Exploration of Malaria Prevention Methods in Endemic African Countries
By: Rachel Passmore
Background
Her fever was extremely high. As she slept, her body shook and her forehead dripped
with sweat. We did not want her conditions to get worse as renal failure, severe anemia, and a
long-term coma could follow. There was no ambulance to call; Two other tourists said they
would help her onto the tro-tro, a refurbished van that would transport her to the hospital as it
picked up and dropped off other passengers along the way. Lainie lived, but not all are so lucky;
660,000 people worldwide die every year from the parasite Plasmodium, which causes malaria
and is transmitted through bites from female Anopheles mosquitos.
I traveled to Ghana, a country in West Africa, in the year 2010. Ghana is one of 43
malaria endemic countries on the African continent. Prior to departure for endemic Ghana, I was
easily able to purchase a mosquito net and insect repellant as they are readily found at American
“outdoor gear” stores. However, when I arrived in the rural village of Eguafo, I noticed that no
village residents had mosquito nets or insect repellant like I did. This made me wonder: How do
permanent residents of endemic African countries protect themselves from malaria, and what are
the pros and cons to each method of protection?
When I returned to the United States, I researched this issue. I found that there a two
commonly used methods for malaria protection in Africa: Insecticide Treated Nets (ITNs) and
Indoor Residual Spray (IRS).
Insecticide Treated Nets (ITNs)
Sir Ronald Ross, a Nobel Prize winner for Medicine, recommended in the year 1910 that
armies use bed-nets as protection against mosquitos. Since his recommendation, bed-net use
surged, and starting in the 1970’s, bed-nets treated with pyrethroids (organic compounds found
in insecticides) were deemed safe. When consistently used, insecticide treated nets (ITNs)
effectively work against malaria in endemic African countries. For example, in endemic
Tanzania, ITNs led to a 78% reduction in the weekly rate of reinfection. Statistics by the Roll
Back Malaria (RBM) campaign show that ITNs reduced deaths in young African children by an
average of 20 percent from 1980 to 1990.
Costs of ITNs are low when viewed through an American lens: A study in Tanzania
showed the total cost of an ITN (including the cost of insecticide, labor, and transportation) to be
$1.02USD per year, with the lowest reported price to be $.050USD in Zambia, made possible
through subsidies. There are acts which help lower costs of ITNs, for example, the Abuja
Declaration, which led to twenty African governments removing taxes and tariffs from ITNs in
the year 2001. However, many persons who need the bed-nets still cannot afford them – a 1995
study by American economist Jeffrey Sachs showed that the gross domestic product (GDP) of
malaria endemic African counties to be 5 times lower than that of non-endemic countries -because of constraints by poverty or because of dependence on hand-outs.
Most ITNs found in Africa are neither made in African nor purchased by Africans
themselves; they are created in the United States and distributed for free via American nongovernmental organizations (NGOs) and “western” philanthropic organizations. There is much
controversy about whether ITN handouts are “good” or “bad.” The “good” argument is that
many Africans cannot afford ITNs themselves, and many are at risk for contracting malaria, so it
is best that these people are just immediately protected. The “bad” argument can be elaborated
by international economist and African native Dambisa Moyo, in her book Dead Aid, in which
she states that hand-outs are undermining the African economy, and are not sustainable. In her
opinion, it is best to have African small businesses produce ITNs and for Africans themselves to
distribute them. This allows for Africans to have employment, and if the ITNs tear, which they
are likely to within five years, Africans that are using the nets can go to their local producer to
receive new ITNs as opposed to waiting for another international shipment.
Even with ITN handouts, most ITNs are not used. As estimated by the RBM campaign,
only 3 percent of African children under the age of five, the most at-risk group for malaria, use
ITNs. In the year 2006, a study was completed by researcher Natalie De La Cruz in malaria
endemic Ghana which correlated a lack of bed-net use to a wide-range of causal theories,
unrelated to mosquitos. Causal theories linked symptoms of malaria to over-working oneself,
staying in the sun too long, and working too close to fire. Although these theories differ from
American viewpoints of health and disease, they should not be looked at as “barriers.” Rather,
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these theories should be looked as something to build upon; For example, De La Cruz believes
that the sun-related theories could “be promoted as a way of keeping mosquitos from detecting
and feeding on hot blood at night…”
Additionally, use of ITNs is low because they can be sold and the proceeds from the sale
can be used for immediate needs, such as food. ITNs also trap heat, causing discomfort during
sleep. Looking back on my own experience, this proved to be true: Children and families in
Eguafo ate riced based meals with “red-red” sauce (a tomato paste), twice a day, and often
complained of hunger. This would lead me to assume that if the residents were given ITNs, they
would sell them for food. Furthermore, children were confused when I went to sleep under my
ITN. It was a scorching 97 degrees Fahrenheit, and they wanted to sleep in the airiest and coolest
space of their residence, not under an ITN.
Figure 1: Boy under an Insecticide Treated Net (ITN) – Photo credit to Sarah Hoibak
Indoor Residual Spray (IRS)
Indoor Residual Spray (IRS) programs involve covering the inside of walls in homes with
insecticide to kill mosquitos. The first large-scale movement, called Global Malaria Eradication
Campaign, to promote IRS programs started in 1955. However, when funding and research
declined, because the task to kill mosquitos via IRS proved to be more difficult than originally
thought, the campaign was shut-down in 1969. Still, as noted by researcher Dohyeong Kim at
North Carolina Central University, IRS programs can reduce the risk of malaria up to 62 percent.
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Dichloro-diphenyl-trichloroethane (DDT) was the main component of IRS programs until
the 1960’s. Because of concerns for the environment, as seen in in Rachel Carson’s Silent
Spring, and concerns for human health, such as possible damage to the reproductive system and
increased risk of liver cancer, DDT was banned in the United States in 1972. This ban lead to a
significant decline of its use in IRS programs, as most programs, like ITN distribution programs,
are initiated through American or “western” organizations.
Even with the DDT ban, the World Health Organization (WHO) still recommends DDT
as one of twelve pesticides to be used in IRS programs, and states that “DDT presents no health
risk when used properly.” DDT is one of the cheaper options for IRS programs, as it was found
that other pesticides such as Lambadacychalothrin, which comes to $2.30USD per spray, can be
up to 62 percent more expensive. According to The World Bank, the agricultural sector makes
up 65 percent of Africa’s labor force. Therefore, it is important to keep in mind the risks of
constant exposure, such as working all day in insecticide sprayed fields and then coming back to
an insecticide sprayed home, in relation to cost of these chemicals used in IRS programs in
Africa.
Africans in research studies oppose IRS programs mainly because of the bad smell and
the wall stains by DDT spray. Upkeep of IRS programs is also quite difficult, as 80 percent of all
walls must be constantly covered by insecticide. Because of those reasons, wall washes or paint
layers to rid the smell increases while reuse of DDT decreases, and subsequently, effectiveness
decreases. Effectiveness also decreases because after prolonged exposure, mosquitos can become
resistant to insecticides. In fact, according to the Center for Disease Control (CDC) there “are
over 125 mosquito species with documented resistance to one or more insecticides.” I witnessed
this in Eguafo; the spray that was used in my home was not effective in trapping or killing most
mosquitos. The smell was terrible, and I did not see IRS applied to the homes around mine.
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Figure 2: Indoor Residual Spray (IRS) being applied to a house in Malawi – Photo Credit to C. Campbell
Conclusion
The people I interacted with, lived with, and worked with, during my visit to malaria
endemic Ghana were absolutely wonderful. However, their risk of being adversely affected by
malaria is unfortunately very high. The two main methods of protection from malaria in endemic
African countries, insecticide treated nets (ITNs) and indoor residual spray (IRS), are not
consistently used, and there is much controversy about their existence in African countries. My
fairly simple experience of buying and using mosquito nets and insect repellant does not
transcend geographic borders; Protection from malaria in countries caught in the complexities of
poverty is very complicated. With continued research, and increased collaboration between those
interested in global health, there is hope for finding a malaria protection method that will pose
low external risks, be sustainable for African economies, and overall, reduce the burden of this
disease which is taking the lives of too many people.
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About the Author
Rachel Passmore is a senior at The Pennsylvania State University at University Park, set
to graduate in May 2014 with a major in Human Geography and with three minors: Global
Health, Sustainability Leadership, and Environmental Inquiry. Rachel grew up in the suburbs of
Washington, D.C., and desired to learn about life outside her “bubble”, so she independently
traveled to Costa Rica, Ghana, and India to be immersed in various cultures and interact with
various peoples. Post-graduation, Rachel hopes to work on the grassroots level of development
initiatives, through the United States Peace Corps or The Fulbright Program. Currently, she
works as a writing intern for NEWBio, a USDA funded research project on biomass as an
alternative energy source, and serves as the co-chair of the Penn State Student Sustainability
Advisory Council (SSAC).
Photos from Rachel’s visit to rural Eguafo, Ghana during the rainy season
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