Not long ago I had written a blog posting suggesting that widespread misuse of ITNs/LLINs was probably not a major problem. To date the main official published information on the topic came from a community near Lake Victoria that had received an abundance of nets through uncoordinated donor activity and the excess was being used to dry fish on the shore.
True, newspaper articles over the years have featured Ministry of Health officials in numerous countries berating their citizens not to use nets for fishing, agriculture and other non-disease control needs, but evidence had not been forthcoming in the numerous national demographic, health and malaria surveys over the years. There is also the acknowledged possibility that old nets are being repurposed since there are inadequate disposal mechanisms available.
Such concerns are not idle. We also documented misuse of LLINs in Akwa Ibom State with photographs of nets used to make football goals, protect seedlings in a nursery, cover small kiosks selling food items and penning animals. This occurred in areas where there was inadequate partnership, planning and follow-up with the community by health officials.
Now the New York Times has stirred up the controversy again with strong visual evidence of a fishing communities in Zambia and Tanzania using ITNs for not only fishing, but also making chicken pens, ropes, footballs and football goals. People in that community explain their economic needs which are huge in this poor area of the world, and present the hard choice between augmenting their livelihoods and sleeping under an ITN. The environmental impact of the insecticides when nets are misused was also highlighted. The immediate thought is that malaria control efforts must be integrated into health and development efforts in a country.
The US President’s Malaria Initiative has issued a statement of concern. PMI recognizes that misuse of nets can depend on the particular environment (e.g. near water), but also recognizes the need, as mentioned above, of collaborating with the community to get things right in the first place. These problems will persist until national malaria control programs focus less on the total numbers of nets distributed and more on the actual factors that influence net use.