When I asked his age, he said with a smile, "I am 66 years old."
Since he could now properly tuck in the bed net, he'd moved the bed net material that had covered his eaves to the latrine outdoors.
"I know that the mosquitoes can infect me if I leave in the night to go to the bathroom, so I need protection there, too," he said sagely.
I could only imagine what it must have felt like for Eliarehemu, at age 66, to have a soft place to lay his head for the first time in his life, to sleep on a cushion instead of the cold dirt floor. I also saw matches and soap and a couple of bowls, all new-purchased with the efforts of a man who finally knew what it felt like to be healthy.
Still in the hut, Eliarehemu leaned over and whispered, "Do you remember those chocolates you brought to me the last time?"
When I nodded, he grinned widely. "I ate one piece, just one, every night for nearly 3 months and, oh, the happy feeling it gave me."
I told him I'd try to find more, though I couldn't promise the same quality. He shrugged and said he'd be happy with anything, as long as it was chocolate.
It was the first time he'd even hinted that he wanted something from me. He was a poor man, but a proud one. I promised to bring chocolates next time and then shared some photos I'd taken of him over the past 3 years.
At the first one, he grimaced and whispered, "I am so old, so old."
"Oh no," I said, "you were sick then. Now you are healthy and beautiful. You've even become a bit fat."
He shook his head worriedly. "I am too old."
Quickly, I turned the pages and showed him a recent photo of himself standing in clean clothes, sporting a much fuller face and figure.
"Ah, I see! I see!" he exclaimed as a wide smile spread across his face. He then patted me on the back and pronounced each of his words slowly and carefully, his eyes dancing, as he happily exhaled. "We've done well."
He had done well indeed, and except for the gift of a simple tool just one bed net, plus some belief from people around him-he had done it all himself.
ANECDOTES ARE POWERFUL IN that they show possibility. One bed net used regularly vastly improved a poor man's health, restoring his strength so that he could work, farm his own land, increase his income, and change his life. There is a strong correlation between investing in health care for people and enhancing their ability to earn income, and with higher incomes come increased investment in their children's educations and lower population rates.
The question then becomes how to ensure that hundreds of millions of nets are distributed effectively and used properly by the people who need them. But that cannot be the only question, for anecdotes can also be misleading. While bed nets are one answer, they are not the only answer. Continuing to look for entrepreneurial innovation enables us to find better and better solutions to extremely complex problems.
Malaria is one of the world's biggest killers, taking the lives of between 1 and 2 million people every year. About 90 percent of these cases are in Africa, and three-quarters of those who contract malaria are women and children. I will never forget my bout with malaria when I lived in Kigali, nor the people I knew who died from it. What it means for Africa is staggering losses of life and human productivity.
Imagine a million people-the entire population of a big city-dying every year. It's estimated that the continent loses about $13 billion yearly because each time someone gets the disease, she or he usually stops working for a week to 10 days. If you take the most conservative estimate of 300 million cases and reduce it by the 150 million cases in children, then you are still looking at a minimum of 150 million lost workweeks each year.
In 2002, we were approached by representatives of a collaboration of UNICEF, Sumitomo Chemical, and Exxon Mobil to see if we might participate in an effort to manufacture a long-lasting, insecticide-treated bed net in Africa for distribution there. Traditionally, people used simple polyester-based nets to cover their beds at night, but there were two big problems with them. First, they ripped easily, and once there was a hole in the net, mosquitoes could easily sneak through to find their victims. Second, continued efficacy required that a person dip the bed net in an insecticide every 3 to 6 months. Humans being humans, few users went to the trouble of dipping the nets. Most of the bed nets in people's homes became fairly worthless after just a few months of use.
Sumitomo Chemical Company of Japan had developed a method of impregnating a polyethylene-based netting material with organic insecticide and created a bed net that could last for 5 years without redipping. The technology itself could revolutionize malaria control. The challenges, however, were to produce enough bed nets to cover a majority of people, to distribute the nets so that people actually got them, and to ensure that once they had a bed net, they used it properly.
Critical to producing the bed nets was identifying an African entrepreneur capable of taking this new technology, transferring it effectively to Africa, and financing a new, unproven venture. This is where Acumen Fund came in.
After reviewing a number of different businesses, Anuj Shah of A to Z Textiles emerged as the best entrepreneur on whom to take a risk. Based in Arusha, Tanzania, the family-owned company had already operated successfully for a quarter century in a tough business environment. Employing 1,000 people, it produced both textiles and plastics. Anuj, the CEO, was smart, ambitious, driven, and hardworking, and had a reputation for follow-through. Acumen Fund provided a loan for the first bed net-weaving machines, and the company worked with Sumitomo to bring a new bed net-manufacturing process to Africa. I remember thinking that if the company produced 150,000 nets a year, we would have made a major contribution.
On my first visit to A to Z, I was reminded of factories in Bangladesh that were efficient, clean, bright, and busy, with women everywhere. Upstairs, Anuj pointed to rows and rows of women sitting behind their sewing machines, producing nets and then handing them over to quality control for testing and packaging. To check the quality of the nets, the women would hang them and stand inside, examining them for unintended holes and tears. They looked like Matisse dancers, fluid figures moving gracefully in a world of blue gauze. The feeling of productivity was everywhere. Anuj proudly told me that production rates were already comparable to those in China.
I sat next to a beautiful, round-faced young seamstress who had worked at the company for 8 months, sewed 160 nets a day, and earned enough at A to Z to move into town and pay for her father's cataract operation. She was in no hurry to marry. Before working there, she'd been selling vegetables on the street, but with a real job, her life was completely different. That was in early 2004.
By 2008, due to the relentless entrepreneurial spirit and determination of Anuj and his team, more than 7,000 women were working with A to Z. Assuming that each job helps support five people, that means more than 35,000 individuals are directly touched by production of a much-needed item for the health of the poor. In quantitative terms, it translates to more than $3 million in new wages to the local economy.
Anuj's third-generation company now supplies 16 million nets a year, more than 10 percent of all long-lasting insecticide-treated nets globally. A to Z is now providing enough bed nets to cover more than 20 million people a year, helping them retain their productivity while saving thousands of lives.
At more than 70,000 square feet, the company's new factory, a joint venture with Sumitomo, is enormous, well lit, and always humming. Women and men alike wear uniforms; there is an aura of professionalism throughout the facility. Though energy supply is still a major problem in Arusha, A to Z has a room full of generators that kick in during the daily brownouts so that work can continue uninterrupted.
The production of a lifesaving product is just the beginning. Identifying the right approaches to marketing and distributing it is where the challenge lies. While most long-lasting bed nets are given away free with support from the Global Fund and UNICEF, many players, including government and aid agencies, each with its own set of incentives,
have to be figured into the equation. Moreover, the roads in many parts of Africa are difficult to travel and sometimes impassable. All these factors are challenging obstacles-and great opportunities.
While Acumen Fund believes in the goal of promoting universal access to life-saving bed nets, we are also committed to experimenting with various private sector approaches to distribution. We and A to Z agreed to try selling nets at different price points, not only to low-income consumers but to companies that had an economic incentive to protect their workers from the disease. Innovation requires experimentation; no one has the answers for solving poverty yet. The total price needed to make and then distribute a bed net to a poor woman in Africa is about $10. We knew that some level of subsidy was needed and wanted to determine how much in order to make the nets available to everyone.
One key assumption we made was that there might be room for a small private market, given that overall production of the long-lasting nets wasn't large enough to reach everyone. This was corroborated when my colleague Molly visited a village of about 4,000 in Zanzibar and saw that a free program had delivered 700 nets to pregnant women and children, the groups included in the United Nations' Millennium Development Goals. The village chief was tremendously grateful for the gift but frustrated that the other 3,000 villagers had no access. Because only giveaway programs were made available-and these were bound to serving only pregnant women and children under age 5-there were no bed nets in the local markets for other people to buy. Having seen the effectiveness of bed nets, many of those villagers were willing to pay as much as $4, but they couldn't find them at any price.
We experimented with selling bed nets at different prices and studied what people might be willing to pay for bed nets in various situations. While some villagers were indeed willing to pay $3 or $4, the majority of rural East Africans moved more quickly to buy them at a $1 price point, and still, a large group couldn't afford to pay anything. To complement this, A to Z agreed to experiment with building a small sales force of women to see what would happen if they tried selling bed nets doorto-door.
The first approach was to build a sort of Tupperware model whereby individual women would sell nets door-to-door and at small house parties. In the first month, three of the women absconded with 17 nets. Having anticipated some amount of stealing early on in the process, A to Z had required the women to leave behind a minimum of two guarantors at the factory, each of whom would be responsible to make full payment for any missing or stolen nets. They held to their policy and no nets were taken after that.
One of the most charismatic saleswomen demonstrated how she pitched the sale of nets to her neighbors at a trial house party. The typical public health language of "shoulds" and "musts" was nowhere in evidence.
"You put the bed net on your floor," the big woman with two long braids bellowed in her baritone voice, "and all the bugs go away, not just the mosquitoes. Can you imagine? You can sleep the whole night long because there is no buzzing in your ears-and your children will do better in school because they won't be so tired."
She continued, "The color is beautiful, and you can hang the nets in your windows so that your neighbors know how much you care about your family." Almost as an afterthought, she mentioned that the bed nets would protect the children from malaria.
Beauty, vanity, status, and comfort: These are the levers that are pulled the world over as we make our decisions. The rich hold no monopoly on any of it. But we're a long way from integrating the way people actually make decisions into public policy instead of how we think they should make them.
A to Z experimented with a number of distribution channels, and two proved promising. Tanzanian companies were willing to buy the nets at a price of $3 or $4 and sell them for the same price to their employees through a payroll-deduction program. A to Z also sold nets off its own trucks when distributing other products in rural areas. Boys with bicycles would buy the nets and then resell them in local markets.
Finding such modes of distribution reminded me of Haddy, the Gambian fertilizer seller I'd met years before. The solution focused on building on systems already in place, systems that worked for the poor and increased their overall levels of choice. I also thought of Charlotte, who wished she could accept the free antiretroviral drugs but appreciated that at least she could afford the European pills in the marketplace that suited her body's needs.
Indeed, when we talk to women in rural areas, they push us to think of more creative solutions altogether. It can be hot and sticky under the nets, and you are vulnerable to mosquitoes if you walk around inside the house or go to the bathroom at night. Consequently, we've been working with a brilliant scientist who has lived for more than two decades in Africa and has been developing a way to cover the walls of a rural home to protect the household not just from malaria, but from all sorts of insect-borne diseases.
We started with a single approach-financing a technology transfer by investing in an African entrepreneur to bring a critical good to Africans. Through the work, we learned a lot about how people make decisions and what it might take to build an alternative distribution system. We also learned that while free bed nets are key to reaching the masses, there is also a place for market mechanisms that put malaria bed nets in shops so anyone who needs them can get them without having to hope that a clinic will provide them, at least until public health policies are reliable enough to ensure truly universal access.
Public health is the thorniest area for change, but not an impossible one. So much can be learned by listening to the market: Indeed, this process may lead to insights about how to price insurance products for the very poor so we'll have a more rational system for bringing affordable, critical goods to them in a way that is reliable and accessible. Malaria bed nets might be one component of such a program, which would have to be built from the perspective of the people who actually use it.
What also makes the process of growing solutions to poverty complex is the noise we hear in the media and among thought leaders who believe their way is the only way. They suffer from a paucity of listening skillsjust at the time when listening has never been more important. Today's media are highlighting a major debate between those who think that everyone in Africa should be given a free bed net to protect him or her from malaria and those who believe that the bed nets should be sold at an affordable price.
The free-nets side cites fast coverage ratios and immediate reductions in malaria. And it's true: Malaria rates fall dramatically when an entire village is given free nets. Social marketing advocates-those who believe that nets should be sold-argue that giveaway programs typically result in quick fixes that don't last and point to evidence in Ethiopia and other countries where, only a few years after net distribution, actual usage rates fell precipitously. This, too, is true.
So often we ask ourselves the wrong question. When it comes to a disease like malaria, the question should not be whether bed nets are sold or given away free. Both distribution methods have their place in a broader attack on the disease. The question instead is, What does it take to eradicate malaria? Without a reliable source of bed nets, people may find themselves abruptly cut off from a supply when they most need it. It's not "either-or," but rather "both-and."
We have to be careful, as well, that the world's focus on bed nets doesn't hold back other potential innovations. The Bill and Melinda Gates Foundation has put hundreds of millions of dollars into researching a malaria vaccine, and efforts are under way to create a line of house paints that kill mosquitoes but are safe for humans to touch. These are exciting possibilities that will work only if the world learns how to collaborate in a system-wide assault on the disease.
In the 21st century, private-sector approaches fueled in large part by creative philanthropy will be vital to solving public-sector problems. Almost nowhere is such innovation needed more than in supplying water. Poor farmers in arid regions can't find enough of it to irrigate their crops. People the world over contract diseases from dir
ty water; an enormous global burden of disease is due to unsafe water and poor sanitation. Increasingly, we're seeing skirmishes that may lead to big wars in this century over who has rights to water.
Meanwhile, the water table in India alone is declining by 6 meters (20 feet) a year. Solving water-related issues is key. Again, no one has all the answers. If they did, we wouldn't have a world where 1.2 billion-or one in five of us-have no access to a glass of clean water.
As with public health, our approach to water at Acumen Fund has been to experiment and innovate to find solutions that can inform the public debate and show the way to wide-scale change. In India, for example, the platforms of many state governments have held largely that water is a human right and should be given free to everyone. At the same time, more than 180 million Indians have no access to safe, affordable water.
Since Acumen Fund started working on water, I have been invited numerous times to sit on panels focused on determining whether water is a human right or its ownership should be privatized. Again, the question is wrong. People need water to live, and there is no better intervention to improve health on a global scale than bringing safe, affordable water to as many people as possible. But how do we make sure it can be distributed to the poor in a sustainable way? How do we ensure that all people have access at least to the minimum amount of water needed to live healthy lives? We're trying to find those brave entrepreneurs who are determined to discover the answers.
Tralance Addy is a Ghanaian entrepreneur who, after a long career at Johnson & Johnson, turned his energies toward creating a company that would deliver safe, affordable water to low-income rural communities. He identified an ultraviolet filtration technology developed by Ashok Gadgil at the University of California at Berkeley, and set off to introduce this new technology to the developing world. In the Philippines, Tralance learned that he was selling the wrong thing to poor villages: People didn't actually care about what kind of technology was cleaning their water. Instead, they wanted a service that was reliable, affordable, and safe. Tralance thus shifted his focus from the technology to building the right distribution system.
The Blue Sweater: Bridging the Gap Between Rich and Poor in an Interconnected World Page 31