Read parts one and two of Zeke Emanuel's Africa diaries.

I just did a rapid diagnostic test for malaria at the Parasite Control Service in Thies. Thies is a research facility that mainly studies the mosquitoes and malaria parasite. (They also showed me how they grow the mosquitoes.) And the test is pretty simple.  Just a pin prick in the fourth finger, a tiny loop of blood, and 4 drops of developing fluid.

We waited the 15 minutes and, presto, No Malaria.  But that was obvious.  It takes 2 weeks to develop malaria. So I will retest myself at the end of the trip in Mozambique.  But good to know the test is simple, painless, fast, and virtually fool-proof. Even I, who hasn't drawn blood from a patient in ten years, could do the test and read the result.

= = =

I am in Gandiaye, a relatively large town with an imposing mosque about five hours east of Dakar on a main highway. I am trying to read the French in the ledger book and I am not doing very well. One of the great deficiencies of my education is my lack of language skills. 

But it doesn’t take a whole lot to figure out that there are a lot of + signs in the column marked TDR, the French acronym for the rapid diagnostic test for malaria. (It seems all French acronyms are backwards.) There were 16  + signs just since the start of October.   

Puzzling my way through the cases one thing becomes clear: the ages of the patients. These were almost all adolescents 12 years old, 15, 18, 14, and on. There were two children under five and one over 30. 

Then, the chief nurse of this health post explains. The local area had distributed nets, but only to children under five and pregnant women. “Universal coverage," the project to distribute nets to everyone, had not yet arrived. And the log book attested to the effectiveness of the insecticide-treated nets.

If I needed any additional proof, I find it at another health post, this one miles from the main road in a small village Diam Diam (“Peace, Peace”). A small, stifling hot room with no electric light has three in-patients. Two gaunt children, a seven-year-old girl and a 14-year-old boy, have that faraway, vacant stare of exhaustion and apathy. They are hooked up to IVs, getting quinine for severe malaria. (The other patient has pneumonia, which is the biggest killer in developing countries.) And why do they have malaria? They came from a neighboring district, one that also did not have universal coverage. These kids, older than five, were sleeping without nets.

To reach all residents throughout the entire countrynot just in a few districts like the one Kissan is in—Senegal needs 5 million nets. But, so far, they have commitments and government funds for 4.1 million. In other words, they are still 900,000 short. And the government has to do more than distribute nets. It must maintain them. LLINslong-lasting insecticide-treated nets—are supposed to last five years. But they rip easily or get burned by candles, even when their owners are careful. Nobody has come up with a plan for repairing or replacing damaged nets.

How to replace the nets where the insecticide has worn off and those that have been too severely ripped on a regular schedule is not solved. But it’s better to have this problem than a lack of nets altogether.

Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.