How not to give credit for malaria reduction


Malaria is both preventable and treatable, at astonishingly low cost. That’s why it’s a global tragedy to see hundreds of thousands of people dying from this disease every year.

Still, there’s good news here: The war against malaria is being fought successfully, with the help of billions of dollars from around the world, and malaria deaths are coming down.

Some of the money comes from individuals giving to places like the Against Malaria Foundation, which has raised some $129 million over the past 15 years, with substantially all of that money going to buy anti-malarial bed nets. But the overwhelming majority of the money is institutional, coming from places like the Gates Foundation, the World Health Organization, and of course the governments of the most affected countries.

At the very heart of the global institutional support for the fight against malaria, one can find the President’s Malaria Initiative, or PMI. This US organization, created by George W Bush, started by spending $30 million in 2006 and grew fast: by 2012 it was spending more than $600 million per year.

As with all such projects, coordination is key. The Roll Back Malaria Partnership and the Alliance for Malaria Prevention are the key bodies making sure that the thousands of different organizations taking part in this fight are working effectively with each other, rather than being duplicative in some areas while unjustly neglecting others. The US government component is a great example of America working extremely closely with the rest of the international community towards a common goal.

This point can’t be stressed enough, and it’s something which is understood at a very deep level both at USAID and at places like the Gates Foundation. When Bill and Melinda Gates wrote their annual letter this year, for instance, they correctly concentrated on global outcomes, rather than trying to disaggregate those outcomes so that they could take sole credit for some small part of them.

It’s entirely proper, then, that in its annual reports to Congress (the latest one is here), PMI concentrates on the official WHO estimate of 6.8 million lives saved between 2001 and 2015. That couldn’t have happened without PMI, and it’s a shining achievement for US soft power. It’s true that PMI doesn’t operate in all the countries affected by malaria, but if the system is working well, then that should be fine: it doesn’t need to. If the US works in one country and Norway, say, works in another, then everything should, in an ideal world, even out.

But now, here comes the NYT. “US Malaria Donations Saved Almost 2 Million African Children,” is the headline, about a new study which attempts to isolate and quantify the effects of PMI alone.

According to the NYT, the results of the study “debunk one of the persistent myths of foreign aid: that it has no effect because more children survive each year anyway as economies improve.”

Except if you wanted to debunk that myth, you’d surely look at the war against malaria more broadly, and make the pretty slam-dunk case that total foreign aid targeting the fight against malaria is strongly correlated, both within countries and internationally, with a reduction in its incidence.

This study didn’t do that. Instead, it looked at the difference in malaria reduction between countries where PMI is active, and countries where it isn’t. It concluded that “after adjusting for baseline differences between countries, overall time trends, other funding sources, and individual characteristics, PMI was associated with 16% annual risk reduction in child mortality.”

(The study did not, incidentally, ever try to turn that 16% annual risk reduction into total lives saved: the 1.7 million number came from one of the authors of the paper, not from the paper itself.)

I do believe and accept that the fight against malaria is more advanced in the 19 countries where PMI is active than it is in other African countries where PMI doesn’t (yet) operate. But insofar as that’s true, it’s a failure of the global fight against malaria, and a failure of international coordination. It seems weird to hold it up as some kind of glowing success.

It’s very natural to want to take sole credit for great achievements. And charities like the Against Malaria Foundation are based on that idea: if you give them $5, they’ll buy a bed net, and lives can directly be saved thanks to your donation. But the truth, at the individual-donation level and even at the PMI level, is inevitably more complicated. These kind of projects involve immense amounts of international teamwork, and it’s invidious to try to single out individual contributions and then quantify their marginal effects.

To take an obvious example: If the Against Malaria Foundation wasn’t operating in Kenya, would none of the people it has given bed nets to have bed nets today? Of course not: everybody realizes how important it is to give those people bed nets, and if one organization didn’t do it, then another one probably would.

That doesn’t mean there’s no point in giving money to the Against Malaria Foundation. It does a magnificent job! And by buying bed nets in Kenya, it frees up other organizations’ resources to fight the disease in other parts of Africa and the world. But ultimately, this is a global project, fought with global resources, which has already cost billions of dollars and which will cost billions more before the day finally comes when malaria has been truly eradicated.

It’s great to be a part of that project, even if you’re only donating a few dollars. But ultimately the amounts involved are so large that the vast majority of the money is going to have to come from governments. And even the US is but one partner in the global scheme.

Let’s have fewer attempts, then, to parcel out quantifiable disaggregated credit for the achievements already made, and more attempts to accelerate one of the most successful public-health projects of this century.

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