I think we are getting closer to the core of your question here: the relationship between cases of malaria (or severe malaria more specifically) and deaths. I think that it would indeed be good to know more about the circumstances under which children die from malaria, and how this is affected by various kinds of medical care.
The question might partially touch upon SMC. Besides preventing malaria cases, it could also have an effect on severity (I’m thinking of Covid vaccines as an analogy). That said, the case for SMC (as I understand it) is that it’s an excellent way to prevent malaria infections. This is what the RCTs measure, and this is where its value comes from.
To answer the question, I believe it would be more helpful to do research into malaria as an illness, rather than doing an SMC trial replication. I continue to think that the evidence base for SMC is good enough. You have doubts since “most published research findings are false”, but “most published research findings” might be the wrong reference class here:
It includes observational studies, surveys, and other less reliable methods; here, we have RCTs.
It includes all published studies, also those with small samples and effect sizes. Here, we have >7 trials, >12k participants, and the effect (SMC’s reduction of malaria episodes) is >6 standard deviations away from zero.
It includes studies with effects that are multiple causal steps away from the intervention (e.g., deworming improves income) and have many confounding factors. Here, we are measuring the effect of a malaria medication on malaria, with clearly-understood underlying mechanisms.
You also ask about the settings in which SMC is rolled out. There is no specific answer here, since SMC is often rolled out for entire countries or regions, aiming to fully cover all eligible children. More than 30 million children received SMC last year. In their cost-effectiveness analysis, GiveWell looks at interventions by country and takes a number of relevant factors into account, such as the “mortality rate from malaria for 3-59 month olds”.
In general, malaria fatality (deaths per case) is trending downwards a bit, due to factors such as better access to medical care, better diagnosis, better education of parents, and certainly many others. It could make sense to make this explicit when doing a cost-effectiveness analysis.
I’d expect GiveWell to be mindful about these things and to have thought of the most-relevant factors. I don’t think additional RCTs would lead to large changes here.
Regarding the post-script about AMF: We are fortunate to have a board of trustees and leaders that think a lot about high-level questions and trends, both those closer to AMF’s work (e.g., resistance to insecticides used in nets) and those more peripheral (e.g., the impact of new vaccines). There is also good and regular communication between GiveWell and AMF. As for myself, the day-to-day preoccupations are often much more mundane ;-)
Thanks as always for your careful and helpful read! I was just telling someone yesterday that this exchange is a positive reflection on the EA community and ethos — as a comparison point, it’s been way more constructive and collaborative than any of my experiences with academic peer review.
It sounds like I haven’t changed your mind on the core subject and that’s totally understandable. I speculate that this is something of a (professional) culture difference — the academics I discussed this essay with all started nodding along with the general idea the moment I mentioned “uncertainty about external validity” 😃
And thanks for the insight into AMF, y’all do great work.
Thanks for the thoughts!
I think we are getting closer to the core of your question here: the relationship between cases of malaria (or severe malaria more specifically) and deaths. I think that it would indeed be good to know more about the circumstances under which children die from malaria, and how this is affected by various kinds of medical care.
The question might partially touch upon SMC. Besides preventing malaria cases, it could also have an effect on severity (I’m thinking of Covid vaccines as an analogy). That said, the case for SMC (as I understand it) is that it’s an excellent way to prevent malaria infections. This is what the RCTs measure, and this is where its value comes from.
To answer the question, I believe it would be more helpful to do research into malaria as an illness, rather than doing an SMC trial replication. I continue to think that the evidence base for SMC is good enough. You have doubts since “most published research findings are false”, but “most published research findings” might be the wrong reference class here:
It includes observational studies, surveys, and other less reliable methods; here, we have RCTs.
It includes all published studies, also those with small samples and effect sizes. Here, we have >7 trials, >12k participants, and the effect (SMC’s reduction of malaria episodes) is >6 standard deviations away from zero.
It includes studies with effects that are multiple causal steps away from the intervention (e.g., deworming improves income) and have many confounding factors. Here, we are measuring the effect of a malaria medication on malaria, with clearly-understood underlying mechanisms.
You also ask about the settings in which SMC is rolled out. There is no specific answer here, since SMC is often rolled out for entire countries or regions, aiming to fully cover all eligible children. More than 30 million children received SMC last year. In their cost-effectiveness analysis, GiveWell looks at interventions by country and takes a number of relevant factors into account, such as the “mortality rate from malaria for 3-59 month olds”.
In general, malaria fatality (deaths per case) is trending downwards a bit, due to factors such as better access to medical care, better diagnosis, better education of parents, and certainly many others. It could make sense to make this explicit when doing a cost-effectiveness analysis.
I’d expect GiveWell to be mindful about these things and to have thought of the most-relevant factors. I don’t think additional RCTs would lead to large changes here.
Regarding the post-script about AMF: We are fortunate to have a board of trustees and leaders that think a lot about high-level questions and trends, both those closer to AMF’s work (e.g., resistance to insecticides used in nets) and those more peripheral (e.g., the impact of new vaccines). There is also good and regular communication between GiveWell and AMF. As for myself, the day-to-day preoccupations are often much more mundane ;-)
Thanks as always for your careful and helpful read! I was just telling someone yesterday that this exchange is a positive reflection on the EA community and ethos — as a comparison point, it’s been way more constructive and collaborative than any of my experiences with academic peer review.
It sounds like I haven’t changed your mind on the core subject and that’s totally understandable. I speculate that this is something of a (professional) culture difference — the academics I discussed this essay with all started nodding along with the general idea the moment I mentioned “uncertainty about external validity” 😃
And thanks for the insight into AMF, y’all do great work.