The entire world has put a lot of hope in bed nets as one of the tools to interrupt malaria and we have discussed to exhaustion the subject in scientific conferences, symposia and even around informal social gatherings. Lots of money, energy and sweat have been spent to distribute them among African, Asian and Latin American families in the last couple of decades.  There is no doubt in our minds that bed nets are effective at preventing mosquito bites if they are properly used but after seeing a photograph like this, perhaps all of us trying to fight this deadly disease should think harder about our own perceptions and change our strategy to include community education as a stronger component of bed net distribution campaigns and vector control programs. 

It is quite obvious in this photograph that the bed net is necessary for a good night of sleep. It is obvious that the intention was to use it for that purpose.  It is also obvious that this family has by far larger problems than mosquito bites and maintaining intact bed nets is either not a priority or perhaps too expensive given the circumstances.  Perhaps the family living in this household is more worried about larger flying insects (cockroaches) or bats but not mosquitoes.  Who is educating these families on the proper use of these life-saving devices? Perhaps tonight the mother living in this home will put her children to sleep one more time under this net convinced that they will remain malaria-free because someone told her bed nets would protect her family.  

Those of us who have had the fortune to visit remote villages in Africa and South America and have met these hard working families agree that while bed nets are effective, they only work when properly used.   In order for a bed net to be effective, it needs to prevent mosquitoes from biting humans.  In order to be effective, the bed net needs to remain intact and it should have holes so small that female mosquitoes are unable to enter and bite the person sleeping under it. It will not be effective if the mosquitoes are able to come inside or if they bite arms, feet or heads touching the net.  Bed nets do not protect people during the day unless they are napping under them.  Malaria parasites are transmitted from an infected to a healthy human through the bite of a female mosquito usually at night.  Female mosquitoes feed on human blood in order to be able to lay eggs. No bites, no malaria.  Simple enough isn’t it? Not quite.

While some claim that one bed net per family should be enough in order to decrease malaria transmission rates in vast areas, those of us who have seen families with 8 to 10 or even 12 children sleeping in different rooms can testify that one bed net per family is not nearly enough for them.  I arrived at a remote village a couple of years ago where families were structured in a very unusual way.  Each man was married to more than three women and each wife had more than 3 children.  The family was given only one bed net.  Each wife and her children slept in a separate hut different from the husband’s hut and the other wives. The husband’s hut was placed in the center as if it was a mini-village.  All wives would go to the field during the day to take care of the family crops while their husband took care of the children.  At night, when they were ready to go to sleep, the man would choose the wife that was going to share his bed for the evening and she was the lucky one to sleep under the one and only bed net.  As the other huts did not have a net, her children, two more wives as well as their children slept unprotected for months. What is even worse is that the children never slept under a bed net according to this scheme. 

 Others claim that bed nets are quite effective after being distributed but we have seen entire communities using them to catch their daily source of income in the nearest river.  They hang to dry at night in order to be ready for the next catch while the villagers sleep with no protection against mosquito bites at night.  It is obvious that distributing them was effective only to improve their income but not to decrease malaria transmission in that area. We agree that bed net distribution is ineffective if it is not accompanied by an integrated vector control program that includes a strong educational campaign tailored for each community.

Looking at this photograph is obvious that bed nets are probably a necessity in this area and that the intention of the bed net distributor was good. The intention of the mother receiving it and placing it on top of her child’s bed was also the best but somewhere in the middle, something failed.  As we intend to contribute to bed net distribution in the flood zone, it will be a priority to educate the community on its proper use.  We have a plan to accomplish this and we need your help. Help us get bed nets for this community. We will take care of distributing them using proper numbers of nets per family and educating them on their appropriate use and when to replace them.