Response to Sandra's comment

I wanted to respond to Sandra's comment about the Nothing but Nets program too, as has Jamie. Sandra expressed concern in her comment that this program could undermine the local bed net economy, and she noted that bed nets in Malawi were cheaper by half than the $10 donation/bed net in the Nothing but Nets program. Thanks to Sandra for bringing these points of view to our attention.

RETAIL MARKETS AND BED NET DISTRIBUTION AND USE
There has been a lot of focus on how to get bed nets into communities of rural Africa, and it led to a pretty sharp debate that seemed to follow the political spectrum to a certain degree. On the one hand was a group of people who felt that retail market forces should drive purchasing decisions. However, it has been determined that under these conditions, when people could simply pay for their own nets in the retail market on the basis of an economic choice when a wide range of choices exists (buy food, a new bicycle tire, a battery for the radio, cell phone time, medicines), that bed net purchases fall behind and the number of bed net users in a community does not rise to a sufficiently high level to lower malaria transmission. Here, it is important to understand that bed nets are really best thought of as community protection tools, as opposed to personal protection devices. The goal is to get as many people using them as possible in a community, so that mosquitoes die and malaria goes away.

Given this observation, a series of "social marketing" programs were tried in several different countries, including Malawi. Traveling shows would put on music events and education programs, hand out hats and t shirts, and try in this way to market bed nets by raising social consciousness of them. Those programs didn't work well either. In both cases, people had to pay part or all of the price of the net and in the realm of choices, bed net purchases were down the list of priorities for people.

On the other end of the spectrum (and I'll admit this is where I fall) is to consider that bed nets are a public good, much like a vaccine, and that poor people should be given them through national roll out programs. But somebody, somewhere, still has to provide the funding to buy the nets. This is where the Nothing but Nets program, the President's Malaria Initiative, and others like it come in. National ministries of health have partnered with this idea.

I recently saw a graph of bed net use in Kenya surveyed from the late 1990s to 2007. Use rates very slowly went up with the initiation of retail sales, but stayed low overall. When the national rollout campaign began in 2006, use rates shot up rapidly to nearly 60%. This shows that the retail market system is inadequate to achieve the high use rates needed to have an impact.

TYPES OF NETS
Another comment is about the kind of nets. There are actually no bed net manufacturers in Africa. The companies that make them are typically "first world." Nets are mostly made in factories in India, Thailand, and Vietnam, and are imported. So, undermining the local economy is not really an issue. A single bed net factory in Tanzania has been constructed to produce Olyset Net, a brand owned by Sumitomo, but the quality of these nets has been variable. Many countries have agreed to eliminate import tariffs on nets to keep prices down.

The cheaper nets that Sandra refers to are an older formulation that need to be retreated with insecticide every 6 months or so, and that are not wash durable. They remain on the market under several brand names but are now being replaced by LLINs. The newer types of nets are so called Long Lasting Impregnated Nets or LLINs and these are wash durable, do not need to be retreated, and may last for up to 5 years depending upon the type of synthetic fiber used in them. These indeed are more expensive and are of the type that Nothing but Nets and other programs purchase for distribution. They are superior to the other non-wash durable types in all respects and in the long run are cheaper because they last so much longer. All of them are manufactured by "first world" companies, e.g., Vestergaard Frandsen of Denmark, Sumitomo of Japan.

ECONOMICS OF MALARIA
The idea that donating bed nets would undermine the local economies of rural Africa (which I think is highly unlikely given the above discussion) must be balanced by a discussion of the positive economic effects that alleviating the malaria burden has. When bed net use is high enough to reduce malaria transmission, there are healthier pregnancies, healthier newborns, fewer trips to clinics for malaria treatment, fewer medicine purchases, higher school attendance rates, and better growth and development of children. When the human population is alleviated from the malaria burden, there is a surplus of resources that otherwise would have gone to malaria prevention and malaria treatment; this surplus can then be used for other types of economic activities. All of these outcomes have clear, positive economic effects and could be viewed as part of a larger, socioeconomic and development context. I believe Jeffrey Sachs and the Earth Institute through its Millenium Village program is having a look at these economic benefits; certainly Dr. Sachs has written about it.