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Hauke Hillebrandt

Malaria may be the worst killer in history. But this map — using the latest data — shows a surprising, and encouraging result.

Bednets Have Prevented 450 Million Cases of Malaria

Malaria may be the worst killer in history. It still kills thousands of people — mostly children — every year.

 that in 2015 alone, 438,000 people died of malaria - 292,000 of whom were children under 5 in sub-Saharan Africa.

But this map shows a surprising, and encouraging result.

The animation shows the percentage of children in Africa who had malarial fevers over the last 15 years. Dark red means 100% -- that is, all children in the area -- had at least one episode of clinical malaria within a given year. Green means 50%, and blue means that no children had a malaria fever within a given year.

Here’s another map using data for people of all ages

 — you can see the same pattern. A massive decrease in malaria cases over the last 15 years.

These maps show a clear trend — in fact, rates of malaria have halved over the past 15 years

. But why has there been such a dramatic decrease in malaria?

The reduction in malaria has been caused — in large part — by people sleeping under bednets. Green means everyone is sleeping under bednets and is protected, yellow means half of all people are protected, and red means nobody is protected from malaria.

Long lasting insecticide-treated bednets are a powerful weapon against malaria

, not only because they’re a physical barrier between mosquitoes and sleeping children — the insecticide coating kills mosquitoes, so they don’t infect other members of the family (and the village) who don’t have mosquito nets.

The data used for these animations comes from a new paper published in 

 (widely regarded as the top science journal). We already had very strong evidence that bednets prevent children from dying of malaria (and related complications like anemia) based on a meta-analysis of 22 experimental trials

But this new paper uses a “spatiotemporal Bayesian geostatistical model of bednet coverage with 27,573 georeferenced population clusters and an optimised suite of temporally dynamic environmental and sociodemographic covariates”.

In other words, this paper tells us about the bigger picture, showing that bednets are incredibly effective, not just at the level of individual villages, but at the level of whole populations. Essentially, the case that we should be distributing bednets just got even stronger.

Women and children carrying insecticide-treaded mosquito nets distributed by the Against Malaria Foundation in Ntcheu, Malawi

The research suggests that anti-malarial interventions have prevented about 

Long-lasting insecticide treated bed nets

 stand out as being particularly effective — being responsible for around 68% of the malaria reduction. This means that 

bednets have prevented around 450 million cases of malaria

 over the last 15 years because of malaria interventions 

We’ve made great progress. But we’re only halfway there.

Notice that, even in 2015, there are red and yellow spots on the map. 45% of all people in Africa are still at risk of disease and death from malaria 

, because they are too poor to buy nets, 

and an additional 245 million nets are needed in the next 2 years.

Blood smear showing Plasmodium Falciparum, the parasite which causes malaria (commons.wikimedia.org)

Malaria is also an immense economic burden on health systems and people: since 2000, malaria treatment in sub-Saharan Africa has cost almost $300 million

. We can see the flip side of this in places in the United States, Brazil and Uganda — children born after malaria was eradicated or heavily controlled and so were not exposed to malaria during pregnancy, had substantially higher income later in life 

We urgently need to keep funding the distribution of bednets, because 

bednet distributions are one of the most cost-effective ways of preventing disease and death.

 Since 2000, one billion bednets have been distributed (costing around 5 dollars each), and have averted 450 million cases of malaria — this suggests that, on average, one episode of clinical malaria can be prevented for about $11 (malarial fevers can be very painful. One recent study suggests that in Kenya, bednet distributions between 2003 and 2008 have prevented a death of a child for about $1,011 on average

The charity evaluator Givewell estimates that the cost per child death averted through bed net distributions funded by the 

 (even though these estimates are uncertain, they're roughly comparable to the new malaria vaccine, which is not 100% effective and experts say should be used in combination with bednets

, and we at Giving What We Can, rank the Against Malaria Foundation as 

. This is not only because we think it is the most cost-effective charity one can donate to, but also because of Against Malaria Foundation’s outstanding transparency and accountability.

 you can see video footage from distributions, as well as detailed financial statements. They also check if the nets they distributed are still hung every 6 months in a random sample of 5% the households (two years after distribution, 81% of nets distributed were still being hung up and the most comprehensive study suggests that bednets are almost never used for things like fishing

preventing deaths will not lead to overpopulation

We can all help to make the maps above more blue and green. The Against Malaria Foundation needs a minimum of $13.4 million to fill their funding gap next year 

. And if you want to keep up the fight long-term, why not join us, and more than 1400 people — among them 

development economists, moral philosophers, students, nurses, entrepreneurs, scientists and teachers

 to give 10% of your income to the charities that you think are most effective (or just 1% for those who don’t work full time).

We’re winning some impressive battles against one of history’s biggest killers. As more people start donating to a cause that is rigorously evidence-based and extremely cost-effective, we can start to win the war.

Giving What We Can’s Recommendations for Giving Season 2015

With the 2015 Giving Season upon us, we’ve reviewed our top charity recommendations so that you can make an informed decision about where to give.

This year we have extensively reviewed our 

We continue to believe that both the Against Malaria Foundation and the Schistosomiasis Control Initiative are some of the most effective giving opportunities and continue to recommend giving to them this season.

, which are charities we are not as certain about as our top charities, but that might have an even higher impact. 

The Against Malaria Foundation, which funds and provides technical assistance with distributions of long-lasting insecticide treated bednets, remains a top charity.We have written an 

 on the effectiveness of AMF’s bednet distributions

The charity evaluator Givewell has also updated their 

 and ranks AMF as their #1 charity. In brief, AMF has funded 

, which have and will avert much suffering and death due to malaria.

. However, there is still a major funding gap 

 for insecticide treated nets - which means that in the long-term there is a funding gap for AMF.

In the the short term, there is also a funding gap for AMF. Givewell estimates that even after taking into account the Good Ventures grant of $22.5 Million and what Givewell donors will give until February 2015 (~$15 million), and what other donors (which includes Giving What We Can donors) are expected to give until February 2015 ($1.6 million), AMF still needs about $13.4 million dollars in order for there to be at least a 50% chance for AMF to not to be funding constrained in the next year

In sum, because there is a big funding gap, and AMF has a good track record of distributing bednets as well as being accountable and transparent, we highly recommend donating to AMF this winter.

The Schistosomiasis Control Initiative provides technical assistance to governments with deworming programmes. We have written an 

 on SCI this year and Givewell has also recently updated their 

SCI has helped implement large deworming programmes in 2015 and plans to scale up and assist with even bigger operations in 2016

. For instance, SCI reports that up to the end March 2015, SCI contributed to delivering about 47 million deworming treatments overall, and from 1st April 2015 to 31st March 2016 alone it plans to help deliver 36 million treatments

unmet need for deworming treatment globally

 and thus a long-term funding gap. In the short-term, Givewell estimates that SCI needs about $4.9 million dollars in order for there to be at least a 50% chance for SCI to not to be funding constrained in the next year.

In sum, SCI remains a top charity. We believe it is one of the most effective charities one can donate to.

Deworm the World Initiative as part of Evidence Action (DtWI)

The Deworm the World Initiative (DtWI), like SCI, provides technical assistance to governments with deworming programmes. We have written an 

 on DtWI this year and Givewell has also recently updated their 

DtWI has helped implement large deworming programmes in 2015 and plans to scale up to other countries and assist with even bigger operations in 2016. For instance, DtWI helped coordinate the first national deworming day in India this year, and 89.9 million children in 12 Indian states were targeted. Next year they will try to include all 36 Indian states and try to intensify their work in Kenya and India and potentially expand their work into Ethiopia, Vietnam, Pakistan

 DtWI will likely receive a grant of $10.8 million dollars from Good Ventures

 and thus a long-term funding gap. However, because of the Good Ventures grant, in the short-term, Givewell estimates that DtWI does not have a funding gap, defined as there being at least a 50% chance for DtWI to not to be funding constrained in the next year.

It is important to note that this calculation takes into account the $2.5 million that Giving What We Can and other non-Givewell influenced donors have donated to DtWI

. Currently, we estimate that Giving What We Can influenced donors will donate $300,000 to Deworm the World Initiative. Moreover, Givewell also estimates that there is a small 5% probability that DtWI might be able to spend an additional $8.2 million, if existing programmes move forward quickly.

Thus, we will keep up our current recommendation of DtWI for now, in order to not disrupt their existing activities or slow down their scale up. However, we might change our recommendation next year, in case we believe that donors following Giving What We Can’s recommendation of DtWI will donate too much for DtWI to productively absorb in the short-term.

In sum, DtWI remains a promising charity, and we believe it is one of the most effective charities one can donate to.

Project Healthy Children provides technical assistance governments with micronutrient fortification programmes (the fortification of staple foods such as oil and salt with vitamins and minerals). We have written an 

 this year and the charity evaluator Givewell is also 

PHC has worked on micronutrient fortification legislation in 2015 and they report that they have made good progress: for instance, a cooking oil supplier holding 60% of the market share in Burundi now fortifies their oil with Vitamin A. There is still large 

unmet need for micronutrient fortification globally

It is important to note that we cannot be as certain about PHC’s effectiveness, because the impact of technical assistance is hard to measure. We also do not know as much about PHC as about the other charities we recommend. However, 

 suggests that micronutrient fortification at (industrial) scales might potentially avert a lot of ill health, that micronutrient deficiency is a very tractable problem, and that the countries that PHC is active in (small countries with a population of less than 20 million) are potentially neglected by larger development agencies and other charities. Next year we will look in more detail into GAIN and IGN, two other charities in the micronutrient space.

In sum, PHC remains a promising charity and we believe it is one of the most effective charities one can donate to.

Concerns about fungibility of donations and Room for more funding

Because the Good Ventures foundation has made grants to AMF, SCI, and DtWI, some people have been concerned about fungibility, i.e. that small donors do not really have an impact with their donations, because a bigger donor might easily fill the funding gap of these charities anyway and will just strategically leave them open.

Givewell has written about their views on this 

. In brief, they will only fill 50% of the funding gap that is related to the scale up and leave the other half for other donors to fill. Givewell also reports that they will not recommend more grants to Good Ventures in the next year.

We do not believe that fungibility is a grave concern against giving to our charities currently. First, Good Ventures is trying to give money away in the most effective way, which is what we are trying to do too. That means that if we’re fungible with each other that effectively leaves the other with with more money to give to other effective charities - which is what we all want.

 giving opportunities in the future and we won’t ‘run out’ of very effective causes to give to. A lot of money is needed for health globally — just look at the differences in health expenditure between countries. In the United Kingdom, $3598 is spent per person per year on health

. In the Democratic Republic of Congo, one of the countries where AMF is active in, the health expenditure is only about $16 per person per year. This means that there will be a very big gap and inequality in terms of health and 

, with many opportunities for effective giving. In other words, global poverty and global health are very big problems, with immense funding gaps, that foundations and governments are struggling to fill.

Finally, in case you’re still concerned about fungibility with Good Ventures, there are two alternatives: first, you could give to Project Healthy Children, which is not currently on the Givewell recommended charities list (however, Givewell seems to be in the process of reviewing them). Alternatively, especially if you’re somewhat risk averse with your giving and are looking for your donation to have an impact with very high certainty, you could consider giving to 

, which, in the long-term, will have the biggest funding gap.

Concerns about deworming, malaria, and aid effectiveness

This year there have been some concerns that deworming is not really effective (

), that malaria nets are used for fishing, and that aid might not be effective in general.

Our response to the deworming controversy 

. In brief, not all deworming is the same. Even the authors of the Cochrane Review that ‘called into question the benefits of mass deworming’ agree that there should be mass deworming for schistosomiasis, which both of our charities are involved in (DtWI is now also trying to expand into schistosomiasis endemic countries).

More importantly, even the authors of the Cochrane review agree that children known to have worms should be dewormed. Since it’s cheaper to mass deworm and there are very few and only minor side effects, we believe that mass deworming is still a cost-effective intervention. Finally, we think that some of the evidence of the developmental effects (cognitive effects, schooling outcomes, and effects on labour productivity later in life) have not been taken into account by the Cochrane review, but are highly relevant.

The misuse of bednets has caused some controversy. 

 claimed that "countless [people in Africa] are not using their mosquito nets as global health experts have intended," preferring to use them as fishing nets. However 

comprehensive analysis of multiple studies

 has done the counting and shown that less than 1% of nets were repurposed for fishing. Most of those which were repurposed had already been too worn out to stop mosquitos.

Furthermore, AMF has excellent monitoring and evaluation of their programmes. Monitoring data from Malawi (among other countries) shows high levels of continued use. After two years, 81% of nets distributed were still being hung up, with 77% still in serviceable condition. 

We have written about this in more detail here

Finally, Angus Deaton, who has often been called an aid skeptic won the nobel prize in Economics this year. Does that mean that aid doesn’t work? Does that mean that the interventions that our charities perform don’t work or don’t make sense? We don’t believe this is the case. In the same way that music critics like some music, aid critics such as Angus Deaton actually view some aid very favourably.

“The Lack of Controversy over Well-Targeted Aid“

. The bottom line is that, even though there is disagreement between economists when it comes to aid, with some economists viewing aid very critically and others 

, even the most prominent aid critics are in favour of the well-targeted health interventions that our recommended charities are engaged in.

Zachary Leather

Do something incredible this New Year

A group of students has got together to take the Giving What We Can pledge this New Year's. If you would like to take the opportunity to join, or just to support the campaign and Giving What We Can, check out and share 

! You can become a Giving What We Can member 

. And please watch and share the amazing video our Cambridge chapter made about why you should take the pledge.

Almost everyone dreams of doing something good for the world. However, it is a sad fact that for us westerners, living in a dreamy bubble so far away away from the pain and suffering we wish to eliminate, it is incredibly difficult to motivate ourselves to act on our altruistic desires. Unless you happen to be fantastically conscientious and aware, you will need to remind yourself daily that the suffering we sometimes see through little screens does actually exist for some people in a terribly real sense.

I’m one of those who needs some sort of motivation to give altruistically, some sort of reminder that ensures that giving becomes normal rather than exceptional. 

 reminds us not only of what we believe is right, but to do what we believe is right.

 I hope that for me it can penetrate the money-grabbing distractions that surround us every day as part of the bubble that is western life.

This is what makes the pledge so perfect for me (and, I hope, for us all).** Giving is something that we should all be doing.** In fact, even though giving is considered exceptional (and optional) by the vast majority of our society, I think it is a moral obligation on the same level of paying tax.

The pledge tells us to forget the idea that not helping some of the most desperate people on the planet is a morally viable option, and forces us to see it as an obligation - exactly what it is for the (relatively) rich. And all of us in the western world are rich compared to most people in the world: 

someone earning the average UK salary (£26,500) is in the richest 3% of the world’s people, and could save a life every year by taking the pledge.

The other major principle upon which the pledge is founded is the idea that some charities are much better than others. Even if we give all the time, we give significant proportions of our income and we do so as a matter of course, it’s difficult to know that we’re actually making a difference. Since becoming acquainted with effective altruism, I have been more and more concerned about the effects of what I do – and in particular about the effects of my donations. There are too many charities out there, too many causes, to figure out for myself what the best way of donating is.

Giving What We Can provides the guidance I need to maximise the effect of my altruistic efforts, and encourages members to donate in a reflective way and taking into account the best available evidence. 

By giving to the very best charities, we can be sure that our donations are making a real difference. And making giving less stressful, less uncertain, is surely a huge step towards making it a normal part of life.

This may seem like too large a commitment for an 18-year-old who has had nothing more than a cashier job. But this is precisely the right time for me to take the Giving What We Can pledge. I can step into the work world knowing that 10% of what I earn is going to charity, as certainly as I know that some will be taken by the tax man. 

It’s another step to making giving a habitual and moral obligation.

When I really think that I may be, in this moment, making the decision to give (over my lifetime) an enormous amount to help people so desperately in need they can’t be sure of their next meal or of their health, I do not feel scared but hopeful. I know that I am taking a step that will help many people who were not lucky enough to be born in a country like the UK, and help correct the deep injustices that make some so much poorer than others. Taking the pledge is, I hope, about making altruism my new normal. It’s not about sacrifice. It is my declaration that I will do my bit, I will not let my selfishness get in the way. 

Blog

Bednets Have Prevented 450 Million Cases of Malaria

Giving What We Can’s Recommendations for Giving Season 2015

Do something incredible this New Year

What can the Reach Act do for Global Health?

Mental Health interventions may be more cost-effective than we think

Giving What We Can needs your support this Christmas

Quadruple your donation to SCI!

Happy #GivingTuesday!

Switching the story: how to change the narrative on development

Highlights from 2014 - 2015