Malaria is a huge medical problem. According to the African Medical and Research Foundation, over 3,000 children die from malaria each day in sub-Saharan Africa. The Center for Disease Control cites between 350 and 500 million cases of malaria worldwide every year. Contemporary policy makers have found long lasting insecticide impregnated bed nets (LLINs) to be an effective, if not the most effective, way to combat malaria. These bed nets not only keep malaria-carrying insects away from potential victims, but also repel or kill the mosquitoes that approach them. There is no question as to the worth of distributing these bed nets across malaria-affected areas. The question is how to do it most effectively.
Jeffrey Sachs, a well-known professor of sustainable development here at Columbia, is deeply involved with the issue of malaria in Africa. He advocates for the distribution of free bed nets over the continent of Africa, at a cost of roughly $3 billion per year. The problem with this plan, however, is precisely what Sachs is best known for: sustainability.
In 1955, the World Health Organization went the route that Sachs is pushing now—they tried to eradicate malaria entirely. Unfortunately, malaria is a disease with survivor instincts. When it was almost wiped out, the disease changed form (as it still does) to resist all vaccinations and treatments. Consequently, the WHO gave up, as did much of the rest of the world.
In a speech for the Bill & Melinda Gates Foundation, Melinda Gates pointed out that “if high energy and high expectations don’t lead to success—it saps money and morale. People give up. Governments, foundations, and corporations cut their funding, malaria surges back—and gains can be quickly wiped out.” This is what happened in 1955 after the WHO had promised to eradicate malaria and this is exactly what could happen again, if $3 billion a year towards bed nets does not solve this international health crisis.
So does that mean we should give up on those 350 million people who are affected by malaria every year? Of course not. There simply isn’t a fool-proof way to eradicate malaria—we must instead try to find a way to lower the death toll and keep it that way.
One sustainable way of distributing bed nets is through a social marketing scheme that involves distributing vouchers. In some African countries, such as Tanzania, voucher systems have been set up to distribute bed nets. Local merchandisers sell bed nets to members of the community, creating a job market where before there was none. Vouchers handed out by the government “allow pregnant women and children under five to buy an LLIN at a substantially reduced price,” Paola Mejia, an assistant at the malaria program of the Earth Institute said in an e-mail.
The problem with expanding the voucher system to include the rest of the population, she writes, is that it “would make the program more costly, as more nets would need to be subsidized. The voucher system needs to fund the net subsidy, plus the administrative and managerial costs of the delivery system.” Once the delivery system is in place, however, it has the potential to last far beyond the foreign aid, making the increased cost not only understandable but worthwhile.
My biggest problem with Sachs’ idea to blanket Africa in free bed nets is the possible harm to the merchandisers that are earning their livelihood from voucher distribution programs. These are the people who will still be in Africa if the eradication plan does not succeed. If their businesses are crippled by an initiative that gives bed nets out for free, for a limited time, will they be able to uphold an infrastructure that could be necessary in the future?
In Tanzania, “it is expected that ... the network of rural retailers will survive the universal coverage with free bed nets, since new LLINs will be needed to ‘keep-up’ coverage, but it is not certain at all,” Mejia admits. While it is a priority for UNICEF and the Global Fund to support the free distribution of bed nets, they also maintain other mechanisms for distribution. Alternatively, the WHO has started a free five-year net distribution plan and the Millennium Villages project, of which Professor Sachs is the director, also distributes free bed nets. There is clearly debate amongst the top global health organizations as to which plan works the best.
What I’m suggesting is not a paradigm shift to voucher systems of distribution, but a recognition of its merits. Mejia points out that the voucher systems work best in the cities, where there is more income disparity, but that most of the areas affected by malaria are rural. If sustainable infrastructures can be maintained in cities or suburbs where there is the market for them, they should be given a chance. At any rate, any blanketing of Africa with nets should try to work with the systems that are already there, instead of potentially suffocating them by destroying their markets. Even if subsidizing nets is not the most cost-efficient distribution mechanism, it is quite arguably the most sustainable, and therefore worthwhile, in the long run.
When the five-year WHO distribution plan is over, when Sachs has moved on, and when the other big organizations declare a job well done, malaria may still be a probably in Africa and Africa may very well still need those individual, local merchandisers.
The author is a Columbia College sophomore. She is an associate editorial page editor.