Mosquito nets save lives. So why is VC Marc Andreessen in opposition to them?

Marc Andreessen, the billionaire enterprise capitalist and early internet browser developer, thinks we’re giving too many insecticidal bednets to individuals uncovered to malaria, tweeting, “Mosquito nets are a triple menace — harmful to individuals, harmful to fish, and harmful to fishing ecosystems and the communities they feed.”

That mosquito nets are harmful to individuals can be information to mainly any public well being skilled who’s ever studied them. A systematic assessment by the Cochrane Collaboration, in all probability probably the most revered reviewer of proof on medical points, discovered that throughout 5 totally different randomized research, insecticide-treated nets cut back little one mortality from all causes by 17 %, and save 5.6 lives for each 1,000 kids protected by nets. That suggests that the 282 million nets distributed in 2022 alone saved about 1.58 million lives. In a single 12 months.

So … what the hell is Andreessen even speaking about?

To know why somebody who has traditionally been extra excited about crypto artwork than world well being is instantly tweeting about malaria, it’s important to know slightly bit about Andreessen’s grudges. Andreessen’s VC agency, Andreessen Horowitz (a16z), has invested in quite a bit in AI corporations recently, and he has aligned himself with a faction generally known as “efficient accelerationists,” who favor aggressive progress in AI with minimal regulation or guardrails.

The efficient accelerationists, or e/acc, outline themselves largely by their opposition to efficient altruists, the social motion that started by specializing in cost-effective world well being interventions and has extra just lately advocated for robust rules to forestall AI from going awry (Future Excellent, the part operating this text, is broadly impressed by EA concepts). Efficient altruists have lengthy been recognized with anti-malarial bednets, a major instance of the very low cost, very efficient world well being causes they favor.

So, largely to stay it to the individuals who need AI regulation, Andreessen has dedicated himself to attacking among the finest strategies of stopping malaria. If that doesn’t make sense to you, don’t fear; you’re not the one performing ridiculous.

But it surely’s price taking the critique right here not less than marginally severely. Do bednets have severe downsides, associated to misuse for fishing, that their advocates are merely ignoring?

In a phrase: no. In a number of phrases: The discovering that bednets save lives just isn’t affected, in any respect, by the minority of people that use bednets to fish, fairly than to guard themselves from malaria. A few of these individuals use nets which might be a number of years previous with insecticide that’s worn off, and are now not efficient at killing mosquitos. There’s little analysis on what fishing with these nets really does to fish or individuals — but in addition little purpose to suppose the magnitudes of those results are remotely close to the variety of lives saved by nets.

Bednets and fishing nets

Andreessen’s objection is rooted in one thing that’s been true of bednets for many years: generally, individuals use them as fishing nets as a substitute.

This has sometimes popped up as an objection to bednet packages, notably in a 2015 New York Occasions article. One associated argument is that the diversion of nets towards fishing means they’re not as efficient an anti-malaria program as they initially seem.

That’s merely a misunderstanding of how the analysis on bednets works. The scientists who research these packages, and the charities that function them, are effectively conscious that some share of people that get the nets don’t use them for his or her meant function.

The In opposition to Malaria Basis, as an illustration, a charity that funds web distribution in poor nations, conducts intensive “post-distribution monitoring,” sending surveyors into villages that get the nets and having them rely up the nets they discover hanging in individuals’s homes, in comparison with the quantity beforehand distributed. When carried out six to 11 months after distribution, they discover that about 68 % of nets are hanging up as they’re imagined to; the % progressively falls over time, and by the third 12 months the nets have misplaced a lot of their effectiveness.

So does this imply that bednets are solely 68 % as efficient as beforehand estimated? No. Research of bednet packages don’t assume full takeup, as a result of that will be a dumb factor to imagine. As an alternative, they consider packages the place some villages or households randomly get free bednets, and evaluate outcomes (like mortality or malaria circumstances) between the handled individuals who bought the nets and untreated individuals who didn’t.

As an illustration, take a 2003 paper evaluating a randomized trial of web distribution in Kenya (this was one of many papers included within the Cochrane assessment). The researchers’ personal surveys present that about 66 % of nets have been used as meant. The researchers didn’t exclude the one-third of households not utilizing the nets from the research. As an alternative, they merely in contrast dying charges and different metrics within the villages randomized to obtain nets to these metrics in villages randomized to not get them. That comparability already bakes in the truth that a 3rd of households who acquired the nets weren’t utilizing them.

So estimates like “bednets cut back little one mortality by 17 %” are already assuming that not everyone is utilizing the nets as meant. This simply isn’t an issue for the impression estimates.

However is it an issue for fisheries? Andreessen cites one current article to make this case. It’s not clear to me he really learn it.

The authors begin by acknowledging that bednets have saved thousands and thousands of lives, and even that using nets for fishing is sensible for many individuals. It’s a free strategy to get meals you could survive in areas typically reliant on subsistence farming. Furthermore, the authors notice that “The worldwide collapse of tropical inland freshwater fisheries is effectively documented and occurred earlier than the scale-up of ITNs.” At worst, you possibly can accuse nets of constructing an present drawback worse.

The larger query the authors increase is that pesticides are poisonous. That’s, in fact, the purpose: They’re meant to kill mosquitoes. The query, then, is whether or not they’re poisonous to fish or people when used for fishing. The authors’ conclusion is perhaps, however we now have no analysis indicating a method or one other. “To our information there’s at present a whole lack of information to evaluate the potential dangers related to pyrethroid insecticide leaching from ITNs,” the authors conclude. They don’t seem to be certain if the quantity leaching from nets is sufficient to be poisonous to fish; they’re not absolutely certain that the insecticide leaches into the water in any respect, although they believe it does. Even much less clear is how these pesticides would possibly have an effect on people who then eat fish that may be uncovered to them.

I requested the research’s lead writer, David Larsen, chair of the division of public well being at Syracuse’s Falk School of Sport & Human Dynamics and an professional on malaria and mosquito-borne diseases, for his response to Andreessen citing his work. He discovered the concept one ought to cease utilizing bednets due to the problems the paper raises ridiculous:

Andreessen is lacking a whole lot of the nuance. In one other research we mentioned with conventional leaders the harm they thought ITNs [insecticide-treated nets] have been doing to the fisheries. Though the standard leaders attributed fishery decline to ITN fishing, they have been adamant that the ITNs should proceed. Malaria is a scourge, and controlling malaria needs to be the precedence. In 2015 ITNs have been estimated to have saved greater than 10 million lives — seemingly 20-25 million at this level.

… ITNs are maybe probably the most impactful medical intervention of this century. Is there one other intervention that has saved so many lives? Perhaps the COVID-19 vaccine. ITNs are vastly efficient at lowering malaria transmission, and malaria is without doubt one of the most impactful pathogens on humanity. My thought is that native communities ought to resolve for themselves by means of their processes. They need to know the potential danger that ITN fishing poses, however in addition they expertise the true danger of malaria transmission.

He notes that the fish toxicity problem is actual and price investigating additional; a colleague, the College of Florida’s Joe Bisesi, is investigating this and, preliminarily, the insecticide does appear to hurt fish. Simply because an intervention like bednets is efficient at its major function doesn’t imply it doesn’t have unintended penalties, and it’s price investigating these absolutely.

However, as Larsen says, individuals like him, me, and Andreessen aren’t the individuals affected right here. The individuals affected, in rural Africa and different malarial areas, overwhelmingly need bednets as a software to assist them survive.

Put your cash the place your mouth is

Fortunately for Andreessen and like-minded people, individuals genuinely nervous about fisheries and insecticidal toxicity in Africa produce other choices. They will assist the Malaria Consortium, as an illustration, which as a substitute of bednets affords seasonal chemoprevention, an method by which individuals in malarial areas get preventive medicines meant to scale back their danger of infections. In the event you’ve traveled to a malarial area, you will have gotten these medication your self from a journey medication clinic; I did earlier than a visit to Burma. There are not any fishing-related issues with chemoprevention, and it additionally saves lives very cost-effectively.

One may additionally fund work on malaria vaccines. The R21 vaccine, just lately authorised by the World Well being Group, is 75 % efficient in opposition to an infection, and stakeholders just like the vaccine distribution group GAVI and the World Fund to Battle AIDS, Tuberculosis and Malaria are at present understanding a plan to fund a mass rollout. Bednet skeptics may simply donate to these teams, or fund advocacy to get governments just like the US to extend their commitments to the World Fund and GAVI to make sure the vaccination effort is sufficiently funded.

The broader level Andreessen was attempting to make by attacking bednets, in his phrases, was that, “It is rather, very exhausting to intervene in different individuals’s lives — significantly from a distance — and never make issues worse.” It’s certainly actually exhausting, and requires a whole lot of analysis — however fortunately individuals have finished that analysis, and even when for no matter purpose bednets don’t clear the bar for you, there are many efficient interventions in opposition to malaria and different illnesses that don’t increase any points round fishing.

The query, then, is whether or not that strikes you to assist these causes, or if attacking bednets is simply an excuse for one’s personal inaction. I don’t know Andreessen’s personal donation historical past; perhaps he’s been giving to the Malaria Consortium this complete time. In that case, god bless. If not, he ought to think about taking his personal arguments a bit extra severely.