The “Misuse” of Bednets Shows the Need for More Community-Led Development

What’s worse: malaria, or hunger?

If you’re reading this, there’s a pretty good chance that you’ve never had to Would You Rather that question.

Millions of people, though, have to weigh the relative chance of their children getting malaria vs. not having enough to eat. Every day. As Jeffrey Gettleman writes in a long piece for The New York Times, many choose the former:

But Mr. Ndefi and countless others are not using their mosquito nets as global health experts have intended.

Nobody in his hut, including his seven children, sleeps under a net at night. Instead, Mr. Ndefi has taken his family’s supply of anti-malaria nets and sewn them together into a gigantic sieve that he uses to drag the bottom of the swamp ponds, sweeping up all sorts of life: baby catfish,banded tilapia, tiny mouthbrooders, orange fish eggs, water bugs and the occasional green frog.

And later:

For Mr. Ndefi, it is a simple, if painful, matter of choice. He knows all too well the dangers of malaria. His own toddler son, Junior, died of the disease four years ago. Junior used to always be there, standing outside his hut, when Mr. Ndefi came home from fishing.

Mr. Ndefi hopes his family can survive future bouts of the disease. But he knows his loved ones will not last long without food.

Emphasis mine. For those who haven’t used one before, this is what a long-lasting insecticide-treated bednet (LLIN) looks like (though they aren’t always pink):

A bednet at the Dive Inn, in Kampala

A bednet at the Dive Inn, in the Kabalagala neighborhood of Kampala, Uganda. Yes, the Dive Inn; worth every penny of the 10,000 UGX ($4) per night cost. (Credit: Mike Miesen)

When used correctly – as they almost always are – LLINs are an incredibly cheap and effective way to prevent malaria and the child deaths, anemia, and other issues it causes. That understates it; they are the best means of preventing malaria. Full stop*. GiveWell helpfully reports on the evidence supporting LLIN distribution here, and it has listed the Against Malaria Foundation (AMF) as one of best uses of charitable funds for the past few years.

But as Gettleman notes, sometimes people use LLINs in other ways, ranging from the sartorial (as a dress or veil) to the life-saving – just not in the way the global health experts assumed they would.

Because it turns out that LLINs are, well nets – and really cheap ones at that. They have incredibly small holes, meaning they’re great at catching small fish like these, from Lake Malawi:

fish like this

Fish drying on the shore of Lake Malawi. Fun fact: with some salt, they’re pretty good. (Credit: Mike Miesen)

For communities living on the shores of large lakes and small streams in east Africa, fish are one of the most reliable sources of calories – and, crucially, protein. They provide live-saving calories to children and adults.

And yet there are people that are shocked – shocked – that some choose to use the nets that “we” gave them to prevent malaria for fishing; that the nets are being “misused” or that “our” benevolence is spurned by ungrateful recipients.

This is misguided. Using LLINs for catching food rather than preventing malaria is an entirely rational decision; it’s so rational that nobody should be the least bit surprised.

The problem isn’t “misuse.” It’s poverty, an utter lack of opportunity. When there’s no work to be done, individuals and families – even entire communities – make do the best they can. They may sell the excess vegetables that come from their plot of land so they can afford school fees, or they may “hack” the LLINs given to them to prevent malaria into a net used to catch fish.

At a broader level, “misuse” is really just another way of saying that NGOs and multilateral organizations failed to do what they were established to do. They impose their answers onto communities, rather than simply ask those communities what they actually need.

This is why integrated, community-led development provides a better path to real and sustainable development. It refuses to tell communities what they need or to implement solutions that aren’t agreed on by the community. Community-led development looks different than top-down development, and so it scares a lot of development experts, many of whom think that communities need solutions brought to them.

So, what does it actually look like? Often, like this:

Spark

A community in Nyagisenyi, Rwanda. (Credit: Mike Miesen)

This is a community in Nyagisenyi, Rwanda, a chilly village near the edge of the country’s border with the Democratic Republic of the Congo and Uganda. The community is building a vocational school that will teach its children and young adults the skills to be seamstresses, carpenters, and more. The project is led, planned, and executed by the community, with support and facilitation from Spark MicroGrants, an NGO that provides small grants — just $3,000 – $10,000 — to entire communities. Spark MicroGrants places virtually no restrictions on the funds, provided that the community (women included) comes to consensus on a project.

Community-led development also looks like this:

GD

How one woman used the approximately $1,000 given to her by GiveDirectly. (Credit: Mike Miesen)

School fees, maize, some nails, a table with some chairs. This list is an accounting of how one woman in Siaya District, a mostly-rural area in western Kenya, used the approximately $1,000 given to her by GiveDirectly**. The innovative NGO simply donates cash, unconditionally, to poor individuals on the phone-based mobile payment system, M-PESA . They use it on whatever they believe they need most. A randomized controlled trial, the most robust and reliable study design, showed that GiveDirectly recipients disproportionately used the money on health and education and home durables – not on the tobacco and alcohol many development “experts” predicted. Those who received funds were, unsurprisingly, happier and less stressed.

The largest expense on this woman’s list is “mabati” – a metal roof. Previously, her home was made of thatch, which does its job pretty poorly. It looked something like this:

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job - they let in rain and need to be replaced every few months

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job – they let in rain and need to be replaced every few months. (Credit: Mike Miesen)

Now, her roof looks like this:

text

A home with a metal roof. According to everyone I spoke with, a metal roof is much better than a thatch roof, for a variety of reasons. Nearly every person I spoke with in Siaya district used GiveDirectly funds to purchase a metal roof. (Credit: Mike Miesen)

How many NGOs exist to provide sustainable roofing for communities? I can’t think of one. But every single individual I spoke with in Niaya district used at least a portion of their GiveDirectly funds on a roof.

This is not to say that the Against Malaria Foundation is doing a poor job. By all accounts, it is doing an outstanding job; it’s worth reiterating that almost everyone uses an LLIN as a means to prevent malaria. AMF is, along with the Schistosomiasis Control Initiative, the best counterexample to my argument***. But there are too few organizations like Spark MicroGrants and GiveDirectly, and too many that assume they know what is best for those they try to help.

*Here, I’m referring to immediately feasible means of preventing malaria. Eradicating malaria is feasible, of course – we did it in the states after World War II, using DDT – but difficult, and currently implausible (if not impossible) in much of the world. It’s a long-term fix; LLINs are a short- and medium-term patch. Other methods – like genetically modifying mosquitoes – are interesting but unproven for Anopheles gambie, the species that transmits falciparum malaria. And it’s unclear what the downstream ecological effects would be of eradicating mosquitoes in regions where they are native

**GiveDirectly is also one of GiveWell’s top charities

*** Also a top-rated charity by GiveWell, the Schistosomiasis Control Initiative (SCI) distributes de-worming pills to children in school

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