"I sliced one bag open, and the veil fell into my hands. One net; a huge promise. Even then, I wondered: could this net save a life?"
The day I arrived in Ghana, I walked down a narrow street to a market to absorb the sights and sounds of my first trip to Africa. Large wooden canoes were wedged up against the sand, shading fishermen who slept beneath them on mats. Women leaned over firepots, smoking fish or stirring yams. I passed by market storefronts with hand-painted English names: God is Grate and Except the Lord. Sweet yellow corn, still in its husk, sizzled and popped on a grill. I handed the corn vender a few cedis—be careful, she said, it’s still hot. I was optimistic and, with my mango-green backpack, I looked just the part: world traveler, activist, envoy of life-saving mosquito netting.
Malaria is a preventable disease for which nearly half of the world’s population is at risk. In Ghana, 14 people die from malaria every month. Early global efforts sought to eradicate malaria, but when that failed, malaria programs turned towards controlling and managing outbreaks. Insecticide-treated bed nets rose to the forefront as the gold-standard of malaria prevention, and free net distributions have sought to protect those most at risk. I participated in one of these distributions in 2011.
Prior to this trip, I spent a year fundraising for malaria prevention. I gave public speeches, traveled to elementary schools to motivate students, and sold the narrative and personal mantra: one $5 bed net—save one life. The donations flowed in. 1,200 nets were purchased, one at time, mostly by local children and their parents. Then, we arranged delivery: first by boat, then by truck. I planned to arrive the same week as the nets to help with this distribution. Once in Ghana, I met with the local chief of the district. The rules for meeting the chief were simple: Don’t speak unless spoken to, don’t cross your legs, and ask permission to stand. He welcomed me and my mosquito nets with open arms.
I watched the truck carrying the mosquito nets rumble into the town of Tamale, navigating around houses, goats, and children. The district’s assemblymen helped unload the nets from the truck, and children piled them into a mountain of dusky white. I sliced one bag open, and the veil fell into my hands. One net; a huge promise. Even then, I wondered: could this net save a life? It didn’t even come with nails to hang it above a bed. Mosquito bed nets are a million-dollar industry—so why are lives still lost to malaria? Should we ramp up our efforts? More nets—more lives saved?
After the distribution, I retreated to the house of my host family. Raindrops roared against tin roofs and goats bleated between gusts of wind. Then the lights went out. I fumbled around for a headlamp and enjoyed the rest of the evening drinking strawberry tea and watching the rain give life to the village. Puddles formed in the streets, mosquitos hovering above them like rainclouds. I wondered if the nets could save the lives of those I had come to know here.
It wasn’t long after the distribution when the nets, instead of hanging above beds, floated in river channels as fishing nets. Others covered vegetables. Some of the Ghana women had sewn nets into ornate wedding veils. Meanwhile, people died. Children die from malaria every day in Ghana. Yet, I could understand how a family might choose to put food on the table (by using the bed nets for fishing) over disease prevention. I would do the same.
I knew that no matter how effective a mosquito bed net is, it cannot prevent malaria unless it is used. A few weeks after the mosquito net distribution, I tossed and turned at 2 a.m. It had threatened to rain all day, but instead a blanket of humidity weighed on me like a thick wool coat. The door and windows were open and a barely perceptible breeze drifted in. It was hot. I jumped up and ripped down the dusty mosquito net, desperate for what little breeze I could get. The hypocrisy of not using the bed net stung, but I needed the air.
I examined the discarded mosquito net the next morning. I thought back to when I first opened this net, believing it would be a spectacular sea-blue, gathered at the top by a single ring, like one I’d seen in the United States. Instead, it was a dull white square. These bed nets work when used properly, but they are not perfect. Some brands of nets have a stiff texture, tend to wrinkle, and will physically shorten after washing. The nets I distributed were white in color, which soon flushed to red as the rust-colored dust that was a hallmark of the town settled on them. Many women would launder the nets to wash out the dust. Repeated washing of bed nets removes the insecticide, quickly rendering these nets ineffective.
In Ghana, I learned that public health interventions, designed thousands of miles away, don’t always cultivate inclusion or empowerment. While I had a vast knowledge of transmission and etiology of malaria, I did not know the community. I did not share the customs, the beliefs, the history, the language. This was the problem. The local community should be involved with each step of the net distribution process. Traditional healers could lead the effort, addressing cultural beliefs and attitudes about malaria. Could bed nets be produced locally, instead of shipped in from other countries? Imagine if locals could influence the color, weight, and texture of the nets. What if rust-colored bed nets were standard in this region of Ghana, thus reducing the need for washing, or if fishing nets were included in each shipment?
Testing of the first malaria vaccine is currently underway. Ghana is one of the first countries to test its efficacy. The World Health Organization considers the vaccine to be complementary to—and not a replacement of—the preventive measures already in place. It is believed that the vaccine, along with other preventive measures could reduce incidence of malaria by 90% and eliminate malaria in at least 35 countries by the year 2030. But without considering local cultural beliefs and attitudes, this goal will never be reached.
The name given to me upon my arrival in Ghana, Maltiti, roughly translates to “restore us.” I’m not sure if I lived up to my name. In hindsight, the lack of community involvement and my understanding of cultural factors may have jeopardized the success of that bed net distribution. Seven years later, the nets I distributed are no longer effective, now that their insecticide is diluted. Future shipments of nets will continue to fall short of the intended goal unless environmental and cultural practices are considered and addressed. This needs to become the new gold-standard in intervention efforts—for malaria, for Zika virus, for Ebola. Charity organizations and health care workers should measure their success not by how many bed nets they distribute, but by who is included in intervention efforts, from the planning stages to implementation to evaluation. Only then can we create an environment where disease eradication is possible.