Do bed nets save lives?

On April 20, 2009, in behavior, infant mortality, malaria, by Karen Grepin

With all of the fanfare that donating bed nets have received this past week, thanks weirdly enough to Ashton Kutcher, and the debate that has ensued in certain circles, I thought this question was worthy of a post. I believe that the answer is yes, bed nets do save lives, however, they may not be the most effective intervention in all cases, and bed nets alone are not going to eliminate malaria.

When used effectively, bed nets can save lives. The benefits of insecticide-treated bednets (ITNs) have been shown in efficacy trials, which have suggested that bed net usage can lead to about a 20% reduction in all cause mortality in children, although the effectiveness depends on the intensity of malaria in the area. Mortality of course is only one indicator that we should care about, malaria also has a tremendous morbidity burden, so a comparable reduction in morbidity would also be a really great thing. Most studies actually show an even slightly larger reduction in incidence. But, it is worth noting than when used in experimental conditions we only see about a 20% reduction in mortality among children, which is likely to be reduced when we leave the world of RCTs and move into the real world where everything is more complex. While twenty percent is a lot, but it is not 100%. This also does account for adult mortality or morbidity.

Although there is not strong agreement, there is some evidence that malaria incidence and mortality may be declining in a number of African countries. Many people attribute this to the successful scale-up of “Roll Back Malaria”-like national control programs, but this too has been debated. I actually don’t see this as the real debate: I think what we are doing with malaria is working (I just wish we had better data systems that allowed us to measure it) I think the real debate is about what aspect of these programs is working and which are the most cost effective. These are all multi-component plans, so it is hard to isolate the contribution of any one part. Research from Kenya, Rwanda, Ethiopia, and the Gambia (among others) has all pointed to declines in malaria even if these studies are not well controlled and rely on terrible data. But something is happening, that I am sure.

Once upon a time I would have probably argued in favor of the simplicity of ITNs as a strategy to improve health because of the minimal behavioral aspects of its use. Public health struggles to influence people to change behavior, which is REALLY, REALLY, REALLY hard. Compared to giving up alcohol, quitting smoking, changing sexual practices, and exercising daily, promoting sleeping under a bed net seemed simple to me. But then I realized, I rarely do it myself when I am in Africa. Rarely is there a hook I can use above my bed (where the fan is usually positioned), I am rarely willing to sacrifice that much of my carry-on space (I never check luggage), and they are really hot and stinky to sleep under. My friends in Africa, mainly young, well educated middle class professionals, frequently complain about bed nets and none of them claim to ever sleep under one. I also think we have largely ignored how individual behavior will affect the usefulness of nets and rather than just focusing on just supplying more and more nets, we need to figure out where they are most useful, and how best to make them effective.

There is an opportunity cost of doing anything when financial resources (from donors, from countries and from households) and domestic capacity to implement are limited (which they are everywhere, in particular developing countries). If bed net programs get prioritized at the expense of other interventions that are equally and potentially more effective than it becomes a problem. Western advocacy and fundraising organizations seem to promote the message that all we need are nets and malaria will go away (case in point one organization is actually called “Nothing but Nets” whose slogan is send a net, save a life). Malaria was eliminated from many parts of the world over the past century or so, largely before bed nets were in common use. Rather many of the victories of the past have been attributed to indoor spraying, vector management strategies, and environmental management. A multicomponent response will be needed in Africa as well.

So while I am pleased to see more debate and awareness over malaria control, I think we should rely more on evidence and history to guide our priorities rather than just celebrity attention.

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