global health.” Jama 291, no. 21 (2004): 2639-2641.

Ferguson, James. “The anti-politics machine.” The anthropology of the state: a reader (2006): 270-86.

Greenough, Paul. “Intimidation, coercion and resistance in the final stages of the South Asian smallpox eradication campaign, 1973–1975.” Social science & medicine 41, no. 5 (1995): 633-645.

Holst, Jens. “Global Health–emergence, hegemonic trends and biomedical reductionism.” Globalization and health 16 (2020): 1-11.

Jones, William I. The world bank and irrigation. World Bank Publications, 1995.

Kurbatova, Ekaterina V., Allison Taylor, Victoria M. Gammino, Jaime Bayona, Mercedes Becerra, Manfred Danilovitz, Dennis Falzon et al. “Predictors of poor outcomes among patients treated for multidrug-resistant tuberculosis at DOTS-plus projects.” Tuberculosis 92, no. 5 (2012): 397-403.

Labbé, Jérémie. Rethinking humanitarianism: adapting to 21st century challenges. International Peace Institute, 2012.

Langan, Mark. “Neo-colonialism and donor interventions: Western aid mechanisms.” In Neo-Colonialism and the Poverty of’Development’in Africa, pp. 61-88. Palgrave Macmillan, Cham, 2018.

Lehmann, Uta, and David Sanders. “Community health workers: what do we know about them.” The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization (2007): 1-42.

Löwy, Ilana, and Patrick Zylberman. “Medicine as a social instrument: Rockefeller Foundation, 1913–45.” (2000).

MacAskill, William. “The definition of effective altruism.” Effective Altruism: Philosophical Issues 2016, no. 7 (2019): 10.

Mansuri, Ghazala, and Vijayendra Rao. “Community-based and-driven development: A critical review.” The World Bank Research Observer 19, no. 1 (2004): 1-39.

Marmot, Michael, and Richard Wilkinson, eds. Social determinants of health. Oup Oxford, 2005.

Merton, Robert K. “The unanticipated consequences of purposive social action.” American sociological review 1, no. 6 (1936): 894-904.

Ofuoku, A. U. (2011). Effect of community participation on sustainability of rural water projects in Delta Central agricultural zone of Delta State, Nigeria. Journal of Agricultural Extension and Rural Development3(7), 130-136.

Packard, Randall M. “‘No other logical choice’: global malaria eradication and the politics of international health in the post-war era.” Parassitologia 40, no. 1-2 (1998): 217-229.

Schambra, William. “The coming showdown between philanthrolocalism and effective altruism.” Philanthropy Daily 22 (2014).

Smith, Ben J., Kwok Cho Tang, and Don Nutbeam. “WHO health promotion glossary: new terms.” Health promotion international 21, no. 4 (2006): 340-345.

Stöhr, Walter. “Development from below: the bottom-up and periphery-inward development paradigm.” (1980).

Wasilwa, Caleb. “Effect of Community Participation on Sustainability of Community Based Devt. Projects in Kenya.” (2017).

The following two tabs change content below.

Douglas Chung

Douglas is currently a PhD candidate under the supervision of Dr. Pamela Ohashi at Princess Margaret Cancer Center. He is currently interested in understanding novel mechanisms of immune suppression within the tumour microenvironment. Beyond research he is actively involved in science outreach such as Let's Talk Cancer and Science Rendezvous. Through these initiatives he hopes to inspire next generation of young scientists.
Previous post The Rainbow Road: Overcoming Obstacles Faced by LGBTQ+ Scientists
Next post The future of work

Leave a Reply

Your email address will not be published. Required fields are marked *

Close
The newest issue of IMMpress is now available! This time, we tackled all things work culture, from universal basic income to unions and more! Check it out by clicking the link below https://t.co/dDatJRPNi8 https://t.co/2scopoDpCU
h J R
@immpressmag
VR has already changed the world in every way, from medical training to how we view entertainment. As education moves online with the pandemic, how will VR change the classroom? Click the link below to find out! 🕹 https://t.co/g1uYViavAN
h J R
@immpressmag
The newest issue of IMMpress magazine is now out! This time, we delved into the world of technology in healthcare 🔬 Check it out and let us know what you think! https://t.co/HyBn12R6Fd
h J R
@immpressmag
One of few positive outcomes from this pandemic was the advent of mRNA vaccines. And with a rise in funding for this research, scientists can continue to improve this technology. Check out this article by @pu_annie to learn everything you need to know! https://t.co/2GtcexUBvl
h J R
@immpressmag
Check out the link in our below to read the newest IMMpress blog post! Our DOI undergrads Rahman and Aly did a great job on this one 🤩 https://t.co/yeTs2q6S7x
h J R
@immpressmag

Sponsors