Overview
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:
- 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;
- Established operational systems;
- Fine-tuned communication and external relations strategy;
- 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:
- 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.
- 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.
- 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:
- 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.
- 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.
While I believe the intent is noble, I have concerns about fortification as the solution to nutritional deficiency, at least beyond the very short term. After a quick search, I came to learn my concerns were shared by the scientific community in India, and have been widely reported on by the Indian mainstream media.
New study calls for restraint in ‘unnecessary’ food fortification
Jagriti Chandra, The Hindu
JULY 30, 2021
https://www.thehindu.com/sci-tech/health/new-study-calls-for-restraint-in-unnecessary-food-fortification/article35640607.ece
Experts raise concerns over mandatory fortification of food items
Special Correspondent, The Hindu
AUGUST 02, 2021
https://www.thehindu.com/news/national/experts-raise-concerns-over-mandatory-fortification-of-food-items/article35685066.ece
The first news item references an article published in The Lancet suggesting that widespread iron deficiency among children and adolescents in India was largely an artifact of arbitrarily high cut-offs set by the WHO.
Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1–19 years in India: a population-based study
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00077-2/fulltext
Using cut-offs based on age and gender-adjusted 5th percentile of the healthy population in India based on its national nutrition survey (CNNS), the incidence of anemia declines by two thirds, from 30.0 to 10.8 percent. It is worth noting that the cut-off based on the CNNS was not dramatically lower than that used by the WHO (see Figure 3 in the referenced article), suggesting many children have barely adequate iron status and could be at risk of deficiency.
This sentence in the news story was of particular interest: “Is there an Indian diet that can meet these requirements? Indeed, there is. You don’t need to fortify to meet the requirements of 15-18 mg of iron per day in the Indian diet,” Dr. Kurpad explained in a webinar.
The interest stems from the relatively high dietary requirements set in India. For context, the US recommended daily allowance (RDA) for children between the ages of 1 and 18 range from 7 to 15 mg of iron per day based on age and gender.
In terms of whether an easily accessible Indian diet could meet those requirements, one cup of spinach, one cup of lentils and two whole-wheat (ie non-fortified) pieces of naan bread provide 17mg of iron in only 870 calories, barely 40% of the caloric intake considered adequate by the WHO for a moderately healthy adult. These are widely available, commonly consumed and inexpensive staples of the Indian diet.
The news story also makes another important point that advocates of fortification fail to consider. With a minority of the population suffering from deficiency, targeted supplementation makes more sense: "Just putting more and more into the diet places a part of the population at risk of exceeding the tolerable upper limit of intake at which adverse events begin to occur,” says Dr. Kurpad.
The second news story adds a few more salient points. It references two other scientific artlcles, from the American Journal of Clinical Nutrition that conclude fortification could cause gut disbiosis and lead to hypervitaminosis.
The effects of iron fortification on the gut microbiota in African children: a randomized controlled trial in Côte d'Ivoire
https://academic.oup.com/ajcn/article/92/6/1406/4597520
Vitamin A deficiency among children younger than 5 y in India: an analysis of national data sets to reflect on the need for vitamin A supplementation
https://academic.oup.com/ajcn/article/113/4/939/6039538
A letter cosigned by 170 scientists, including the former deputy director of the National Institute of Nutrition, notes that many of the studies upon which the Indian government was relying to promote fortification were sponsored by food companies who would benefit from it, leading to conflicts of interest. Studies funded by the Nestle Nutrition Institute and the Global Alliance for Improved Nutrition were specifically mentioned.
A link to the full letter, the names of its signatories and numerous academic citations can be found here:
https://im4change.org/upload/files/ASHAs%20letter%20to%20FFRC%20on%20mandatory%20fortification%20Aug%202021.pdf
Just throwing out the word 'evidence-based' without citing the evidence is problematic. As the letter from the Indian scientists contesting the government's push for mandatory fortification suggests, there appears to be a great deal of evidence suggesting detrimental short and long-term impacts of food fortification as a means of addressing nutritional deficiency.
Also, while I am new to Effective Altruism, I imagine any such concept at the minimum should take into account the needs, wants and long-term well-being of the targeted population, which appears not to have been taken into consideration with respect to food fortification in India.
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.)
Thanks!
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.
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?
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. ^_^
Thanks!
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:
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
https://issarice.com/against-malaria-foundation
https://timelines.issarice.com/wiki/Timeline_of_Against_Malaria_Foundation
Disclosure: I funded the creation of the latter page, which inspired the creation of the former.