Eradicate malaria with growth, not nets
IPN Opinion article
The New Times, Rwanda
KAMPALA -- This month, the World Health Organization (WHO) will give four brands of Long-Lasting Insecticide-Treated mosquito net its seal of approval, increasing the total to seven. This is good news. The market for these anti-malarial bed-nets is mainly foreign aid agencies which only buy WHO-approved nets, so more authorised products will increase competition, drive prices down a bit and should, in theory, make them more available to those in need. But aid donors' single-minded determination to give everyone nets is just not going to eradicate malaria.
Long-lasting insecticidal nets are indeed important in the fight against malaria, a disease that kills over a million people each year.
Sub-Saharan Africa is hit hardest. Malaria causes one in five of all deaths of African children under five and is a significant cause of anaemia in pregnant women, causing miscarriage and low birth weight. The disease costs the continent an estimated $12 billion annually.
Mosquito nets work best when people use them consistently and appropriately. Many don't. A recent UNICEF report found that despite multiplying its distribution of nets by 20 since 2000, to 25 million, it has reached less than eight percent of children and pregnant women across Africa. How they actually use those nets is a separate problem.
Part of the problem is that mosquito net distribution is outpacing education. Some people use donated nets for fishing, wedding gowns or as a sieve, while others only use nets during the rainy season when there are more mosquitoes around, not realizing that even one mosquito can transmit the deadly disease.
Sub-Saharan Africa's hot, humid climate allows malaria-carrying mosquitoes to thrive year-round in many countries. It also makes sleeping under a net very uncomfortable, especially for children. In Uganda, my home country, the Ministry of Health recently reported on a small study of treated net use among children. Four hundred and ten children were given nets and instructions to sleep under them every night. A few weeks later, over half had malaria.
"The use of nets relies greatly on behavioural change and compliance, while indoor spraying eliminates that factor and protects everyone in the sprayed house," noted Ugandan Health MInistry Malaria Programme Director John Rwakimari.
Indoor-surface insecticide spraying is a safe, cheap alternative approved by the WHO. One or two applications each year provides round-the-clock protection to everyone in the home. In the four Ugandan districts where 'residual' spraying was conducted, over 95% of people welcomed sprayers into their homes and attained this protection. This method is increasingly popular in other countries as well. All 15 African governments participating in the US President's Malaria Initiative have opted to run indoor spraying programmes. And last month the Global Fund approved unprecedented funding for indoor spraying.
Historically, high- and middle-income countries have used indoor spraying along with effective anti-malarial drugs to eradicate malaria. But the malaria transmission cycle has only been broken in the long term by economic development. Malaria was widespread throughout northern Europe up until the late 19th century, when it spontaneously declined as a result of changing land use, improved agricultural practices, swamp drainage and the introduction of windows to houses. At the same time, increased prosperity meant fewer people working outside on the land. Mosquitoes therefore had fewer opportunities to bite humans, so the malaria parasite eventually died out.
A 1999 study of dengue prevalence along the Mexico-US border is illustrative. Two towns with similar climates are separated only by a river. Researchers found that while the dengue-transmitting mosquito was far more numerous on the US side, the number of people suffering from dengue was much greater on the Mexican side. Air conditioners were the major factor accounting for the lower risk of dengue infection. These allowed Texans to remain indoors and shut their windows, avoiding exposure.
A decent standard of living rather than living under nets should be Africa's long-term goal. Donors should be ambitious in their plans for disease control and strive to sustain funding for successful programmes. But African governments must be equally ambitious in fighting corruption and enacting market reforms that promote economic growth: these policy failures are what keep Africans in poverty.
The island of Zanzibar in Tanzania shows the pitfalls of aid dependence. It recently used a combination of nets, spraying and effective drugs to beat malaria prevalence down to one percent of the population. Yet 90% of its budget comes from donors and, perhaps unsurprisingly, this is the third time in two decades it has nearly eradicated malaria. If Zanzibar remains mired in poverty, dependent on donors and politicized aid to control malaria, you can bet malaria will be back.
The WHO's approval of four new types of treated net may help reduce malaria. Yet we must not lose sight of the long-term goal, which such efforts obscure. Without economic development, Africa will always depend on donors and their nets to fight malaria.
Carlos Odora is a Fellow of the campaigning non-profit advocacy group Africa Fighting Malaria and is based in Kampala, Uganda.