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Malaria in Nigeria

Thomas Hopkins
ATY525 – May 12, 2010
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abstract
This report outlines malaria in Nigeria and provides an assessment of methods currently used to

combat the disease. I find that many of the problems reducing the burden of malaria going forward

stem from the various dissemination challenges that Nigeria presents with its large population and

pronounced rural-urban divide.

executive summary
Nigeria’s large population and rural-urban divide makes distributing malaria aid difficult. Though

a number of circumstances—political, social, economic, and demographic in nature—combine to

catalyze and coproduce Nigeria’s large number of malaria cases, there is no doubt that the disease

can be stopped; effective measures for preventing the disease are inexpensive. Nigeria would do well

to follow the example of Brazil and establish a comprehensive system of public health care that pro-

duces insect netting (LLINs) and malaria treatment (ACT) among other health care materials. Such

a system would allow Nigeria to 1) decrease their reliance on foreign powers for their health care

needs, 2) mitigate the “brain drain” of health care personnel from Nigeria that has in part reduced

the number of physicians to 3 per 10k population, 3) make treatment and prevention methods avail-

able freely or at low cost with a voucher program for the most impoverished people in the country,

and 4) better design culturally-sensitive programs for education about malaria prevention (includ-

ing vector control programs) and treatment, which is particularly important giving the diversity of

the Nigerian people.

In order to distribute both netting and necessary treatments for malaria and other diseases, Ni-

geria should enlist the assistance of female craft production networks, informal distribution chains,

and children by integrating and involving these groups in the process of distributing malaria knowl-
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edge, treatment, and prevention materials. Involving these groups is absolutely imperative with or

without a comprehensive national program for producing supplies, and, more importantly, can pro-

vide serious benefit even without such a national program. With these measures, meant to combat

the challenges of disseminating malaria aid in Nigeria, the burden of malaria can be significantly

reduced.

Nigeria: A History of Diversity, Turmoil, and Poverty


Nigeria is a coastal West African country situated near the countries of Chad, Cameroon, and Niger.

It is so named because the Niger River, the foremost river of western Africa, flows through the

country, draining into the massive Gulf of Guinea along the west coast of Africa. Nigeria is unique

for a number of reasons, not the least of which is its population; it is the most populous country

in Africa, with a 2009 estimated population of around 154 million people, and the eighth most

populous country in the world. To gain a better sense of the population density of Nigeria, consider

that the United States of America has a total land area of around 9.8 million square kilometers

with an estimated population around 308 million people. Nigeria, by contrast, has a population

of 154-million people in a land area of only around 923,000 square kilometers. The implications

this can have upon healthcare within Nigeria are obvious. Programs for widespread disease are

challenging (but not impossible) to implement if only because of the great number of people that

must be helped.

With such a large population, it logically follows that Nigeria should be host to a number of di-

verse ethnic groups. Indeed, there are at least two-hundred fifty recognized ethno-linguistic groups,

the primary of which are the Hausa-Fulani, Igbo, and Yoruba groups.
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Nevertheless, Nigeria has not chosen any of its 521 documented languages to be its official language.

The country's official language is English.

There is a marked rural-urban divide in Nigeria’s population. Approximately 48% of people

in Nigeria, per the CIA World Factbook, live in urban areas, and52% of the population is classified

as rural; the rural percentage of the population is sparsely distributed throughout Nigeria. Most of

the country’s urban population is densely concentrated in major southern territories, particularly

around the southeastern province of Imo Abia.

This rural-urban divide resulted from circumstances that began during Nigeria’s colonial pe-

riod. Nigeria, an area of densely concentrated cultural diversity, has had a history of ethnocultural

conflict, partially rooted in disparities that the British government established during its colonial

project there. Britain divided the Nigeria area into two territories, a northern and southern area,

that correlate roughly with the primary religion within the region: the predominantly Muslim north

and the Christian missionary-project south (Zinn 2005). Britain’s engagement with local people

was greater within the southern compared to the northern region. Southerners, due to this greater

level of interaction, gained a greater number of positions within the colonial governance. Britain’s

withdrawal, beginning late in the 1950s, exacerbated ethnic tensions within Nigeria, as competition

for resources increased in its wake. “As the … Yoruba and … Ibo occupied government posts left

behind, patronage—whereby government officials favor their home regions in granting … access

to government jobs, funds for local development, and government contracts—became widespread”

(Zinn 2005:97).

Nigeria gained independence from Britain on October 1, 1960, forming a new republic with

a coalition of two conservative parties, the Nigerian People’s Congress (NPC), a civilian group rep-
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resenting the populous northern area of the country, and National Council of Nigeria and the Cam-

eroons (NCNC), a minority party representing the eastern region. The “new republic” established

a parliamentary democracy modeled after the British government, but this formulation did not

come to an entirely cooperative group of people. Ethnic and regional tensions began to spark; these

tensions were the primary reason that the Nigerian Civil War began in 1967, as various military

groups vied for power, acting off a desire for regional autonomy. General Emeka Ojukwu, governor

of Nigeria’s eastern region at the time, spoke presciently about the situation leaving up to the war

in a radio broadcast on August 1, 1966: “the brutal and planned annihilation of officers of Eastern

Nigerian origin … has again cast serious doubts as to whether the people of Nigeria, after these

cruel and bloody atrocities, can ever sincerely live together as members of the same nation” (Ojukwu

1969:35).

Civil war lasted around 30 months and claimed the lives of anywhere from one to three million

people, mostly from the famine the war produced. Material reconstruction after the war was rela-

tively swift, thanks in no small part to the fact that Nigeria, having tapped into the area’s substantial

oil resources, joined OPEC approximately a year after the war ended, in 1971. Most oil revenue, and

thus most of the improved material conditions it allowed, concentrated in the northern military

regime. After the war, throughout the ‘80s and ‘90s, Nigeria had a series of leaders, each of whom

seem to have been installed by military coup. A few of these are worth briefly discussing, the first of

which is the coup of 1985 that installed General Ibrahim Babangida as president of Nigeria.

Babangida’s regime is noteworthy for a variety of reasons. He instituted the IMF structural ad-

justment program for Nigeria in order to mitigate the international debt the country had accrued

since becoming an independent nation in 1960. Structural adjustment programs stipulate that a
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government cut social sector expenditures, remove state subsidies, and privatize some portion of

their state-owned enterprises, and all of these actions can—and often do—have a negative effect on

health care. Babangida saw some of this during his regime, as the reduction of spending on public

services and falling wages for public sector jobs combined to create a strong sense of discontent in

Nigeria during this period.

Recent years have been slightly less tumultuous. In 1999, a third republic began in Nigeria with

the election of Olusegun Obasanjo to president. Obasanjo served from 1999 to 2007, though both

the election in 1999 and his reelection in 2003 were condemned locally and in the international

community. The 2007 election of Umaru Yar’Adua was similarly condemned because of a perception

that it was rigged in favor of Yar’Adua. Most recently, the Nigerian senate handed over power to vice

president Goodluck Jonathan because Yar’Adua has been under treatment for pericarditis. The politi-

cal landscape in Nigeria, nevertheless, remains unstable.

Economically, Nigeria has been slightly better as far as superficial statistics are concerned. Ni-

geria’s economy is currently among the fastest-growing economies in the world, with a projected

growth rate of 8.9% in 2009, per IMF estimates. Oil revenues have made Nigeria the secondlargest

economy in Africa; only South Africa’s GDP is higher. Indeed, the majority of Nigeria’s export rev-

enue comes from oil. The World Bank estimates that 97.5% of the country’s $76.03 billion (2008)

in export revenue results from petroleum export. Dependency on oil may be partly responsible for

creating or sustaining social disparities since it concentrates wealth in the hand of the few. Income

statistics suggest that this is the case.

Graphic 6 of the data section in this document portrays the income distribution by quintile in

Nigeria. Note the marked difference between the first and fifth quintile; the top quintile controls ap-
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proximately half of the income in Nigeria, and the first quintile controls only five percent of income.

Consider also that approximately 70% of Nigeria’s workforce works in agriculture, owing in small

part to the rural-urban divide in population; another 10% work in industry, and 20% work in the

service sector, which includes both petroleum-related and financial services (CIA World Factbook

2009). Industry and services are the work of only 30% of Nigeria’s people, but they comprise about

68% of the country’s total GDP. This sharp divide in income has obvious effects on health care, forc-

ing individuals into the perverse position where they must choose between feeding themselves and

purchasing treatment for illnesses, including malaria.

There is another dismal situation in additional statistics for Nigerian health care. Throughout

the entire country, there are approximately 35,000 physicians, which, divided by Nigeria’s total

population, means that there are only three physicians per 10,000 people (per WDI database 2008).

Approximately 35% of the total population has access to sanitation facilities, which is particularly

unacceptable considering that the majority of the population is between ages 0–25, the largest popu-

lation group being between ages 0­–5 (see graphic 7). Much of the population is concentrated within

this age group because Nigeria has a relatively low life expectancy, only about 47 years for both men

and women. Nigeria also has a high infant mortality rate, around 96 per 1000 births (per WDI da-

tabase). These are, in turn, the result of a myriad number of circumstances that limit access to health

care, such as income disparities, the rural-urban divide, and tumultuous political circumstances.

We can look at the status of women in Nigeria as an indicator as well. Literacy among women

is less than it is among men; approximately 60% of women are classified as literate (defined as “age

15 and over can read and write”), where the same statistic for men is nearly 76%. Most women

are employed in the service sector, and 47% of women between the ages of 15–64 are employed.
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Table 2 provides a comparison of pregnant women receiving prenatal care in Nigeria; as of the last

assessment year, only 57.7% of pregnant women received prenatal care (data here from WHO and

CIA World Factbook 2009). The specific treatment of women may vary between ethnic group. Nev-

ertheless, Nigeria has the most number of female circumcisions in the world; however, this may be

resultant primarily of the country’s large population.

Malaria: An Easily Preventable but Problematic Disease


The disease with which this report is concerned is malaria, a mosquito-borne infectious disease

endemic to a variety of tropical locations, including significant portions of Asia, South America, and

sub-Saharan Africa; see graphic 1 for a visual representation of worldwide malaria distribution. The

agent of the disease is any one of the several Plasmodium parasites. Once inside the body, the parasite

causes a number of initial symptoms, including fever, sweats, vomiting, chills, jaundice, and weak-

ness. As the disease progresses, more severe, life-threatening symptoms can occur. These include im-

pairment of consciousness, coma, severe anemia, acute respiratory distress syndrome, acute kidney

failure, hypoglycemia and associated metabolic acidosis, and, ultimately, death. Even if an individual

survives the initial infection, there is some chance that additional malarial attacks may occur in the

future, months or even years after the first infection.

The parasite needs a way to enter the human body before it can cause any harm. It lacks any

direct way of doing so and therefore relies on female mosquitoes of the genus Anopheles to enter the

body. It is for this reason that mosquito population control is a major factor in controlling malarial

epidemics; preventing mosquito bites at any level, either with the individual with the use of netting

or through effective control of mosquito breeding grounds, will limit the extent of the disease.
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Pregnant mothers are uniquely vulnerable to malarial infection. Not only does the disease pose

a risk for the mothers themselves, it can have a disastrous effect on their developing infant, causing

low birth weight, stillbirth, a number of neurological problems, and early infant mortality. (Graphic

2, a summary of mortality in children aged 0–5 in Africa, may note malaria separately, but note that

“neonatal causes” can include malaria-induced stillbirth or birth defects.) A 2000 study by Lindsay et

al. found that this dynamic extends to patterns of mosquito activity as well. Its authors say that “twice

as many A. gambiae mosquitoes—the main malaria vectors in Africa—were attracted to pregnant

women than to their non-pregnant counterparts. Similar findings were also found with [a variety

of other mosquito species, all of which] … are important disease vectors in different parts of the

tropics” (Lindsay et al. 2000). They continue to speculate that this is the result of two physiological

processes: women in advanced pregnancy exhale 21% more breath on average than non-pregnant

women; and increased blood flow to the skin, necessary for heat dissipation. They also assert that, for

women using bed netting to protect themselves, increased urination frequency during pregnancy

can put them at risk for a greater number of night-biting mosquitoes.

Pregnant women are uniquely but not exclusively vulnerable. Malaria affects and depresses im-

poverished societies through a remarkable pattern of cyclicity. Poverty is both a “risk factor” for and

burden to treatment of malaria, and, particularly where prevention services and treatment are not

available free-of-cost, malaria serves to increase poverty, stress, and, in many cases, further marginal-

ize already marginalized people. Where it is endemic, malaria can indicate what anthropologist Paul

Farmer calls “structural violence,” in that malaria sickness is result of “historically given (and often

economically driven) processes and forces [that] conspire to constrain individual agency” (Farmer

2005).
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Malaria is an entirely preventable disease. Primarily this means that we can easily control the

vector for the disease by distributing insecticide-treated nets (ITNs) for widespread use. Netting is

one of the most feasible options because it is relatively inexpensive—around $2 to $3 USD—and,

while not perfect, greatly decreases the chance for malaria infection. Widespread distribution of

ITNs can also reduce the number of mosquitoes in a given region, thanks to the pesticide they

contain. Standard ITNs, however, need to be retreated every several months in order to stay effective;

therefore, manufacturers developed long-lasting insecticidal mosquito nets (LLINs) to combat this

issue, though they can cost double the price of a standard ITN.

We can also control the spread of malaria through campaigns to prevent mosquito breeding or

otherwise control mosquito populations. Such programs may include education programs to teach

agricultural workers to eliminate large pools of standing water or insecticide spraying such as Inter-

Residual Spraying (IRS).

In a perfect world, all areas in which malaria is endemic would have widespread access to net-

ting and other preventative measures, but that is not the case. For those who are infected with ma-

laria, there are several treatment options available. Unfortunately, all of them are more expensive than

the inexpensive netting that could have completely prevented infection. The primary treatment today

is artemisinin-based combination therapy (ACT). As the name suggests, this treatment involves oral

administration of several drugs, particularly artesunate, artemether, and dihydroartemisinin, derived

from artemisinin. Multiple drugs are necessary because certain species of the Plasmodium parasite, par-

ticularly the most deadly P. falciparum, have become resistant to some of the available monotherapies;

graphic 3 illustrates this trend, which coincided with the rise of malaria prevalence in Africa. Never-

theless it is necessary to recognize circumstances where monotherapies may be useful; this is the case
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for areas where multidrug-resistant strains of the Plasmodium parasite are not highly prevalent. Nigeria

is, unfortunately, not one such region. Strains of malaria that are resistant to antimalarial drugs, par-

ticularly chloroquine, have been endemic to Nigeria for at least ten years (Chukwuani 1999).

The number of malaria cases in Nigeria is or, rather, may be staggering. Graphic 4 shows the

the distribution of reported malaria cases in Nigeria; all of Nigeria’s territories have between 1 and

100 reported cases per 1000 people in each of those territories. The WHO’s 2009 report estimates,

via some very complicated statistical calculations, that the number of actual malaria cases in Nigeria

could be close to 57 million; the number of reported cases was around 2.8 million in 2008. This dis-

crepancy arises from the fact that many people that show signs of malarial fever are not able to access

an appropriate health care facilitity for a variety of reasons, both in terms of physical and economic

access; and that there is varied knowledge about the signs of a malarial fever.

In children ages 0–5, the number of malaria cases is also high. In 2007, the number of reported

cases in that age bracket was around 1 million. What is particularly staggering is that only around

37,000 cases in children under five resulted in clinic admission in the same year; this increased to

around 186,000 in 2008, as somewhat demonstrated in graphic 5. Though it may seem anomalous

that the number of reported cases in children under five years of age increased once data were avail-

able, beginning in 2003, bear in mind that various WHO recommendations were progressively im-

plemented beginning around that time. For example, per the WHO’s 2009 country sheet for malaria

in Nigeria, health care workers in Nigeria began “targeting children < 5 years and women” begin-

ning in 2001, but ACT was not available free of charge for the same age bracket until 2006. The rise

in reported cases probably correlates with the rise in available services. Malaria is still undoubtedly a

serious burden to the Nigerian people; 98% of Nigerians are “at risk” for malaria.
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Data: Graphics and Tables

Graphic 1: Cartogram of malaria incidence - the largest region is Africa; from www.worldmapper.org

Graphic 2: Africa and death in ages 0-5; from UNICEF 2009 update to “Malaria and Children”

Graphic 3: A history of malaria deaths correlated with major epochs; from Roll Back Malaria’s 2008 Global Malaria Action Plan
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Graphic 4: Number of reported malaria cases in Nigeria per 1000 people; every Nigerian province has a reported incidence of 1–100 cases per 1000
people. Graphic from WHO Malaria Report for 2009.

Graphic 5: Malaria cases per 1000 in Nigeria; note that infants account for most of the reported cases; from WHO 2009 report

Graphic 6: Nigerian income distribution by quintile; data from UN World Inequality Database
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Graphic 7: 2010 Nigerian population pyramid; data from US Census Bureau International Database

Graphic 8:WHO report on malaria interventions in Nigeria


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Operational
Population at 2006 LLINs 2007 LLINs 2008 LLINs Cumulative ITN
risk, 2008 distributed distributed distributed 2006-2008 coverage,
2008 (%)
DR
64,703,615 2,981,026 2,385,684 5,788,513 11,115,223 34
Congo
Kenya 29,244,399 6,378,465 1,591,492 2,437,621 10,407,578 71
Nigeria 151,478,123 8,853,589 3,225,594 6,700,000 18,778,183 25
Table 1: LLIN distribution; data from WHO World Malaria Report 2009, p. 15

1989 1990 1993 1995 1996 1998 1999 2000 2003 2004 2006 2008
Nigeria 56.5 63.6 58 57.7
Kenya 77 95 92 76 88
Thailand 85.9 91.8 94.3 97.8
South
Africa 89 94.2 91.9
United
States 99
Table 2: Percentage of women receiving prenatal care; data from World Development Indicators Database

Assessment and Recommendations


Insecticide Treated Nets (ITNs) and Long-Lasting Insecticidal Nets (LLINs)
This relatively simple measure, bed netting draped over sleeping areas, is probably the most feasible,

least expensive option for malaria prevention, but it is necessary to assess whether or not they have

been effective so far in controlling malaria in Nigeria. We know for certain that insecticide-treated

netting is effective in controlling mosquito bites, and may be more effective with increased distribu-

tion thanks to the widespread distribution of insecticides that may serve to lower overall mosquito

populations (Killeen et al. 2007). It would be simplistic, however, to argue that simply dis-tributing

nets and then stepping aside will solve all future malaria issues.

There is a special dynamic, as noted, between malaria, women, and infants. Malaria tends to

affect pregnant women thanks to unique physiological changes that occur during pregnancy and

that tend to increase their attractiveness to mosquitoes. Though, as figure 2 indicates, malaria only

accounts for around sixteen percent of deaths in African children aged five and under, UNICEF’s

umbrella category of “neonatal causes” can include various birth defects that that Plasmodium parasites
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create, including low birth weight (which is estimated to result in approximately 100,000 infant

deaths in Africa each year), anemia, and perinatal stillbirth (Desai et al. 2007). Worldwide, about

85% of all malaria deaths occur among children between zero and five years of age (WHO Malaria

Report 2008, 2009). Given this increased vulnerability for mothers and their young children, it is

necessary that mothers receive netting and instruction on how to utilize that netting.

Per the WHO’s 2009 report on malaria, ITNs/LLINs (it is not clear which is currently dis-trib-

uted or in what proportions—I will come to this issue in a moment) have been distributed free-of-

cost in Nigeria since 2001 and have been part of antenatal care programs since the same year. There

is no denying that this is a good thing, but it is not the end of the effort. Graphic 8 above, which

describes surveys that Measure DHS (Demographic and Health Surveys) conducted to assess the ef-

fectiveness of malaria aid, provides some elucidating visualizations to that effect. Though data are not

available for many years, the available numbers are grim. Both “households with at least one ITN”

and “children under 5 years [old] who slept under an ITN” increased across the two years surveyed,

2003 and 2008, but percentages hover around only 10% and 6% respectively in 2008. While there

may be problems with the survey design, this is an unacceptable number for net usage.

In the same figure, we can see that “operational coverage of ITN” within the larger population

is not much better, and, indeed, there are some anomalous figures in that graph on the top right,

“coverage of IRS and ITN.” ITN coverage rose steadily until reaching a peak at around 15% to 20% in

2006 but dropped rather dramatically to around 10% in 2007. Table 1 tells a similar story; net distri-

bution dropped sharply from 2006 to 2007 in all three countries in the summary example here. The

report does not seem to account for this sudden decrease in distribution. Nevertheless, even if we

accept the 25% operational ITN coverage in table 1, 25% of any population—particularly Nigeria’s
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immense population—still leaves a significant number of people bereft of the most cost-effective

malaria prevention method.

The first method to correct this is simply to distribute more nets. Again per the 2009 WHO

report, there were approximately 20 million LLINs sent to Nigeria in the period 2006 to 2008, but

this pales in comparison to the country’s 154 million people. More netting is the first way to increase

coverage, but it cannot come alone. A 2009 paper by A.A Aliyu and M. Alti-Mu’azu, published in the

Annals of African Medicine, assesses knowledge of ITNs among five secondary schools in Nigeria,

and finds that 87.3% of respondents knew about or had seen an ITN of some sort, while only 43.3%

used netting at the time of the survey. Once the net delivery numbers increase to an acceptable level,

it will then be necessary, the paper recommends, “[for] the Government [to conduct] public health

awareness campaigns” (Aliyu and Alti-Mu’azu 2009). Information campaigns will be necessary, and

integrating this into school lessons could be useful.

Aliyu and Alti-Mu’azu raise another important point about insecticide netting that any report

would be remiss to avoid addressing. Because ample netting is not freely available, it is plausible that

people may try to buy a net. This would be a problem for many Nigerians, as these authors poi-

gnantly note: “Even though the cost of ITN has been described as low its price ranges from N500—

N2000 (US$3.91—US$15.63) which in Nigeria is still very high in view of the fact that more than

70% of Nigerians are currently living below the poverty line of less than US$1 per day. This is further

compounded by low per capita Federal government expenditures on health at US$2” (Aliyu and

Alti-Mu’azu 2009). Certainly this problem lessens as freely available nets increase, but alleviating this

problem also requires that we employ doctors in the active prevention process as well as in treatment.
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Currently, “most clinicians [maintain] that their job [is] to treat malaria and not to control

mosquitoes” (ibid.).

According to the 2009 WHO report, net delivery in 2008 versus 2006 and 2007 increased

sharply (see table 1), so perhaps the ITN situation will improve in the future. The report also notes

that distribution programs began targeting “all groups” (rather than just pregnant women and

women with young children) in 2009; statistics for ITNs/LLINs in 2009 will be in-teresting to

see. Targeting all groups for net distribution is important because of the insecticidal atmosphere it

creates. In a 2007 paper on the subject, Killeen et al. conclude that “coverage of entire populations

will be required to accomplish large reductions of the malaria burden in Africa. While coverage of

vulnerable groups should still be prioritized, the equitable and communal benefits of wide-scale ITN

use by older children and adults should be explicitly promoted and evaluated by national malaria

control programmes. ITN use by the majority of entire populations could protect all children in such communities, even

those not actually covered by achieving existing personal protection targets of the MDG, Roll Back Malaria Partnership, or the

US President’s Malaria Initiative” (Killeen et al. 2007, emphasis mine).

It is unclear what proportion of the nets distributed in Nigeria is “long-lasting” versus stan-

dard insecticide-treated netting. It is important to know this because, as the names indicate, LLINs

are coated with an insecticide that will last longer before it becomes ineffective, and more frequent

retreatment increases the logistic burden that net distribution imposes. Several sources assure that

“most” of the treated netting in Nigeria today is of the long-lasting variety; it is important that LLINs

are the majority of the distribution plan.

We must also address the problem of net redistribution or insecticide reapplication. In any

event, even with LLINs distributed over less effective options, insecticide does not maintain its ef-
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fectiveness forever. Nets can be retreated, but this is another procedure about which people must be

educated. In an instance where a net cannot be reused—for example, it has been torn or otherwise

degraded—it is imperative that individuals acquire a new net. Assuming an increase in the number

of people seeking nets, the strain on current distribution chains may become too problematic and

even deter some from seeking a net. Lengeler et al. provide the basis for an innovative solution to

this possible supply problem, though they frame it in terms of sustainable investments. They say, “the

private sector has the potential to get ITNs distributed nationwide in most countries; from our ob-

servations, it can do so far more efficiently than the public sector … Through public sector subsidies,

vulnerable groups will be able to obtain ITNs … through public channels … Within the commercial

market, prices will be kept as low as possible by economies of scale and competition at all levels”

(Lengeler et al. 2007). While the development of a better commercial market for ITNs may assist the

sustainability of net proliferation, it does little to alleviate the burden of purchasing a net; as noted

above, netting can cost a significant portion of the average Nigerian salary, no matter how inexpen-

sive it may seem from an outsider’s perspective. Nevertheless, we may reasonably employ the private

sector in order to solve potential distribution problems going forward, but, if nothing else, we might

provide some government subsidy for acquiring netting on this private market as well, perhaps a sort

of “voucher” one can legally redeem with a commercial supplier.

Privatization may introduce a number of unforeseen consequences because it ultimately re-

quires that mosquito net markets turn a profit. For this reason it may be more beneficial for Nigeria

to build a publically-funded, publically-owned net production industry. This solution draws on Bra-

zil’s successful public health care system. The Brazilian government funds the production of generic

drugs, which are available at much lower cost to consumers, and a similar situation could be imple-
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mented for insect netting in Nigeria with some modifications. Given Nigeria’s wide wealth dispari-

ties, evidenced in graphic 6, it is better that any government-produced insect netting be available

free of charge. Nevertheless, the possible benefits of a national net industry are numerous. It could

allow the Nigerian government to produce the number of nets necessary, gives the government a

way to employ more individuals and ensures that malarial infection is not dependent on the whims

of corporations that produce netting.

There is, then, the problem of distributing the nets that are produced. This problem exists even

in the absence of a national netting manufacturing program. Nigeria, as mentioned, is marked by

stark rural-urban divides, and getting nets to more isolated rural populations is a challenge. While

the World Health Organization notes that health workers deliver some aid “at the community level,”

clearly this has not been effective at combating the spread of malaria. For this reason, it would be

more beneficial to employ, for example, existing craft networks. Women in many rural communities

have, for many years, produced crafts to survive in Nigeria’s male-dominated economy (Akingobun

and Ogunduyile 2009). This practice is widespread enough to aid in the distribution of netting,

though it is difficult to determine an exact breadth. Enrolling these networks in the process of LLIN

distribution combats net distribution issues caused by stark population distribution and increases the

influence of women on malaria control, which is important if only because malaria affects women

and their children most severely.

Health workers may further mitigate issues of net distribution by employing traditional healers

in the process as well. Nigeria is an incredibly diverse country, and the majority of its resi-dents rely

on traditional healing for their various health problems (Okeke et al. 2005). In the case of insect net-

ting, these healers could be instrumental for distribution and education. With female craft networks
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and traditional healers, Nigeria has two ways that can, in combination, lessen problems caused by

rural isolation.

Finally, it is necessary that we evaluate how education about netting occurs. Roll Back Malaria’s

report entitled “Scaling up Insecticide-treated Netting Programmes in Africa” describes the general

means for educating people: “The choice of media and messages should be based on for-mative

research into local perceptions of mosquitoes, malaria, nets and ITNs. The cultural factors that

determine ITN purchase, ownership and use must be taken into consideration to ensure that demand

creation activities are appropriate and effective” (Roll Back Malaria 2005). These are all beneficial

measures but may not go far enough to make a great difference, and, as the number of net users

increases, it may be more feasible and effective to utilize community-oriented means of education.

This means we should involve communities in the process of educating the unknowledgeable

through the use of, perhaps, community support groups and local education meetings or seminars.

Traditional healers can also assist in this process, as they provide a vital source of expert knowledge

(Okeke et al. 2005); children in some areas can also assist, particularly if malaria education programs

are integrated into their school curriculum. The ability of mass media to change behavior may at

least be bolstered by such community-oriented measures and can change patterns of net usage

significantly.

Increasing Treatment Availability


For the time being and likely through the foreseeable future, there will be a need for malaria treat-

ment. Primarily this will be in the form of artemisinin combination therapy (ACT), and therefore we

must focus on the access that individuals have to free ACT treatment. The WHO reports that ACT has

been free of charge for children under five years of age since 2006 and that the same treatment be-
Hopkins 22

came freely available for people over five in 2009. These are both good implementations, but clearly

there is a problem according to the WHO’s own assessment.

Again, graphic 8 in the data section above depicts this problem. In the two survey years, 2003

and 2008, only about 30% to 35% of children under age five took antimalarial drugs. The WHO also

provides a misleading statistic, that 100% of reported cases were treated beginning in 2006; it is im-

possible that, with only around 500,000 reported cases, all the cases of malaria are being treated in

a population of nearly 154 million people. We may remedy this issue by means similar to the netting

situation described above—education and keeping drugs free of cost are key to ensure that we alle-

viate the malaria burden.

The salient recommendations for drug availability are similar if not identical to those proposed

above for insect netting. Here again, Nigeria encounters a problem of dissemination and knowledge.

A 2005 survey on treatment knowledge among rural and urban caregivers found abysmal levels of

malarial drug usage, particularly among rural respondents; only 21% of rural care-givers reported

using any sort of malaria drug, and neither drug (chloroquine and sulphadoxine-pyrimethamine)

was given in correct dosing or in combination with other drugs. The problem with treatment in

Nigeria thus does not reside with clinics represented in the WHO’s reports but with the people that

these clinics have not been able, for a variety of reasons, to treat.

Again, as with netting, community-based efforts are essential in combating this problem. Tra-

ditional healers, rural craft networks operated by women, and, in some cases, children can assist

with treatment dissemination and education. The first two of these should function in the same

way as net distribution: get drugs and give drug administration training to those groups—healers

and women—and allow them to distribute the drugs throughout their communities as necessary.
Hopkins 23

Children, however, are a special case. Because they may not be as reliable for controlling drug dis-

tribution, they can assist by, for example, training their communities to use ACT drugs. Children are

particularly applicable in the urban context where a greater amount of known schooling occurs.

Rural communities are not necessarily a wasteland of educational depravity, so children there can

aid in knowledge dissemination there as well. A mention of schooling implies the route by which

children should learn these methods. Like with knowledge of net usage, drug administration can be

integrated into their schooling, or, in the case where no such schooling exists, it may still be possible

for local health workers to teach them drug administration practices. This has the added benefit that

they will likely teach their children the same knowledge in the future.

Once again, to reiterate the usefulness of Brazil’s example, this is easier to implement with a

steady, government-backed drug production industry that could provide more drugs free of cost

to Nigerians. Such an industry has at least one additional benefit when considering antimalarials.

Nigeria is among many sub-Saharan nations affected by the infamous “brain drain,” the ultimately

damaging migration of medical personnel from their nation of origin to the United States or several

other European nations (Serour 2009). A national drug production program would offer employ-

ment for medical professionals, thus allowing Nigeria to at least partially mitigate the loss of trained

personnel.

Mosquito Control Programs: IRS and Otherwise


Controlling the many species of mosquito that transmit Plasmodium parasites is another simple

method to halt the spread of malaria and other mosquito-borne diseases, including yellow fever. Vec-

tor control is important in Nigeria for the additional reason that, per the CIA World Factbook, 70% of

the Nigerian labor force works in agriculture. Some agricultural processes in Nigeria are in need of
Hopkins 24

reform, as they can promote mosquito breeding. In the words of Oladepo et al. (2009), “the dump-

ing of cassava tuber peelings which allows the collection of pools of water in the farms, storage of

peeled cassava tubers soaked in water in uncovered plastic containers, digging of trenches, irrigation

of farms and the presence of fish ponds were the major observed agricultural practices that favored

mosquito breeding on the farms. … There is an urgent need to engage farmers in meaningful dia-

logue on malaria mosquito breeding. Multiple intervention strategies are needed to tackle the factors

related to malaria prevalence and mosquito abundance in the communities.”

In this specific case, though it is not necessarily representative of widespread agricultural prac-

tices, we can see that local communities must be taught to associate open pools of standing water

with mosquito breeding and that, therefore, they should strive to eliminate such pools. We can

achieve this teaching through local agents, and children are again useful here. Children can have a

transformative effect on communities. If taught to control standing water, they can teach their com-

munity to do the same; eventually, they will pass these practices along to their own children. It is

important to remember the role of their mothers within communities as well. Women also have a

similar—perhaps greater—potential to change practices in their community regarding the elimina-

tion of standing water.

Eliminating standing water is an important activity to encourage, but it is impossible to en-sure

that all open pools are eliminated. For this reason, insecticide spraying can be useful in con-trolling

mosquito population. The WHO notes that Inter-Residual Spraying (IRS) is always used in combina-

tion with ITNs of some sort but also reveal (see graphic 8) that operational coverage of IRS is poor

at best. Obviously, it may be prudent to increase spraying in residences. We must do so with caution,

as certain insecticides are incredibly harmful to human health. For example, a study by Bornman
Hopkins 25

et al. (2009) established a strong relationship between IRS with dichlorodiphenyltrichloroethane

(DDT) and urogenital defects in children born to mothers where such spraying is utilized. Part of

the problem, note Bornman et al., is a lack of awareness. Residents must know to avoid, for example,

storing food in areas sprayed with insecticides. Aforementioned methods can be applied here as well;

teach women, children, and traditional healers to avoid areas with pesticide and to disseminate this

knowledge, and the use of IRS can increase with a decreased danger of health de-fects. Combining

IRS acceleration and community-oriented training is the only way that IRS can reasonably succeed.

Summary and Conclusion


Malaria is a remarkably simple disease to control considering only at the simplicity of the means

for doing so. Campaigns to control mosquito populations through standing water control and in-

sect netting have proven greatly successful in, for example, Brazil, Eritrea, India, and Vietnam. Barat

(2006) explains, in brief, what these countries have done correctly and how other nations can use

these four countries as an example of malaria eradiaction (emphasis mine):

“The success of these four malaria control programs appears to be the result of the confluence

of factors. A sound targeted technical approach, skilled human resources, and good infrastruc-

ture at national and sub-national levels, strong technical and programmatic support from part-

ners, and sufficient and flexible finances were all essential for these programs to accomplish

their goals. Many of the lessons learned from these program successes could easily be appropri-

ated by other countries. The key … factors … should not be viewed as a menu, but rather a group of essential

characteristics required for program success. Countries interested in achieving such successes must strive

to address all of these factors. … [but] if a country is involved in civil conflict or a program

manager has no access to those who control the finances, then success is unlikely.”
Hopkins 26

It is difficult, but not impossible, to envision a successful malaria reduction and eradication pro-

gram in Nigeria. Nigeria’s immense population, widespread poverty, and sharp rural-urban popula-

tion divide present the primary challenges to this vision. In order to properly address malaria, the

Nigerian government must put more attention on health care than it has put on debt repayment

or oil revenue; government spending on public health care has been lackluster at best. Certainly

distributing more treatment will help, but as Olaniyan and Lawanson (2010) note, the value of

preventatitve treatment in Nigeria should not be underestimated: “There is … need to re-examine

the allocation of resources in relation to health policy guidelines. More resources are required at the

primary or preventative level while the secondary and tertiary levels are strengthened to provdie the

required referral for the health sector to function effectively.” For Nigeria, this means that netting

and vector control programs are in need of significant augmentation.

In order to combat the high number of malaria cases in Nigeria, the government would do

well to follow Brazil’s example and establish a comprehensive health care program that has among

its chief programs LLIN and ACT drug manufacture; this system could then provide netting and

treatment free-of-cost to Nigerian people. Such a program can also assist in mitigating the loss of

physicians and other health care workers from the country, allowing Nigeria to increase its number

of physicians, which is desperately needed to serve such a massive population of people.

Even in the absence of such a national program, Nigeria faces a number of dissemination chal-

lenges. Rural populations in particular are relatively isolated and therefore pose a serious challenge

to distributing malaria aid of both a material and intellectual type. In order to combat this, Nigeria

should enlist the help of informal distribution networks (which is more useful primarily for material

distribution), female craft networks, regional traditional healers, and, particularly in the more urban
Hopkins 27

south, children through school curriculum additions. All of these groups are integral to distributing,

for example, insect netting, ACT drugs, and knowledge about how to use both. With a combined

effort that includes these groups, Nigeria can significantly reduce malaria. Implementing these plans

will not provide a quick fix; it is important to remember that, while these steps are integral to de-

creasing Nigeria’s malaria burden, time, of all things, is required to completely bear them out.

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