I’ve now read everything on the GiveWell website about the Against Malaria Foundation, a top rated charity since 2011. This has helped me increase my understanding of the work they do and the challenges involved. This is the fourth in a series of posts summarising my outstanding questions from this reading.
It may be that I’ll find the answers to some of these questions by looking elsewhere, for example reading the AMF website or getting in touch with them directly. That means this is not the final word on my view of the Against Malaria Foundation. However, I’m capturing my progress at this stage so that I have a clear basis to build on for further work.
Concern #4: Distributing bednets may have some downsides, and overall we risk doing more harm than good.
Many discussions of aid cost-effectiveness focus exclusively on the cost per life saved. There is no allowance for the other benefits of distributing bednets, such as preventing non-fatal cases of malaria or other mosquito-transmitted diseases, and no allowance for the other costs due to distributing bednets, such as damage to the local economy and community independence. All of these impacts, good and bad, occur in the real world when we donate to AMF, so they should be considered even if they cannot be quantified.
We could make a reasonable estimate of the extra benefits, as non-fatal malaria cases and other diseases can be measured in the same way as fatal malaria cases and with a similar level of accuracy. GiveWell do this in their cost-effectiveness calculations, and then allow for the extra income people will earn by avoiding illness in childhood.
Quantifying the downsides is harder. We could estimate the number of people who would have been making anti-malaria nets locally if we didn’t provide such nets for free. In many countries nets were made and sold locally before international action changed expectations to be that such things should be provided for free. Those who worked making and selling bednets lost their jobs and it is unlikely anybody would start up a new business knowing the next free distribution is only a year or two away. On top of this are second-order impacts on connected industries, where reduced investment and a less-skilled population means clothing & textiles manufacturers are also affected by donations of bednets.
This matters because the countries receiving bednets are some of the poorest in the world, so anything that reduces income is a significant matter. Developing the economy of these countries will allow the people that live there to escape poverty and all of its harms, not just malaria. Economic development is not just about factories, it cuts across the whole of society. Political power, public institutions and the daily interactions between individuals and groups all combine to generate wealth. By trying to help in one specific area we are definitely disrupting this complex web. Whether that disruption is overall good or bad is a matter of debate.
Including these concerns in our assessment of donating bednets makes the range of outcomes even wider. Perhaps net donations are an even better deal than GiveWell allows for, where a few thousand dollars saves a life AND prevents 100 non-fatal malaria cases without any noticeable effect on incomes. Or perhaps net donations do more harm than good, and holding back economic development more than cancels out the benefit of fewer cases of malaria. Even if we did have the data and knew exactly what the impacts were, these things are hard to compare. How many jobs lost are a good trade-off for malaria lives saved? The answer probably varies from person to person, both in the country receiving the nets and among donors. But ignoring the question doesn’t make it go away.
What do people receiving donated bed nets want? A large number of these people have tough lives, with less wealth and more illness than we are used to. If they want to prioritise increasing their wealth, which in turn will naturally reduce illness, we would need to be very confident in our assessment of long lasting insecticidal nets to override that choice.
As a thought experiment, imagine if we gave recipients a choice between receiving a bed net or $5 (the typical cost of the bed net). How many do we think would choose the $5? Certainly a significant proportion would take the money, since bednet coverage was not universal before global aid programs kicked in. That may be because they do not understand the risks of malaria as well as we do, though again we’d need to be careful in making that claim considering they have day-to-day experience of life with malaria. It may be because there’s a coordination problem, where they believe bednets only work if everybody else buys them too, or because the people who make buying decisions are not the ones who would benefit from bednets. Or it may just be that there are people in sub-Saharan countries who have a full understanding of their own needs and can think of much better things to do with $5 than buy a bednet to reduce the risk of malaria.
There are some people who think free bed nets are a bad deal. One international development worker writes:
Here in West Africa, Malaria is seen very much like the flu…Imagine that you need jobs in your small town, but a foreign NGO comes in and claims you need more flu shots to eradicate the flu. In fact they put your local doctors out of business by bringing in their own trying to eradicate it. Your community did not want flu shots, you wanted jobs, but this foreign NGO came in and ignored your right to choose your own intervention and did more harm than good. That is exactly what AMF does in villages here every day.
One way to reduce the uncertainty here would be to buy bednets locally. The Against Malaria Foundation don’t do this as they see their duty as buying bednets at the cheapest price they can to save as many lives as possible. If they didn’t, the cost-per-life saved for this intervention would increase, perhaps beyond the threshold considered acceptable by GiveWell. And trying to solve many problems at the same time, rather than a targetted intervention with measurable outcomes, is a typical failing of aid programmes generally.
As a donor, I think there’s a huge difference between the following three scenarios
- “You’re probably doing some good, and at worst you’re doing no harm”
- “You’re probably doing a lot of good but at the cost of doing some harm”
- “You’re probably doing some good, but there’s a chance you’re making a bad situation worse”.
This point about unknown impacts is not restricted to malaria and bednets. There is a wider conversation about cluelessness and the interactions between aid and economic development. The majority of people quietly think we can’t really help those living in the world’s poorest countries. Those who think we can risk focussing on short term benefits which are clear and measurable and overlooking long term costs which are fuzzy and hard to measure. There is no clear feedback mechanism for donors who live far away and don’t see the consequences of their interventions, meaning there will always be the risk of doing harm when we try to help those most in need.