[This is the first 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.]

The GiveWell-recommended program run by the Malaria Consortium does seasonal malaria chemoprevention– that is, they give children under five preventative anti-malarial drugs, so that the children don’t get malaria and don’t die. And their cost-per-death-averted is..

…drumroll please…

$2,292.

Okay, you shouldn’t take cost-effectiveness analysis literally. The GiveWell cost-effectiveness analyses are comprehensive, but there are a lot of factors that aren’t included, and there’s always a bunch of uncertainty that disappears with an overly precise number like “$2,292”. At the very least, you should go to that spreadsheet, click on the tab that says “moral weights,” and put in your own numbers, because otherwise you’re saying “my ethical beliefs are exactly equivalent to the median of what all GiveWell employees believe about ethics,” which is a stupid way to do ethics.

But nevertheless it is true that the cost-per-life-saved numbers for the Malaria Consortium are stupidly cheap.

If you’re a charity nerd like me, you’ve gotten a bit used to the situation with global poverty charities. The top charity is always bednets, and the cost-per-life-saved-equivalent is always about the same– sometimes it’s $3,500, sometimes it’s $4,000. But SMC is super cheap.

Like, what the fuck?

The Cochrane Collaboration summarizes the effects of seasonal malaria chemoprevention as follows:

[Seasonal malaria chemoprevention] prevents approximately three quarters of all clinical malaria episodes (rate ratio 0.26; 95% CI 0.17 to 0.38; 9321 participants, six trials, high quality evidence), and a similar proportion of severe malaria episodes (rate ratio 0.27, 95% CI 0.10 to 0.76; 5964 participants, two trials, high quality evidence). These effects remain present even where insecticide treated net (ITN) usage is high (two trials, 5964 participants, high quality evidence).

This is the Cochrane Collaboration we’re talking about here. These are the people who think there’s not adequate evidence that flossing makes your gums better. When Cochrane says “not only does this work, it prevents three quarters of all malaria episodes,” you sit up and take notice.

Unfortunately, it’s not clear that seasonal malaria chemoprevention reduces overall mortality. Not that many people die of malaria every year, so you need to have a huge study to be able to detect changes in overall mortality. One study, Cisse (2016), was supposed to be big enough to detect changes in mortality, but fewer children died than was expected, which probably makes the scientists involved feel like horrible people every time they complain about it.

GiveWell thinks the Malaria Consortium could productively use way more money than they’ll actually get: their room for more funding is $43.9 million.

So this is great, right? Time to give away all our money to the Malaria Consortium!

Well, there’s one little problem and one big problem.

The little problem is that the surveys to find out how many children get seasonal malaria chemoprevention suffer from some severe methodological limitations: for example, the villages often aren’t randomly chosen, and caregivers often say they’ve given a dose when they didn’t mark the card they were supposed to mark when they gave a dose. It’s true that the surveys sometimes show really low rates of children getting treated, which would be weird if the Malaria Consortium were deliberately giving GiveWell misleading results. But even if the Malaria Consortium isn’t being misleading it might be hard to know how well they’re implementing the program.

The big problem is drug resistance.

Seasonal malaria chemoprevention uses two drugs: sulfadoxine–pyrimethamine (SP) and amodiaquine (AQ). The good news is that both drugs are basically only used for malaria, so we don’t have to worry about any other nasty bugs developing resistance to them. The bad news is that they’re both very commonly used, effective, and cheap treatments for malaria, and if you give them to everyone under the age of five, it makes it much more likely that malaria will evolve resistance to them.

The experts GiveWell has talked to expect that seasonal malaria chemoprevention will not result in malaria evolving drug resistance to SP and AQ within the next five to ten years. But five to ten years is not a very long time. We’re probably still going to have malaria in the next five to ten years. It would suck if malaria were harder to treat.

The Malaria Consortium is doing a study right now of how fast resistance seems to be evolving, so we might have more information and better estimates in the future. But right now drug resistance is something I at least am really worried about.

The Malaria Consortium needs $43.9 million dollars over the next three years. Donations should be restricted to its seasonal malaria chemoprevention program and not other programs it runs, which GiveWell does not recommend.

Why might you donate to the Malaria Consortium?

You care a lot about saving the lives of children under five.

You want to donate to a program that definitely works and is cost-effective, even if it might have other negative impacts.

You’re optimistic about making significant progress in eradicating malaria in the next few decades, or about malaria not developing drug resistance.