The Ethics of Malaria Prevention

by Randy Hendrickson

Dr. Susanna Dodgson, the Chair of the Biomedical Writing Department, is a woman with a mission. Her goal is high—the total elimination of malaria. She has traveled to Africa numerous times and has met with key policymakers and influencers. She has done a lot of work to spotlight this problem and bring it to the attention of people who can make a difference, both in Africa, which carries the heaviest burden of malaria, as well as in the United States. She started the Medical Journal of Therapeutics—Africa, several issues of which are devoted to malaria prevention and treatment. One of her latest efforts includes a video “Malaria: A Preventable Disease,” which is now available on You Tube (http://www.youtube.com/watch?v=18UH-bvMWpc).

Malaria is largely preventable, yet over one million Africans die from this disease each year. Prevention is largely achieved through vector control or reducing the rate of transmission of the deadly disease. One of main preventive measures is the use of indoor insecticide sprays and insecticide-treated bed nets and curtains.

These measures are often difficult to implement and quite costly, especially in the poorer countries of Africa. Starting in 2003, however, there was a big increase in funding for malaria prevention. For example, between 2003 and 2006, the Global Fund spent more than $1.7 billion on malaria prevention. There has been other government and corporate sponsorship of malaria prevention projects, creating a “net culture” that includes groups such as the Bill and Melinda Gates Foundation, the President’s Malaria Initiative, Roll Back Malaria, and others. Although these groups provide subsidized bed nets to vulnerable groups, resources are still scarce and current methods of implementation are insufficient (1).

The ethical question involved is how are these scarce resources for bed net protection to be distributed?

• The target groups who would benefit the most from bed nets are pregnant women and children under the age of 5 years. Pregnant women, especially primigravidae women, have the highest risk for infection, and as a result, they are at risk for anemia, low birth weight, premature delivery, and even maternal death (2,3). Morbidity and mortality are also very high young children; most of the 1 million Africans who die each year are children under 5 years of age (4). Clinical trials in the 1990s consistently showed a 20% decrease in childhood mortality from regular use of insecticidal-treated bed nets (5).
• Conversely, should resources for net protection go to all people community-wide, without any discrimination or inclusion criteria? Coverage of the most vulnerable pregnant women and children is good for these target groups, but it has little if any impact on the vector population (6), which is important for the overall long-term public health of the area. Clinical trials also showed that there is a “community effect” (similar to the herd effect from the use of vaccines) by using insecticidal-treated bed nets. In these trials, entire families were targeted, not only the most vulnerable population. The bed nets were shown to be effective in reducing the vector population, and the chances of being bitten by an infected mosquito were greatly reduced (7).
• Should the money be spent on education of the people and the supervision of control efforts? Although clinical studies have shown the effectiveness of bed nets against malaria, will individual communities be able to maintain the 75% coverage that is necessary to significantly impact disease transmission? Human behavior may be the missing factor in this equation (8). The nets have to be procured and distributed, people have to be taught how to properly use them, compliance should be monitored, and disease surveillance is required (9). Education of the people is a key element for success.

These are the ethical issues that government officials and policymakers are grappling with in dealing with resource allocation for the prevention of malaria, and there are no easy answers. The international community (i.e., WHO, United Nation’s Development Programme (UNDP), UNICEF, and the World Bank) is committed to reduce the mortality and morbidity from malaria, but there is still much to be done. People like Dr. Susanna Dodgson are bringing these issues to the forefront of public awareness by making it the focus of research, education, and academic collaboration.





1. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
2. Steketee RW, Wirima JJ, Slutsker L, Heymann DL, Breman JG: The problem of malaria and malaria control in pregnancy in sub-Saharan Africa. Am J Trop Med Hyg. 1996, 55:2-7.
3. Menendez C: Malaria during pregnancy. Curr Mol Med. 2006, 6:269-273.
4. Owusu-Agyei S, Awini E, Anto F, Mensah-Afful T, Adjuik M, Hodgson A, Afari E, et al. Assessing malaria control in the Kassena-Nankana district using the RBM tools. Malaria Journal. 2007; 6:103.
5. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
6. Kitua AY, Mboera L, Magesa SM, Maxwell CA, Curtis CF. The untapped potential of bed nets. Science. 2008; 319:900.
7. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
8. McCutchan TF. Beyond bed nets. Science. 2008; 319:33.
9. Roberts DR. Preventing malaria in endemic areas. BMJ. 2007; 335:1001-1002.