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Column: Where do you hang a mosquito net in the bush?

April 2, 2014 - 19:22 -- Bart G.J. Knols
So you live in DR Congo. Your youngest child has visited the health post today, she is diagnosed with malaria. You were lucky that there was somebody at the clinic today. They gave you a blister with drugs. It is not quite clear how you got the first capsule into this two year old, but you managed. She is asleep now, safely under a mosquito net that was donated to you last year.
All of a sudden you hear noise outside. Gunshots, men running, men screaming. You know what this means. You, your family, you have to run. NOW.
With your five children and your pregnant wife, you run. You flee into the bush, in the dark night. You carry two children; the rest has to take care of them selves. Two hours later, you find yourself in the pitch dark forest with most of the rest of the villagers.  Your two year old is asleep in her mother’s arms, the rest of your family is right awake. You are safe for tonight. 
After a scary two nights in the bush, you return to your village. There is nothing left of your village. All the houses have been burned down. There is nothing left of your possessions, no food, nothing. Not even the birds sing. Your child is getting more ill by the hour. The only hospital that you know is a day’s walk. It is too late to go today, you will try tomorrow. 
One more night in the open air. One more night at the mercy of the most aggressive Anopheles species. Your whole family is now being attacked, not by rebels, but by mosquitos. When you reach the hospital the next day, they can just safe your two year old with iv artesunate. The whole family tests positive with an RDT. You receive treatment, and you can actually take it, staying in relative safety of yet another village. It will take only two months, before the scenario repeats itself.
You and I cannot stop the war. But we can think out of the box and try to look for solutions that can reach people who live in conflict and war.
This is a daily scenario for families all over eastern Congo. If you live in a village is DR Congo, sleeping under a mosquito net could mean a fatal delay in fleeing if the rebels attack. A certain death sentence. Would you take your ACT blister to treat your child if you had to run? Would you take a net to hang in the bush in the middle of the night? No, you would probably not.
Most of us in the malaria community are content with the decline of malaria morbidity and mortality in the world. We focus on success countries. We focus on countries that are thinking about elimination after a tremendous effort to scale up malaria control. The success of the increased funds to combat malaria is something to be proud of. But fragile states do not benefit enough. They see the reverse trend. Malaria is on the rise again. The effect of conflict on malaria has been documented over the last century (Cohen et al 2012).
And it is documented NOW by aid organisations working in conflict settings. Every year they see more and more malaria cases. It is a battle that seems to be without end.
Data of one MSF clinic as example.
Prevention, good diagnostics and effective treatment are the mainstay of our tools to fight malaria. But how can you spray a house, when there is no house? Where should you hang a mosquito net in the bush? Can we blame papa Kambale for leaving his ACT blisterpack when he had to run? Can we blame the health worker for not being in his clinic when he has not been paid or received supplies in this part of the country? The tools we have will not work for papa Kambale. If we don’t want malaria to be a synonym for conflict and poverty, we must act NOW. 
So if you walk to your office/lab/university tomorrow, think about papa Kambale. What can you do to make him less vulnerable to malaria? You and I cannot stop the war. But we can think out of the box and try to look for solutions that can reach him.  And his family.  Whether they sleep in their hut, in a refugee tent, under plastic sheeting, or under the naked sky in the tropical rainforest of Congo. He needs you.
Cohen et al: Malaria resurgence: a systematic review and assessment of it’s causes. Malaria Journal 2012 11: 122 
Note: The people in the story are not featuring on the photo.

Marit de Wit is the Malaria Advisor for MSF-Operational Centre Amsterdam. She is also the Health Advisor (overall medical programme responsible) for Ethiopia, Kenya and Nigeria. Her passion is improving malaria care in conflict settings, where conventional malaria interventions can’t be applied.




William Jobin's picture
Submitted by William Jobin on

Prevent malaria or prevent war?

The issue you raise Marit is very important, and poses serious ethical choices for those of us who are concerned with the fight against malaria in Africa. I have no easy answer, but maybe can think of one. However the ethical dilemma it poses then troubles me.

How do we protect children from malaria in a war zone? The easy answer is that we can’t, so we should use our limited resources to fight malaria in stable areas where our efforts will endure. Efforts we make in war zones will be blown away in the violence of the conflict. From a public health perspective we realize that we can protect more people by working in stable areas. That is the easy answer from a conventional public health approach in which we count the number of lives saved for each dollar of effort.
But what about the people: the families and children who are in those war zones? Can we just cross them off – throw them away because they are in the wrong place? Obviously for people like you Marit, with humanitarian spirits, we can’t throw those people away; in fact they seem to be the ones who need us the most. We must admire and appreciate people like you and others in MSF who go to these dangerous places and minister to those in greatest need. We can see that they are motivated by a loving concern for people unprotected by their own societies.
But perhaps the reason for our dilemma is that we are mixing our concern for fighting this one specific disease – malaria – with our more basic concern for the well-being of people and their children caught in war. If malaria is our focus, then we might search for special medical or technical interventions against malaria. But what if our focus is simply to meet the most pressing need for these people in the war zone? Is malaria their greatest problem? Or is it an end to the violence? If our concern is for the people, why are we wasting our time fighting malaria when what they really need is Peace? Within their world, at this time, although malaria is important, it has a low priority in comparison with an end to the violence. Malaria has a high priority for us because we know so much about it, but perhaps Peace is more important for our friends caught in the war.
So perhaps what we should be doing is seeking help from the UN to send a Peace-Keeping Force, and when the violence is ended, and then we can work on the issues next in priority, such as malaria. In reality however, the dilemma remains. We know that the UN is weak, and establishing Peace will take a long time. It might never even happen. The wars and violence in Afghanistan and Iraq have been going on for more than a dozen years. What should we do in the meantime; prevent malaria or prevent war? I am sorry Marit, I am afraid I really haven’t answered your question. Maybe some of our other readers can help us?


William Jobin Director of Blue Nile Associates