Wednesday, February 9, 2011

George Clooney answers your questions about malaria! Hooray!

George Clooney got malaria in Sudan.  Now him and buddy Nicholas Kristof have a Q&A on the disease at  I tried not to be cynical.  I thought it would be a cute, gimmicky way to draw attention to an important disease, and perhaps dispel some myths along the way.  Unfortunately, they ended up creating some along the way instead.

The answers range from harmless:
What side effects did you have? And what were your symptoms when malaria was detected?
Not much in side effects, the symptoms are fever, the chills, and exciting adventures in the toilet..weak..really just very bad flu conditions with a little food poisoning thrown in to make you the perfect party guest.
To mildly dim:
George – A dear friend of mine had malaria…does it recur? And if you’ve had it once, can you get it again?
It can…it depends on what type you get..i didn’t get that strain thankfully.
— George Clooney
[Big aside: The number one reason malaria reoccurs is inadequate treatment, meaning all the parasites were not killed in the first place. Old treatment regimes caused the parasite to "retreat" to the liver, rather than fully killing it. Today, when malaria is treated with drugs that it has developed resistant to, or treated incompletely (with a partial course), malaria can reoccur.  Many drugs available to treat malaria experience partial parasite resistance, but are still used either because they are effective first line treatments (in an area of incomplete parasite resistance), or because they make the symptoms go away, encouraging clinicians and patients as to their effectiveness.  Recurrence is more common in certain strains, but usually because these strains have delayed symptoms, causing malaria to not be treated or to be treated inadequately, or high rates of drug resistance.  Adequate, complete, and timely treatment can prevent malaria recurrence in almost all cases (except in the case of reinfection, which is also quite common).  Malaria recurrence despite adequate treatment is treatment failure, in which case second-line treatments are deployed.]

To foolish and misleading:
George – How did your treatment for malaria differ from the treatment that the average Sudanese would receive?
Joy F.
I had drugs to take before during and after…pills that should be just provided to these people, like a polio saving drugs for diseases that kill millions needlessly, belong to mankind not to companies to profit from….we need another Jonas Salk.
— George Clooney
OK, first of all, I don't know what he means by "before, during, and after."   If by the "before" part he is referring to prophylaxis pills, then, no, these wouldn't be available to the typical Sudanese, because prophylaxis pills aren't meant to be taken for a long period of time.  They're essentially ongoing treatment for malaria, which kills the parasite immediately in case you contract it--the liver has to work over-time to process these pills, and they have to be taken daily or weekly.  Ongoing prophylaxis use in endemic areas is medically inadvisable, financially unsustainable, and logistically infeasible.

Let's move on to the next part of his response: "life saving drugs for diseases that kill millions needlessly, belong to mankind not to companies to profit from."  I agree, the sentiment sounds nice.  It's just a matter of wresting the life-saving drugs from the evil pharmaceutical companies, and all our problems are solved!  It certainly sounds much nicer than, "How do we sustainably ensure supply, distribution, and use of lifesaving technologies in a constantly changing disease environment, where even free commodities face take-up challenges?"  Unfortunately, that's the actual problem at hand.

It is a MYTH that drug companies' failure to provide treatment at free or discounted prices is responsible for the failure to stop the toll of malaria in the developing world.  Many drug companies do provide these commodities for free or at deeply discounted prices, and where they don't, aid funds exist to purchase and distribute them (which is often where the largest cost is incurred).  I'll get to why the model of having aid dollars purchase drugs makes sense in a minute.  First, let me just emphasize that there are massive logistical challenges involved in getting "diagnosis and treatment within 24 hours of onset of symptoms," the malaria gold-standard, to every patient.  You need clinicians able to accurately diagnose malaria (meaning you need electricity for microscopy or adequate supply and usage of Rapid Diagnostic Tests), you need patients who go to a health facility instead of traditional healers, you need health facilities or Community Health Workers within walking distance of patients, you need drug regimens that are tailored to the drug-resistance of common strains, you need these drugs to be distributed across entire countries (including rural areas) and arrive at regular intervals to avoid stock-outs, you need patients to accurately follow the drug regimen, and you need to prevent over-prescription of effective medications to avoid future drug resistance.  All of this is extremely difficult, despite being tackled by the best and brightest minds in aid work.  Why?  Because without prices and other market systems to dictate supply, supplying things is actually a tricky proposition! (See: shortages in Soviet Union)

But Clooney has a solution, which is fewer market incentives!  I'm so glad we asked him.  Before I dive in to justify all that sarcasm, let me just say that I am in no way suggesting that anti-malarial commodities should not be free to end users.  I absolutely think free diagnosis and treatment of malaria is a worthy goal, and one that should be possible.  I also think there's some cases in which free distribution of things, such as bed nets, insufficiently communicates their value, resulting in misuse or disuse, and the need for further free distribution.  There's good research showing that giving bednets away for free works, but in a setting that already communicates their value, by limiting distribution to pregnant mothers.  For free distribution to work, you have to create sufficient consumer demand to ensure proper use.  Organizations like Tam Tam are pursuing free distribution of bed nets with this problem in mind.  In setting where resources are limited, nominal prices for health commodities can help separate out end-users who are likely to use from those who are likely to misuse.  Moreover, pricing enables positive brands to be created for health commodities that have traditionally been pushed onto populations, such as condoms.

All that aside, I agree we should be working toward providing malaria diagnosis and treatment to end users absolutely free.  I don't think, however, that this means drug companies shouldn't benefit from their participation in this goal.  If we decide drug companies should be allowed zero profit, either direct or indirect, from providing pharmaceuticals to combat developing-country diseases, we decide we never want to cure another disease ever again.  The latest and most promising treatment for malaria, Coartem, exists because Novartis believed it could get sufficient positive press, and perhaps future government contracts, for developing it and distributing it for free that it was worth the investment.  Malaria is continually evolving drug resistance, meaning we need pharmaceutical companies to be continually investing in developing new treatments.  TB and HIV--even respiratory infections--are highly drug-resistant, requiring constant introduction of new technologies.  Moreover, few would claim to be satisfied with the currently available technologies to treat HIV, which allow management but not recovery; avoidance but not prevention.  Instead of railing against the existence of market incentives to create better treatments, we should be asking how these market incentives can be made compatible with free delivery to the end user.  We should be asking what sources of profit can be built in, such as the frequently under-priced payoff to Corporate Social Responsibility, to a system that denies access to no one in need.

We have not failed to treat malaria because we have failed to control big, bad, greedy drug companies.  If anything, our failure is to insufficiently incentivize these companies to join in the fight.


  1. I wish you were a celebrity when you got malaria, so NYT readers would actually learn something.

  2. What's the best evidence so far that CSR payoffs are underpriced? Why is that so? Do you mean in this industry or in general?

  3. @DRDR
    I know, right. I didn't realize the sequence should have been make movie first, then get Econ PhD, to actually make a difference in development.

    With regards to CSR, I'm not talking about how the stock market prices it, which we know very little about. What I mean is that most companies do not think about CSR as an investment, and do not "price out" projects that they undertake. When I was at [Big Consulting Firm], I worked on a white paper on CSR where we interviewed companies about their practices. What we found is that most companies had no systematic way of valuing CSR investments against the payoff in customer brand awareness or purchasing decisions, even when they believed this payoff to be positive. Rather, the companies set a target to do a certain amount of CSR based on tax incentives, common industry practice, etc. In other words, they would not consider whether a CSR project was NPV positive when creating their CSR targets and deciding which project to undertake. This is probably a consequence of the stock market not having a clear valuation of CSR, but the point is that if you believe a CSR project will create sales growth, then it will create shareholder value through that sales growth, and therefore it doesn't matter whether the market immediately prices in the project.
    This article from the McKinsey Quarterly discusses the uncertainty around CSR pricing, which leads to underinvestment.

  4. Thanks for the link! That's interesting. I did understand from the original post you were talking about internal investment decisions, not stock pricing.


Commenting is now open, but we'd love it if you chose one username so other commenters can get to know you. To do this, select "Name/URL" in the "Comment as" drop down. Put the name you'd like others to see; the URL is optional.

Any profanity, bigotry, or synonyms for "[ ] sucks!" will be deleted. We welcome criticism as long as you're making a point!