A conversation with a donor interested in supporting fistula surgeries

Jeremy to GiveWell, 5/18/09


Have you all researched The Fistula Foundation? I am a kindergarten teacher and have thought about trying to do some serious fund raising for them during the time off that I have this summer. Is it an aid organization to which you would give your blessing?


GiveWell to Jeremy, 5/20/09

Dear Jeremy,

Thanks for contacting us. We always appreciate hearing from people interested in our work.

We are trying to find an organization to recommend that provides fistula repair, but we have yet to do so. We have contacted the Fistula Foundation for more information, but thus far, they haven't been very responsive.1 We plan to continue trying to get in touch with them.

Please don't hesitate to contact me with any additional questions or comments about GiveWell.

Elie Hassenfeld

Jeremy to GiveWell, 5/21/09

Dear Elie,

I am a kindergarten teacher and am finishing up the school year, so I am pretty busy right now, but I did want to take a moment to say thank you so much for the great work that you all are doing! Also, thank you for replying to my inquires in such a timely fashion.

Part of my vision is to try to rouse local leaders to collaborative, periodic action on behalf of those who are suffering, deprived, or dying. What if we could get many leaders interested in giving, and if these leaders could then influence those whom they lead to do the same. I have in mind the creation of a network of givers that come together to fund periodic projects.

I am in the earliest stages of learning about aid, but I'll just give a thought experiment. Suppose that Oxfam was planning on trying to build a new hospital somewhere. They had the staff in place, the vision, the plan for services, and so on. What they lacked was the money. Well, enter the network. If X number of leaders could each influence Y number of people to give Z dollars, then the money might very quickly add up, without any one person having to give to the point of great sacrifice. (I am all for sacrificial giving, but the point is that the more people there are the easier it is to raise a lot of funds, even if no one gives sacrificially). But I would see Give Well playing a vital role here. If you all could say, "Yes, in general, this aid organization is reliable, and, specifically, it looks like what they are wanting to do here, i.e. this particular project, is quite sound," then this would make it a lot easier for those raising funds, i.e. the leaders of the network, to get their job done. There could be real confidence that if we all act together we can really help to bring about an all-things-considered good.

After the network had helped Oxfam build its hospital, it could then go on to help PIH build theirs, and so on. That, at any rate, is my idea. Get leaders involved and then you exponentially increase your impact. But the sell becomes easier if a group such as yours is behind the aid organization/project for which funds are being raised. It also become more integrous, because it is based on solid data that points to the agency's reliability.

That is why I asked you about the Fistula Foundation. If you all could put your stamp on it, that would make me even more enthusiastic about trying to raise funds for them. Do you think that I should contact them and tell them that? If they start hearing from potential fund raisers such as myself, and if they hear that such people think that Give Well provides a very crucial service, then they might be more inclined to provide the sort of evidence that you seek.

Well, I better run. Those kindergartners won't be lacking in energy tomorrow just because I will be. Once again, thank you for all that you do. Never give up! Know that you are appreciated.


GiveWell to Jeremy, 5/22/09

Dear Jeremy,

Thank you for your email and kind words.

In brief, yes, I think it would help us if you told the Fistula Foundation that you, as a donor, rely on our research and reports. We believe that showing charities that donors care about evidence of effectiveness is essential to our mission. Thank you.

Also, in case you're interested, we've come across other organizations (in addition to the Fistula Foundation) involved (to one degree or another) in fighting Fistula. We haven't reviewed them fully yet, so we don't have any conclusions about their effectiveness, but perhaps, this list will help you in your personal research:

We're planning to publish our take on this area and these organizations this summer. Please let me know if there's anything else I can do to hep you.


Jeremy to GiveWell, 5/31/09

Dear Elie,

I am most grateful for the information that you sent me about other organizations that are fighting fistula. I had meant to express my thanks sooner, but I just finished out the regular school year of teaching and things have been busy non-stop!

I have not yet personally contacted the Fistula Foundation about providing your organization with the information that you are seeking, but I plan to do so soon.

Since the Fistula Foundation targets a specific condition, and since it is highly treatable, it would seem to me that existing clinics and hospitals that treat fistula are certainly doing great good. I think, for example, of Dr. Hamlin, and the good that she has been doing for decades in Ethiopia. Surely it can't reasonably be doubted that the funds given in order to support her efforts, or the efforts of those who do the same work, are instances in which people have given well.

Since you seek information from people working with fistula, I was wondering what kind of information you seek. You all are the experts on this, but for me, as I have thought about it, these are the sorts of questions about which I have wondered. Do they have enough funds to sustain their present operations, or is there danger of having to scale back because present giving is not enough? If they have enough funds to sustain present operations, then why do they continue to ask for donations? Is it because they want to have some savings, against the possibility of a future decline in giving? That seems reasonable, but how much savings does an organization accumulate before it puts a cap on it? Because we live in a world of such great need, it doesn't seem right to go on and on accumulating savings, if there are other organizations that are struggling even to sustain their present efforts. Those who give, and thereby increase the savings of organization X, might have given more wisely to organization Y, that is struggling to sustain basic operations. Or, does an organization ask for more funds, even when its present services are adequately funded, because it wishes to expand, to replicate, its efforts somewhere else?

I would be particularly enthusiastic about raising funds for an organization such as the Fistula Foundation if it had pressing needs to sustain existing services, or if it had clear plans to expand. I would also support savings, within reason. Shouldn't it be easy for organizations, such as the Fistula Foundation, to provide answers to these kinds of questions?

If they did, and if there was clear need, I would enthusiastically raise funds for them. Are these the kinds of answers that Give Well seeks to provide to potential givers?

What other kinds of information do you seek? With something like fistula, it seems that if a clinic or hospital is in place, with trained staff, they will clearly be doing good that is measurable and open to clear confirmation. Thus, if such locations need more funds, or if there are plans to build new locations, then surely one can "give well" by supporting such projects.

If Give Well could say, "Yes, the Fistula Foundation has clear needs for more funds to sustain its present activities," or, "Yes, the Fistula Foundation has clear plans to expand, and needs funds in order to do so," then I would think we have the bulk of the evidence that we need in order to justify giving to them, but I am new to these things and would welcome any additional thoughts that you have.

Thank you again for your work and for the information that you provided about other organizations working with women who suffer from fistula.


GiveWell to Jeremy, 6/3/09

Dear Jeremy,

There are two primary questions we have for organizations like the Fistula Foundation and you've hit on one of them.

  • How will they use additional funds? Like you, I'm very interested in donating money in order to increase the number of women who can undergo surgery to repair a fistula. However, I'm unsure that a donation to the Fistula Foundation (or the other organizations I mentioned in my previous email will do that.) In order to answer that question, I'd ask them for more detail on how they plan to use additional funds and/or what they currently wish they could do, but can't due to lack of funds. Now, if for example, they plan to train new surgeons (as opposed to use donations to fund existing surgeons), there would be a whole new set of questions regarding their past experience and track record in training surgeons. (Just think how rigorous and difficult medical school is in the U.S. -- it's far from simple to train people to perform difficult surgeries.)
  • How do they ensure quality and monitor patients for surgical complications? Surgeries are often risky. Charities we've looked at who perform cleft lip/palate surgeries (i.e., Interplast) or cataract surgeries (i.e., Aravind Eye Care System) monitor each patient to determine whether they were safely treated. (Both those organizations are listed on the page which shows the organizations we're reviewing in our current report - http://givewell.org/node/393) Those organizations can also report the "complications rate" -- i.e., the % of people who undergo surgery but have some problem either during or after surgery. Knowing this % gives us some indication of the risk of causing harm by supporting a given charity.

I hope this information helps.


Jeremy to GiveWell, 6/9/09

Dear Elie,

Thanks for the information. It helps.

It does seem that any well-run organization, that provides medical care, should have very good records on each of its patients. Thus, in the case of the Fistula Foundation, we should know how many women have been treated. Of these, we should know how many were cured, and how many were not. Of the latter group, we should know whether the failure to cure the patient was due to preventable mistakes on the part of the surgeons, or whether the cases were untreatable. Of the untreatable cases, we should know whether other options were then tried, i.e. options other than surgery. (On this last point, I thought the film A Walk to Beautiful had a wonderful case of this, i.e. the woman who could not be successfully treated, surgically, but who was able to use some kind of insert that allowed her some measure of control over her bodily movements; she was the one who went on to work in an orphanage and seemed to derive much personal meaning from that kind of service. Also, I am very impressed, from what I know of it, of Dr. Hamlin's "City of Joy," for those who have not been cured, and who have no other means of alternative treatment. They can at least live in a community where they will no longer be shunned, and where they will be treated with dignity!).

Thanks also for insight about the kind of financial information that you seek. I like how you put it: "What do you wish you could do, if you had the funds." Putting it that way covers questions concerning both urgent needs, having to do with the continuation of present operations, as well as funds needed for expansion. Again, it seems that any well-run organization should be able to answer that question.

It seems to me that a fistula clinic/hospital with well-trained staff is probably doing good work. Thus, donations are doing good, for they help to keep such operations going. However, it is this question of excess funds that gets to me. At a certain point, if you keep receiving funds, your budget for present needs will be met, but if you have no plans for expansion, why keep asking for donations?

The information that you have given me will help me to know how to approach the Fistula Foundation, in order to ask them to provide the data that your organization is seeking. If you have any advice about how to do so, in addition to the helpful information that you have already provided, I would of course welcome it.


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    Update: On 7/20/09, Kate Grant, the Executive Director of the Fistula Foundation contacted us. We spoke over the phone with her on 7/21 and she sent us additional information that day. We anticipate future back and forth with the Foundation.

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