Malaria is one of Africa's biggest child killers. The WHO has set a target to provide mosquito nets to all those at risk by 2010. But providing the nets is just half the battle.
7:00AM BST 05 Oct 2009
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Atong Deng put on her finest clothes today and walked for two hours to receive a household item that could save her life and the lives of her four children. Mosquito nets impregnated with insecticide are being distributed for free in the remote village of Riang Aker in the state of Northern Bahr el Gazal, Southern Sudan. It will be the first time Atong Deng has ever had a bed net.
Sitting under a tree, surrounded by other women from her village, she listened to a volunteer explain how to use the net, and which family members are most at risk of contracting malaria. "I learnt that children are more vulnerable," she said.
In Africa, children under the age of five die from malaria at an astonishing rate – around 3,000 a day, or one every 30 seconds. The disease is caused by a parasite, which is transmitted to humans when they are bitten by female Anopheles mosquitoes. Transmission occurs between dusk and dawn, when the mosquitoes feed on human blood and inject saliva containing the malaria parasite.
Malaria exerts a heavy toll in Northern Bahr el Gazal. A 2006 survey by the Government of Southern Sudan found that just over half of all children under five suffered from fever, thought to be malaria, in the two weeks before the survey.
Young children are vulnerable because they have not yet developed enough immunity to fight the infection, as are pregnant women. If patients don't receive effective malaria drugs within 24 hours of the onset of symptoms, the disease can quickly progress and damage the kidneys, liver, lungs, and brain. Severe cases can rapidly cause coma and death.
Cheap drugs, such as chloroquine, are rarely effective across Africa because the malaria parasite has become resistant. There is an excellent life-saving drug called artemisinin-based combination therapy (ACT), made from the Chinese wormwood plant, but it is expensive and often in short supply.
If Atong Deng's children sleep under an insecticidal net, they will cut their risk of contracting malaria in half. Their risk of dying from the disease will fall by around 20 per cent. The net works in two ways; serving as a mechanical barrier, it repels mosquitoes and prevents them from biting, and it will also kill them provided the mosquitoes are susceptible to the insecticide in the net's fibres.
The distribution of nets was organised by the Malaria Consortium, one of Africa's biggest malaria charities, set up in 1994 by the UK Department for International Development (DFID) as a centre of expertise on malaria control. It advised DFID on its global malaria projects, and also directly assisted countries that were struggling with the disease. It's a "boots on the ground" operation, which works hand in hand with national ministries of health to roll out malaria control strategies and monitor their impact.
"We marry our academic and research background with real world implementation experience," said Dr Graham Root, the charity's managing director, a British tropical disease expert based in Kampala, Uganda. The advice they give to countries like Sudan, he said, "is grounded in the realities that the countries face." The charity has distributed around nine million mosquito nets in Africa to date. Since two people can sleep under one net, that's protection for 18 million people. One of its newest projects is its support for Nigeria's campaign to distribute nets, launched in May 2009, with funding from the British and US governments, the World Bank, and UNICEF. More than a quarter of Africa's malaria cases are found in Nigeria.
The newest type of mosquito nets last up to five years, and some experts consider these to be one of the few "magic bullets" in global health. The World Health Organization's (WHO) malaria programme has set an ambitious target. It wants everyone at risk of malaria in Africa to sleep under a long-lasting insecticidal net by the end of 2010, which they hope will cut deaths by one half.
But while countries, such as Zambia, are moving towards universal net coverage, the continent as a whole is lagging behind. The WHO estimates that fewer than one in four children in Africa under five sleeps under a net at night.
One reason is that there just aren't enough nets to go around, even though Western donor organisations, such as DFID, have become more generous in paying for mass distributions.
"The UK has already delivered almost 10 million nets, with more on order," said International Development Secretary, Douglas Alexander. "This is part of the 20 million nets we are committed to delivering by 2010, and we have pledged to supply a further 30 million nets by 2013." Yet, Kenya, for example, needs to distribute about 14 million more nets next year to reach the WHO target, requiring at least $140 million of additional funding.
In Southern Sudan and Uganda, many of the communities most affected by malaria are the least accessible. One week after the net distribution in Riang Aker, the Malaria Consortium organised the delivery of 6,000 nets to a string of fishing villages along the shores of Lake Albert in western Uganda. The country has the world's highest recorded level of malaria transmission but the villages sit at the bottom of steep cliffs formed by the Rift Valley, which can only be accessed by plane and then boat, presenting major logistical hurdles to net distribution.
Another major threat to the WHO goal is that nets are not always used. Some people say they experience a sense of suffocation or discomfort under their net. Across East Africa, there is also a rich variety of cultural explanations for why nets go unused. In Uganda, malaria nets have been sewn together for use in fishing or turned into bridal veils. Some villages in Uganda and Kenya have been afraid to use white nets out of their belief that white is the colour of death. On the Kenyan coast, people mention "the talking nets" – some communities were convinced that their malaria nets were speaking to them. In pockets of Kenya, people believed nets were medicated with a drug that would make them infertile.
Dr Elizabeth Juma, director of Kenya's Division of Malaria Control, Ministry of Health, believes it is hard to get people to change their behaviour. "You have to get people into the habit of hanging a net," she said. In many Kenyan homes, there is no fixed sleeping area – a different place or room in the house might be used on subsequent nights. So people must be encouraged, she said, to carry their net with them to their next sleeping place.
Interviews with women in the village of Malou in Northern Bahr El Gazal also suggest there is substantial seasonal variation in whether nets are used. Amir Garang has three nets for her household, but she still hasn't used them because there are few mosquitoes at this time of year. "I'm looking for sticks to hang them, and waiting for the mosquitoes," she said. Distributors express frustration when they hear about nets sitting folded and unused in the corner of a hut while a child comes down with fever.
Dr Root believes that education is the key to improving the rate of net usage, driving home the message that nets save lives. When health workers give out nets in antenatal clinics, usage rates increase if they hang up a demonstration net in the clinic and show women how to use it.
Although net coverage and usage is on the rise, global health targets come and go, rarely being reached.
"There is a real concern about what will happen after 2010 when the jamboree ends," said Dr Root. The 2010 target has been simplified, he said, to raise funds and explain to the world that malaria can be controlled relatively easy. "That simply isn't true."
