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A bargain in saving lives




WHEN vaccines for Covid-19 became available, governments’ highest priority was to get them approved as quickly as possible, in order to save millions of lives. Regulatory authorisation of a new, low-cost malaria vaccine, recommended by the World Health Organisation in October, deserves to be treated with the same degree of urgency.

In 2021, malaria caused 619 000 deaths, 77% of which were children under five, and 96% of them in Africa. But now, after decades of research – and several false dawns – a malaria vaccine known as R21/Matrix-M (henceforth just R21) has been shown to be effective in 70-78% of cases. Although three doses are required before that level of protection is reached, and a booster is needed one year later, the vaccine, developed at the University of Oxford and the Serum Institute of India, is cheap. It can be produced for US$2-$4 per dose – comparable to the cost of other childhood vaccines.

Adding costs for delivery and administration, we can say that R21 costs approximately US$5 per dose. A recent study indicates that fully vaccinating eligible children in areas where malaria is prevalent would save more than 600 lives per 100 000 children vaccinated, as well as prevent nearly 200 000 clinical cases of malaria (because once someone gets malaria, it is likely to recur). This suggests that the deaths of hundreds of thousands of children could be prevented for roughly US$3 300 per life saved.

In October, R21 was recommended by the World Health Organisation. It now needs to go through the WHO’s prequalification process and receive the recommendation of the WHO’s Strategic Advisory Group of Experts on Immunisation. Then a broad international rollout can begin.

Children eligible for R21 are between five months and three years old. About 80 million eligible children live in malaria-prone regions of Sub-Saharan Africa. To give them all three doses of the vaccine in 2024 would require 240 million doses, followed by a further 80 million boosters in 2025. After that, with the backlog of currently unvaccinated children dealt with, the roughly 30 million children born every year would need 120 million doses. This would save about 450 000 lives per year.

Saving a life for US$3 300 is a bargain. In the United States, Medicare covers the cost of kidney dialysis for patients over 65 who would otherwise die while awaiting a transplant. Fifteen years ago, economists from Stanford and Wharton calculated that the average cost per quality-adjusted year of life gained by this coverage was US$129 000. Adjusting that figure for inflation (and overlooking the fact that medical costs have risen faster than other prices) takes it to US$182 000 – and that’s just for one extra year of life. By comparison, if we conservatively estimate that the children saved by vaccination against malaria have a life expectancy of 50 years, the cost per year is US$66.

Even when judged by global, rather than American, standards, saving a life for US$3 300 is an exceptionally good value. The most cost-effective evidence-backed programs that leading charity evaluator GiveWell has been able to find cost roughly US$3 500-$5 500 per life saved. For example, the Against Malaria Foundation, which is also one of The Life You Can Save’s top charities, distributes bed nets to protect children against malaria. Although each net costs only a few dollars, distributing enough of them to save a life costs over US$4 000.

When vaccines for Covid-19 first became available, governments’ highest priority was to get them through the regulatory process. The US Food and Drug Administration normally takes about ten months to authorise the use of a new vaccine, but it approved the use of the Pfizer vaccine in a breathtaking 21 days, and authorisation for Moderna’s vaccine took just 19 days. WHO prequalification normally takes 270 days after the WHO recommends a vaccine. That is an unacceptable delay. The WHO should accelerate its process and tell the public how quickly it can complete prequalification.

1Day Sooner was founded to represent people who wanted to volunteer to take part in human challenge trials to accelerate vaccine development. When the organization was established in March 2020, its focus was a vaccine against Covid-19: getting it out one day sooner would, quite literally, save thousands of lives. Many of the organization’s staff and a high proportion of the volunteers were effective altruists.

The organisation’s original mission has broadened to promoting efficient development of life-saving medical research and the speediest and most equitable distribution of its products. As part of that broader mission, 1Day Sooner set up 1Day Africa to promote vaccination on the continent by strengthening Africa’s scientific capacity and its ability to manufacture vaccines locally.

Now, 1Day Africa is concerned that the WHO and national governments are not assessing the safety and effectiveness of the new malaria vaccine with the same urgency as they assessed the Covid-19 vaccines. As a result, the organisation is pressing for the production of as many doses of R21 as possible in 2024, and getting those doses into the arms of children as quicky as possible, to prevent millions of cases of malaria and save hundreds of thousands of lives.

Some of the relevant facts are in dispute, including how long the WHO’s prequalification process needs to take, and how quickly the necessary quantity of doses can be produced. But one thing should be clear: failing to save the lives of African children when that can be achieved for as little as US$3 300 each would render hollow our lofty rhetoric about the equal worth of every human life.

About the writer: Peter Singer is professor of bioethics at Princeton University and founder of the non-profit organisation The Life You Can Save.–Project Syndicate.

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