Bed nets for all?

30 Apr 2023
There is a river which runs through Goundry, a village in rural Burkina Faso, West Africa.

Actually it's more of a stream with lots of exposed riverbed even as the rainy season finishes. And among the still pools of mustard-coloured water, if you look closely enough, you can see the darting of tiny mosquito larvae.

Nearby is a village of thatched-roofed huts and enormous terracotta water pots. It is where the Nikiemas, a farming family live. They grow peanuts and sorghum, among other crops.

It's dusk and still well above 30 degrees and the mosquitoes are coming out to feed. The villagers, as usual, will provide a ready source of food for them.

The mosquitoes have given Mrs Tinkouna Nikiema, a 70-year old grandmother, malaria many times. Her granddaughter Catherine, a toddler, has already had malaria too.

In fact, Catherine has probably averaged about 300 bites from mosquitoes that could give her malaria before her first birthday. That's an enormous number given that children in other malarial countries in Africa average 50 infective bites a year.

That's why half of all deaths of children under five in Burkina Faso are caused by malaria. Pregnant women are vulnerable too. And that's why the family tries to sleep under insecticide-treated bednets (ITNs) here she says.

But in one of the tiny houses, where some of the Nikiema children sleep, there is no sign of a bednet. The problem is the family cannot afford nets for the whole family, explains Mrs Nikiema. Only pregnant women and children under five have been entitled to free nets, so family members sometimes go without or give their nets to others. The situation is worsened by wear and tear. "Last year I slept under a bednet but it was damaged. My daughter-in-law had to go to the hospital and gave me hers," she says.

Recognising this, the government of Burkina Faso has made universal coverage - getting several nets to every household - a key priority.

Dr Laurent Moyenga, Burkina Faso's malaria controller says everyone, not just pregnant women and very young children, should be prevented from getting malaria. Burkina Faso is already a very poor country and is 80% dependent on agriculture. So, when farmers are sick with malaria, there is a huge economic cost. "The peak time for malaria is the rainy season and that is time when farmers have to cultivate," he says.

Countries across Africa are expanding coverage too. Congo and Nigeria - with 36 percent of all malaria cases - are embarking on the largest net distributions in history. The global community too, views treated nets as a key tool in the fight against malaria. The Roll Back Malaria (RBM) partnership, a group of agencies, NGOs and governments, wants 700 million ITNs delivered worldwide by the end of 2010.

The momentum is understandable. Ninety per cent of all the malaria cases in the world take place in Sub-Saharan Africa. Around 850,000 die every year - and most of them are five-year-olds or younger.

Global ITN production has therefore increased 5-fold since 2004 to 150 million last year and the results are encouraging. Regular use has reduced child deaths in Africa by a fifth already. In 12 countries between 2000 and 2009, nets saved around 373,000 lives.

And that's why the mass net distribution is viewed as one of the cornerstones in the fight to control malaria.

But efforts to distribute nets more widely are running into problems.

Many countries say they cannot afford to provide enough free nets to every household by themselves. And although donor governments help to pay for schemes, the massive global bank bail-outs are leading to less aid. Burkina Faso, last year said a funding gap could result in a shortfall of up to 2.5 million nets. There is considerable extra expense because damaged and well-used nets need replacing too.

Secondly, more nets do not necessarily mean less malaria. Not everyone entitled to a free net sleeps under one and for a number of reasons. Some people do not fully understand the link between malaria and mosquitoes. Others do, but cook and sleep in a single room - especially in the rainy season - and nets are an impractical fire-hazard. Some have even been charged for nets that should be free.

Most worryingly, mosquitoes are becoming resistant to some insecticides used to treat nets. It's an unintended consequence of agriculture-dependence in countries across West Africa says Dr Sagnon N'Fale, a mosquito scientist at Burkina Faso's National Centre for Malaria Research and Training. "The prevalence of resistance is increasing because farmers are using a lot of insecticides in the agriculture," he says.

That's why there are increasingly calls for more focus on longer-term alternatives to ITNs, such developing a vaccine or new mosquito controls. Kenya's public health minister, Beth Mugo told reporters last month[April] that ITNs can only ever be a stop-gap. And Dr Chetan Chitnes, an Indian scientist who is developing malaria vaccines says: "We need long-term sustainable solutions and vaccines have always been the most cost-effective."

But others disagree. Dr Graham Reid, a health researcher at the International Development Research Centre in Kenya says the priority should be to improve rollouts of proven existing tools, including ITNs, because they could make an enormous difference if more widely available. "Universal coverage of bednets is still largely a distant dream and many countries are nowhere towards achieving it," he says.

Other existing tools will help immensely too, he says. Women who receive malaria tablets intermittently during pregnancy are far less likely to die or lose their babies. Children's lives can be saved by existing treatments too, says Reid. Yet there's far less access to these live-saving tools especially in places like Goundry. "It is not bednets which should be questioned but the political will," he says. "Pushing the talk into topics such as vaccines is only management by dodging."