18 December 2007

Uganda: A Decent Standard of Living Will Help Eradicate Malaria


Kampala — THE month, the World Health Organisation (WHO) will give four brands of the 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 and should, in theory, make them more available to those in need.

But aid donors' single-minded determination to give everyone nets will not eradicate malaria.

Long-lasting insecticidal nets are 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 the deaths in African children under the age of five and is a significant cause of anaemia in pregnant women, causing miscarriages and low birth weight. The disease costs the continent an estimated $12b annually.

Mosquito nets work best when people use them consistently and appropriately. But many do not. 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 the children and pregnant women in Africa. How they actually use those nets is a different problem.

Part of the problem is that mosquito net distribution is outpacing education. Some people use donated nets for fishing, to make wedding gowns or as sieves, while others only use the nets during the rainy season when there are many mosquitoes, not realising 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 uncomfortable, especially for children. In Uganda, the Ministry of Health recently reported a study on 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 of them 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," says the health ministry's Malaria Programme director, John Rwakimari.

Indoor-surface insecticide spraying is a safe and a 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 the people welcomed sprayers into their homes.

This method is increasingly popular in other countries as well. All the 15 African governments participating in the US President's Malaria Initiative have opted to run indoor spraying programmes. 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 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 that same time, increased prosperity meant fewer people working outside on the land. Mosquitoes, therefore, had fewer opportunities to bite people, 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 more on the US side, the number of people suffering from dengue fever 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 politicised aid to control malaria, you can bet malaria will be back.

The WHO's approval of four new types of treated nets 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.

The writer works with Africa Fighting Malaria in Uganda, a non-profit advocacy group

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