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There has been some buzz recently about the new malaria vaccine. And now Marginal Revolution has pushed a provocative take. 

We should treat this as an emergency and push for rapid rollout.

Is this true?

I'm not great at thinking clearly during the middle of the day, but I reckon we could kind of whip up a tweetstorm about this. So I am asking you, the more careful thinkers of EA, would this be good? Do we actually want decision makers to consider this.

Eg is the following true?

Hill is correct: the case for urgency is strong. More than a thousand children are dying daily and the Serum Institute already has 20 million doses on ice and is capable of producing 100 million doses a year. Why not treat this as an emergency?! Implicitly, however, people think that the case for urgency in Africa is weak because “what will another few months matter?” The benefits of vaccination in Africa are treated as small because they are measured relative to the total deaths that have already occurred. In contrast, vaccination for say COVID in the developed world (Town B) ended the emergency and restored normality thus saving a large percent of the deaths that might have occurred. But the percentages are irrelevant. This is a base rate fallacy, albeit the opposite of the one usually considered. Lives are lives, irrespective of the historical context.

Some things I could tweet:

  • Western Governments probably cannot solve the Israel-Palestine crisis, but if we worked together we could solve malaria. Let's not delay a couple of months.
  • Malaria is an emergency every day. 1000s die for every day we delay rapid rollout of the vaccine. This is a covid-level crisis. We rose to that occasion and we can here too

I'm not saying I'm gonna tweet these things, I don't know if they are true and I am too frazzled to check, but I could and I'd appreciate your opinion.

Why ask?

  • It is important not to say inaccurate things.
  • Message discipline matters. If we decided this was true and all talked about it there is a small chance we could meme it into the discourse (1-5)%
  • When there are opportunities to align on stuff like this it's good to take them. Tabarrok is going out on a limb. I think he's probably right. Let's back him up
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In the spirit of quick answers, yes

R21 is good, the case for going faster is ethically strong and is pretty well articulated already, making this a relatively easy lift. Concerns around relative cost effectiveness vs other malaria control measures (e.g. bednets, SMC) are reasonable questions to raise but largely irrelevant for this given the proposal is to accelerate something that will happen anyway, the funding for delivering a malaria vaccine is largely secured already (via Gavi, Global Fund, national governments) and is unlikely to meaningfully funge more cost-effective alternatives. R21 is much cheaper than RTS,S, and almost certainly more effective.

Thanks for bringing this to our attention Nathan. I completely agree, and am a little sheepish that I did not pick up on this obvious moral problem myself sooner. The reality that malaria vaccines which work so well have been around for so long now, has almost numbed me to the fact that we don't have them yet.

To confirm this is probably possible, in many African countries like Uganda where I manage health centers, there are few practical problems rolling out vaccines like this. Government and private sector healthcare providers have the cold chain, community health workers and willing population ready to get started any time. This ability has been proven with many other successful mass vaccination campaigns which have been rolled out almost at the drop of a hat, like measles last year. 

I would say that mass vaccination campaigns like thisare probably one of the very few things that Uganda does well on a national level.

If 10 million doses arrived in Uganda tomorrow, with moderate confidence I think thousands more lives would be saved compared to if it dropped in 6 months. 

Another guess with lower confidence, is that the RTS-S vaccine is already in the process of being rolled out slowly, so there will be concerns and politics about accelerating another vaccine (that looks far better) over the top of it. As much as the WHO is talking about both of these vaccines being rolled out together over the next few years, I don't think it will be long before the R21 vaccine mostly takes over due to the far greater production capacity and potentially slightly better efficacy.

Another problem might be that its not just about the vaccine availability, but the  large additional costs of the rollout as well. These malaria vaccination campaigns will be almost completely donor funded - its not just about getting the doses to the countries, millions of dollars  also has to be mobilised to make it happen in every country. Countries don't pay for these rollouts themselves, which I think needs to change but that's a whole nother discussion.. Vaccinators are hired, vehicles are fueled, important people are paid to sit at meeting tables. Mobilising this money quickly might be a barrier - which is why GiveWell recently provided 5 million dollars to an NGO to solve this exact problem for an RTS-S rollout, and that was only for a few hundred thousand doses. Multiply that by 10 and you might find that the money isn't sitting around ready right now.

As ChrisSmith said I don't think cost-effectiveness compared with nets or SMC is an issue, because this is basically already paid for and happening anyway.

If anyone's interested, 1Day's hosting a brainstorming session this Friday at noon eastern to share information and identify possible tactics for accelerating the R21 rollout. Message me or reply here if you're interested in joining or want to be kept updated.

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I wonder if a Hollywood fundraiser for this could be interesting to try (some contacts to try would be Mike Schur, Damon Lindelof, and Mr Beast). If that were attractive, would be good to tie it to a GiveWell estimate if possible.

I think it's more about getting a sense of urgency than money.

But then what’s the path to creating a sense of urgency?

I can kind of picture a celebrity fundraiser drawing attention and the money purchasing speed. But I don’t have a great vision of what an advocacy campaign that changes the distribution timeline might look like. I don’t understand the decision-making structure we’d be trying to influence very well though so very open to alternatives.

Relevant news is the recent explosion of the Anopheles stephensi species of mosquito. It infects during the day, so bednets don't help. It's resistant to all insecticides. And unlike usual, it thrives in cities and in the dry season. Here's a recent article:

An Invasive Mosquito Threatens Catastrophe in Africa

A malaria-carrying species that thrives in urban areas and resists all insecticides is causing outbreaks in places that have rarely faced the disease.

[...] It is now breeding in locations across the center of the continent, and entomologists say further spread is inevitable.

Africa has expertise and strategies to fight malaria as a rural disease but now faces the threat of urban outbreaks, putting vastly more people at risk and threatening to wipe away recent progress against malaria, which still kills 620,000 people each year, mostly in Africa. Although some mosquito experts say it is too soon to be certain of the magnitude of the threat, the potential for outbreaks in cities, they fear, may set up a competition between urban and rural areas for scarce resources to fight the disease.

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