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[This is the fourth post in a brief series explaining the current GiveWell top charities. You can get all the information in this post on GiveWell’s website, but my blog post is both shorter and less boring. In order to reward you for reading a whole blog post about a charity you already know about, I have included at the end the Most Interesting AMF Fact.]

The Against Malaria Foundation is one of the most iconic effective altruist charities. “Bednets”, to many people, are synonymous with “effective altruism.” With one year’s exception, AMF has consistently been a GiveWell top charity since 2009– not long after the term “effective altruism” was coined.

The Against Malaria Foundation provides long-lasting insecticide-treated bednets to partner organizations, which distribute the nets. Randomized controlled trials of insecticide-treated bednets find that insecticide-treated bednet distribution has the following benefits:

  • Reduces the rate of malaria and severe malaria episodes.
  • Reduces the rate of common complications of malaria, such as anemia, enlarged spleen, low birthweight, and placental malaria.
  • Improves the nutritional status of children.
  • Averts 5.53 deaths among children under 5 per 1000 children under 5 protected.
  • Prevents miscarriages.

The last bullet point is not included in GiveWell’s cost-effectiveness analysis. Preliminary results from a friend of mine suggest that it costs about a thousand dollars to prevent a fetal loss by donating to the Against Malaria Foundation.

it is believed that bednet distributions also reduce mortality among people over the age of five, mostly because it would be really weird if they didn’t. However, no RCTs have addressed this question.

It is believed based on studies of previous malaria eradication programs that reducing the prevalence of malaria in a country increases the income of people in that country, which means that people are less likely to go hungry, can get medical treatment when they’re sick, can buy televisions, and so on.

The studies were conducted of insecticide-treated bednet distribution programs, not of bednets specifically. Some people were in the treatment group of the study but didn’t put up bednets, and they were still counted as part of the statistics. That makes us think the research is more likely to apply to a program like AMF. However, it’s often much easier to have a really, really good bednet distribution program in a small study than it is to have a really, really good bednet distribution program that gives millions of people bednets. If fewer people use AMF’s bednets than used the bednets in the study, the effects will be smaller.

The bednet usage rates that AMF finds in its surveys are comparable to the bednet usage rates in the small-scale studies, and AMF similarly works in places with high rates of malaria. In general, AMF is a well-run charity. However, to the best of my knowledge, no research has been conducted on the health effects of AMF’s program specifically. It is conceivable that AMF is making some error that we don’t understand and does not have effects as large as the effects found in large-scale surveys.

There is one fact that is very commonly believed about the Against Malaria Foundation. Unfortunately, all the evidence shows that this fact is incorrect. For this reason, I will set the record straight.

AMF’s malaria nets are not usually used for fishing. AMF’s malaria nets are not usually used for fishing. AMF’s malaria nets are not usually used for fishing. 

  • AMF’s malaria nets are not usually used for fishing.
  1. AMF’s malaria nets are not usually used for fishing.

AMF’S MALARIA NETS ARE NOT USUALLY USED FOR FISHING.

Tell your friends and family. Shout it in the streetcorners. Educate your children about it. Tie it as symbols on your hands and bind it to your foreheads. Write it on the doorframes of your houses and on the gates. AMF’s malaria nets are generally not used for fishing.

How do we know this? AMF requires all its partner organizations to do followup surveys every six to nine months for two and a half years after the malaria nets are distributed. Outside of the Congo, after one year of use, about 80% to 90% of nets are properly hung. (In the Congo, nets decayed more quickly than expected.) Of course, over time, nets are more likely to break, so the usage rates two and a half years are lower– but that’s because they’re broken, not because they are used for fishing. The cost-effectiveness analyses for AMF incorporate the fact that not all nets are properly hung, and have done so long before anyone thought of the “what if malaria nets are used for fishing?” issue.

Of the ten to twenty percent of nets that are not hung up, many are not going to be used for fishing: they’re sold, or thrown out, or left in a corner because people can’t get it together to hang them up, or perhaps used for some other purpose. But it is possible some of them are, in fact, used for fishing. On this subject, Kelsey Piper writes for Vox:

What about harm to fisheries from people fishing with nets? Researchers have only recently started looking into this. No one has measured detrimental effects yet, though they could emerge later…

The insecticide in anti-malarial bednets also does not have negative effects on humans, because the dosages involved are so low. It’s unclear whether there are any harmful effects from fishing with nets. (And, it’s worth noting, there is one oft-forgotten positive effect from the use of bednets for fishing: People are fed.)

The insecticide-treated bednets issue shows the importance of the effective altruist approach to charities. AMF proactively checks whether the bednets are used as expected instead of assuming that they are. Therefore, if malaria nets were commonly used as fishing nets, we’d be able to find that out right away and account for it in our cost-effectiveness models. If we didn’t monitor bednet usage, it would be easy not to notice that. The “but AMF’s malaria nets are used for fishing!” argument– commonly deployed as a gotcha for effective altruists– actually shows why effective altruism is important.

AMF distributes nets for free. Some people object to distributing nets for free, because it puts local net salespeople out of business and it teaches people that they should get bednets for free. However, way more people will take a free bednet than a bednet that they have to pay even a little bit of money for, and GiveWell thinks that outweighs the effects on local net markets.

Neither fishing nor the fact that the nets are free is a real concern. However, there is a real concern about AMF: insecticide resistance. Insecticide resistance is very hard to quantify, but GiveWell’s best guess is that insecticide-treated bed nets are about a third less effective than they would be in the absence of resistance; this is still very very cost-effective. AMF is going to begin distributing nets that use a different chemical to which mosquitos have yet to develop resistance. GiveWell has not addressed the role of insecticide-treated bed nets in causing insecticide resistance.

Sometimes, AMF has talked to partner organizations about funding a distribution, but ultimately not done it. When they haven’t done so, another organization has usually stepped in to buy nets eventually, but it usually takes at least six months. In the intervening time, people aren’t covered. GiveWell’s cost-effectiveness model accounts for the fact that at least sometimes a different funder will buy the nets if AMF doesn’t. 

It is very very unclear what the Against Malaria Foundation’s room for more funding is. However, AMF has a good track record for scaling up and productively spending large amounts of money, and it would cost hundreds of millions more than anyone is spending on malaria nets to buy everyone who needs a malaria net a malaria net. So probably they will be able to use any sum of money that we can expect people would give them.

In conclusion, as promised, here is the best AMF fact. AMF’s CEO does not take a salary; they receive other pro bono work from volunteers. GiveWell’s model of the costs of an AMF net distribution includes the amount the CEO and other volunteers would be paid if they were paid. AMF, however, has apparently requested that GiveWell include the following caveat:

Comment from AMF: AMF would like all donors reading this to know that the costs included for the CEO and pro bono services are not actually incurred. Each of them is very happy to provide their services for free.

Why might you donate to the Against Malaria Foundation?

  • You care a lot about the deaths of children under five.
  • You think the deaths of fetuses matter as much as the deaths of children under five.
  • You want a program that is robustly good on a bunch of different axes: it makes people less sick and less likely to die and increases their income.
  • You want a program that definitely works and has very few negative side effects, even if it might be less cost-effective than other programs.
  • You grew up in a place with mosquitoes and have sworn eternal vengeance on the tiny blood-sucking monstrosities.