The Current:
Spring 2007
Preventing Malaria: Net Gain or Net Loss?
Evan Daar

"American foreign policy is more than a matter of war and diplomacy," said President George W. Bush in his State of the Union address this year. "Our work in the world is also based on a timeless truth: To whom much is given, much is required." During his address, the President pledged $1.2 billion as part of the President's Malaria Initiative, which was launched in 2005 with the stated goal of halving the number of malaria-related deaths worldwide. The $1.2 billion will be given over the course of five years to help fight malaria in fifteen African countries. The World Health Organization (W.H.O.) estimates that malaria kills more than one-million people every year. That is one person every thirty seconds. Most of these victims are women and children in sub-Saharan Africa, where the deadliest strain of the malaria parasite, plasmodium falciparum, is most prevalent. The W.H.O. estimates that malaria costs Africa $12 billion in lost GDP every year.

President Bush is absolutely right for confronting this deadly pandemic. Fortunately, the President is not alone in the fight against malaria. The Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, donates funds to countries with a proven perfor­mance of confronting these three diseases. Today, The Global Fund is the world's larg­est source of funding for countries fighting malaria. Additionally, the Bill and Melinda Gates Foundation, the largest charitable organization in the world, recently announced a $258 million donation to help fund research into malaria. Established in 2000 by Bill and Melinda Gates, the Foundation has the goal of promoting global health, education and economic development. Their recent donation adds to the $230 million that the Foundation has already contributed to malaria research since 1999. Each of these groups donates large portions of its total resource pool to fight malaria because of the timeless truth that President Bush referenced: "To whom much is given, much is required." Beyond the responsibility to use their wealth of resources to benefit those in need, these groups have an even greater responsibility: to use their resources effectively.

A large portion of President Bush's $1.2 billion pledge to fight malaria will go to the purchase and distribution of insecticide-treated bed nets. In addition to the President's Malaria Initiative, charitable groups like The Global Fund and The Gates Foundation pour millions of dollars every year into bed nets. The Global Fund is the largest financier of bed nets in the world, having donated 109 million bed nets for distribution in sub-Saharan Africa. In addition to funding the distribution of bed nets, there is also a need for research which will make the product more effective and longer lasting. In 2005, The Gates Foundation donated $50 million for research into longer lasting bed nets. Because they are an integral factor in the fight against malaria, it is important to understand how they work, and more importantly, whether they work.

Bed nets act as a barrier between people and the mosquitoes that carry the malaria parasite. The nets are first treated with an insecticide spray that repels or kills the para­site-carrying mosquito, and are then draped around a person's bed during the evening. People are told to sleep under the nets throughout the night because the peak infection times in most of sub-Saharan Africa are between 10:00 p.m. and 4:00 a.m. Most bed nets can fit two people at a time.

If implemented properly, a bed net can be a cheap and effective tool in the fight against malaria. A study of rural villages along the Kenyan coast showed that the introduction of insecticide-treated nets led to a 33% reduction in overall childhood mortality rates. This results from a 44% drop in severe, life-threatening malaria among children. These are all very encouraging numbers.

Unfortunately, proper distribution and implementation of nets on a large scale is much easier said than done. Making sure the nets get to the people that need them in a cost-effi­cient manner is a complex process. And if they are not distributed in the right way, their effectiveness is reduced dramatically.

Bed nets are typically distributed to people in one of two ways. The first method involves free distribution through local health clinics in rural African villages. This is the way that the President's Malaria Initiative chooses to distribute them, as does The Global Fund. In this scenario, bed nets are first given to an African government and are then distributed to local health clinics run by local health officials or volunteers. Citizens then come to the clinic to receive the nets and receive information on how to use them. Some distribution programs combine bed net distribution with a vaccine initiative, thus giving citizens two reasons to come to the clinic.

The other method of distribution involves selling the nets to people using a process known as social marketing. Social marketing is the process of incoluding a particular good to a population with the goal of changing the social practices of that population. The social marketing strategy involves the use of existing social and financial institutions in an African town or village to sell bed nets to groups of citizens who can afford them. This typically means middle or upper class citizens in urban centers. Changing the behavior of these citizens, so the strategy anticipates, should result in a societal shift encourag­ing people to pursue and buy nets. Advocates of social marketing argue that when this method is applied to the sale of bed nets, a sustainable market is created which can outlast the generous but limited donations of individuals and governments. The most prominent social marketing campaigns are carried out by Africa-based non-governmental organiza­tions and various African governments. The benefits of social marketing are trumpeted by its proponents. Opponents of the technique, however, argue that it is unethical to charge for nets when most people cannot afford them at all.

One such opponent is Dr. Awash Teklehaimanot, professor of clinical epidemiology at Columbia's Mailman School of Public Health and director of the Malaria Program at the Earth Institute. Dr. Teklehaimanot does operational field research on malaria epi­demics and assesses the efficacy of malaria program implementation. He works with the Millennium Villages in Africa, which are rural villages under the direction of the Earth Institute established as models of how small villages can lift themselves out of poverty. With regards to social marketing, Dr. Teklehaimanot argues that bed nets only work if they are distributed for free. "The poorest of [the] world should not be charged," he argues.

In 2003, a team of nine researchers from around the world set out to a group of Western Kenyan villages to determine if people in rural villages would be willing to pay for bed nets. The project involved the distribution of nets to these communities in addition to a survey taken of the mothers in the community on a range of issues relating to malaria. After the nets were distributed, the researchers asked the mothers how much they would be willing to pay for the nets and whether or not the mothers considered them a priority item. Mothers were willing to pay approximately $4.50 for a bed net. However, the par­ticular nets distributed in this study had to be chemically re-treated every six to twelve months or they would lose their effectiveness. Most mothers said they were not willing to pay to have the nets re-treated this often. And when they were asked about the priority they would place on buying bed nets, only 7% of the mothers placed them as a top-three priority item. Most put food and clothing as the top two items on their list. Considering that a majority of people in sub-Saharan Africa live on less than one dollar a day, it seems unreasonable to think that people can afford bed nets in addition to the bare necessities of food and clothing.

From A. Platt McGinn, "Malaria, Mosquitos, and DDT," World Watch.

A 2006 study done by a team of researchers from London and Tanzania, published in the Malaria Journal, also examined the effectiveness of bed net social marketing. The study focused on the number of people with working bed nets after a social marketing campaign. The research­ers studied a Tanzanian town and its surrounding villages where citi­zens were sold the nets, as well as a separate cluster of Tanzanian villages where the nets were pro­vided for free. The researchers then recorded the percentage of people using bed nets (the bed nets' "cover­age") in the two groups. The differ­ence between the two was striking. In the town where the bed nets were sold, coverage was very good, well over 50%. In the surround­ing villages where the people were charged for the nets, though, only 9.3% of people had ones that were functioning. In contrast, the sepa­rate cluster of villages where the nets were provided for free had over 90% coverage. It should be noted that most people in sub-Saharan Africa live in villages smaller than the town studied in this report. So while social marketing might prove to be an effective tool in larger, more urban centers, it seems ineffective in reaching the large number of at-risk people in rural villages.

To confront the malaria pandemic and reach the largest group of people, bed nets must be provided for free.

Recently, the emergence of long-lasting insecticide nets has replaced the use of older forms of bed nets. Old bed nets had to be re-treated with insecticide every six to twelve months, increasing their cost. As the research team in Western Kenya showed, most rural Africans were not willing to incur the costs of re-treatment. These new long-lasting nets help to solve that problem because they do not require constant re-treatment. Long-last­ing nets have an effective duration of five years and cost $5 apiece—a significant reduction in cost compared to the old ones.

Unfortunately, there is still cause for concern even if long-lasting nets are provided for free. The price of bed net distribution is more than just the cost of the net itself. These added costs are a result of the disparity in information regarding malaria between Africa and the West. The same 2003 research team that looked into the priority that women in Kenya placed on bed nets also set out to grasp the severity of the information gap. Before the study, 75% of the Kenyan mothers were aware that mosquitoes were a cause of malaria; however, only 27% thought that mosquitoes were the sole cause. Forty-seven percent of the mothers thought getting cold was the sole cause of malaria. Almost half the population did not know that protection from mosquitoes prevents malaria. Combating this wide­spread ignorance about the basic facts of malaria is an enormous hurdle that any distribu­tion campaign will have to clear before the nets will really be effective. It will involve the mass distribution of information about the causes of malaria, and about the proper way to use bed nets. According to the Center for Disease Control and Prevention (C.D.C.), these information campaigns effectively double the cost of a bed net, from $5 to $10. Millions of nets are usually purchased at one time, resulting in additional costs ranging in the hun­dreds of millions of dollars. This means fewer bed nets are delivered because a significant portion of the overall donation must go to the education campaign.

The researchers of the Western Kenya study conducted a public information campaign involving the dissemination of leaflets and announcements at public gatherings. Even with their effort, though, the lack of information about malaria after the distribution of the nets was significant.

In that particular study, the bed nets distributed were the older kind that required re-treatment every six to twelve months. The researchers attempted to inform citizens that the nets needed to be re-treated, and that the re-treatment would not cost anything. Still, only 76% of those given nets were aware that they had to be re-treated periodically, leaving almost one quarter of the population with a dysfunctional bed net in a year's time. Furthermore, only 43% of the mothers knew that they had to use the nets every night, and only 37% knew that the nets needed to be replaced if they were torn. This means that even with the public information campaign, less than half of the citizens given a bed net were actually using it properly. This severely reduces the efficacy of the bed nets and is a direct result of the information gap. The true cost of waging an effective public information cam­paign—one that will lead to a sufficient understanding of malaria and bed nets—is probably much more than the C.D.C.'s estimate of double the cost of the net. So while a donation of $1 million may technically be able to buy 200,000 bed nets, factoring in the cost of educa­tion significantly increases the actual cost of each net.

What about when the bed nets do finally reach the people, and the recipients know how to use them properly, are they effective then? For the most part, yes. Most studies show that the introduction of bed nets to a community results in a 30% reduction in the overall child mortality rate. This results from an almost 50% reduction in the number of children infected with malaria. One study in West Africa showed that long-lasting nets deterred mosquitoes more than 90% of the time.

There is a common claim that "bed nets won't work without beds." The implication is that bed nets are a useless prevention method in poverty-stricken Africa. As the numbers above show, though, this is not the case. Naturally, there are a number of problems with bed net manufacturing and distribution. But when distributed properly and paired with an effective information campaign, bed nets can have a serious positive impact on malaria prevention.

In order to improve effectiveness rates, a lot of work is required. Firstly, an effective and widespread information campaign must precede the distribution of the nets. Without the knowledge of how to use them, the bed nets are essentially useless. Secondly, bed nets must be provided for free. Social marketing campaigns have only been shown to work in large urban settings with middle to upper class populations. The fact remains that a majority of those infected by malaria are in poor rural villages, where social marketing campaigns have failed. The argument for social marketing—that it will create a sustainable market for bed nets—does not hold when one considers that a majority of Africans live on $1 a day or less. This is barely enough to afford the food and shelter that almost all Africans identify as priority items, let alone a bed net, even if it is priced below the $5 cost. As a result, the sale of bed nets in small African villages will not generate enough demand to create any market. Lastly, the bed nets distributed need to be long-lasting. Most Africans are not will­ing to pay for the cost of re-treatment every six months, and we have seen that, even with a public information campaign, a large number of people do not know that the nets need to be re-treated. Newer nets that will last for five years help to eliminate this problem.

The future of bed nets and their ability to fight malaria is promising. The generosity of the United States and groups like The Global Fund and The Gates Foundation will help save millions of lives. When millions are spent every year on bed nets, the money must be spent responsibly, and the nets must reach people in need. This means asking important questions about how bed nets are distributed and about the education campaign that goes into their distribution.

Evan Daar is a sophomore in Columbia College majoring in Economics. He can be reached at ehd2106@columbia.edu.

design by zach van schouwen