BUNGOMA, KENYA – Mary Nafula is just 4 years old. She is lying on a slender cot in the children’s ward at Bokoli Sub-District Hospital. Today is the first day she has been able to speak since being incapacitated by a high fever and body aches. The emaciated girl has survived this bout of malaria, which the attending nurse says nearly killed her.
“Malaria is one of the main causes of child deaths in the surrounding villages,” says Jane, the nurse at the hospital attending to Mary, who asked that her real name be withheld to protect her job because she was not allowed to speak to the media. “The nets are part of our strategy to reduce its impact on young children and pregnant women.”
Mary’s mother says the family has a mosquito net, but says her daughter does not like to use it because her room gets hot at night – just one of many reasons local people give for not properly using the mosquito nets here.
As Mary continues to recover, another woman rushes into the hospital carrying a 3-year-old boy. The woman, Angeline Juma, has no shoes on and is wearing a torn skirt and a patchy jacket. She is the child’s grandmother.
Earlier today, the boy was running a fever, refused to eat and drink, and was coughing and vomiting. Juma says the child’s mother is on her way to the hospital, but when her grandson began convulsing, she says she jumped onto her neighbor’s motorcycle and sped to the hospital.
After a series of tests, the doctor says that the boy has an advanced and dangerous form of malaria known as cerebral malaria.
“Cerebral malaria patients have to be treated quickly, as the infection can cause various changes in mental condition, as well as coma, and can be fatal in one to three days,” says David Busolo, a retired clinical officer who used to work at the hospital.
Busolo describes cerebral malaria as a severe form of infection of the brain associated with a high fever of 37.5 C to 41 C (100 F to 105 F) and failure to eat and drink. Vomiting and coughing are also common.
Juma says she is furious. She blames her son for the fact that her grandson has contracted malaria. She says he took the family’s mosquito net and gave it to the men working outside nearby.
“When the malaria net arrived at the house, he took it for himself, saying that children did not need mosquito nets, as it was the men who worked, and therefore they needed to protect themselves,” Juma says in halting Swahili.
Juma says she has never had a job or been to school. Her family, made up of seven children and four grandchildren, live deep in the interior of Kuywa village, where malaria routinely threatens children. In Kuywa, mosquito nets distributed by the government are often misused.
Though preventable and curable, malaria is the leading cause of morbidity and mortality in Kenya, according to the Ministry of Health’s Division of Malaria Control. Pregnant women and children under 5 are the most vulnerable to malarial infections in Kenya. The government has distributed millions of nets to families to guard them from mosquitoes at night. But a number of families admit to using the nets to protect their chickens instead of their children.
At least 90 percent of worldwide malaria cases occur in Africa, according to the World Health Organization, WHO. In November 2009, the government here launched the Kenyan National Malaria Strategy 2009-2017 with the goal of reducing morbidity and mortality associated with malaria by 30 percent, according to the Division of Malaria Control.
Despite its devastating toll, malaria is a preventable and curable disease, according to the WHO. Insecticide-treated nets, ITNs, have been widely distributed and provide a barrier between potential victims and mosquitoes during the night, which is the vectors’ most active period. According to the Division of Malaria Control, 15 million nets were distributed between 2001 and 2009. Spraying tiny amounts of insecticide on the walls of homes and inside the nets is also highly effective at repelling and killing the mosquitoes that transmit the disease.
But it is estimated that millions of nets are misused here, so the next line of defense is the artemisinin-based combination drug therapy, known as ACTs. ACTs are derived from an ancient Chinese herbal remedy, but widespread implementation remains a challenge because the drugs are expensive and millions of people throughout Africa are known to have a natural resistance to anti-malarial drugs, according to the WHO’s Global Malaria Program.
For Jane, the nurse at Bokoli, the misuse of bed nets that can prevent mosquito bites is frustrating to see. The WHO says that Kenyans are not alone, as many other countries on the continent are failing to implement the recommended intervention strategies to eradicate malaria.
“Treating a net is simple, inexpensive and reduces nuisance insects, as well as malaria,” Jane says. “Despite major efforts, it appears uptake has remained poor.”
But another reason for the infrequent use of nets is a perceived lack of evidence on how to distribute nets in poor rural areas and little evaluation of their use.
On further prodding, Juma, who was furious with her son for giving one net to his workers, whispers another reason her grandson might be sick. She admits that she has another net, but she uses it to keep her chickens safe from birds of prey.
Juma is not alone. A visit by The Press Institute to homes in Bokoli revealed that bed nets are commonly used to cover chicken coops. Several owners admitted to using the nets to protect their chickens – a vital source of food and income – against birds of prey, such as eagles and hawks, snakes and diseases.
Christine Nasambu, whose youngest daughter recently recovered from a bout of malaria, says she has invested a lot in her chickens and would not allow them to get sick or be eaten by the birds of prey.
“I bought the rooster for 500 shillings ($6 USD) and the hens at 400 shillings ($5 USD) each so I could begin this project,” she says of her new coop. “As you can see, it is bearing fruit, and I do not want to lose any of them to those predators.”
She says she knows that that nets are intended to protect children against malaria.
“As a mother, I know that treated nets are also associated with the increase in child survival,” Nasambu says.
Up the road is Catherine Mulati, who also uses her net to protect her chickens because she says she fears they will get sick otherwise. Mulati says the net protects her chickens from getting diseases, such as coccidiosis, an intestinal disease caused by parasites.
“This disease attacks young chicken[s] and is very infectious,” Mulati says. “Most of the time chickens get this disease when the weather is warm and moist.”
Mulati, a mother of four, says she is aware of the danger she is exposing her children to by failing to use the mosquito nets for their intended purpose, but she believes her children can be treated at the public health facility at a cheaper price than what she would incur for losing her chickens.
Susan Machuma, another farmer, says chickens are susceptible to several parasites, including lice, mites, ticks, fleas and intestinal worms, as well as other diseases.
“Many farmers here invest in poultry production: in hybrid layers, broilers or in indigenous chicken[s],” Machuma says. “Most of us prefer indigenous, as it is sweeter and is not prone to disease outbreaks. I build chicken houses and buy foodstuffs and birds, hoping to earn a good return on investment.”
She says she has to take extra precautions to protect her investment, such as using a mosquito net.
“Often, farmers are surprised by disease outbreaks that decrease production or even kill the precious birds,” she says. “I do not invest to lose and, therefore, will use whatever means to protect my chicken[s] against birds of prey and diseases.”
Martha Sifuna, a widow and mother of seven, who also rears chickens as her family’s primary food source, says she covers her chickens with nets to protect them from snakes.
“I have seen chickens dying after being bit by venomous snakes,” she says. “Mosquito nets give me the assurance that my chickens are safe.”
She says it is also good to have the chickens contained to avoid complaints from her neighbors. Her chickens have been known to destroy neighbors’ food crops.
“I do not want any problems with my neighbors,” Sifuna says. “People keep complaining that my chickens are eating their maize and beans. Now I am able to put these nets over them during the day and avoid any confrontations.”
Although distribution of mosquito nets has become a popular international development tool and more than 15 million have been distributed in Kenya alone, the implementation and follow-up remain limited. According to The Standard newspaper, the Ministry of Public Health and Sanitation announced last November that, in partnership with UNICEF, it would distribute more than 14,000 more mosquito nets in all district hospitals in Kakamega, Vihiga, Bungoma and Busia counties.
According to a September 2010 article in the Malaria Journal, 95 percent of the households surveyed owned at least one net. But only 59 percent of families with nets said they slept under them. And at least 40 percent of the nets were reported to have holes in them.
Busolo, the retired clinician, says he has long urged net recipients to use them to protect their children instead of their chickens.
“This will go a long way in saving life, that is, if the nets are properly used,” he says. “It is vital that the responsible authorities, especially those involved in the anti-malaria program, educate the general public on proper use of nets and make follow-ups to make sure that the nets are not misused.”
