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You can say, yeah, obviously. Follow NPR's pop culture happy hour wherever you get your podcasts. This is Planet Money from NPR. This is a story of two groups of people doing life-saving work in totally different ways.
One group up close with their hands and the other with numbers at a desk. That first group provides basic health care and medical supplies in the far north region of Cameroon. Their doctors and nurses give vaccines, they monitor pregnancies, train patients to look out for signs of malnutrition with tools as simple as a little piece of tape, like a measuring tape with red, yellow, and green on it. So a mom can wrap it around her kid's arm and measure whether her kid is nourished.
It's a very easy to use tool that we train the mothers to use on their children so that they get to identify malnutrition very early. That allows us to manage grants for the organization called ALIMA. It's an acronym that stands for the Alliance for International Medical Action. Last year in Cameroon, ALIMA treated almost 400,000 people.
ALIMA has been able to do this work by staying far out of the fray during an armed conflict that has been going on for years, by building trust and also by managing difficult logistics. Sometimes there's no road to face, potential attacks. It's scary, it's dangerous. To continue that work, ALIMA's Cameroon program was supposed to get $1.9 million this year from USAID.
When the Trump administration announced it was cutting USAID, Madaland had just gotten back from a visit to ALIMA's doctors and nurses up in the mountains in an area called Mokolot. They had malleged children in the beds of the hospitals. They knew that if we had to do this to discharge all of these children, then they will not get treated. So I jettled, oh my god, what if we had to stop all this?
Who's going to be able to take over? What was the answer? Well, the answer is how this thing is not able to take in all the patients. And that means those patients just don't get care.
Yeah. ALIMA's Cameroon project is one of thousands of programs helping millions of people around the world that all of a sudden this year stopped having money. Tens of billions of dollars gone. An estimated 620,000 people have already died for lack of care.
So while people like Madaland and Cameroon are triaging, choosing what clinics and what services to sustain, across the world there's a parallel triage at the desks of that other group doing life-saving work, the other part of our story, the people with the numbers. They are a philanthropic group. They have money and have been trying to figure out if and how they can help. But they have their own very particular way of doing things.
They have a lot of math to do, all while racing against the biggest worst loudest ticking clock they could imagine. Hello and welcome to Planet Money. I'm Mary Childs. Today on the show, we get to be a fly on the wall, while one organization tries to fill in a tiny part of the enormous hole left by USAID.
The calculations they're making are ruthless. If I'm adding up the deaths of Verde, it's like 650 of Verde in total. Is that right? Yes, I think so.
This group led us in as they tried to reconcile this chaotic and terrible moment with their particular procedures. Sorry, where's the agenda? I haven't spotted it yet. So week after week?
Oh, yeah, I'm not going to say that I'm sorry. We were able to watch up close as they wrestled through one decision, whether to give their money to the project in camera. In the days after USAID got guided, private philanthropy groups everywhere were in a kind of panic trying to figure out how to help. And a few recently unemployed USAID workers used their newfound spare time to compile a list of all the projects that they just lost funding, from water sanitation in Yemen to researching bio-fortified maize in Guatemala.
And that list landed on the desk of a philanthropic group called Give Well. Give Well donates hundreds of millions of dollars every year, and they have this very explicit goal. To make that money, save or improve the most lives per dollar through those ruthless calculations, through research and proof. So Give Well assigned a special team of researchers and advisors to start sorting through the list, including Rosie Vettel.
I was on a rapid response team trying to like, who grew up and stuff between the cracks? Give Well expected that they could spend about $50 million to try to fill in a little tiny part of that USAID hole. So Rosie and the rapid response team start zeroing in on a few specific projects. And one of them was Manalen and all those doctors and nurses in the mountains of Cameroon.
So now Give Well has to see. Is this project a better choice than all of the other projects Give Well could give their limited money to right now? And way back then in March, I asked Give Well if they would record themselves as they try to sort that out. So I wanted to start this meeting actually for Mary for Planet Money, because I know you'll be listening to this recording.
That's Taren Maddox, the director of research who for my sake starts the meeting, laying out what she sees as the challenge Give Well is diving into. The mismatch between Give Well and their love of crispy clear data and this project in Cameroon. We're facing a super learning curve in understanding the context because it's just turning we don't know as well. So in this first meeting, Give Well is mapping out what they will need to know.
Actually, I'm curious Rosie if you can talk me through why this, why are we prioritizing this among the other opportunities that we looked at? So is this region which is heavily affected by conflict? In many ways, this Cameroon program is emblematic of the kinds of things USAID had given money to. Big, multi-pronged programs in areas where there's conflict and poverty and malnutrition, disease, or if under programs promoting global stability or trade.
And historically, Give Well has operated more at the margins, looking for specific, efficient, and neglected projects so that they can prove with research and data and preferably randomized controlled trials that they are saving the most lives. The canonical example is buying mosquito nets to prevent diseases like malaria. The nets are super effective and super cheap. So for this project in Cameroon, the Give Well team is starting by trying to understand the most basic facts, how many people are in the area and at what rate do they die?
Yeah, and these are populations that we think are just higher risk, higher mortality populations in general. Yeah, that's definitely something I really want to get into through this investigation, but coming in, my sense would be, yes, they more than the vast majority of people on the planet really critically need good healthcare at this moment. They spend the rest of this first meeting on what they will need to find out. It could convince them to fund this grant or not.
Okay, we'll take it soon. I'll look forward to seeing the investigation plan. Taryn is Rosie's boss, and when I spoke with her later and learned on this rapid response team, it is her job who decides who gets money and who doesn't. Well, I managed the team to decide where the money goes.
I tried to make sure that we're doing that, making those decisions in the highest quality way possible. Yeah, but you are kind of the the buck stops. The buck stops with me. What you're looking for is the least expensive way possible to save the most lives or improve the most lives in the unique language of Ivoille.
They call it life saved equivalent. So we're taking all of the benefits, like a furting disability, improving somebody's income, improving someone's cognitive outcomes. They assign precise numerical values to the benefits that a program provides so that they can compare how effective one kind of intervention is versus the next. Or putting that all into one measure and calling it like an equivalent life saved.
So that's a little bit of like nuance. And this type of calculation is unique to a little group of nonprofits and philanthropic organizations like Give Well. They overlap with a philosophy called effective altruism, in which people try to quote, do the most good based on the evidence. This arose with our new found ability to gather and crunch vast amounts of data, which enabled more rigorous research.
That transformed development economics. Everybody started doing randomized control trials and this whole new way of thinking about aid was born. That is the context in which Give Well started in 2007. And that's their promise to their donors who have handed their money to Give Well because they also believe in this idea of saving or improving the most lives per dollar.
But for all this to work, Give Well has to have proof. So a couple days later, Give Well asked the people running the Cameroon project to meet them on Zoom. We are recording this. If anyone's uncomfortable sharing externally, that sign just shoot us a note.
First, the Give Well people want to know how urgent the needs are. And then they'll start to fill in the numbers they need. Okay, so if it's good, my first question is to get a sense of the current status of Alima's work in Cameroon. Like is everything still fully operational or some parts of the program, maybe not running like at the moment?
No, they are not running in 100%. Joelle Kambale Kameite is in charge of the program in Cameroon. And he says, yeah, we are already having to pull our doctors and nurses and staff. Like in Macquarie, where they were in 14 health centers.
Now we have only four health centers and one hospital. So it's made from 14 health center to four. And in Mocolo, their other location under discussion, they were in eight health facilities and now are down to just one, just the hospital. In Mocolo, if there's no other funding coming, then we'll have to shut down the project.
Madaland is in the meeting too, the one in charge of raising money for the Cameron project. And Rosie, the researcher from Give Well, she asks Madaland for more clarity on the demographics. This figure will go into one of Rosie's give-willian calculations to get at the rate of lives being saved. So it's a mix of internally displaced people, host communities, is that correct?
So I can give you the population from Mocolo health districts that will be around 350,000 people. After their first meeting with the Cameron group, the Give Well team spends several weeks trying to compile the answers to several sounding questions. Like how many children under five generally die in that area, and how many children will die without the Cameron project's work. So the baseline mortality versus the counterfactual.
And during Give Well's internal meetings, Rosie and Taryn are doing this sort of unnerving child mortality meth. When children die because of malnutrition, it's because it's usually because of a complication. Right? So we have children that are very unwell because they're malnourished and then they have they get pneumonia or they get in the case of diarrhea and that just puts their little bodies over the edge.
And so I wonder if we would be double counting essentially because- These mortality figures are weirdly hard to come up with, and it's a conflict zone. So a lot of the patients are displaced people or refugees. They're pretty mobile, so they don't come back for follow-up visits. So Give Well needs information that basically doesn't exist.
Throughout April, clock ticking, they keep trying to make sense of the numbers. Like this one data point of how many kids under five die every year per 10,000 people. Oh, so I'm just looking at this row 15, 730 total deaths per year. And then if we're averting 650 of those.
And with you. Taryn and Rosie are passing this data point and asking is that with the Cameron project's doctors and nurses? Because that would mean without them. Is that potentially like a little bit higher still, which would seem like really gutting, right?
Okay, so is this on the list for us to just ask them about tomorrow? I think it's not an edge I think it should be. In addition to not having all the numbers Give Well needs for this project, there's another missing component so far that's just as important on the ground research. Rosie told me later both are crucial if you're just like spreadsheets spreadsheet, model model, without of course like really thinking like, hey, what's happening on the ground?
You're liable to go equally astray in the opposite direction, right? But where Give Well might normally hire some trusted research firm to fly in and confirm the Cameron project's numbers? To say yes, this many people are there. Looks like the hospital does indeed employ 54 people.
They cannot do that here because the area is so unstable. Like two researchers were killed here a few years ago. Give Well talks a lot about this in their meetings by themselves and with Alima. Like should they commission a study?
Is it safe any areas around these types of surveys? Like how the street area will be hard to cover and that's usually where we have the worst figures. A comprehensive study like the kind they want would take a year to get done. All while that clock is still ticking.
On the other hand, the Give Well team is thinking if we don't spend the time we need to complete on the ground research and our spreadsheet spreadsheet spreadsheet, how can we be sure we're backing the right project? Taryn told me she's learned that sometimes real measured evidence-based outcomes can be counterintuitive. Like this one time when she first joined Give Well in 2019. I remember looking into two different interventions around the same time.
One was an intervention that was designed to reduce maternal mortality. And the other was helping a government switch an HIV test for pregnant women to test for syphilis as well. So which should they fund? Preventing birthing mothers from dying or testing for syphilis in addition to HIV?
When you do the math, maternal mortality is extremely rare. And syphilis is not as rare if you find the right places and then the effects of having syphilis are lifelong and horrible. And it came out like one program was like a thousand times more cost effective than the other one. Adding the syphilis test saved way, way, way more lives per dollar.
So they did the same cold calculations you hear in all these meetings and that is the project they funded. That's like an illustrative moment but that happens a lot actually. Like where you go in and you crunch the numbers and your strong intuitions end up being wrong. I like having a framework that can discipline my compassion.
Are you ever like, oh, I can't, I'm going to do this like syphilis HIV switch. It's like so high yielding. Like how do you not think about the mothers that you're not saving? No, you think about them.
I mean, I don't know. Oops. No, it's okay. I'm sorry.
This is going to be bad audio. You think about them. And so I think that the best that we can do is say we have this limited pot. We're going to use this the best way we possibly can.
The Give Well team goes into their next meeting with the camera and team hoping to sort out some of the data that's not making sense to them. You can really hear these two groups trying to speak each other's languages. Taryn from Give Well is talking to Susan Shepherd from Alima and the Cameroon Project. We've heard about this like two children per 10,000 more.
Right. Yeah. I knew this was going to become a key point for you guys. Is this the first time you guys are trying to do a project evaluation in a humanitarian context?
I was just thinking. A humanitarian context. I mean, there's armed conflict. There are refugees and displaced people.
These are places where doctors without borders work and before this year USAID. And Susan explains there's a whole decades long history of data crunching in regions like these. Measuring mortality and trying to get different ways of doing it. And it causes us endless discussions.
Like she says, the demographic and health surveys that everyone uses across the industry, those measured by live births per year. But humanitarian projects use number of deaths per 10,000 people per day. I have never found a way to join those two to find out. Yeah.
I have never. I just say, okay. In another meeting, Taryn from Give Well asks Susan a question that kind of goes to the heart of the difference and approach between the two groups. Why is service provision kind of targeted at places with conflict as opposed to just really high rates of mortality?
Yeah, it's kind of the humanitarian. Susan again gives a bit of a history lesson explaining that humanitarian aid, including this Cameroon project, is focused on reducing mortality, but not just that. I think it's the idea that people who are the victims of all of these conflicts, they're forced to flee or they're forced to move, trying to provide the services that allow them to maintain some level of dignity. Gotcha.
Okay. Thank you. On the last day of April, the Give Well team meets on its own again to go through their current back of the envelope calculations, which they call Botex. I would like to start with a mortality coverage.
One? So to give an overview, Botex, back on the population, relatively simple. Rosie has said all the information she's managed to collect into three different models, three ways of slicing the data to see how the Cameroon projects work impacts mortality in the populations they serve. One big thing they ask themselves, which I think of as very effective altruism, is do these Cameroon programs work better than just giving people money?
And Rosie tells Taryn that all three of her models are spitting out the same basic answer. They all say, yes, a fair amount better, which Taryn says, just pretty, the practice I think is it how different approaches are. Still, for Give Well Too Fund a project, they usually want it to beat cash transfers by even more than what Rosie's calculations show so far. But she is still doing her maths.
I've got like three Botex at the moment, but one is currently my like, problem child. Her problem child, because it's hard to calculate how effective the Cameroon program is when they're doing so many different kinds of interventions at once. From prenatal care to pediatric medicine to vaccines, sanitizing water, so it's hard to attribute an outcome to any one given intervention. For example, very often moms bring kids in to get those nutrient-dense packets of basically peanut butter paste.
And while they're in there, the staff can run other diagnostics. They can give kids vaccines, get them malaria treatment. They can train the moms to look for signs of malnutrition themselves with that too. And Rosie says there's actually another downstream effect.
They are also educating other medical staff. If all the doctors who are capable of training other doctors leave and don't pass on their knowledge, then what happens like three or four years down the line, left community health workers will be being trained, all this kind of, her, slightly difficult to quantify stuff. Yeah. I think that you mentioned I could see accruing to child health and child survival.
Rosie and Taryn wrapped that meeting on the last day of April, and well into May, the Give Well Rapid Response team is researching, crunching numbers, asking more questions. And to me, this seemed like it might be exhausting for the Cameroon team. But Adalynne told me later that he did not mind. They asked for lots of data in history, but I mean, when we have a donor asking so many questions and really wanting to understand the situation in the field, we can't poll because it means that they're interested, that they understand the urgency as well.
On May 21st, they get on another Zoom and Give Well asks another round of questions, including one that I cannot tell you how many times I heard Rosie ask. I was wondering, is there any more mortality data from Cameroon that we could check out? Yeah. Well, it's really difficult to have data on Cameroon, especially of data data.
Madalynne explains the most recent survey they have is old, and their internal data is informal. It's not a proper assessment, but they can send it. Okay. Well, thank you for your interest.
Maybe if we have one quick question from our side, maybe an idea of the deadlines that you have on your site. Do you think that you'll be able to give us an answer by the end of the month, or give us a list of indications of the potential budget, what would be possible on your site? Who would be interested to know more? Rosie responds with questions of her own, like, do you need an answer by a certain date?
Madalynne says, for the patients the more we wait, the worse it will be. Eventually, Madalynne asks her question in the language of Give Well. What is the probability that we will get this money? And Rosie answers.
Please don't poll me to this. If I had to put a number on it right now, I'd probably be like, 55%, 60%. 55% to 60% sure that this grant is going to come through. That kind of amount?
Like, we're still very much considering, but we're not certain yet. Okay. Yeah, it's also far as just to know on which grants we might rely on for next year and for the upcoming months as well. But yeah, okay.
So it is May 21st. It's been more than three months since the news that USAID was getting shut down. The Cameroon Project has already had to poll doctors and nurses from health centers across the far north, and the rainy season has just started, meaning mosquitoes and malaria. After the break, Will Give Well Give Them the Money?
So in Cameroon, Joelle and Madalynne are waiting to find out if they will get the money to continue doing their work. In the meantime, they were already having to make decisions they did not want to make. They cut all the mental health programs and educational programming, like nutrition and hygiene best practices and information about where to get the project's help for free. The health facilities were open less, Joelle says, and that has its own cost.
If people make the trek and the hospitals closed at that moment, they give up, even someone about to give birth. If they are the hospital's close, if you deliver directly to the bush. A mother will deliver her baby outside somewhere without any medical care. And they have learned she'll kind of give up on the hospital, on the health facilities altogether.
She won't try again. I asked Madalynne if she ever loses hope. No, we don't lose hope. Otherwise, we would just stop working.
We always have hope to find more support. It cannot accept that. Okay. No, the situation is so dire in the field that we cannot just lose hope.
But she says that is getting harder and harder, because while the USAID situation was acute and unexpected and devastating, it was the most extreme example of a larger trend. Countries all over the world are reducing how much money they allocate to international aid. So it's not just the US, it's also France, it's also Germany, it's also the UK, it's everyone. So it's really, it's just less and less everywhere.
There are lots of reasons why it's largely a worldwide move towards tightening budgets, austerity politics, and also spending more on defense. It's not the top priority anymore. Which makes the Cameroon Project one among so many more organizations looking for funding, competing for money from organizations like GiveWell. And through most of May, the GiveWell team continues to have two hang ups about choosing the Cameroon Project.
One, given their imperfect data, are they overestimating lives saved or improved? And two, how can they be sure of any of this data without independent on the ground confirmation? One of the researchers, Alice Redford, keeps pushing on that. Have you managed to speak to anyone that's not Alima but is in the area?
No, I've asked Alima. I feel very unsure about how to get this without Alima. Alice is like, we gotta figure this out. This piece of just taking so much on face value from them when we have at least some reservations about it, that probably is the sticking point for me.
So I can see if I can source a reliable contact. That'd be great. Finally, on May 30th, Alice speaks in French with the director at one of the hospitals, Alima's Cameroon Project staffs. This is the closest they can get right now to what Rosie calls round truthing, talking to someone on the ground in the place.
Of course, this is one person's opinion, you don't want to over update. But he was so much blunter than I was expecting. Like the word he used was, like, Alima pull out, it would be a catastrophe. It would be a catastrophe.
Because he told Alice, Alima's Cameroon Project is key to so much of what the hospital does. Right away, Alice hops on his own to update Taryn on what the hospital director told her about the impact of Alima's doctors and nurses on patients there. That's why Alima is pretty much the only driving force to bring anyone into the hospital. So even more of them would just not get any care at all about Alima.
And that's because without them, there's not really much to offer at the hospital that way. One, there's not much to offer at the hospital, two, another piece that I have not appreciated, the nutrition services that Alima offers is a major draw for people to go to the health facilities. And he was saying that you take that away, mothers won't come for anti-natal care. Alice tells Taryn she is still uncomfortable with how much uncertainty is embedded in their calculations.
But this conversation with hospital director finally made her believe some of the numbers she was skeptical about before. Hopefully we can close this. I feel like we learned a lot over the last couple of weeks, so that's pretty cool. Taryn later told me that she did have a moment where she was sort of like, oh crap, we just may not be able to fund this project.
It was like, we're probably not going to get good data. But then the flip side of that was that I think that's why this is probably pretty high impact. Alima has done so much work to gain access to these really difficult places. So it was like a mind shift.
So okay, maybe this time we just won't know everything, but we can use this to learn. And that learning would save more lives in the future. And listening to all of this over the past seven months, one lesson already seems clear, that saving the most lives is a lot harder when you don't have a local government taking care of the basics or international governments pitching in on the big picture stuff like stability and safety. Over the weekend, Taryn reviews all the information they've collected and on Tuesday, June 3rd, she clicks the guess button.
They approved the grant for $1.9 million for Alima's work in the far north of Cameroon, to fill in the entire hole left by USAID for one year. These two groups, one working with numbers, the other with their hands, they found a way to work together and Gival's grant allowed the Alima workers in Cameroon to restart what they had paused. They decided I'm really happy about it. We succeeded in proving that the intervention that we were proposing was cost-effective.
Joelle is happy to, but he also is thinking about next year. Alima will continue to push and look for other private actors to maintain those videos projects. So this is a relatively happy ending, but it is not the norm. Gival started with a list of 140 programs that had lost funding, and as of today, they have given money to 23 of those, $39 million so far to fill a hole of tens of billions that USAID has left.
Many, many more aid programs in countries everywhere are having to shut down or reduce services. And Madeline says that creates another problem. Information, exactly the kind donors like Gival need. As aid programs get shut down, information gets lost.
Then it means that new one will get information out of where it's happening. And then when we don't have information, then we don't think anything is happening. So the risk I would say is that if there's less aid, then it looks like there's less needs, which is not the case. All around the world, there is more need, and we're just not going to know.
Today's episode of Planet Money was produced by Sam Yellow Horse-Kessler. It was edited by Marianne McEwan, fact-checked by Vito Emmanuel, and engineered by Jimmy Kelei with help from Robert Rodriguez. Our executive producer is Alex Woehler. If you want more economics, you can sign up for our excellent weekly newsletter by local hero Greg Wuzalski, npr.org slash Planet Money newsletter.
I'm Mary Childs. This is NPR. Thanks for listening.