Mosquito nets, malaria prevention, and the challenge of public health.

PSI, a US-based NGO that promotes family planning and disease prevention internationally, set up a malaria education/prevention station a couple blocks from my house last week. With funding from the Global Fund to Prevent TB & Malaria and USAID (that’s YOUR tax dollars at work), they distributed free insecticide-treated bed nets to all families with children under the age of 5 and hundreds of malaria prevention pamphlets that are now half-buried in the muddy streets of the neighborhood. In the last decade, programs like this one have reduced the number of malaria-related deaths in children by the millions, but after several years of seeing these programs implemented in Africa, and after discussing the logistics of PSI’s campaign with my Kiswahili teachers, I can’t help but wonder how much more successful such programs would be if the people designing them had a better understanding of the culture of the country in which they’re working.

From an American perspective, we think that by giving people the education and resources they need to prevent themselves from getting a disease, they’ll do it. If we distribute mosquito nets to families and tell them these nets will keep their kids from dying of malaria, they’ll use them. Right? Unfortunately it’s not that simple, for a number of reasons:

1. Since the Global Fund is focusing on preventing disease in children, all the nets PSI distributes are for child-sized beds. This would work in the US, where babies sleep in bassinets and cribs and twin-sized beds, but most African under-5’s sleep in a full-sized bed with their parents or siblings. A crib-sized net is pretty much useless here.

2. Many African families sleep on foam mattresses or grass mats on the floor of a one-room house. During the day, the beds are stacked against the wall and these rooms are used for cooking, bathing, radio listening, tea drinking, homework doing, and a hundred other daily activities, so permanently installing a insecticide-stinking mosquito net in the middle of the room isn’t exactly practical. (In fact, it’s probably a fire hazard.) And taking it down and putting it back up every day gets old really quick.

3. The nets aren’t distributed with the hardware and/or ropes needed to hang them, and most families don’t have these things just lying around. Four little hooks and enough rope to hang a single net cost about 25% of an average family’s monthly income. Who can afford that?

4. There’s no way to ensure that the people receiving the nets actually need them. Families that received free nets last year collected new nets again this year, and there’s no way to prove that someone who says they have a 2-year-old doesn’t actually have a 2-year-old. Since many children are born at home, there’s no master list of all children under the age of 5, and many children aren’t counted by any government registry until they enroll in the first grade. Basically, anybody who wants a net gets a net. Or two.

5. Mosquito nets have considerable market value so many families sell them. Hotels constantly need new nets for their malaria-fearing foreign guests who expect clean, hole-less nets over their beds. Dress-makers use the tulle-like netting as a lining for dresses. Fishermen double up the netting to make low cost fishing nets. And others are just re-sold as is to the net-needing public at the local market, which is how I ended up with my not-free PSI/USAID mosquito net. 

6. Treatment for malaria is widely available and 100% free courtesy of USAID, WHO, and other organizations. At any hospital or clinic, children and adults with malaria or malaria-like symptoms gets chloroquine or primiquine, usually with a free overnight stay in a warm, comfy bed and a couple of meals. So why bother prevent it when you can treat it just as easily, plus perks? 

I can’t help but wonder if there’s a better way to prevent malaria in Africa. If PSI gave out full-sized nets, how many more malaria-related deaths would be prevented? If the nets came with a couple yards of rope, would more people hang them? If PSI distributed them door-to-door, would fewer nets be given to families that already have nets? If nets were given to new mothers at the hospital or clinic after birth or when the child is brought in for his first vaccinations, would the number of nets distributed more accurately match the number of infants in the country? If retailers found to be re-selling free nets were punished in some way, would they think twice about re-selling the nets? If parents had to pay for malaria treatment, would they try harder to protect their kids from it in the first place?

Most importantly, does the benefit of this kind of mosquito net distribution outweigh the faults of the program and warrant its continuation? I think so.

No public health program implemented in the developing world (or anywhere, really) is 100% effective. The eradication of polio is most often cited as an example of a successful public health initiative, but 10 minutes in any African city full of polio-crippled beggars will prove that polio hasn’t been eradicated. But if the alternative to a program that reduces new infections of HIV by 5% is no program at all, isn’t that 5% still worth working for?

I found myself asking a similar question a few years ago when I was working for A Wider Circle, a fantastic DC-based non-profit that provides nutrition education, after school programs, job training, and furniture to low-income families in DC, Maryland, and Virginia. Day after day I taught low-income seniors how to make heart-healthy fruit smoothies and helped Hurricane Katrina refugees move free furniture from Bethesda demi-mansions into their tiny FEMA-subsidized apartments, and I felt like it was worth it.

But I remember one Saturday morning when a woman with a Baby Phat track suit and a fancy cell phone rolled up in her big black Escalade, a flock of Nike- and Roca Wear-clad children in tow. We helped her load her new bedroom set into her Escalade and strapped a brand new mattress to the roof, reserved for her a dining room set and big color TV, and sent her off with a big bag of day-old high end pastries from a Georgetown bakery. The other volunteers and I couldn’t help feeling taken advantage of. Were we giving up our Saturday mornings to give free things to selfish pseudo-poor people in expensive clothes? If a woman driving an Escalade could get a free queen-sized mattress from an NGO, why was I sleeping on a broken-down twin mattress on the floor of a walk-in closet?

Mark, the organization’s director, was the only one who was still smiling. He asked us, “If 99% of the families we help actually need the help we give them, is it worth putting up with the other 1% who are like that woman?” We agreed that it was. “What if 25% of the people we help are like her, and only 75% actually need the help. Should we keep working?” Sure, we said—those 75% of families are still better off than they would be without our help. “What if 95% of the people we help are like her and only 5% actually needs us?” By our own logic, that’s still 5% of families that are better off because of our work, so we should keep working. But what’s the threshold?

With any project intended to help people, there’s going to be failures. Selfish people who don’t need help will get free stuff, and people who actually need help will be overlooked. Mosquito nets that are intended to protect a child from malaria will be sold so his mother can buy new shoes or pay school fees, and when the child gets sick his new shoe-wearing mother will take him to the hospital for free treatment. Where there’s free stuff, there’s someone waiting to take advantage. But there are also people whose lives can be saved by free food, and children whose lives can be improved by free health care, so shouldn’t we keep providing it? The only alternative is to deny help to EVERYBODY, which punishes the freeloaders of the world by refusing to help people who actually need it. That’s not really fair either, is it?

Even if the world will never be FAIR, I hope that the work that NGOs and aid agencies and I myself do at least helps make life little less UNFAIR. That’s reason enough to keep distributing mosquito nets, to keep learning a seemingly useless African language, to keep trying, right? I think so.