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Hi all!

Gage Weston and I made a video on preventing malaria! We talk about the malaria vaccine that is in trials, gene drives, GiveWell, AMF and Malaria Consortium's SMC program.

Feel free to give us any feedback in the comments here or on YouTube.

If you liked the video, I would encourage you to share it with your friends (especially those who aren't in the effective altruist movement). You're also welcome to use it for any EA events you're hosting! In case you do, let us know how it went!

I would love to hear if this video was interesting for fellow aspiring effective altruists as well: Did you learn any new things? Has it changed/updated your mind on anything?

The links in the description to donate to AMF and Malaria Consortium will help us give an idea of whether or not people actually made any donations because of our video.

More on A Happier World in this earlier EA forum post.

Transcript

Sources are marked with an asterisk. Text might differ slightly in wording from the final video.

When we think of deadly animals, we usually think of creatures like sharks or lions. But these don’t even kill 1000 people per year.* And there are animals who kill plenty more.

Some people may say: “Humans kill the most humans!”. They’re close.

The deadliest animal is the mosquito. Specifically, the female mosquito. Mosquitoes kill over a million people. every. single. year. They’re deadlier than war*, plane crashes*, and terrorist attacks*, and all of these combined.

When one of these bugs sucks your blood, it acquires whatever transmissible diseases you had. Then, when it goes on to bite another person, it spits disease-carrying saliva in that person’s bloodstream.

This is how diseases like malaria, zika, yellow fever, and west nile virus spread. Malaria is the leading cause of death by mosquitoes, killing more than 400 thousand people every year, which is why we’ll be focusing on it in this video.

The good news is, if you’re watching this, you can have a big impact to help fight this awful disease.

Malaria isn’t only widespread and deadly, but it also causes a lot of suffering for those who get it.

“I’ve had malaria… 

I had a fever, headache. 

My body was shivering, chills, cold.

I was so scared I thought I was going to die.”

Nausea and vomiting also often occur. 

These symptoms last for 1-2 weeks on average, during which time you are bed-ridden and unable to complete virtually any task.***

Children younger than 5 years old comprise over half of the deaths from malaria, making it one of the world’s leading causes of child mortality.* It kills over 250 thousand children every year, which means a child dies from malaria every two minutes.*

In addition to its enormous death toll, over 200 million people fell ill with the disease last year, leading to massive economic losses. Each year malaria is estimated to cost Africa roughly $12 billion in lost GDP, which is more than the GDP of Madagascar.***

Malaria used to be prevalent across the world, even in the US and Europe. Thanks to insecticides, changes in land use and economic development, most countries eradicated malaria.* 

Yet, some regions have far more malarial mosquitoes, more humid and rainy climates, and less access to insecticides and well-sealed housing. 

These conditions are optimal for malaria to spread, which is why nowadays nearly 9 out of 10 cases take place in sub-saharan Africa.* 

Thankfully, malaria deaths are declining, both according to the World Health Organisation and the Institute of Health Metrics and Evaluation. This is largely due to the increased usage of mosquito nets, anti-malaria medicine and insecticides.**

So why don’t we have a vaccine for malaria? After all, it took less than a year to get COVID vaccines.

According to the CDC, “The development of a malaria vaccine has faced several obstacles: the lack of a traditional market, few developers, and the technical complexity of developing any vaccine against a parasite,” as opposed to a virus like the coronavirus or a bacterium like the one that causes Cholera.*

Some malaria vaccines have undergone clinical trials in the past but were not very effective. But a new vaccine is in trials that has an efficacy of 77%, meaning that a vaccinated person is 77 percent less likely to get malaria than an unvaccinated person. This new vaccine could cut malaria deaths dramatically.*

Another potentially promising solution is gene drives. For a few years now, we have been able to genetically engineer mosquitoes to be immune to malaria. We can then spread these mosquitoes into affected areas. 

Normally when you genetically engineer an animal and put it in the wild, only half of the offspring will get the altered gene. So it won’t really spread through all of the population. 

But using gene drives it can, as nearly 100% of the offspring will carry the altered gene. This way after a couple of generations, entire mosquito populations will be immune, eradicating the disease in that area. 

Some worry genetic engineering could have disastrous ecological consequences, while others think the risk is insignificant. Right now, the idea is still being researched.****

Vaccines and gene drives look really promising and will hopefully be widely used soon. But at the moment, more than a thousand people still die from malaria every day.

So what can we as individuals do to help now? Are there effective things we can do?

It turns out malaria is among the most cost-effective diseases to fight. The non-profit GiveWell publishes a small list of highly impactful charities every year. Out of this list, two giving opportunities focus on malaria prevention: The Against Malaria Foundation (or AMF) and Malaria Consortium’s Seasonal Malaria Chemoprevention program. These charities are also being recommended by other evaluators such as The Life You Can Save and Giving What We Can, though these use much of GiveWell’s research.

“GiveWell’s goal is to direct funding to save and improve the most lives and the way that we do that is by conducting intense research into giving opportunities: identifying the ones that best fit our criteria and publishing the full details of our analysis so that anyone who comes to our website can see what we recommend and why.”

So what do these two recommended charities do and what makes their programs stand out? Are there any good reasons not to donate to them?

An estimated 5 dollars donated to the Against Malaria Foundation buys and distributes an insecticide treated bed net for people in developing countries.* AMF has been a GiveWell recommended charity every year since 2009 except for 2013.*** Over 90% of contributions are used to directly buy and distribute nets. These nets surround the bed of 1 to 2 people for 2 to 3 years*, preventing mosquitoes from biting them while they sleep. Studies have shown that bed nets are very effective, reducing malaria cases by 45% on average.**

AMF works with local communities and governments to distribute the bed nets.*

“So nine months after the Against Malaria Foundation supports a net distribution in a particular location they go back and they check to see how many nets are hung. So they visit a proportion of the households and they look to see: are the nets still in use, are they in good condition?* And based on that information we feel reasonably confident that the majority of nets are in use after these distributions and that they’re doing their job of preventing malaria.”

Many people are worried the insecticides aren’t that effective anymore because mosquitoes are becoming slightly resistant against them. GiveWell takes these and many other factors into account, yet they believe AMF remains highly cost-effective.*   

AMF also funded large-scale research with a new type of insecticide treated net, the PBO net, which inhibits the enzymes in mosquitoes that enable insecticide resistance. Preliminary data suggest that these nets may be even more effective at preventing malaria in areas where mosquitoes have developed insecticide resistance.***

Now let’s look at the Malaria Consortium, recommended since 2016.* Their Seasonal Malaria Chemoprevention, or SMC, program administers antimalarial medicines to children under 5 during the rainy season, when malaria transmission is at its peak. 

The medicine reduces malaria cases by approximately 75% for a month* and is given 4 months in a row. It costs about $7 per child for the full treatment each year. 

“During the administration stage of SMC medicine we go door-to-door.

Once we explain SMC, they know that it is a treatment for malaria and no family refuses it.

Before SMC, malaria affected a lot of our children.

Every season, almost all the children were afflicted with malaria.

With SMC, there are fewer children getting malaria.”

Communities notice this extreme decrease in malaria cases.

“I have had 8 children, two have died due to malaria and the other ones have had malaria before.

I am happy because the previous years they have not been given the SMC drugs but I like this one now, as you can see my son is not sick.”

Since these medicines are given to children under 5, it’s possible they will be less immune to malaria when they grow up. And only just over half of the targeted children receive the medication for the full 4 months.* 

The chemoprevention may sometimes have rare side effects too, and like with bed nets, the malarial parasites may be developing a resistance to these drugs.* GiveWell accounts for all these effects in its assessment, and overall, Malaria Consortium remains a very cost-effective charity

GiveWell estimates that AMF and Malaria Consortium’s SMC program will each save one life for about 3000 to 5000 dollars.

“That number might sound high if you’re used to seeing charity marketing claims that say “Oh, one dollar can save a life or 5 dollars can save a life”. But when we’re calculating the cost to save a life we look at all of the different costs to a program and all of the different factors that go into achieving that program successfully.”

“So in order for the cost to save a life of giving to the Against Malaria Foundation to be five dollars it would need to be true that 100% of people who don’t receive these nets would have otherwise died of malaria. And we know that’s not true.”

“We look at how long we expect a net to last and how many people we expect to sleep under a net.”

“And so we look at all of these different factors and many many many more. Our cost-effectiveness model has hundreds of inputs into it and ultimately comes out with that bottom line figure of around 3000 to 5000 dollars”

Even if the true cost per life saved is anywhere near $3000, the average American would still save a life every year if they donated just a few week’s wages to one of these charities.* 

Most people think saving lives is restricted to doctors or firefighters. But in fact, many of us can save lives by donating to effective charities like these. Even much smaller donations will still have a tremendous impact.

Many families are very grateful for these organizations’ efforts. They remove the almost constant fear from parents that their child might die. Communities celebrate the fact that they are more free from the disease and the poverty and pain it brings.

“When we heard talks about this project that has the goal of preventing malaria with children under 5, we were very happy. We hurried to pray for God so he could quickly bring the medicines to better protect our children that suffer every year of malaria. Today I’m not the only one that appreciates and thanks this project. All mothers are really happy to be able to benefit from this project. We thank God for this project.”

We’ve mentioned GiveWell a lot in this video, but that’s just because we believe it’s a good source of information. None of the organizations mentioned funded this video or asked us to make it. 

Right now, donating to the Malaria Consortium’s SMC program and the Against Malaria Foundation are one of the best things you can do to help the global poor. 

There’s a link to donate to both of these charities in the description. But perhaps you think other problems in the world are more pressing, so subscribe to learn about more ways we can move towards a happier world!

Hi! Jeroen here, the editor of this video and creator of this channel. If you liked the video and you think it’s important, share it with your friends! We’ve tried our best to explain this topic as accurately as possible. But since we’re human, there’s a good chance we’ve made mistakes. We welcome discussion on the issue raised and feedback on our presentation of it in the comments below. Thanks for watching!

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Sorted by Click to highlight new comments since: Today at 10:08 PM

Really great to see this and also the video channel more generally. Thanks for doing it! I just subscribed and look forward to watching and sharing your work.

Thank you!! :) 

What do you think the unintended consequences of these efforts to stop malaria could be? Nassim Taleb argues that the Gates Foundation is repeating the errors of Mao Zedong. It's also possible that donating malaria nets could cause local net manufacturers to go out of business, which could increase African dependence on foreign aid in the long run.

I've seen you link to the Mao video multiple times. Whenever you're linking to a long resource in a way that isn't self-explanatory, it really helps to share a summary of what you mean. 

Mao Zedong made (to be charitable) many errors, so that summary is much less informative than "cause local net manufacturers to go out of business". 

But since you've already seen the video, you could probably write a brief summary in much less time than it will take, say, five interested readers to watch enough of the video to see what you mean. And you'll be able to use that summary in other threads where you want to raise the same question, so it pays dividends.

The Gates Foundation is financing a campaign to genetically engineer the mosquito population in order to control malaria. He compares it to Mao Zedong's Four Pests Campaign, and how Mao's attempts to wipe out the sparrow population resulted in the Great Chinese Famine. Taleb argues that there may be similar unintended consequences, and something similar could happen with genetically modifying mosquitoes. He also talks about processes that are too fast for nature, and he draws a graph comparing the speed at which the ecosystem changes and the corresponding risk of harm, and how harm scales non-linearly in proportion to speed.

Thanks for sharing a summary! It doesn't seem like it applies to AMF's work, but it does describe other malaria control efforts. My impression is that the scientists who work on these things all day often pay more attention to risks and safety than other people realize, but I hope that the initial tests being run on this technology include appropriate follow-up to understand any unintended consequences.

On the question about AMF's impact on local manufacturers, here's Rob Mather, head of AMF, on exactly those concerns. The response (copied below) is ten years old, so the information may be out of date. 

It sounds like a difficult trade-off, and I'd be happy to see data on manufacturing conditions or other economic conditions in areas where AMF has worked, or on longer-term malaria rates that might reflect the impact of nets becoming less available locally. But I'll note that I haven't really seen a "go out of business" argument that reflects these points:

  • Lower malaria rates obviously increase productivity in a vacuum. I'd expect that losing a child, or having to care for a sick child, also has a negative impact on productivity. If one local manufacturer goes out of business, but thousands of additional cases of malaria are prevented, what's the net economic effect?
  • If a net manufacturer goes out of business, and AMF's nets only last a few years, how often can that manufacturer (or another one) get back into business? Consider that:
    • Any local business must have been a startup at some point, grown from nothing.
    • Someone who used to run such a business would have useful contacts and experience for starting it again — presumably, that's easier than starting up the first time!
    • If lots more people are now accustomed to sleeping under nets, local demand for nets may be higher post-AMF, another good sign for local manufacturers.
  • Given that AMF targets areas with very high numbers of people not sleeping under nets, how often are they actually competing with local manufacturers?
    • Rob's answer seems to imply that many areas can't actually support local manufacturers (I don't know how common this is).
    • How likely is it that someone who gets a free AMF net would otherwise have purchased a net locally? In other words, is AMF actually taking much business from local manufacturers?

The story where AMF has a major negative impact seems to indicate some combination of:

  • Lots of people taking free nets who would otherwise have bought them locally, to the extent that the local manufacturer goes out of business, and
  • Demand for nets not shooting back up once the AMF nets wear out and there are no more free net options, or
  • There being no one who has the ability + desire to start a net business, even though economic conditions prior to AMF allowed at least one such business to succeed and a huge number of people now need new nets
  • ...and finally, the health and productivity benefits of much higher net coverage for a few years not outweighing the losses that come from slightly lower net coverage for some amount of time after that.
    • I say "slightly lower" because, based on the coverage data above, it seems like few people in the areas AMF covers actually had nets in the first place — if an area jumps from 20% coverage to 80% coverage, then drops to 0% coverage, the 0% condition has to persist for quite some time to negate the 80% condition.

I can imagine this story happening, perhaps because people see AMF crush a local business and decide not to start a new one themselves. But I'd be somewhat surprised if this set of conditions were common, mostly because net coverage was so low originally.

Of course, you could argue that given this dynamic, it would be more effective to find a way to support and scale local manufacturers by donating or investing, or that AMF would do more total good by purchasing from local producers even when it isn't (as Rob says) "near-economic". That seems more likely to me than AMF actually being net-negative.

If you're interested in evaluating this, next steps might include:

  • Trying to convince GiveWell that it's worth investigating (they often respond to emails, and they have regular open threads on their blog).
  • Doing some research and presenting it on the Forum (it might be feasible to find data on long-term coverage and malaria rates in places AMF or other net distributors have worked, and there are other ways to build evidence for the pro-"out of business" case).
  • Asking Rob what he now thinks about this issue, since the below response is ten years old. Or you could talk to other charities that work in net distribution and may have done their own internal research or built their own models.

Anyway, Rob's response:

Hi Rob, 

Thanks very much for your comprehensive answer. My main concern is (as I have read) that floods of foreign-sourced charitable nets have actually had the unfortunate negative effect of putting African mosquito net manufacturers out of business. As you probably know, Africa's health, environmental, social, political and economic woes are largely tied together. This concern is mentioned in Dambisa Moyo's book entitled "Dead Aid". I'm not sure if you're familiar with this argument but I felt compelled to contact you regarding this issue, since it can potentially make a difference for the lives of Africans. I would suggest that as whole it might be of greater benefit to Africans to make sure they manufacture the nets they use - that way the charity $$$ would pay dividends of creating jobs which would help lift them out of the poverty which makes them so vulnerable. What do you think?

-Alan

Dear Alan-

Yes, I think this is an important issue.

It must be a better situation if long-lasting insecticide treated nets (LLINs) are manufactured in the countries in which they are needed. That would bring two advantages. First, reduced transport costs. Second, local employment. There is a manufacturing facility in Tanzania, a Sumitomo-AtoZ textiles joint venture, so 'local' production, and the employment this brings, is possible.

We are alive to this issue and, where we can, act in a way to support local enterprise. We have bought tens of thousands of nets that way when it has been 'near-economic' to do so.

However, there are challenges to the speed of local capacity development and the number of facilities that could be developed.

First, economies of scale mean only a small number of large factories are required to produce world demand. Micro-factories, located in each net-consuming country would not be economic. The number of countries that could benefit from locally located facilities therefore would be small. Some countries benefiting would be better than none of course.

Second, domestic markets are often not enough to sustain a production facility: nets are required to be exported. This leads to a problem, or inefficiency, in that shipping and transport from some African countries to others can be more difficult and more expensive than shipping from Asia to many African countries given established shipping routes. This raises overall prices for net buyers and reduces the number of nets that can bought for a given level of funds.

Further, technology transfer is an issue with challenges around training a workforce and guarding against technology intellectual property loss, the latter being a reasonable concern of the primary manufacturer. Ensuring raw material, spare parts supply and quality control are also issues to overcome.

The first and second issues are the structural ones and present the greatest challenge. The other issues can be overcome as the Tanzania joint venture has indicated. With major capital investment required and the need to consider the long term viability of a new facility, these developments take year/s not months.

Another method of developing local capacity has been via shipping large rolls of netting from an African based manufacturing facility to another African country where the cutting and stitching of nets then takes place. This has some shipping cost savings and provides local employment. We have bought nets in this way also.

Note, we are only talking about LLINs here as that is the only sensible net to distribute. If part of the background to your comments is concern over local insecticide treated nets (ITNs, but not long-lasting, so an entirely different net), or untreated net production being threatened by the import of LLINs, the higher issue is going to be the need to protect people with LLINs rather than ITNs or untreated nets. This is because LLINs are much more effective than these other nets at protecting people from malaria. For information on different types of nets, see: http://www.againstmalaria.com/FAQ_Bednets.aspx

Our approach, therefore, is with our priority being to buy the most nets possible for the funds available. We keep a close eye on local-sourcing options and where it is 'near-economic' to do so, we do. Economics will drive manufacturers to locally locate and we can do our bit by applying this 'near-economic' approach.

I hope this helps.

Kind regards

Rob