Malaria kills more than a thousand children every day. Measures like antimalarial medications and insecticide-treated bed nets, which stop infected mosquitoes from transmitting the disease-causing parasite to people while they sleep, have saved millions of lives at a relatively low cost. Yet despite these interventions, which reduced mortality by about 29 percent, over 430,000 children died from malaria last year. With the recent approval of two new malaria vaccines, RTS,S and R21, we have the opportunity to make another leap in the fight to eradicate malaria. Malaria can be deadly for people of all ages, but its especially life-threatening for young kids: Over 75 percent of malaria deaths happen in children under 5. For now, malaria-endemic countries like Cameroon, Burkina Faso, and the Democratic Republic of the Congo (DRC) are focusing vaccination efforts on infants, who are already brought into clinics for routine shots anyway. Over the past year, 10.2 million doses were delivered to children across 17 countries. (So far, neither vaccine is approved for adults.)The shots are largely paid for by Gavi, an international organization that uses donations from rich governments and philanthropies to subsidize lifesaving vaccine rollouts in countries with a gross national income per capita below $1,810 about 2 percent that of the United States.Last summer, Gavi announced its goal to raise $9 billion to fund immunizations from 2026 to 2030, with over $1.1 billion of those funds earmarked for new malaria vaccines. Thats enough to save around 180,000 childrens lives over the next five years. But we could theoretically save many more. A new paper by the Center for Global Development (CGD) estimates that 800,000 more child deaths could be avoided between now and 2030 if Gavi buys and distributes as many vaccines as manufacturers can make. Though manufacturers say they have over 100 million doses ready to go, Gavis plan would buy only a fraction of them. To buy all of the currently available doses and put them into the field now, Gavi would need to triple its $1.4 billion malaria vaccine budget.CGDs proposed strategy to buy and distribute as many doses as possible today, and trust that manufacturers will replenish their supply quickly goes against conventional wisdom about vaccine rollouts. Gavis current strategy is to gradually ramp up R21 vaccinations, prioritizing the most vulnerable children first, while only distributing as many doses as can be stably purchased in the long run. By doing so, Gavi hopes to balance the urgent need to save lives with the importance of maintaining a sustainable vaccine supply. This is how most vaccines are introduced, including the first Covid vaccines in the US: quickly get them to the people who need them most, then ramp up to bigger populations slowly enough that suppliers can keep up. Scott Gordon, head of Gavis malaria vaccine program, said that the success of a vaccine rollout largely depends on how ready a country is to get those shots into arms. Both available malaria vaccines require at least three doses to work, which means giving a person one shot isnt enough. Clinics have to make sure people come back. But other global health experts argue that now is the time for a more aggressive approach, to take advantage of the opportunity presented by these new vaccines.We suddenly have a tool where we can save lives at fairly low costs, said Justin Sandefur, senior fellow at the Center for Global Development and co-author of its new paper. He argues that shying away from the most ambitious vaccine rollout possible costs too many lives to justify: Logistically, bureaucratically, and politically, this is the kind of thing that we know how to do.Choosing the right vaccine will give countries more bang for their buckThe RTS,S and R21 vaccines are very biologically similar. Both vaccines target the same protein on the surface of malaria-causing parasites, teaching the body to attack the parasites before they make it to the liver and cause an infection. The RTS,S vaccine, which was recommended for use by the World Health Organization in 2021, is about 56 percent effective much better than nothing, but short of the WHOs 75 percent target. Last December, the WHO also prequalified the R21 vaccine, which performed about 20 percent better at preventing severe malaria than RTS,S in its clinical trials. Prequalification is essentially approval: It means WHO believes R21 is safe, effective, and ready to be sold to UN agencies. Effectiveness aside, R21 is much cheaper: $3.90 per dose, versus $10 per RTS,S dose. Because R21 particles are more densely packed with malaria protein antigens than RTS,S, a single dose of R21 can be much smaller than a single dose of RTS,S. Some other chemical differences also make R21 simpler to manufacture than RTS,S. As it currently stands, Serum Institute of Indias production capacity for R21 is nearly seven times greater than GSKs production capacity for RTS,S. In fact, Serum Institute has already made 100 million doses, and it says it has the capacity to make even more. So, R21 is more effective, much cheaper, and theres loads more of it than RTS,S. 1Day Sooner, a nonprofit focused on high-impact infectious disease studies, argues that R21 should be rolled out as quickly as possible, in addition to RTS,S. Demand for the vaccine is high among parents in malaria-endemic countries who are well aware of the danger to their children. But so far, its been hard for clinics to ensure parents bring their babies back for all four doses they need. Many people, in African countries and elsewhere, are hesitant to get themselves and their children vaccinated against anything at all. But demanding poor parents in rural areas to travel long distances to get to a clinic not once, but four times creates extra logistical hurdles. Ghana, for example, used a combination of strategies to get people to return for all their shots, including sending text reminders and making vaccinations part of regular checkups at local clinics. While public health experts considered the rollout an overall success, Ghana still struggled with monitoring and logistics. With these challenges in mind, Gavi plans to ramp up R21 vaccinations gradually, to avoid overwhelming health care systems and to make sure the vaccine supply remains stable in the long run.Phase 3 clinical trials suggest that three doses of the R21 vaccine work about as well as four doses, the last of which would be administered as a booster shot a year after the first three. But protection offered by only one or two doses seems to deteriorate relatively quickly without the final shots, according to some preliminary field reports. Experiments havent specifically tested the efficacy of getting one or two doses yet, but while even a single dose may reduce malaria risk relative to getting no shots at all, existing evidence suggests its nowhere near as effective as a full four-dose course. It comes down to a couple of major strategic questions, neither of which have clear answers. First, would more lives be saved by fully vaccinating fewer people, or by partially vaccinating more people? In either case, organizations still have to decide whether to buy and use up all the doses that Serum Institute has to offer, potentially trading lives saved in the short term for supply stability lost in the long term, or to proceed with a more gradual rollout. The problems with Gavis current vaccine rollout planDespite R21s advantages, Gavi isnt accepting applications from countries who want to update older requests for RTS,S to request R21 instead. The situation is baffling, Sandefur told me: The groups strategy seems to be standing in the way of its own vaccination goals.Gavis goal is to help vaccinate at least 50 million children against malaria by 2030. Combined with other tools like bed nets, insecticides, and antimalarial medication, Gavi estimates malaria vaccines could reduce the burden of malaria on poor countries by up to 92 percent.At its current pace, Gavis rollout plan will require a decade to fully vaccinate everyone whos eligible. GlaxoSmithKline (GSK) and Serum Institute, the makers of RTS,S and R21, theoretically have the combined capacity to produce as many as 115 million vaccine doses per year. Thats enough to fully vaccinate 25 million children right now. If Gavi bought and distributed every available dose, it would meet its 2030 goal in just one year, and save about 300,000 kids who might otherwise die. By gradually incorporating RTS,S and R21 vaccines into their regular slate of vaccines, countries can harness the health care infrastructure they already have available and deliver shots at routine checkups. Vaccinating all infants also means everyone will eventually be vaccinated against malaria. But focusing on getting everyone protected in the long run sacrifices the opportunity to save more lives in the short term. Vaccinating infants maximizes the number of lives saved per shot, but focusing exclusively on infants now, despite the vaccines being approved for children up to 5 years old, will leave many kids unprotected.Gavis long-standing view is that having multiple vaccines on the marketplace inspires competition, which helps them get better procurement prices, adds to the challenge. This would make sense if they were paying for a cheaper less-effective vaccine to drive down the cost of a better, more expensive vaccine. But theyre doing the opposite, Sandefur said, by purchasing a vaccine thats not better than R21 but costs significantly more. Several countries that originally requested RTS,S have since asked Gavi to switch to R21 to lower their end of the bill. At first, Gavi was hesitant, but they have since started to direct R21 to richer countries that can pay more of their share, saving RTS,S for poorer countries who wont have to pay more.The new vaccine does reportedly have some skeptics, however. In conversations that informed their latest analysis, the Center for Global Developments experts said they heard the same thing again and again: Gates hates this vaccine. But why would the Gates Foundation, which spends millions upon millions of dollars vaccinating the Global South, not like an effective vaccine that could save hundreds of thousands of lives?Its not that the Gates Foundation is snubbing malaria vaccines as one of Gavis biggest donors, Gates is helping to fund the R21 rollout. But rather than put all its eggs in the R21 basket, its also investing in self-replicating vaccines and monoclonal antibodies (like the one my colleague Dylan Matthews tested in a human challenge trial earlier this year). Philip Welkhoff, director of the Gates Foundations malaria program, said, We should work to save as many lives as possible with existing tools and resources including these vaccines while continuing to innovate to develop the next generation of tools which will be required to end malaria for good. The problem, though, is that these next-gen vaccines are still years away. Withholding decent vaccines while waiting for better ones could result in thousands of preventable deaths. One monoclonal antibody treatment, called L9LS, is undergoing phase 2 clinical trials, and results are promising so far. However, Welkhoff estimates that this treatment is still at least five years away from being widely available, much less affordable. The risk of regret from underspending on vaccine rollout today, the Center for Global Development states, far outweighs any risk of regret from spending too much.Gavi has budgeted $1.4 billion to vaccinate 52 million children by 2030. According to the Center for Global Developments calculations, it would need another $2 billion to vaccinate all infants in malaria-endemic countries, and another $1 billion on top of that if it also vaccinated toddlers under three. But Gavis only got so much money, Sandefur said. Theyre not actually sure theyre going to get the money that theyre banking on, much less the extra $2 to 3 billion it will take to save the maximum number of lives.The big thing stopping an ambitious vaccine rollout in the Global South is money. Getting a full multi-dose vaccine regimen to people is challenging enough in rich countries; remember Covid? Its much harder in countries like the DRC, where the government spends as little as $2 per capita on health (the US spends about $12,500). Vaccines cost more than the doses themselves. Getting shots in arms requires basic supplies like syringes and alcohol wipes, keeping vaccine doses refrigerated, and training clinicians in far-flung clinics all of which cost money. Then countries have to pay for community outreach programs. Its just like in the US, said Sandefur. Youre going to have to win the public debate about this being a good thing for the community to embrace.Even if Gavi rustles up enough money to buy every available dose of the R21 vaccine that Serum Institute has available, Sandefur said its not clear that theyve budgeted for the spending you would need to actually do the rollout. Sandefurs impression, after visiting the DRC in September, is that all of this data-crunching is a bit academic. Were all sitting there trying to work out numbers, he said, and I think the country just has a demand to go big.Nigeria has the largest malaria burden in the world, and may want these vaccines more than anyone. Nigeria only misses Gavis income cutoff by a couple of hundred dollars per capita, but its been hovering just above that line for enough years that per Gavis pricing system theyre expected to pay more for new malaria vaccines than they currently spend per child on health care. So, theyre not buying them. Every year that Nigeria cant afford vaccines, 95,000 children under 5 could die. Given numbers that stark, the Center for Global Development is urging Gavi to bend its eligibility rules enough to give Nigeria more support.Where will the money come from? In a dream scenario, Gavi could simply ask Elon Musk to fork over 0.5 percent of his wealth to fill its $2 billion funding gap. But since hes busy cozying up with President Donald Trump and planning a $2 trillion federal budget cut in the US, that seems unlikely.More realistically, Sandefur suspects the money will come in bits and pieces, almost certainly, if it comes at all. Im not sure that it will.Some of it will need to come from stepped-up contributions from rich countries like the US and the UK. This March, Gavi will co-host a pledging summit with the European Union and the Gates Foundation in an attempt to raise at least $9 billion. The guest list includes government leaders from wealthy countries, vaccine manufacturers, and private company executives. Support for the program is more bipartisan than most things in the current political landscape, which is good. But Western countries generally dont treat the fight against malaria with the same urgency as they treated the Covid-19 pandemic. In order for Gavi to hit its funding goal, rich countries like the US and the UK will all need to donate more than they have in the past. The Global Fund, which invests in anti-malarial treatments like bed nets, doesnt currently fund the new vaccine rollout. Theyre very worried that malaria vaccines are going to come and steal their malaria budget, Sandefur said. New dual insecticide-treated bed nets are cheaper than a full four-dose vaccine regimen, making them a great, cost-effective tool in areas where malaria transmission rates are relatively low. At their current efficacy rates, neither available vaccine can replace tools like antimalarial drugs and bed nets. But vaccines should be treated as an extra line of defense, on top of other things like insecticides and first-line drugs. At least temporarily, Sandefur suggested that the Global Fund help Gavi pay for the vaccine rollout. (The Global Fund did not respond to a request for comment.)This is also an opportunity for everyday folks to step up and help fund the rollout of existing vaccines not just innovative pilots and technical assistance at the margins, Sandefur said. Lets buy some vaccines, guys.Malaria has long been a target for effective altruists, because its a massive problem with several existing, low-cost solutions. Open Philanthropy, a foundation that does rigorous research to guide charitable giving, helped fund the clinical trials that got R21 recommended by the WHO. But while two of the top four charities listed by GiveWell, a nonprofit focused on cost-effective, high-impact charity, support malaria prevention efforts, neither buy vaccines directly. Sandefur thinks this should change.You can fix this with a shot, he emphasized. Lets go ahead and do that.Youve read 1 article in the last monthHere at Vox, we're unwavering in our commitment to covering the issues that matter most to you threats to democracy, immigration, reproductive rights, the environment, and the rising polarization across this country.Our mission is to provide clear, accessible journalism that empowers you to stay informed and engaged in shaping our world. By becoming a Vox Member, you directly strengthen our ability to deliver in-depth, independent reporting that drives meaningful change.We rely on readers like you join us.Swati SharmaVox Editor-in-ChiefSee More: Future Perfect