What are your thoughts on the indirect (“flow-through”) effects of AMF? For example:
1. What do you think are the main positive and negative indirect impacts of the program, both long- and short-term? (E.g. increasing productivity and economic growth, increasing/decreasing total population, strengthening health systems, greenhouse gas emissions, consumption of factory-farmed meat...) Do you have any data on these? Are you planning to gather data on any of them?
2. What proportion of the long-term benefit from the program is due to short-term direct effects such as saving lives and averting unpleasant episodes of malaria, relative to indirect benefits?
3. Do you hold a particular view of population ethics (totalism, averagism, person-affecting, etc)?
4. What is your response to critics who claim we are ultimately “clueless” about the long-run magnitude or even sign of interventions like this? (I think the basic argument is that e.g. averting deaths has a wide range of knock-on effects, both good and bad, and that we may not be justified in being confident that ultimately – say, over the next few hundred years—the impact will be net positive. See e.g. here, here, and here for a better explanation)
1. What do you think are the main positive and negative indirect impacts of the program, both long- and short-term? (E.g. increasing productivity and economic growth, increasing/decreasing total population, strengthening health systems, greenhouse gas emissions, consumption of factory-farmed meat...) Do you have any data on these? Are you planning to gather data on any of them?
The main positive indirect impact of distributing nets is to improve the economy in the areas in which the nets are distributed. If people are sick, they cannot teach, they cannot drive, they cannot farm, they cannot function. They cannot be productive members of the community, and they may in addition draw on the heath service. It has been estimated that there is a 12:1 multiplier i.e. that for every $1m we spend effectively fighting malaria we improve the GDP (Gross Domestic Product, a measure of economic performance) by $12m. A pretty good return, aside the humanitarian benefits of such funding. Similar calculations and analysis can be found in: The economic burden of malaria – Gallup & Sachs, 2001, The American Journal of Tropical Medicine and Hygiene; The economic and social burden of malaria, Sachs & Malaney, Feb 2002, Nature.
The main negative indirect impact of distributing nets is millions of pieces of plastic being brought into the environment. A net is ultimately a piece of plastic. However, this is an OK price to pay for the impact the nets have on health outcomes. FYI, over the last few years we have moved to not providing individual packaging for nets but provide nets loose in bales (typically 40, 50 or 100 nets per bale) and that avoided 4.8 million pieces of plastic going to Guinea in the recent distribution, so we are making progress in this area.
2. What proportion of the long-term benefit from the program is due to short-term direct effects such as saving lives and averting unpleasant episodes of malaria, relative to indirect benefits?
I guess you’d have to say a high proportion of the long-term benefits from our work (people living healthy lives, being productive members of society and reducing the funds spent avoidably on health care) are due to the short-term direct effects (saving lives and avoiding illness) rather than any indirect benefits.
(I may not have fully understand the question as an indirect benefit of our work is improved economic performance but that is also a long-term benefit. If I have not understood correctly, please do feel free to explain further.)
3. Do you hold a particular view of population ethics (totalism, averagism, person-affecting, etc)?
My population ethics could best be summed up by saying that my four children go to sleep at night with the consequence of a mosquito bite being an annoying itch and not severe illness or worse and I wish to do all I can to make sure it is the same for children, and others, in currently malarious areas.
4. What is your response to critics who claim we are ultimately “clueless” about the long-run magnitude or even sign of interventions like this? (I think the basic argument is that e.g. averting deaths has a wide range of knock-on effects, both good and bad, and that we may not be justified in being confident that ultimately – say, over the next few hundred years—the impact will be net positive. See e.g. here, here, and here for a better explanation)
My response would be that the short and medium term consequences of distributing bednets – saving lives, avoiding illness and improving economic circumstances, are very persuasive for me and I could not imagine any unknown long term consequences could persuade me that the actions we take now are not worthwhile.
As you’ve said, in addition to averting deaths it looks like AMF considerably improves lives, e.g. by improving economic outcomes and reducing episodes of illness. Have you considered collecting data on subjective wellbeing in order to help quantify these improvements? Could that be integrated into your program without too much expense/difficulty?
On the other side of the coin, one possible negative impact of programs that increase wealth and/or population size is the suffering of animals farmed for food (since better-off people tend to eat more meat). Do you have any data on dietary changes resulting from bed net distribution (or similar programs)? Would it be feasible to collect that data in future?
Have you considered collecting data on subjective wellbeing in order to help quantify these improvements? Could that be integrated into your program without too much expense/difficulty?
We haven’t considered this, no, but an interesting thought and we’ll keep the suggestion in mind.
Do you have any data on dietary changes resulting from bed net distribution (or similar programs)? Would it be feasible to collect that data in future?
No, we don’t have any data here. I suppose it may be possible to collect those data but I wouldn’t see it as a priority for AMF. I am comfortable that our focus on helping prevent deaths and illness is a good one and I cannot currently conceive of negative impacts of this work that would change that focus.
To add on to the question of mid to long term effects, do you have a theory on what role bednets play in transitioning a country to malaria under control or even be malaria free? How long after a country reaches either of these two stages would bednets become less critical (if ever?)
How different is it to have malaria under control vs formally being malaria free? Is there a significantly higher risk of malaria becoming out of control in the former and the rates increasing again?
How does the role of bednets in getting countries to either stage factor into your effectiveness estimates on shortening those timelines?
To add on to the question of mid to long term effects, do you have a theory on what role bednets play in transitioning a country to malaria under control or even be malaria free? How long after a country reaches either of these two stages would bednets become less critical (if ever?)
There is significant evidence that bednets have played a ‘majority role’ in reducing the number of deaths and cases of illness due to malaria. An article from the Oct 2015 edition of Nature suggested (or stated) that 68% of the 60% reduction in malaria deaths (over the prior 15 year period) was due to bednets.
When malaria is under control bednets are largely unnecessary, aside areas where it may persist. When a country is malaria free, bednets are unnecessary, aside small pockets potentially and with the exception of considering border areas next to countries that are not malaria free.
How different is it to have malaria under control vs formally being malaria free? Is there a significantly higher risk of malaria becoming out of control in the former and the rates increasing again?
Malaria under control means it is still present but at a low level that can largely be dealt with via case-by-case management when they do appear rather than national, regional or district-level malaria control activities. Malaria free is defined as having no native cases of malaria in a country for a three year period, something achieved by Sri Lanka in 2017.
How does the role of bednets in getting countries to either stage factor into your effectiveness estimates on shortening those timelines?
We don’t develop effectiveness estimates per se, because all our work is in medium to high malaria-affected countries so we are working in the ‘helping to bring under control’ category. Please do clarify further if I have not understood the question.
What are your thoughts on the indirect (“flow-through”) effects of AMF? For example:
1. What do you think are the main positive and negative indirect impacts of the program, both long- and short-term? (E.g. increasing productivity and economic growth, increasing/decreasing total population, strengthening health systems, greenhouse gas emissions, consumption of factory-farmed meat...) Do you have any data on these? Are you planning to gather data on any of them?
2. What proportion of the long-term benefit from the program is due to short-term direct effects such as saving lives and averting unpleasant episodes of malaria, relative to indirect benefits?
3. Do you hold a particular view of population ethics (totalism, averagism, person-affecting, etc)?
4. What is your response to critics who claim we are ultimately “clueless” about the long-run magnitude or even sign of interventions like this? (I think the basic argument is that e.g. averting deaths has a wide range of knock-on effects, both good and bad, and that we may not be justified in being confident that ultimately – say, over the next few hundred years—the impact will be net positive. See e.g. here, here, and here for a better explanation)
1. What do you think are the main positive and negative indirect impacts of the program, both long- and short-term? (E.g. increasing productivity and economic growth, increasing/decreasing total population, strengthening health systems, greenhouse gas emissions, consumption of factory-farmed meat...) Do you have any data on these? Are you planning to gather data on any of them?
The main positive indirect impact of distributing nets is to improve the economy in the areas in which the nets are distributed. If people are sick, they cannot teach, they cannot drive, they cannot farm, they cannot function. They cannot be productive members of the community, and they may in addition draw on the heath service. It has been estimated that there is a 12:1 multiplier i.e. that for every $1m we spend effectively fighting malaria we improve the GDP (Gross Domestic Product, a measure of economic performance) by $12m. A pretty good return, aside the humanitarian benefits of such funding. Similar calculations and analysis can be found in: The economic burden of malaria – Gallup & Sachs, 2001, The American Journal of Tropical Medicine and Hygiene; The economic and social burden of malaria, Sachs & Malaney, Feb 2002, Nature.
The main negative indirect impact of distributing nets is millions of pieces of plastic being brought into the environment. A net is ultimately a piece of plastic. However, this is an OK price to pay for the impact the nets have on health outcomes. FYI, over the last few years we have moved to not providing individual packaging for nets but provide nets loose in bales (typically 40, 50 or 100 nets per bale) and that avoided 4.8 million pieces of plastic going to Guinea in the recent distribution, so we are making progress in this area.
2. What proportion of the long-term benefit from the program is due to short-term direct effects such as saving lives and averting unpleasant episodes of malaria, relative to indirect benefits?
I guess you’d have to say a high proportion of the long-term benefits from our work (people living healthy lives, being productive members of society and reducing the funds spent avoidably on health care) are due to the short-term direct effects (saving lives and avoiding illness) rather than any indirect benefits.
(I may not have fully understand the question as an indirect benefit of our work is improved economic performance but that is also a long-term benefit. If I have not understood correctly, please do feel free to explain further.)
3. Do you hold a particular view of population ethics (totalism, averagism, person-affecting, etc)?
My population ethics could best be summed up by saying that my four children go to sleep at night with the consequence of a mosquito bite being an annoying itch and not severe illness or worse and I wish to do all I can to make sure it is the same for children, and others, in currently malarious areas.
4. What is your response to critics who claim we are ultimately “clueless” about the long-run magnitude or even sign of interventions like this? (I think the basic argument is that e.g. averting deaths has a wide range of knock-on effects, both good and bad, and that we may not be justified in being confident that ultimately – say, over the next few hundred years—the impact will be net positive. See e.g. here, here, and here for a better explanation)
My response would be that the short and medium term consequences of distributing bednets – saving lives, avoiding illness and improving economic circumstances, are very persuasive for me and I could not imagine any unknown long term consequences could persuade me that the actions we take now are not worthwhile.
Thanks Rob!
As you’ve said, in addition to averting deaths it looks like AMF considerably improves lives, e.g. by improving economic outcomes and reducing episodes of illness. Have you considered collecting data on subjective wellbeing in order to help quantify these improvements? Could that be integrated into your program without too much expense/difficulty?
On the other side of the coin, one possible negative impact of programs that increase wealth and/or population size is the suffering of animals farmed for food (since better-off people tend to eat more meat). Do you have any data on dietary changes resulting from bed net distribution (or similar programs)? Would it be feasible to collect that data in future?
Have you considered collecting data on subjective wellbeing in order to help quantify these improvements? Could that be integrated into your program without too much expense/difficulty?
We haven’t considered this, no, but an interesting thought and we’ll keep the suggestion in mind.
Do you have any data on dietary changes resulting from bed net distribution (or similar programs)? Would it be feasible to collect that data in future?
No, we don’t have any data here. I suppose it may be possible to collect those data but I wouldn’t see it as a priority for AMF. I am comfortable that our focus on helping prevent deaths and illness is a good one and I cannot currently conceive of negative impacts of this work that would change that focus.
To add on to the question of mid to long term effects, do you have a theory on what role bednets play in transitioning a country to malaria under control or even be malaria free? How long after a country reaches either of these two stages would bednets become less critical (if ever?)
How different is it to have malaria under control vs formally being malaria free? Is there a significantly higher risk of malaria becoming out of control in the former and the rates increasing again?
How does the role of bednets in getting countries to either stage factor into your effectiveness estimates on shortening those timelines?
To add on to the question of mid to long term effects, do you have a theory on what role bednets play in transitioning a country to malaria under control or even be malaria free? How long after a country reaches either of these two stages would bednets become less critical (if ever?)
There is significant evidence that bednets have played a ‘majority role’ in reducing the number of deaths and cases of illness due to malaria. An article from the Oct 2015 edition of Nature suggested (or stated) that 68% of the 60% reduction in malaria deaths (over the prior 15 year period) was due to bednets.
When malaria is under control bednets are largely unnecessary, aside areas where it may persist. When a country is malaria free, bednets are unnecessary, aside small pockets potentially and with the exception of considering border areas next to countries that are not malaria free.
How different is it to have malaria under control vs formally being malaria free? Is there a significantly higher risk of malaria becoming out of control in the former and the rates increasing again?
Malaria under control means it is still present but at a low level that can largely be dealt with via case-by-case management when they do appear rather than national, regional or district-level malaria control activities. Malaria free is defined as having no native cases of malaria in a country for a three year period, something achieved by Sri Lanka in 2017.
How does the role of bednets in getting countries to either stage factor into your effectiveness estimates on shortening those timelines?
We don’t develop effectiveness estimates per se, because all our work is in medium to high malaria-affected countries so we are working in the ‘helping to bring under control’ category. Please do clarify further if I have not understood the question.