Introducing fortify hEAlth: an EA-aligned charity startup

by e19brendan27th Oct 20177 comments


Micronutrient programsFortify HealthGlobal health and development

We’re engaging in an exciting entrepreneurship experiment: can a new EA-aligned organization effectively reduce the burden of iron deficiency anemia and neural tube defects? The burden is so large that we hypothesize that there exist opportunities for impact beyond already excellent work being done by major organizations. We have begun to develop relevant expertise and curate potential strategies for intervention. We are now consulting with experts to deepen our expertise and build partnerships, as well as narrowing down potential locations in which to focus our work. We hope to develop a GiveWell-worthy charity that can exceptionally effectively put donations to work in improving the lives of vulnerable people. We believe that despite the challenges to achieving this ambitious goal, this initiative is worth our efforts. It provides great career capital and learning opportunities for us, and we believe this project will have valuable lessons for the effective altruism movement. We are grateful for the opportunity to work on this potentially high-impact and exciting project.
The problem

Anemia and neural tube defects are widespread, preventable health problems that primarily lead to the suffering of women and children. Poverty predisposes people to anemia and neural tube defects for a variety of reasons, including inadequate nutrition, weak health systems, infectious/parasitic disease, and limited access to fortified foods.

Iron deficiency anemia (IDA) occurs when the body does not have enough iron to produce hemoglobin and cannot carry sufficient levels of oxygen around the body. IDA is responsible for roughly half of the 2.36 billion cases of anemia globally, and accounts for four percent of all years lived with disability. Anemia can cause chronic tiredness/fatigue, impaired cognitive development in children, low moods and low productivity in adults, and even increase risk for depressive symptoms and heart disease.

Neural tube defects (NTDs) are developmental abnormalities affecting the spine, spinal cord, and brain, largely due to folic acid deficiency within the first month of pregnancy. NTDs account for over five million DALYs and over 40 thousand deaths annually.
A response

Fortification of staple foods with iron and folic acid is an evidence based strategy to reduce the burden of these diseases. IDA and NTDs account for widespread illness and their prevention is evidence-based and cost-effective. An organization transparently and successfully facilitating fortification would align well with GiveWell’s criteria for exceptionally effective organizations, and we’ve set out to try to develop such an organization.
Charity Science is incubating this initiative. According to their rigorous evaluation, iron and folic acid fortification is among the top causes that could become a GiveWell top charity. Causes were evaluated in terms of cost-effectiveness, scalability, strength of evidence, ease of testing, flexibility, and logistical possibility. Experts in the field, including GiveWell, 80,000 Hours, and Charity Science think charity entrepreneurship is an effective way to make a difference in the world.

What we hope to learn

Is it possible or realistic for non-expert, effective altruism-aligned individuals to establish a GiveWell-worthy organization from scratch?

 In the interest of setting up an organization that meets GiveWell’s criteria, we are eager to test the possibility of EAs founding effective charities. Our first steps have been to begin gaining expertise on iron and folic acid fortification, and we will be grateful to the experts willing to share their knowledge with non-experts entering the field.

Charity Science: Health, an EA-aligned organization that provides SMS reminders for vaccines, is a good example of an implementation organization that has been developed from scratch by non-experts. This is the only charity startup of its kind that we are aware of and we hope to employ a similar model in building a micronutrient fortification initiative.

Are there gaps in the current work focused on IDA and NTDs through staple food fortification that likely won’t be met by other institutions in the near future?

At present, one of our priorities is to understand the current global landscape in micronutrient fortification and the different stages involved in the fortification process. By extensive reading and expert consultation, we hope to pinpoint the most neglected areas in the fortification process and we are considering a range of potential strategies (discussed below). As we gain expertise and familiarity with the existing actors, we will prioritize potential locations and strategies.
Who are we?
Brendan Eappen, Co-Founder, most recently worked with Partners in Health (Socios en Salud) in Peru on the development of their mental health program. Brendan studied Cognitive Neuroscience & Evolutionary Psychology, and Global Health & Health Policy at Harvard College.
Nikita Patel, Co-Founder, most recently worked at Malaria Consortium in global health communications, and prior to this completed an internship at the Centre for Effective Altruism. Nikita studied French and German at University of Oxford.
Joey Savoie, Mentor and Funder, CEO and Co-Founder of Charity Science (an effective altruism organization based in Vancouver) is providing extensive mentorship and initial funding to fortify hEAlth. Joey directs Charity Science: Health, the first EA-aligned charity startup of its kind. Their project sends text message reminders for vaccinations in India, where only 65 percent of the 20 million children in India receive all recommended vaccinations by age two. Charity Science: Health has been awarded two GiveWell incubation grants.
If fortify hEAlth advances beyond its initial stage, we plan to hire industry experts with specific skills and experience relevant to the chosen strategy and location.
Progress so far
In brief, during our first month, we have:

  1. Curated a library of relevant literature available on micronutrient supplementation and fortification. We are continuing to review this and will publish a summary in a later blog post;
  2. Established operational systems;
  3. Fine-tuned communication and external relations strategy;
  4. Identified roles and gaps we could fill in the fortification landscape, with an aim to narrow these down upon speaking with experts in the field.

Potential approaches
Our initial research suggests that, despite the attention of several organizations to iron deficiency anemia (IDA) and neural tube defects (NTDs), there may remain many gaps that prevent people from access to iron and folic acid. Several potential approaches may be employed to improve access to these key nutrients and therefore combat IDA and NTDs. Any strategy we implement would be pursued in coordination with local organizations, international organizations, academic experts, and others. We will rigorously evaluate the potential for EA-aligned action consistent with these and other strategies.
Here are some intervention approaches we have identified as possibilities:

  1. Facilitating mandatory fortification of staple foods. We would work with local health professionals, lobbyists, and governments to establish requirements for specific staples that are industrially processed (such as flour or rice) to be fortified with iron and folic acid, to evidence-based standards.
  2. Short of working towards the introduction of legislation where it does not already exist, we could work with the government to update technical standards for fortification to reflect the WHO and Cuernavaca guidelines. One analysis suggested that only nine out of the 78 countries countries with mandatory iron fortification of flour are doing so most effectively, yet the infrastructure and political will exists (existed) to take on this issue, it could be a particularly feasible opportunity for impact.
  3. Within countries that mandate fortification, there may be poor adherence to fortification policy. We could develop capacity for (and carry out) quality assurance (monitoring, and evaluation) of fortification practices, working with the government to improve the effectiveness of existing programs that might exist on paper without adequately serving the people they are meant to support.

The above strategies are particularly appealing because of the scale of the potential impact. However, if further investigation proves they are either too crowded or infeasible, our efforts may be most impactful in extending fortification initiatives to communities often outside their reach, such as by:

  1. Providing technical support and subsidize fortification at small-scale, local mills in communities outside the reach of fortification initiatives that tend to target large-industrial mills.
  2. Revisiting strategies beyond fortification to improve nutrition, such as supplementation.

If you would like to learn more, guide us, or join us, please email us. Especially if you have expertise in this domain, but in any case, we would love to hear from you. This article is also posted on our blog.

5 comments, sorted by Highlighting new comments since Today at 12:13 AM
New Comment

Awesome that you're launching and doing this! :)

Not that I disagree, but can you elaborate more on why you think the space is uncrowded enough for a new charity? Can you also elaborate on why you decided to create a new charity rather than join an existing one?

(Disclaimer: I'm affiliated with Charity Science Health and work closely with Joey Savoie, so this is more of a devil's advocate question, but I'm still genuinely curious about the thinking behind this.)


can you elaborate more on why you think the space is uncrowded enough for a new charity?

This question is a key consideration about which we hope to become more certain in the next couple of months. This is to say, we don't know that the space is sufficiently uncrowded. However, we have a few reasons to believe this very well could be the case:

  • The prevalence, particularly of iron deficiency anemia, is geographically diffuse.

  • Implementing an impactful strategy likely needs to be reiterated independently across geographic borders, and existing organizations may be limited in the number of high-intensity projects they can/decide to manage at one time.

  • Large organizations working on this issue may systematically neglect working in certain populations or employing certain strategies that a new EA-aligned organization may not.

  • Large organizations' impact may depend on an abundance of specific projects to support, the lack of which may bottleneck their efforts.

  • The marginal impact of funds to their efforts compared to specific implementation projects may be relatively weak.

  • The burden of disease associated with iron deficiency anemia remains quite high, and in absolute terms and in terms of percent of all cause DALYs is actually growing (although the rate accounting for population growth is in fact declining). This suggests that what has already been done has not been sufficient so far, and that accelerating the gains existing organizations will eventually bring about may have a substantial impact.

Over the next month or so, our priority is to interview experts within the large global institutions involved in iron fortification as well as local implementors within locations we might work in order to better understand whether our assumptions are reasonable, what gaps they see in the field, and whether those gaps could be met by EAs like ourselves.

Can you also elaborate on why you decided to create a new charity rather than join an existing one?

The brief answer is that it is reasonably possible that forming a new charity has greater counterfactual impact than joining an existing charity operating in this space. We assume that the existing charities are able to hire competent people to carry out their agenda, and that the positions for which they would hire us would likely provide little opportunity to redirect their efforts towards higher-impact opportunities identified through an EA approach. That said, we would almost certainly be partnering with those existing organizations in carrying out any sort of intervention. They are the experts! Projects in micronutrient fortification in the past and present have been highly collaborative across institutions. We would work together, or even within existing organizations if that emerged to be the most impactful step forward.

We would also consider this venture to be worthwhile even if we later recognize that this space is too crowded for a new charity or that we are the wrong people to start it. We think there is a somewhat low, hard to quantify, but meaningful probability that there is a gap in iron fortification that EAs like us would be able to fill. If we fail, we won't be overwhelmingly surprised, but the value of success would be high. Charity Science (more specifically, Peter Hurford, the comment's author) modeled the impact of creating new GiveWell Charity here. We’re also evaluating the feasibility of EA entrepreneurship more generally and hope that what we learn can support the movement.

Nikita and I determined that our time was worth even a low probability chance of having such substantial impact. We also believe that this effort will strongly improve our ability to improve the lives of others in future endeavors.

That is awesome and exciting!

What made you decide to go down this path? What decision-making procedure was used? How would you advise other people determine whether they are a fit for charity entrepreneurship?

How do you plan on overcoming the lack of expertise? How does the reference class of nonprofit startups founded by non-experts compare to the reference class of nonprofit startups founded by experts?

fortify hEAlth

Is this the actual name? I personally think it's cute, but it might be confusing to those not familiar with the acronym.

I think what you're doing could be very high-impact compared to the counterfactual; indeed, it may be outright heroic. ^_^


I decided to go down this path by carefully examining my priorities for what work I might do after a fellowship wrapped up, first considering how I might best approach the following year with respect to my values and goals. Having been quite interested in doing EA-aligned work, I surveyed some opportunities to work within EA organizations. Along the way, I spoke with Joey Savoie, who encouraged me to cofound my own charity startup rather than joining his (Charity Science Health). I was tentative given my limited experience, but as I considered the counterfactual impact of various alternatives, I grew more interested and took initial steps to find a cofounder (after speaking with a number of people within and outside of EA who encouraged me to proceed). There was a lot of interest; I interviewed a number of qualified candidates; and I was quite happy to find Nikita.

In parallel, I developed a shortlist of the jobs/kinds of jobs I might start this year, and applied to some. I considered factors such as learning/career capital, earning potential, lifestyle, and direct impact, consisting of quite a few weighted subfactors across a variety of opportunities I was considering. If anyone is particularly interested, I am happy to share this model, but I'm not sure I want it posted publicly at this point. This process left me with two rather different "best opportunities." After much deliberation and many conversations with mentors, I took the plunge into charity entrepreneurship. I'll let you know in a few months whether I think that was the right choice. Below is a non-exhaustive list of questions I'd recommend someone considering EA entrepreneurship ask themselves:

  • How should my values and long-term goals influence what I do next?
  • What alternative opportunities exist (including maintaining the status quo)?
  • How well do these opportunities and EA entrepreneurship align with the conclusions of the first point?
  • What qualities should an EA entrepreneur have? (This point may require a longer post, with some input from others)
  • What degree of expertise is necessary to have a decent shot at positive counterfactual impact? (Many EAs might suggest this bar is lower than your first instinct.)
  • Do I think I'd be relatively well-suited for EA entrepreneurship?
  • How much will what I'd learn and how I'd grow from such an initiative make my future endeavors more impactful?
  • Do other EAs think I'd be well-suited for EA entrepreneurship?
  • Are there somewhat specific projects identified (by others or myself) to be potentially high impact that appear feasible, interesting, and fulfilling?
  • Will somebody fund me, or am I confident enough and financially able enough to fund myself?
  • Do others outside EA think this is a good idea?
  • Is this the right time to do this?
  • Are the structures around me supportive of success? Will they guide me well? Will they complement my strengths and compensate for my weaknesses? Will I know whether I'm on the right track, when to re-evaluate, and when to move on?
  • Can I imagine a reasonable path forward, build a tentative plan, convince the appropriate critical people, and commit?
  • Do I have an exit strategy, and how much better or worse is it compared with alternative opportunities/exits?
  • Do I believe that people's lives may be better if we try this?
  • Do I still want to do this?

If it's of value, I could address my own answers to these questions and others, but it may be best to have more of a conversation - I'd be happy to skype (just email me). The answer to the last question on the list is still yes!

fortify hEAlth is the actual name, for now. We'll have to decide how we like seeming cute. For non-EA correspondences, we can just avoid the capitalization, but it may be worth changing this on our website or universally for the sake of the non-EA community (which may take more convincing than all of you supportive folks). Feel free to email us suggestions, but this is where we're at for now.

It is pretty hard for me to know now just how impactful we should expect this venture to be. Considering the counterfactuals, the expected value does seem worthwhile, but I'll humbly admit that the most likely outcome is nearly no direct impact, i.e. if we learn that we should stop before actually improving anyone's access to iron. So, please don't mistake risk tolerance for heroism. However, the scale of direct impact may be quite large if successful, and it so far doesn't seem too infeasible to advise against continuing. We need to learn more in order to assess the value of continuing or desisting.

Other factors influencing my own justification of this risk of failure include the value of motivating or deterring others in pursuit of EA entrepreneurship; my buy in to "doing good together," which might include a portfolio of activities with varying levels or risk across the movement; and the counterfactual learning possible here compared with alternatives. Plus, I'm excited about what we're trying to accomplish! Nikita may have a somewhat separate framework, so do reach out to her as well!

Against Malaria Foundation was started by a guy who had some business and marketing experience but no global health chops. It is now a GiveWell top charity

Disclosure: I funded the creation of the latter page, which inspired the creation of the former.