Christian Rassi and Diana Thomas: Effective altruism on the front line — transforming lives and international development

Malaria Consortium has received funds from effective altruism organizations since 2016 to help save lives in some of the world’s most vulnerable communities. Through their seasonal malaria chemoprevention program, they have reached millions of children in Africa’s Sahel region with life-saving treatments for malaria. In this talk, Malaria Consortium Programme Director Christian Rassi provides insights into the impact of the programme from the front line, and Media and Communications Manager Diana Thomas considers how partnering with effective altruism has transformed Malaria Consortium’s thinking.

Below is a transcript of their talk, which we’ve lightly edited for clarity. You can also watch it on YouTube and read it on effectivealtruism.org.

The Talk

Christian: This is an anopheles mosquito. Most of you have probably heard that it's one of the deadliest animals in the world because it transmits malaria. What you might not know is what it looks like when a mosquito kills.



This is what it looks like. This is a girl with what we call “severe malaria.” She will have a very high temperature. She'll be drifting in and out of consciousness. She'll have difficulties breathing, she'll experience bleeding, and she will be very, very unwell.

And yet, she's among the lucky ones, because her parents took her to a health facility where she can be treated — and where her chances of survival are about 80%. Many children never make it to a health facility, maybe because their parents live at a great distance from the nearest clinic. Among children who have severe malaria and are not treated, 90% will die.

In 2017, which is the most recent year for which we have global malaria data, there were over 200 million cases of malaria worldwide. The vast majority — over 90% — were in Africa. There were also about 435,000 deaths from malaria, and 60% (almost two-thirds) were among children under five years old, who are particularly vulnerable to malaria because their bodies haven't developed immunity to the disease yet. (This immunity protects older children and healthy adults.)



This is the kind of environment in which mosquitoes thrive [depicted in the slide]. They like it hot. They like it lush. They need pools of water to breed, so in tropical areas where it's hot year-round and where rainfall is common year-round, malaria transmission will be high year-round.



There are things we can do to prevent and control malaria to a certain extent. We can make sure that people have access to bednets to sleep under. We can spray houses with insecticides to repel the mosquitoes, and we can make sure that people who do get sick receive prompt diagnosis and treatment. And Malaria Consortium, the organization for which Diana [Thomas] and I work, is involved in all of those interventions in Africa and Asia.
Given the kind of environment mosquitoes like, you might think that there's not much work for us to do [in areas like the one shown in the slide above]. It's dry. Mosquitoes don't like dry heat. You'd be all right for most of the year. However, for about four months every year, this area actually looks like [the second photo in the slide].

[This second photo shows the same area during] the rainy season. Mosquitoes like the rainy season, so what we see in these areas is that malaria transmission is quite low for most of the year, and then during the rainy season it shoots up. That's a pattern we see across most of the Sahel zone — a band ranging from Mauritania and Guinea in the west to Chad and Sudan in the east.



In [the areas comprising this band], the World Health Organization recommends an additional intervention to prevent and control malaria. It's called “seasonal malaria chemoprevention,” or SMC. SMC involves the regular administration of antimalarials to entire populations during the period of greatest risk — regardless of whether they're infected with malaria at that point or not. In practice, that means giving a combination of two antimalarials to children under five years old, because they're the most vulnerable, in monthly intervals from July to October, which coincides with the rainy season.

What does that actually look like on the ground?



This is a “community distributor.” She's a volunteer from the community that she serves, and she will go door to door in her community and identify children under five. She’ll carry blister packs just like [the one in the photo below].



There are four tablets: one white tablet and three yellow tablets. (Remember earlier, when I told you we're using a combination of two different antimalarial drugs?) She will take the white tablet and one of the yellow tablets, disperse them in a little bit of water, and then give it to the child.



What if the child spits out the drug? You can probably imagine that happening, because no one likes to take medicine — especially children. And to be perfectly honest, the yellow tablet doesn't taste very nice. We actually worked with manufacturers in the past to sweeten the taste of the drug to give it an almost gummy-bear-like orange taste, but it's still not the most pleasant of experiences. So when a child spits out the drug, then the community distributor will provide a replacement dose. Then, over the next two days, the parents will give the remaining two yellow tablets to the child.

If the drugs are given correctly, then the concentration of antimalarials in that child's bloodstream will be high enough to kill mosquitoes for about one month. So in a month's time, the same community distributor will come back to the same household and give the same drugs to the same child, and will repeat that four times over the course of the rainy season. Actually, the last of four cycles of SMC are happening [at the time of this talk, in late October] across the Sahel zone.

So what's Malaria Consortium's role in this? We were involved in SMC from the very early days. It's actually a fairly new intervention. It was only recommended by the World Health Organization back in 2012. In 2013 and 2014 we were involved in some of the early pilots in Northern Nigeria, reaching about 500,000 children, which showed that the intervention can be implemented at scale. We then led the very rapid scale-up of SMC across the Sahel zone in a project called Access SMC. Together with our project partners, we reached about seven million children in seven countries across the Sahel.

Then, starting in 2018, we continued implementing SMC, mainly using philanthropic funding, in Burkina Faso, Chad, and Nigeria. And most of that philanthropic funding is coming our way because GiveWell gave us “top charity” status.

In 2019, we're reaching just about six million children in those three countries. The campaign is happening as I'm standing here [in the fourth quarter of 2019], with community distributors going door to door and treating every child under five that they can find.

We're planning to reach even more children over the coming years, because despite our best efforts and the efforts of other implementers and funders, there are still areas that could benefit from SMC and are not currently reached.

What does Malaria Consortium do [in practical terms]? We provide technical assistance to ministers of health and to malaria programs. For example, we develop guidelines. We develop job aids like [the one below], which shows how to disperse those tablets in a little bit of water.



We're involved in training community distributors. Reaching six million children requires a big [operational] machine. This year, for example, we were involved in training about 76,000 people across the three countries where we work.

Much of our work is about managing commodities. We procure these drugs from a manufacturer in China, and then we oversee the delivery of the drugs across the Indian Ocean and over much of the African continent to West Africa, to central medical stores in the countries where we work, to [the requisite] districts, and to health facilities. That's where the community distributors pick up the drugs to then distribute them to children. So there's a lot of work involved in managing that process. And because, as an organization, we believe in evidence-based interventions, we're also committed to contributing to the evidence base, so we collect and analyze routine monitoring and evaluation data. We also carry out research to try and improve the effectiveness and quality of the SMC program.

I'm still relatively new in this role. I started working on the SMC program back in May [2019]. And the thing that has really struck and moved me is how transformational the SMC program can be. It's transformed the way we prevent and control malaria, because it's added to the fairly limited number of interventions that we have at our disposal to tackle this disease. And it responds to a trend to tailor interventions to a specific context; it’s tailored to areas where malaria transmission is seasonal. But more importantly, I've seen firsthand how the program’s intervention can change people's lives in the areas where we work.

Don't just take my word for it. Here's what Chantal, a mother of five from Burkina Faso, said about SMC:

[Christian plays a video, in which a resident of Burkina Faso describes her experience with the SMC program. The text below is a translation.]

Dananduru Chantal: My name is Dananduru Chantal. I have five children, three of whom have been taking SMC for three years. Before SMC, my children were always sick. But since they have been taking SMC medicines they do not get sick anymore. Thanks to SMC, I manage to save some money, because the children do not get sick anymore. If SMC is stopped, the children will suffer.

Diana: So as Christian has explained, over the last five years, SMC and Malaria Consortium have gone through a transformation. I want to tell you a bit more about that journey.

It was a journey that really started by chance. In 2012, one of my colleagues came across GiveWell, and their focus on evidence and data analysis really resonated with us given that,, as Christian has explained, we are a technical organization in word and deed. So we started looking into their approach.

However, it became clear that GiveWell's perception of us was that we were focused only on providing technical assistance and carrying out operational research, but we needed to present more evidence of the work that we did on the ground. We spent nine months sharing reams of information with each other — project data analysis, results, and reports — and we had many long phone calls.



It's worth noting that traditionally, the Malaria Consortium has been funded by governments and institutions. For example, we work with USAID, UK Aid, The Global Fund, and The Gates Foundation. And with GiveWell we assumed that we were entering into the same sort of donor relationship. But we were mistaken. It was soon clear that it was quite different. The depth of analysis [we experienced] from a potential donor was completely new to us.

We found ourselves learning from this experience. For example, as we drilled down into the details of the cost-effective analysis, we found that interventions which focused on children under five years old are actually less cost-effective than those which include adults. So GiveWell and Malaria Consortium didn't always agree on everything, and there was much healthy debate.

But we found alignment, and I think it's fair to say that the journey we're now on together is both challenging and insightful. It's a journey that introduced us to the EA [effective altruism] community. So your adoption of GiveWell's recommendations, and therefore your support for our SMC work, has helped us to build the evidence that SMC works at scale. And we were able to scale up super fast and [maintain] that scale because of your support (although, as Christian said, there is still more that we need to do).

This rapid scale-up has also greatly multiplied the demand for the drugs used. And before we could expand SMC coverage, our chief executive had to travel in person to China to meet the world's only manufacturer of the drugs, and persuade them to increase production so that there would be enough. And thanks to what is now clear demand across the Sahel region, we expect new manufacturers to come online soon.



The program has been truly transformational on many levels. Over the six years since we first trialed SMC, we've reached six million children every year. And it's not only about saving lives. The positive economic effect on households from the prevention of malaria, as Chantal pointed out [in the video], and on national economies, is huge. In settings with seasonal malaria, the rainy season is a time when adults should be out in the fields planting and carrying out agricultural work. But if a mother is caring for a child with malaria and not spending time on the farm, the economic costs can be crippling, not only from loss of productivity and therefore income or earnings, but also because of the unplanned costs associated [with the child’s illness], such as for medicines and travel.

With our traditional funders moving to focus on service delivery rather than program co-design, we now find ourselves competing with consulting firms instead of other NGOs. This squeeze [is costly], and NGOs struggle for the bandwidth to be creative and innovative. Through the EA community, however, Malaria Consortium now has new options and possibilities for partnership, so you have catalyzed an organizational shift in the way we see our future as an organization. This is a really exciting outcome.

Christian and I have told you in some detail about the impact of the SMC program because we want you to be inspired by what you have helped us achieve with your support — and to see how far we've come. [We want to] continue our journey of change and impact, and we aspire to new creative relationships with the EA community so that you will see us as a partner for the future. We want to test out new ideas so that we can lead the next scaled intervention that will disrupt the status quo and save lives. We want to find solutions to stop people dying or being debilitated by diseases of poverty. These include malaria in pregnant women and infants, and pneumonia and diarrhea, which are bigger killers of children under five than malaria. [They also include] a fast-spreading (but neglected) tropical diseases: dengue.

We want to pioneer new tools and innovations, such as the new malaria vaccine in seasonal chemoprevention once it's ready for scale-up, or aids for the diagnosis and treatment of pneumonia in the community, or next-generation mosquito nets. We want to share information and best practices on the tools and ways of working that already exist but haven't been properly analyzed for most effective use. We don't have to keep reinventing the wheel. Sometimes we need to be consistent and change small things, such as asking the drug manufacturer to sweeten the pills so that children don't spit them out.

You already know that the EA community brings with it great transformational power. You've heard how the support from GiveWell and the EA community has allowed us to bring about huge and lasting change with SMC. So I ask you, how will the EA community use its power going forward, and what change will you help us bring about next? Thank you.



Moderator: I just wanted to say I found it really fascinating to hear about the process of your organization, working with GiveWell, and how that's changed your perspective and methodologies. That is of interest to a lot of people who are intimately familiar with GiveWell, which many of us use as sort of a guiding light.

I'm interested to hear whether you think there is one particular outcome of working closely with GiveWell that is maybe going to be the most influential one as your organization continues to move forward.

Diana: As I alluded to in my presentation, I think the biggest outcome has been how [Givewell’s support] has transformed the way we look at philanthropic giving. This has never been something we've received before. We don't have a public membership base. Traditionally, we’ve received all of our funding from governments and from institutions, so to have this opportunity to scale up something so important through philanthropic sources has made us completely rethink how we can do more of that in other ways, and with other relationships that [could lead to] partnerships.

Christian: Diana has presented the organizational perspective. From a [programmatic] point of view, I think one of the biggest differences is the level of flexibility this gives us. In traditional, institutionally funded programs, there'd be a lot more requirements for us to comply with certain donor regulations, whereas the philanthropic funding is enabling us to make decisions about where we want to go with this program geographically, but also in terms of the scale and the scope of the program. That's a lot easier with the kind of support and relationship we have with GiveWell, and the EA community in general, than it would be with traditional institutional funders.

Moderator: Fantastic. That's great to hear. Well, thank you both for this presentation and for being here this year. We really appreciate it.