Battling Insects, Parasites and PoliticsBy DONALD G. McNEIL Jr.

SOMJI, Nigeria—The reason for all the excitement, one public health doctorafter another trooping into her mud-walled room to have a look, was thatPatience Solomon had correctly hung hernew royal blue mosquito net over thebed she shared with her 2-year-old son, James.

Mosquito nets are not terribly complicated, as long as you have some-thing to suspend them from —in Mrs.Solomon’s case, a hand-hewn rafter justat head-knocking height beneath her corrugated iron roof.

Permeating the nets with insecticidedoes take a little concentration.

A state health worker had just given a demonstration beneath the village’scentral baobab tree: take half a Coke bottle full of water and a big enamelbowl, mix in the sachet of white powder,dunk the net, and let dry. Remember torinse out the bowl before making food init. (If you forget, it’s not a disaster; thelambdacyhalotrin is more lethal to bugsthan to children.)

Mosquito nets are technically very simple but in their own mundane way, in rural Africa, they are highly politicalobjects.

Somji, a hot, dry collection of mudcompounds in the sorghum and milletfields of Nigeria’s central plateau, is one of the special weapons and tacticslaboratories in the global struggle overmosquito net policy—a “piggybackingvillage.”

“This is the first place in the historyof the country where we’re combiningthe distribution of bed nets with the distribution of drugs,” said Dr. EmmanuelMiri, chief of Nigerian operations for theCarter Center in Atlanta.

The drugs are for lymphatic filariasis, a disease caused by eight-inch wormsthat ball up and nest in the lymph glands,clogging them until victims’ legs swell tothe thickness of an elephant’s. There isno cure for the leg, nor do the worms die, but, given once a year to everyone in the village, the drugs Mectizan andAlbendazole, donated by Merck andGlaxoSmithKline, kill the worms’

microscopic progeny as they circulate in the blood.

Unable to reproduce, the infestationdies out when the adult worms shrivel up of old age, in about five years. But

there is an exception: the drugs cannotbe given to children under 5 or to pregnant women.

Normally, they go unprotected, hopingto shelter under the umbrella of “herdimmunity” created when the rest of the village is de-wormed. (When herdimmunity works, the uninfected havebenefited from a combination of pre-ventive medicine and dumb luck.)

But pregnant women and childrenunder 5 are also the most likely to die of malaria. And malaria, like lymphaticfilariasis, is spread by mosquitoes.

James had already had malaria once,Mrs. Solomon said.

Asked what she gave him for it, sheproduced a bottle whose label she

could not read. It turned out to be a local brand of Tylenol, meaning thatJames had already had a serious strokeof luck with one fatal disease.

The Carter Center, a health and peace organization founded by formerPresident Jimmy Carter, has been hand-ing out de-worming drugs in Nigeria sincethe 1980’s. It has no budget for mosquito

nets. But Roll Back Malaria, a WorldHealth Organization campaign started in1998, does, has some money becausemalaria is relatively “hot” at the moment,thanks to the Global Fund to Fight AIDS,Tuberculosis and Malaria. So in Somji,the two programs are piggybacking,meaning everyone in each family shouldget either Carter drugs or a W.H.O. net.

But that requires juggling layers ofbureaucracy, since the W.H.O. sends itsdonation through the Nigerian federalgovernment, which filters the nets downto state governments, which send outworkers to do demonstrations. In the twocentral states where the program is cen-tered, Niger and Plateau, three millionpeople get the drugs. The two states

CASES WITHOUT BORDERS

TUESDAY, MARCH 22, 2005

Patience Solomon and her son James sit under the mosquito net they recently received.

Photographs by Vanessa Vick for The New York Times

received only 60,000 nets. (Nigeria hasmore than 100 million people, and nonational program.)

What will happen when those run out?“That is why we are begging you

people to come to our aid,” said RachelTiti Bitrus, the net-dunking HealthMinistry demonstrator. “We pray maybewe will get some more.”

Equally good nets are sold at roadsidemarkets, but they are several hours awayon foot and cost from $6.50 to $14, shesaid, adding, “Many complain that that is too dear.”

Big donors and their consultants aredeeply divided on whether mosquitonets, like condoms, should be distributedby “social marketing” in which donatedgoods are not distributed free, but adver-tised as rival brands with catchy namesand sold for nominal sums.

Some economists argue that poorAfricans value and use only things theyhave paid for. Others retort that suchschemes benefit only the “richest of the

poor,” like city dwellers who can affordcigarettes, while the poorest poor—peasant farmers in dirt-track villages likeSomji, who bear the greatest burden ofmosquito diseases—die for lack of itemsthe West can mass-produce for pennies.

Officials from the United States Agencyfor International Development favorsocial marketing of nets; those from the Centers for Disease Control andPrevention oppose it. Unicef favors it;W.H.O. opposes it.

And even if the macroeconomic disputes are resolved, there are microproblems. Somji is a two-hour drive fromthe regional capital, Jos, but Mrs. Bitrushas only occasional use of a truck. The Carter Center program relies on anetwork of volunteers from thousands oftiny villages, the kinds of places whereownership of a bicycle or a radio putsthe owner in an upper-income bracket.

“The same guy who used to ride hisbike to pick up a box of meds now has tosomehow pick up a ton of bed nets,” saidDr. Frank O. Richards Jr., a parasitologistat the C.D.C. who advises the CarterCenter. “They’ve got to figure that out.”

Dr. Richards was watching the volun-teers juggle the new complexities. Withpigs rooting at their feet, they stood out-side a compound, called out each resi-dent by name, and spooned out pills.

One 5-year-old gagged on his fatAlbendazole tablet. “Let him chew it! Tell him he can chew it!” Dr. Richardsshouted, trying to get his words trans-lated from English to Hausa to the village language.

“What about the baby?” he askedaloud, when the volunteers had dosed anursing mother and said they were fin-ished. “He’s supposed to get a net,” hemuttered. “This is the crucial thing. Theydidn’t even think about babies before.”

The volunteers explained that theywanted to do that later in the day. Theirdata-recording system consisted of two

lined primary school notebooks, one forpills and one for nets, and doing both atonce would sow confusion.

Hence the eventual excitement aboutMrs. Solomon. The successful hoisting ofher net—made in Kenya, paid for inGeneva, arranged for in Atlanta, demon-strated in Somji—was no simple matter.

The next move, Dr. Richards said,would be a surprise visit in a few weeks.Now that nets had value, he said, “we’llwant to see if the right people are usingthem—or if all the fathers are sleepingunder them.”

As the team climbed into its trucks to leave, a loud argument broke out. Avisitor from another village was shoutingat a Carter Center volunteer, accusinghim of handing out nets free here whiledignitaries were watching, but charginghis village 80 cents each. Dr. Miri steppedout of his truck, questioned the volun-teer, fired him on the spot and asked thevillage chief to pick another.

The team left; the politics went on.

Article © 2005 by The New York Times. Used with permission.

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Far left, a Nigerian child is measured to determine the right dosage of treat lymphatic filariasis, a diseasecaused by worms that nestin the lymph glands. AMinistry of Health worker,below left, shows residentshow to treat their mosquitonets with insecticides. Left,another worker providesinformation about treatinglymphatic filariasis.