Blog FeedNETS ARE NOT ENOUGH
When Janet Aqua’s 11-year-old son, Ray, became ill with malaria, Janet wasted no time in taking him to a nearby clinic. In the rural Ghanaian town where Janet lives, malaria strikes often and wreaks havoc on lives and livelihoods. Janet knows firsthand how fast malaria can take the life of a child. She has already lost two children, a four-year-old daughter and a six-year-old son, to malaria. When Ray became listless and developed a fever, she closed down her street-side kiosk-her family’s primary source of income-and took him straightaway to the doctor. Janet also asked for an insecticide-treated net from the clinic’s free distribution program. Unfortunately, clinic supplies were running low and the clinic nurse said Janet could only have a net if she had a child under the age of one. Janet, who had left her baby with relatives so she could take Ray to the doctor, told the nurse she would be back tomorrow with her baby. When she returned the next day, she was told the nets were gone. The nurse said there would be another shipment, but she didn’t know when.
“I have lost two children to malaria-they died in my arms,” said Janet of her determination to get a net. “I can have no peace of mind. I am afraid for my children.”
When our staff met Janet, it was easy to solve her problem by giving her one of our own nets on the spot. But what about all the other families in rural villages who were trying to get nets?
April 25 is World Malaria Day
You may have noticed that this is the third time I have focused on malaria in the past few months. This disease is just that important! Especially for anyone concerned about Africa, where ninety percent of malaria deaths occur, says UNICEF. According to the World Health Organization’s Fact Sheet on Malaria:
- A child dies of malaria every 30 seconds.
- There were 247 million cases of malaria in 2006, causing about 880,000 deaths.
- About half of the world’s population, mainly the poorer half, is at risk of malaria.
- Malaria cuts economic growth rates up to 1.3% in countries with high infection rates.
In some countries, personal and public expenditures on prevention and treatment are enormous-accounting for up to 40% of public health expenditures, 30-50% of inpatient hospital admissions, and up to 60% of outpatient health clinic visits.
UNICEF states that malaria contributes greatly to anemia among children-a major cause of poor growth and development. Malaria infection during pregnancy is associated with severe anemia and other illness in the mother and contributes to low birth weight among newborn infants-one of the leading risk factors for infant mortality and sub-optimal growth and development.
No wonder this disease, which in some countries is almost as common as the common cold, is getting so much attention these days!
Just sleep under a mosquito net
Even more remarkable is how easy it is to prevent malaria-or at least reduce the frequency of infection. Just sleep under a mosquito net! For this reason, the World Health Organization is pushing for widespread distribution of nets in countries with high infection rates, especially in Africa. Not just any nets, but Insecticide-Treated Nets (ITNs). These ITNs don’t just prevent malaria-carrying mosquitoes from biting and passing on the malaria parasite; they kill the mosquitoes that land on the net as they try to get to the sleeping person. The result is reduction of the local mosquito population and increased protection even for nearby people who aren’t sleeping under a net.
Should the nets be given away?
There is controversy over whether these nets should be distributed free of charge, especially to serve those who cannot pay. A good-quality ITN costs around $10 at full price. While the net can last five years, $10 is a great deal of money for those most vulnerable to malaria, the very poor in Africa. On the other hand, centuries of experience shows that products do not get distributed widely over many years if they are not sold at a price that yields a profit for the distributor. Governments (supported by the World Health Organization and other donors) can subsidize the distributors in various ways-such as paying them salaries-but this can drive private distributors out of the net business. This is bad when governments that depend on donations of nets cannot maintain the steady supply of nets, especially in the rural towns and villages. That’s when people like Janet Aqua get frustrated. Janet got an ITN. She was determined, because of her own tragic experience with malaria and because she has learned about the causes, prevention and treatment of malaria from a local microfinance institution that offers Freedom from Hunger’s Credit with Education program. But others more often just give up on getting an ITN or any kind of net.
There are promising experiments with mixed public-private approaches, such as government giving poorer people vouchers they can give to private distributors to get the nets at a steep discount. Nets are sold by the same distributors, whether at full price or at the voucher-based discount. The distributor makes enough money either way to make the nets dependably available.
The importance of a mixed approach is underlined by a 2007 article in the American Journal of Tropical Medicine and Hygiene,[i] which found that mass distributions of free nets can achieve high coverage rates quickly. However, there is also need for additional approaches to 1) provide continuous provision of ITNs for newly pregnant women and their babies and 2) provide protection for the rest of the population. Targeted subsidies will continue to be an important tool to achieve the first objective, either through direct distribution of ITNs or through vouchers. To achieve objective 2, a strong and competitive commercial sector for ITNs seems to be a good option. The article concludes that “one size doesn’t fit all.” With planning and good promotion campaigns, these strategies can co-exist and reinforce each other.
Nets are not enough
As I’ve written in this space before, most rural West Africans do not know that getting bitten by a mosquito is the one and only cause of malaria. Think how hard it would be to persuade people to sleep under a mosquito net if they don’t know that mosquitoes are the cause of malaria! It’s hotter to sleep under a net. It takes time to put it up properly. Why bother? Unless you know that if you don’t, you will get malaria and get very sick and maybe die, especially if you’re very young or pregnant or malnourished.
The distribution of nets must be accompanied by health education sessions and work to raise awareness of mosquito-borne diseases, including malaria.[ii] UNICEF recommends that a good-quality education package needs to go hand-in-hand with the free distribution of ITNs. This recommendation applies equally to promotion of commercial distribution.
You may remember last month’s Uncommon Sense featured Pricilla, also a Ghanaian participant in Credit with Education. Pricilla and the other women in her group meet once per week under a shady tree to do their microfinance transactions and to learn. One meeting started with a learning session about malaria-where it comes from and who is most vulnerable when it strikes.
“What else will we learn about malaria?” Pricilla asked during the meeting. “My children both had malaria a month ago and are still weak.” There is surprisingly little knowledge about the disease in spite of its prevalence. Some women have heard that mosquitoes are the culprit but most have more traditional ideas: working too hard, standing in the sun, bad food. The learning session generates a great deal of conversation and sharing of ideas and stories. Over the next few weeks, the women learn together how to protect their families against malaria, how to administer medicine to reduce the chance of drug resistance and where they can get insecticide-treated nets. When Pricilla was told of the importance of ITNs, she said, “I will start saving for one now. I want to get a good-quality one.”
Once again, we discover there are no silver bullets for solving even straightforward problems like malaria. The powerful combination of money and information in the hands and minds of the poor, especially women, always seems to be necessary to achieve true progress. Nets are absolutely necessary … but not enough.
[i] Lengeler C, Grabowsky M, McGuire D, and deSavigny D. Quick wins versus sustainability: options for the upscaling of insecticide-treated nets. Am. J. Trop. Med. Hyg. 2007 Dec; 77 (6 Suppl):222-6[ii] http://www.odihpn.org/report.asp?id=2736
