In Africa, mosquito nets go unused

Last week, in honor of World Malaria Day, viewers of American Idol were urged to donate $10 for an insecticide-treated bed net to save an African child from malaria, the mosquito-transmitted scourge that infects 300 million people every year, killing one million.

The premise behind the idea of treated nets is simple. The netting prevents malarial mosquitoes from biting people while they're asleep, and the insecticide kills and repels the insects. World health experts say that using the nets can reduce child mortality in malarial regions by 20 per cent.

But even as donations roll in data suggest that, at least in some places, nearly half of Africans who have access to nets refuse to sleep under them.

Why that is gets to the heart of the trouble with efforts to dislodge the diseases of the very poor. When scientists first developed the nets in the late 1990s, they were hailed as a magic bullet for malaria. Unlike nearly everything else that combats the disease, including drainage and anti-malarial drugs, nets are cheap and easy to use. Equally important, they require little infrastructure. A single volunteer on a motorcycle can distribute hundreds of nets a day, in even the most remote locales.

To date, millions of dollars have been spent to get treated nets into the hands of impoverished, sub-Saharan Africans. Roll Back Malaria Partnership is calling for 730 million more.

But, as even the staunchest advocate will admit, the treated nets were not designed with the cultural preferences of the rural African villager in mind. Among other design flaws, their tight mesh blocks ventilation, a serious problem in the hot, humid places where malaria roosts. Minor discomfort might be tolerable in rural African communities desperate for anti-malarial prevention. But, as medical anthropologists have consistently found, because malaria is so common in much of sub-Saharan Africa, and because the overwhelming majority of cases go away on their own, most rural Africans consider malaria a minor ailment, the way Westerners might think of the cold or flu.

As a result, while we see the treated nets as a lifesaving gift, they see them as a discomfort that provides only partial protection against a trivial illness. Is it any wonder that many use them to catch fish, as wedding veils or room dividers -- all documented uses? If that sounds ungrateful, think about what would happen if public health officials, concerned about the 41,000 lives that Americans lose every year due to flu, blanketed the U.S. with anti-viral face masks to be worn during the winter flu season. Would people wear them?

At a recent meeting in Washington, people active in various net programs met to consider the bed net dilemma. All agreed that thanks to the sheer scale of the distribution effort, many nets will be hung over sleeping mats, even as others are hoarded, resold and diverted to other uses. As a result, many cases of malaria will be averted.

But then what? The nets don't last forever. In three or four years, they will need to be replaced and today's remarkable and historic net donation effort will have to begin anew, and be repeated, indefinitely.

Nobody in the room underestimated the dilemma, and their frustration was palpable. "You can see the train wreck coming," one said dolefully.

This is not an insoluble problem. Some aid groups, aware of local ambivalence about the nets, have started education programs to support bed net distribution efforts, urging the rural poor to actually unwrap and sleep under the nets they've been given. It's not an easy or cheap fix, of course. Such exertions take time and money -- exactly what bed nets were supposed to save.

Perhaps what we need is a whole new approach. Instead of masterminding solutions for distant problems and then handing them down from on high -- as we do not just in our anti-malaria efforts but in a variety of aid programs aimed at extreme poverty -- we should empower the poor to come up with their own solutions, and then help figure out how to implement them.

Such a process might not lead to grand, magic-bullet solutions. More likely, we'd get micro-solutions, variable from locale to locale, from village to village.

But we'd be supporting self-reliance and building goodwill along the way. And we'd surely avoid the wastefulness -- and really, the affront -- of befuddling communities with "gifts" that many neither want nor use.

Sonia Shah is the author of The Fever: How Malaria Has Ruled Humankind for 500,000 Years," which will be published in July.

--Los Angeles Times

Republished from the Winnipeg Free Press print edition May 13, 2010 A15