Desta Ayanew, who lost her vision to the trachoma that plagued her for decades, kept her eyes closed because blinking was too painful. Ms. Ayanew, about 60, awaited an eye operation last year at a clinic in Alember, Ethiopia.

PART THREE | On the Brink: Trachoma
Preventable Disease Blinds Poor in Third World

By CELIA W. DUGGER
March 31, 2006 | The NY Times | Graphic | Map

ALEMBER, Ethiopia - Mare Alehegn lay back nervously on the metal operating table, her heart visibly pounding beneath her sackcloth dress, and clenched her fists as the paramedic sliced into her eyelid. Repeated infections had scarred the undersides of her eyelids, causing them to contract and forcing her lashes in on her eyes. For years, each blink felt like thorns raking her eyeballs. She had plucked the hairs with crude tweezers, but the stubble grew back sharper still.

The scratching, for Mrs. Alehegn, 42, and millions worldwide, gradually clouds the eyeball, dimming vision and, if left untreated, eventually leads to a life shrouded in darkness. This is late-stage trachoma, a neglected disease of neglected people, and a preventable one, but for a lack of the modest resources that could defeat it.

This operation, which promised to lift the lashes off Mrs. Alehegn's lacerated eyes, is a 15-minute procedure so simple that a health worker with a few weeks of training can do it. The materials cost about $10.

The operation, performed last year, would not only deliver Mrs. Alehegn from disabling pain and stop the damage to her corneas, but it also would hold out hope of a new life for her daughter, Enatnesh, who waited vigilantly outside the operating room door at the free surgery camp here.

Mrs. Alehegn's husband left her years ago when the disease rendered her unable to do a wife's work. At 6, Enatnesh was forced to choose between a father who could support her, or a lifetime of hard labor to help a mother who had no one else to turn to.

"I chose my mother," said the frail, pigtailed slip of a girl, so ill fed that she looked closer to 10 than her current age, 16. "If I hadn't gone with her, she would have died. No one was there to even give her a glass of water."

Their tale is common among trachoma sufferers. Trachoma's blinding damage builds over decades of repeated infections that begin in babies. The infections are spread from person to person, or by hungry flies that feed from seeping eyes.

In large part because women look after the children, and children are the most heavily infected, women are three times more likely to get the blinding, late stage of the disease.

For many women, the pain and eventual blindness ensure a life of deepening destitution and dependency. They become a burden on daughters and granddaughters, making trachoma a generational scourge among women and girls who are often already the most vulnerable of the poor.

Trachoma disappeared from the United States and Europe as living standards improved, but remains endemic in much of Africa and parts of Latin America and Asia, its last, stubborn redoubts. The World Health Organization estimates that 70 million people are infected with it. Five million suffer from its late stages. And two million are blind because of it.

A million people like Mrs. Alehegn need the eyelid surgery in Ethiopia alone. Yet last year only 60,000 got it, all paid for by nonprofit groups like the Carter Center, Orbis and Christian Blind Mission International.

As prevalent as trachoma remains, the W.H.O. has made the blinding late stage of the disease a target for eradication within a generation because, in theory at least, everything needed to vanquish it is available. Controlling trachoma depends on relatively simple advances in hygiene, antibiotics and the inexpensive operation that was performed on Mrs. Alehegn.

But the extent of the disease far exceeds the money and medical workers available. In poor countries like this one, faced with epidemics of AIDS, malaria and tuberculosis, a disease like trachoma, which disables and blinds, has difficulty competing with those big killers.

Dr. Abebe Eshetu, a health official here in Ethiopia's Amhara region, described the resources available for trachoma as "a cup of water in the ocean."

Nowhere is the need greater than across this harsh rural landscape.

As dawn broke one day last year, hundreds of people desperate for relief streamed into an eyelid surgery camp run by the government and paid for by the Carter Center. Some of the oldest had walked days on feet twisted by arthritis to get here.

The throng spread across the scrubby land around a small health clinic. They wrapped shawls around their heads to shield themselves from sun and dust, made all the more agonizing by their affliction. Their cheeks were etched with the salty tracks of tears.

'Hair in the Eye'

Typical of those was Mrs. Alehegn, led stumbling and barefoot through stony fields by Enatnesh, who worriedly shielded her mother under a faded black umbrella.

As they waited their turn, Mrs. Alehegn explained that her troubles began more than 15 years ago when she developed "hair in the eye," as trachoma is known here. The pain made it impossible for her to cook over smoky dung fires, hike to distant wells for water or work in dusty fields, the essential duties of a wife.

Gradually the affliction soured her relationship with her husband, Asmare Demissie, who divorced her a decade ago, so he could marry a healthy woman.

"When I stopped getting up in the morning to do the housecleaning, when I stopped helping with the farm work, we started fighting," Mrs. Alehegn said.

The operation she had come for is still exceedingly rare in Ethiopia. Only 76 ophthalmologists practice in this vast nation of 70 million people. Most work in the capital, Addis Ababa, not in the rural areas where trachoma reigns.

Because of the extreme doctor shortage, nonprofit groups have paid for the training of ordinary government health workers over two to four weeks to do the eyelid surgery. The Carter Center, which favors a month of training, estimates the cost at $600 per worker, plus $800 for two surgical instrument kits for each of them.

Those trained make an incision that runs the length of the eyelid's underside, through the cartilagelike plate, then lift the side of the lid fringed with the eyelashes outward. Then they stitch the two sides back together. The patient is given a local anesthetic.

The operation cannot undo the damage already done to corneas, which makes the abraded eyes vulnerable to infections. But it can stop further injury. And because the disease often takes decades to render its victims blind, the operation can save a woman's sight and halt disabling pain.

For Mrs. Alehegn, the surgery was her second. Her plight is typical, for trachoma is both a disease of poverty and a disease that causes poverty.

After separating from her husband, she, Enatnesh and another daughter, Adelogne, then just 4, moved to a small, poor piece of land belonging to Mrs. Alehegn's family. About a year later, Mrs. Alehegn scraped together enough money for her first eyelid surgery. But as she aged, the underside of her eyelids - scarred by past trachoma infections - continued to shrink, turning her lashes inward again.

In recent years, her poverty was so dire she could not afford to have the surgery again. Her only income was the dollar or so a week that Enatnesh collected when she went to market to sell the cotton fabric her mother wove. They were so poor they could not afford even 15 cents for soap.

"If I get my health back, it means everything," Mrs. Alehegn said. "I'll be able to work and support my family."

The others who journeyed to the camp told many such stories of hardship. In a land where early death is commonplace, some of those with the disease see their wounded eyes, ceaselessly leaking tears, as a kind of stigmata of sorrow.

Banchiayehu Gonete, an elderly widow, said three of her eight children had died young. The bitterest loss was of her eldest daughter, carried off by malaria at 40 with a baby still inside her. It was this daughter who had plucked her in-turned lashes, cooked for her and kept her company.

"God killed my children," said Mrs. Gonete, old and wrinkled, but unsure of her age. "I feel this pain as part of my mourning."

Nearby, Tsehainesh Beryihun, 10, sat with her grandmother, Yamrot Mekonen. Trachoma ended the girl's childhood years ago.

When her parents divorced, her mother gave Tsehainesh, then just a baby, to her paternal grandmother. As the old woman's sight failed, Tsehainesh became her servant. Since she was 7, she has fetched water, cooked, cleaned, collected dung and wood for the fire and swept the dirt floors, her grandmother said.

The girl sees her half brothers and sisters, the children of her father's second marriage, happily dashing to school, while she lives apart, her days filled with the grinding work of tending to a sickly, demanding old woman.

Her grandmother explained that the girl owes her. "I've supported her this far," Mrs. Mekonen said impassively, "so now it's her turn to support me."

Tsehainesh wept bitterly as her grandmother spoke, refusing to utter a word.

Ending Disability and Dependency

To break this cycle of debilitation and dependency, the goal is not eradication of the eye infections themselves, which most agree is neither practical nor necessary, but rather to reduce their frequency and intensity, a more achievable goal. This would avoid development of the devastating late stage of trachoma, called trichiasis, that makes surgery the sufferers' only salvation.

Toward that end, the World Health Organization has approved a strategy known as SAFE, an acronym that stands for surgery, antibiotics, face washing and environmental change, notably improved access to latrines and water.

Already, some researchers say, the growing use of antibiotics around the world to treat infections, even those unrelated to trachoma, has probably contributed to trachoma's decline. That is true even in very poor countries where there is no organized effort to tackle the disease, like Nepal and Malawi, they say.

The use of Zithromax, an antibiotic manufactured by Pfizer, has proved a breakthrough. The most common alternative is a cheap, messy antibiotic ointment that has to be applied twice daily to the eyes for six weeks. Zithromax, in contrast, can be taken in a single dose - making compliance easier and distribution to millions simpler.

By 2008, Pfizer, the world's largest drug maker, will have donated 145 million doses for trachoma control. Its contribution is administered by the International Trachoma Initiative, a nonprofit group. The drug has been provided in 11 of the 55 countries where trachoma remains a problem.

But globally, the World Health Organization estimates that at least 350 million people need the antibiotics once a year for three years to bring infection rates under control.

That equals more than a billion doses of azithromycin, the generic name for Zithromax. Trachoma is so rampant here in Ethiopia that an estimated 60 million people, or 86 percent of the country's population, need the drug.

Pfizer has not officially announced any additional donations, but Dr. Joseph M. Feczko, a Pfizer vice president, says the company will provide whatever is needed. "There's no cap or limit on this," he said. "We're in it for the long haul."

But even free drugs cost money to distribute. No global estimates are available for carrying out the SAFE strategy for trachoma control, but the Ethiopian government, beset by competing social problems, would have to come up with $30 million to reach even half the people who need the antibiotic, and $20 million more for public education on basic hygiene.

For now, the aim here is a more modest effort at localized control, but even that will not be easy.

An Ancient Scourge

Chlamydia trachomatis, the microorganism that causes trachoma, has been a source of misery for millennia, thriving in poor, crowded and unsanitary conditions. In ancient Egypt, in-turned eyelashes were plucked, then treated with a mixture of frankincense, lizard dung and donkey blood. In Victorian England, infected children were isolated in separate schools.

At the turn of the century, doctors at Ellis Island used a buttonhook to examine the undersides of immigrants' eyelids. Those with signs of trachoma were often shipped back to their home countries.

Swarming Musca sorbens flies play an ignominious role in spreading the disease. They crave eye discharge and pick up chlamydia as they burrow greedily, maddeningly into infected eyes.

"They cluster shoulder to shoulder around an infected eye," said Paul Emerson, the entomologist who did pioneering work on the role of the flies in spreading trachoma and who now runs the Carter Center's trachoma control program.

So inescapable, so persistent are they here in the Amhara region that children learn not to bother shooing them away. Even at the surgery camp, flies buzzed through the chicken wire that covered the windows of cramped operating rooms, harassing trachoma victims at the moment they sought relief.

Once the eggs of a female fly are ripe, she lays them in her preferred breeding medium, human feces, plentiful because most people here go to the bathroom outdoors.

But the flies cannot breed in simple, inexpensive pit latrines, Mr. Emerson said. He said he does not yet know why, but he thinks that a competing species that does thrive in latrines may eat the Musca sorbens maggots.

Ethiopia is now making a national effort to get people to build latrines, training thousands of village health workers to spread the word. It is also teaching children the importance of face washing in school.

But soap and water are scarce, too. Women often walk hours a day to wells to carry home precious pots of water balanced on their heads. And soap is a luxury for the poorest of the poor.

For those like Mrs. Alehegn, with late stage trachoma, surgery will continue to be necessary.

When her operation was complete, the health worker who performed it, Mola Dessie, pressed white cotton pads on Mrs. Alehegn's eyes to soak up the blood and applied antibiotic ointment to prevent infection. Then he covered her eyes with bandages.

Enatnesh wrapped her mother's head in a dingy cloth and slipped her stick-thin arm around her mother's waist to lead her away.

Mrs. Alehegn, who is illiterate, says she hopes that once she heals she will be able to weave more cloth, earn more money and do the domestic chores, leaving Enatnesh freer to pursue an education. "I don't want her to live my life," she said.

Despite her dependence on her daughter, Mrs. Alehegn has allowed the girl to go to school. Enatnesh, though having fallen behind, is a diligent fifth grader at age 16, who proudly said she is ranked 5th out of 74 students in her class. She dreams of being a doctor.

Two days after her mother's surgery, Enatnesh led the way to her father's sturdily built hut a couple of hours walk away. There, as his second wife swept the compound and Enatnesh's 9-year-old half-brother sat in the shade, Mr. Demissie, 58, offered a regretful explanation for his decision to divorce his first wife.

He, too, had developed "hair in the eye," he said. And like his wife, he, too, had been forced to stop working. If they had not separated, he reckoned, they would both have died. Finally, Mr. Demissie decided to save himself.

His sick wife would never find anyone else to marry, he realized. But for him, a new, hardworking wife would provide a second chance. And after his marriage, he got the surgery to prevent his own blindness.

"If we had not been sick," he said sadly, "we would have raised our children together."

As he spoke, Enatnesh listened sorrowfully, her hand cupped over her mouth, her head bent low.

ON THE BRINK

A Joint Attack on Many Perils of Africa's Young

By CELIA W. DUGGER

December 23, 2006, The NY Times

PONYAMAYIRI, Ghana - In this poor, dusty village of 550 people, four babies died of malaria in October, among them 11-month-old Yire Are. As word spread that the government would be handing out mosquito nets that prevent malaria, his uncle made sure he was there with his own children, their heads shaved in mourning.

"I came to claim a mosquito net," the uncle, Konyiri Doorkono, said firmly, his 3-month-old son clasped in his arms.

But when he and many of the village's families lined up beneath the spreading arms of a neem tree, they got much more. Children gulped down polio vaccine, vitamin A and deworming medicine. They howled at the prick of a measles shot.

They had joined a campaign to better children's odds of surviving past their fifth birthdays. It reached into even the most remote communities in Ghana over five days in November. Similarly monumental drives unfolded in eight other countries across Africa this year, with the mosquito nets alone expected to save the lives of 370,000 children over the next three years.

But while the world's leading public health officials praise this common-sense strategy to provide inexpensive, lifesaving doses of prevention to different diseases at the same time, it is far from simple to pull off. Getting an unwieldy collection of international organizations and charities to work together effectively is a major challenge.

In one measure of the difficulty, even as the Ghana campaign gathered steam, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria rejected a $46 million proposal to expand the approach to six more African countries.

An alliance of more than a dozen groups sponsored the proposal, but each of the six countries also submitted its own malaria application to the Global Fund, which controls most international malaria spending - and no one made sure the many requests did not overlap or conflict with one another.

"There were too many cooks," said Dr. Arata Kochi, who leads the global malaria program for the World Health Organization, whose experts helped draft the six-country proposal.

Though the proposal failed, Dr. Kochi called the combined campaigns "a winning strategy," and Dr. Richard Feachem, head of the Global Fund, described them as "spectacularly successful."

"Everybody is slack-jawed, aghast" at the rejection, said Mark Grabowsky, a public health doctor with the federal Centers for Disease Control and Prevention, who joined the Global Fund this year as a malaria program officer and who has long championed the marriage of measles and malaria in joint campaigns.

Dr. Feachem and Dr. Kochi say they hope that their organizations can improve their coordination.

"Malaria is a preventable child holocaust which occurs in Africa for no reason," Dr. Feachem said. "We can stop this. The Global Fund's role is finance, and we must work more closely with the W.H.O., the Red Cross and others to ensure that the money flows to those who can use it effectively on the front line."

Much of the challenge stems from the fact that each drive against a disease - polio, measles, malaria - has its own leaders, charitable groups and donors at the international level. Piecing them together in unified campaigns requires the logistical skills and diplomatic finesse of a skilled battlefield commander.

While public health officials know well the difficulties of mounting even individual campaigns, they say they have learned they can save more lives by piggybacking campaigns, particularly by adding malaria and distributing mosquito nets.

The need is great: malaria kills about 800,000 children a year in Africa. The W.H.O. estimates that only 3 percent of the most vulnerable African children under age 5 are covered by the insecticide-treated bed nets that can last four to five years. The cost for each net is $5 to $6.

Studies have also established that giving children vitamin A (2 cents per dose) boosts their immune systems and reduces deaths, while medicines to rid them of intestinal worms (also 2 cents) greatly improve their health and school attendance.

The push to give every child polio vaccine (15 cents a dose) has prevented some five million cases of paralysis worldwide since 1988, while inoculating children with measles vaccine (16 cents) has saved more than a million lives since 1999, according to the W.H.O.

The combined campaigns in Africa this year have made it possible to sustain gains from earlier measles and polio drives, while the net distributions promise a new payoff in reduced malaria deaths.

Dr. Grabowsky, who has devoted much of his professional life to measles, said the need for joint measles and malaria campaigns dawned on him gradually. In the late 1990s, on a visit to a mission hospital in Gulu, Uganda, he had an epiphany when a doctor there told him: "If you get rid of measles, we can close the measles ward. If you get rid of malaria, we can close the hospital."

In 2001, he was assigned by the C.D.C. to serve as an adviser to the Red Cross when the groups started the Measles Initiative, an effort to reduce measles deaths in Africa, along with the W.H.O., the United Nations Children's Fund and Ted Turner's United Nations Foundation.

As measles campaigns radically reduced measles deaths in country after country, Dr. Grabowsky worried that the undertaking would become a victim of its own success.

Why would a mother walk hours to get her baby immunized once measles was mostly gone? And what would happen if parents stopped flocking to campaigns? The answer was ominous: a resurgence of measles, an extremely contagious disease.

He had only to look at the 18-year slog to eradicate polio, which still has not wiped out that crippling disease. In northern India, more than two dozen polio-only campaigns in recent years have generated fierce resistance among some parents, who are mistrustful of the vaccine, fed up with the campaigns and angered that officials are not doing more to fight other diseases that kill their children.

In Africa, Dr. Grabowsky figured that parents would keep coming for measles vaccines if the campaigns also offered mosquito nets to prevent malaria, which routinely kills small children across the continent.

In 2002, the Red Cross, with a $50,000 grant from the Exxon Mobil Foundation, ran the first test of combined campaigns here in the impoverished, northwestern corner of Ghana, where one in five children dies before age 5. In the Lawra district, it got measles vaccines and nets to more than 90 percent of children under age 5.

Three years later, researchers returned and were startled to find the benefits had persisted. Most of the children still slept under the nets at night, when malarial mosquitoes bite.

Evaluations of combined campaigns carried out nationally in Togo in 2004 and in Niger last year also found soaring numbers of children under 5 sleeping under bed nets. But the surveys also discovered that more people owned nets than actually used them. In Togo, for example, more than 9 of 10 families with young children got a net, but only about 6 in 10 children had actually slept under one the previous night.

Unlike vaccines, which are effective once given, nets must be used regularly to work - and that means education and following up. The Red Cross has mobilized thousands of volunteers to help in the task.

Still, getting the nets to children is the first step, and this year more than 18 million nets were handed out in combined campaigns - far more than ever before.

It was, in fact, a breakthrough year. Combined campaigns, which included some combination of measles shots, polio drops, deworming pills, vitamin A and nets, were carried out in nine African countries spanning the continent, from Ghana in the west, to Ethiopia in the east, to Angola in the south.

But even when all the donors and charitable groups are pulling in the same direction, such campaigns are a daunting challenge. Each Wednesday, representatives of a dozen groups working on measles and malaria call a common phone number to coordinate this complex undertaking.

Here in Ghana, Unicef officials scrambled before the campaign to raise money for the mosquito nets. Britain and Japan paid for two million nets, enough to cover all children under age 2, though less than the hoped-for coverage of children under 5.

In the month before the campaign, the Ghanaian government, which embraced and executed the strategy, dispatched 70 container-loads of bulky nets across the country by truck, boat, tractor, bicycle and donkey cart.

The last nets arrived at the port of Tema, Ghana, only days before the campaign began on Wednesday, Nov. 1. "We were sweating it until Friday," said Dorothy Rozga, Unicef's Ghana representative.

As the campaign days dawned, squadrons of health workers zoomed off on motorbikes along pitted country roads, kicking up clouds of dust that enveloped the small, gray boxes of vaccine lashed to the backs of their two-wheelers.

Villagers waited stoically in the shade for the workers to arrive, then waited hours more with squirmy children on their laps for the medical elixirs.

In places like Ponyamayiri - a village with no electricity or telephones that is in a district with no hospital, doctor or ambulance - prevention is often all that stands between a child and death.

After the vaccines were given and the mosquito nets handed out, a villager led the way along a maze of sandy paths, through tall grass and millet fields, to the homes of children who had died in the previous couple of weeks.

In the heavy midday heat, 14-month-old Suonguno's family lay under a mango tree in a stupor of grief. The little girl had died of malaria two days earlier. She was buried beneath a fresh mound of red earth hard against the family home. One of her tiny white shirts lay on the grave.

Her name means Witch's Catch in the local language - and she was given it in memory of her father's four siblings who died in childhood of measles, mumps and dysentery. Her grandfather believed that evil spirits had claimed them. Now she, too, had been snatched away.

Her father, Manama Bejie, 37, a hardscrabble farmer who said he had only enough food to feed his family once a day, described his daughter's torment. She had developed a high fever. She cried and cried. She vomited bile. Her body was shaken by convulsions.

He took her to the clinic in Wechau, headquarters of the West Wa district, where he was told that she was anemic and that she needed a blood transfusion and laboratory work that could only be done at the regional hospital in Wa, more than an hour's drive away.

"We were going to go to Wa the next morning, but she died that night in her grandmother's arms," he said.

All too often, even those who try to reach the hospital do not make it. "They go back as corpses," said Dr. Erasmus Agongo, the health director here in the Upper West region.

Hoping to prevent suffering across Africa, the Global Fund itself has financed the purchase of nets for other combined campaigns in Angola, Niger, Rwanda, Kenya and Ethiopia.

The six-country proposal - for Benin, Liberia, Burkina Faso, Mali, Ivory Coast and the Central African Republic - was rejected because it was not well coordinated with the countries' malaria strategies and because it inadequately explained how infrastructure problems would be overcome, Global Fund officials said.

Dr. Feachem, the head of the Global Fund, said that he deeply regretted that the application did not meet the fund's standards and that he hoped that the applicants would reapply next year.

Dr. Kochi, who is trying to help fix the troubled global malaria effort at the W.H.O., said he would try to make sure that the organization's malaria team masters the art of winning grants from the Global Fund.

For now, the fund's rejection of the six-country net request will slow the momentum of combined campaigns. Even if the countries successfully reapply, the money will come too late for the measles campaigns next year in Burkina Faso, Liberia and Mali.

The groups organizing the campaigns hope to raise money for nets from rich countries and charitable groups. The United Nations Foundation, Sports Illustrated, the National Basketball Association's NBA Cares and the United Methodist Church are also turning to the public for donations through a Web site, www.NothingButNets.net.

Andrea Gay, an official with the United Nations Foundation, part of the measles-malaria alliance that submitted the six-country proposal, sputtered with frustration that the Global Fund had not come through.

"They agree we have a strategy to prevent malaria using nets and then they don't do anything," she said, soon after learning of the rejection. "They go back to their desks. Six countries could have had full coverage for children under 5. How many lives would have been saved?"

ON THE BRINK

A Joint Attack on Many Perils of Africa's Young

By CELIA W. DUGGER

December 23, 2006, The NY Times

PONYAMAYIRI, Ghana - In this poor, dusty village of 550 people, four babies died of malaria in October, among them 11-month-old Yire Are. As word spread that the government would be handing out mosquito nets that prevent malaria, his uncle made sure he was there with his own children, their heads shaved in mourning.

"I came to claim a mosquito net," the uncle, Konyiri Doorkono, said firmly, his 3-month-old son clasped in his arms.

But when he and many of the village's families lined up beneath the spreading arms of a neem tree, they got much more. Children gulped down polio vaccine, vitamin A and deworming medicine. They howled at the prick of a measles shot.

They had joined a campaign to better children's odds of surviving past their fifth birthdays. It reached into even the most remote communities in Ghana over five days in November. Similarly monumental drives unfolded in eight other countries across Africa this year, with the mosquito nets alone expected to save the lives of 370,000 children over the next three years.

But while the world's leading public health officials praise this common-sense strategy to provide inexpensive, lifesaving doses of prevention to different diseases at the same time, it is far from simple to pull off. Getting an unwieldy collection of international organizations and charities to work together effectively is a major challenge.

In one measure of the difficulty, even as the Ghana campaign gathered steam, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria rejected a $46 million proposal to expand the approach to six more African countries.

An alliance of more than a dozen groups sponsored the proposal, but each of the six countries also submitted its own malaria application to the Global Fund, which controls most international malaria spending - and no one made sure the many requests did not overlap or conflict with one another.

"There were too many cooks," said Dr. Arata Kochi, who leads the global malaria program for the World Health Organization, whose experts helped draft the six-country proposal.

Though the proposal failed, Dr. Kochi called the combined campaigns "a winning strategy," and Dr. Richard Feachem, head of the Global Fund, described them as "spectacularly successful."

"Everybody is slack-jawed, aghast" at the rejection, said Mark Grabowsky, a public health doctor with the federal Centers for Disease Control and Prevention, who joined the Global Fund this year as a malaria program officer and who has long championed the marriage of measles and malaria in joint campaigns.

Dr. Feachem and Dr. Kochi say they hope that their organizations can improve their coordination.

"Malaria is a preventable child holocaust which occurs in Africa for no reason," Dr. Feachem said. "We can stop this. The Global Fund's role is finance, and we must work more closely with the W.H.O., the Red Cross and others to ensure that the money flows to those who can use it effectively on the front line."

Much of the challenge stems from the fact that each drive against a disease - polio, measles, malaria - has its own leaders, charitable groups and donors at the international level. Piecing them together in unified campaigns requires the logistical skills and diplomatic finesse of a skilled battlefield commander.

While public health officials know well the difficulties of mounting even individual campaigns, they say they have learned they can save more lives by piggybacking campaigns, particularly by adding malaria and distributing mosquito nets.

The need is great: malaria kills about 800,000 children a year in Africa. The W.H.O. estimates that only 3 percent of the most vulnerable African children under age 5 are covered by the insecticide-treated bed nets that can last four to five years. The cost for each net is $5 to $6.

Studies have also established that giving children vitamin A (2 cents per dose) boosts their immune systems and reduces deaths, while medicines to rid them of intestinal worms (also 2 cents) greatly improve their health and school attendance.

The push to give every child polio vaccine (15 cents a dose) has prevented some five million cases of paralysis worldwide since 1988, while inoculating children with measles vaccine (16 cents) has saved more than a million lives since 1999, according to the W.H.O.

The combined campaigns in Africa this year have made it possible to sustain gains from earlier measles and polio drives, while the net distributions promise a new payoff in reduced malaria deaths.

Dr. Grabowsky, who has devoted much of his professional life to measles, said the need for joint measles and malaria campaigns dawned on him gradually. In the late 1990s, on a visit to a mission hospital in Gulu, Uganda, he had an epiphany when a doctor there told him: "If you get rid of measles, we can close the measles ward. If you get rid of malaria, we can close the hospital."

In 2001, he was assigned by the C.D.C. to serve as an adviser to the Red Cross when the groups started the Measles Initiative, an effort to reduce measles deaths in Africa, along with the W.H.O., the United Nations Children's Fund and Ted Turner's United Nations Foundation.

As measles campaigns radically reduced measles deaths in country after country, Dr. Grabowsky worried that the undertaking would become a victim of its own success.

Why would a mother walk hours to get her baby immunized once measles was mostly gone? And what would happen if parents stopped flocking to campaigns? The answer was ominous: a resurgence of measles, an extremely contagious disease.

He had only to look at the 18-year slog to eradicate polio, which still has not wiped out that crippling disease. In northern India, more than two dozen polio-only campaigns in recent years have generated fierce resistance among some parents, who are mistrustful of the vaccine, fed up with the campaigns and angered that officials are not doing more to fight other diseases that kill their children.

In Africa, Dr. Grabowsky figured that parents would keep coming for measles vaccines if the campaigns also offered mosquito nets to prevent malaria, which routinely kills small children across the continent.

In 2002, the Red Cross, with a $50,000 grant from the Exxon Mobil Foundation, ran the first test of combined campaigns here in the impoverished, northwestern corner of Ghana, where one in five children dies before age 5. In the Lawra district, it got measles vaccines and nets to more than 90 percent of children under age 5.

Three years later, researchers returned and were startled to find the benefits had persisted. Most of the children still slept under the nets at night, when malarial mosquitoes bite.

Evaluations of combined campaigns carried out nationally in Togo in 2004 and in Niger last year also found soaring numbers of children under 5 sleeping under bed nets. But the surveys also discovered that more people owned nets than actually used them. In Togo, for example, more than 9 of 10 families with young children got a net, but only about 6 in 10 children had actually slept under one the previous night.

Unlike vaccines, which are effective once given, nets must be used regularly to work - and that means education and following up. The Red Cross has mobilized thousands of volunteers to help in the task.

Still, getting the nets to children is the first step, and this year more than 18 million nets were handed out in combined campaigns - far more than ever before.

It was, in fact, a breakthrough year. Combined campaigns, which included some combination of measles shots, polio drops, deworming pills, vitamin A and nets, were carried out in nine African countries spanning the continent, from Ghana in the west, to Ethiopia in the east, to Angola in the south.

But even when all the donors and charitable groups are pulling in the same direction, such campaigns are a daunting challenge. Each Wednesday, representatives of a dozen groups working on measles and malaria call a common phone number to coordinate this complex undertaking.

Here in Ghana, Unicef officials scrambled before the campaign to raise money for the mosquito nets. Britain and Japan paid for two million nets, enough to cover all children under age 2, though less than the hoped-for coverage of children under 5.

In the month before the campaign, the Ghanaian government, which embraced and executed the strategy, dispatched 70 container-loads of bulky nets across the country by truck, boat, tractor, bicycle and donkey cart.

The last nets arrived at the port of Tema, Ghana, only days before the campaign began on Wednesday, Nov. 1. "We were sweating it until Friday," said Dorothy Rozga, Unicef's Ghana representative.

As the campaign days dawned, squadrons of health workers zoomed off on motorbikes along pitted country roads, kicking up clouds of dust that enveloped the small, gray boxes of vaccine lashed to the backs of their two-wheelers.

Villagers waited stoically in the shade for the workers to arrive, then waited hours more with squirmy children on their laps for the medical elixirs.

In places like Ponyamayiri - a village with no electricity or telephones that is in a district with no hospital, doctor or ambulance - prevention is often all that stands between a child and death.

After the vaccines were given and the mosquito nets handed out, a villager led the way along a maze of sandy paths, through tall grass and millet fields, to the homes of children who had died in the previous couple of weeks.

In the heavy midday heat, 14-month-old Suonguno's family lay under a mango tree in a stupor of grief. The little girl had died of malaria two days earlier. She was buried beneath a fresh mound of red earth hard against the family home. One of her tiny white shirts lay on the grave.

Her name means Witch's Catch in the local language - and she was given it in memory of her father's four siblings who died in childhood of measles, mumps and dysentery. Her grandfather believed that evil spirits had claimed them. Now she, too, had been snatched away.

Her father, Manama Bejie, 37, a hardscrabble farmer who said he had only enough food to feed his family once a day, described his daughter's torment. She had developed a high fever. She cried and cried. She vomited bile. Her body was shaken by convulsions.

He took her to the clinic in Wechau, headquarters of the West Wa district, where he was told that she was anemic and that she needed a blood transfusion and laboratory work that could only be done at the regional hospital in Wa, more than an hour's drive away.

"We were going to go to Wa the next morning, but she died that night in her grandmother's arms," he said.

All too often, even those who try to reach the hospital do not make it. "They go back as corpses," said Dr. Erasmus Agongo, the health director here in the Upper West region.

Hoping to prevent suffering across Africa, the Global Fund itself has financed the purchase of nets for other combined campaigns in Angola, Niger, Rwanda, Kenya and Ethiopia.

The six-country proposal - for Benin, Liberia, Burkina Faso, Mali, Ivory Coast and the Central African Republic - was rejected because it was not well coordinated with the countries' malaria strategies and because it inadequately explained how infrastructure problems would be overcome, Global Fund officials said.

Dr. Feachem, the head of the Global Fund, said that he deeply regretted that the application did not meet the fund's standards and that he hoped that the applicants would reapply next year.

Dr. Kochi, who is trying to help fix the troubled global malaria effort at the W.H.O., said he would try to make sure that the organization's malaria team masters the art of winning grants from the Global Fund.

For now, the fund's rejection of the six-country net request will slow the momentum of combined campaigns. Even if the countries successfully reapply, the money will come too late for the measles campaigns next year in Burkina Faso, Liberia and Mali.

The groups organizing the campaigns hope to raise money for nets from rich countries and charitable groups. The United Nations Foundation, Sports Illustrated, the National Basketball Association's NBA Cares and the United Methodist Church are also turning to the public for donations through a Web site, www.NothingButNets.net.

Andrea Gay, an official with the United Nations Foundation, part of the measles-malaria alliance that submitted the six-country proposal, sputtered with frustration that the Global Fund had not come through.

"They agree we have a strategy to prevent malaria using nets and then they don't do anything," she said, soon after learning of the rejection. "They go back to their desks. Six countries could have had full coverage for children under 5. How many lives would have been saved?"

Copyright 2006 The New York Times Company