Distribution of Nets Splits Malaria Fighters Veronica By REUBEN KYAMA and DONALD G McNEIL Jr Published October 9 2007 MAENDELEO Kenya Veronica Njeri 45 says she has never healed since losing two of her six children to malaria 20 years ago and she still feels vulnerable While her oldest are adults or teenagers and have presumably built up immunity to the disease she worries about her youngest Anthony who is 4 Enlarge This Image Evelyn Hockstein for the New York Times Kenyan rice fields are breeding sites for mosquitoes Enlarge This Image Evelyn Hockstein for The New York Times A health center sign in Mwea Kenya says malaria kills 36 000 children under 5 every year But since hundreds of free mosquito nets came to Maendeleo her rice farming village in west central Kenya malaria epidemics have become rare she said happily even though the village sits amid stagnant paddies where swarms of mosquitoes breed Villages like Maendeleo are at the center of a debate that has split malaria fighters how to distribute mosquito nets Recently Dr Arata Kochi the blunt new director of the World Health Organization s malaria program declared that as far as he was concerned the debate is at an end Virtually the only way to get the nets to poor people he said is to hand out millions free In doing so Dr Kochi turned his back on an alternative long favored by the Clinton and Bush administrations distribution by so called social marketing in which mosquito nets are sold through local shops at low subsidized prices 1 or so for an insecticide impregnated net that costs 5 to 7 from the maker with donors underwriting the losses and paying consultants to come up with brand names and advertise the nets The time for social marketing of bed nets in a big way is over Dr Kochi said in an interview It can become a supplemental strategy for urban areas and middle income countries Two years ago social marketing was at the heart of a scandal when it was revealed that the United States Agency for International Development or USAid which distributes foreign aid was spending 95 percent of its malaria budget on consultants and 5 percent on goods like nets drugs and insecticide Under attack from several senators championing the fight against malaria the agency later announced that it would spend at least half its budget on goods Senator Tom Coburn Republican of Oklahoma called the new W H O policy a great move adding We knew social marketing doesn t work In practice nothing much had been working In 2000 a world health conference in Abuja Nigeria set a goal by 2005 60 percent of African children would be sleeping under nets By 2005 only 3 percent were The theory behind social marketing which is also used to distribute condoms and oral rehydration salts is that the poor see more value in brand name goods they pay for than handouts they get free and that the trade creates small entrepreneurs The usual comparison made is to Coca Cola which reaches Africa s remotest corners But Dr Kochi rejected that model saying I m not sure whether the poorest of the poor actually drink Coca Cola He argues that the insecticide filled nets when used by 80 percent or more of a village create a barrier that kills or drives off mosquitoes protecting everyone in the area including those without nets Individual nets tended to just drive mosquitoes next door to bite someone else As such he said nets ought to be treated as a public good like the measles or polio vaccines which the world does not charge the poor for Free net distributions are usually done in a week or two by armies of workers who are paid a few dollars a day by the Red Cross or health ministry to cover a country or other large region Distributions have been tried in Sierra Leone Niger Togo and elsewhere sometimes in conjunction with measles shots or deworming drugs The new model is beginning to prevail but has not completely swept the field Some donors still use some social marketing Unicef the world s largest buyer of nets distributed 25 million last year of which 92 percent were given away said its medical director Dr Peter Salama The main American program the President s Malaria Initiative plans to hand out more than 15 million nets by 2008 of which about 75 percent will be free said its coordinator Rear Adm Tim Ziemer In June Admiral Ziemer and the first lady Laura Bush who has made malaria her crusade helped hand out 500 000 free nets in Mozambique and Zambia Social marketing may be useful during gaps between mass distributions said Trent Ruebush a malaria expert at the initiative and USAid The best insecticide filled nets last three to five years but babies will be born in that time or new families will move into an area We feel it is one of various effective ways to go Dr Ruebush said Experiences in Kenya played a large part in persuading the W H O to change its policy said Dr Peter Olumese a medical officer in the agency s malaria program Maendeleo a village of about 140 mud walled shacks with tin roofs was part of a five year study of 40 health districts When it started in 2002 the only nets were those for sale in small shops Dr Olumese said and only about 7 percent of people had them Social marketing was introduced by Population Services International a large aid contractor That increased coverage to about 21 percent by early 2006 Then late last year the health ministry got a big grant from the Global Fund to Fight AIDS Tuberculosis and Malaria that allowed it to hand out 3 4 million free nets in two weeks Coverage rose to 67 percent and distribution became more equitable Under social marketing Dr Olumese said the richest of the poor had 38 percent coverage while the poorest of the poor like Maendeleo s rice farmers had only 15 percent After the handouts they were about equal Deaths of children dropped 44 percent It also turned out to be cheaper Dr Olumese said With consultant fees transportation advertising and shipping social marketing added about 10 to the cost of each net beyond the 5 to 7 that Danish or Japanese makers charged But even with payments to volunteers the added cost of free distribution was only about 1 25 per net There has been a paradigm shift Dr Olumese said We need to use the momentum we have right now Between the giveaways he said nets should be handed out free to all pregnant women and mothers who visit health clinics Some women struggle to afford even the 10 cents per child cost of identity cards that let them visit clinics Asking a mother to make a