Mali’s only notoriety for many people is Timbuktu, the city that signifies the farthest reaches of the world. But the village of Piron, where I hope to persuade its 100 or so families to use insecticide-treated mosquito nets (ITNs) for malaria prevention, is far more remote. Since my previous visit three years ago, the village has added two wells and one solar-powered black-and-white television. Otherwise, little has changed.
When my guide, Nouh, leads me to the village chief’s compound, I notice that its mud walls are cracked, needing repair as they do every few years. This thought discourages me. The villagers can fix their walls only with the few resources they have, as they can treat malaria only with simple medications to which they have limited access. The solutions are temporary: the next heavy rains bring these walls and their owners down again.
The village chief, whose permission I need to implement mosquito-net treatment services, is a small, fragile man with white hair and thick glasses. “I spoke to you last night in my dreams,” he says, as Nouh translates for me. “You told me you were coming today. It is lucky you came. You bring the rains with you. We will eat well this year.” In a region like this, people sicken and starve when rainfall dips below the annual average of 8 to 20 inches. Two of Nouh’s five children have died since my visit here in 2000.
Although I am flattered the village chief has called me a good omen, I know heavy rains are a double-edged sword. In the rainy season, more than half the population may fall ill. Sufferers will be drenched in sweat, alternating between shaking chills and fever. They will lie on their mats, too weak to walk the 10 miles to the nearest health clinic.
My research grant is such that I will leave before the worst of it arrives. Unlike my previous endeavors in Africa, I will not see children with conjunctivae white as clouds, nor hear the difficulty of their breathing, both symptoms of severe anemia caused by the parasites destroying their red blood cells. I will not have to watch their bellies distend from the enlargement of spleens trying to clear inflammations caused by the infection. I will not bear witness to their comas or watch so many of them die. I can leave. The villagers cannot. Witnessing and enduring the full force of malaria is a part of their lives.
This specter is especially disheartening because the world knows how to combat malaria and do it with relatively little expense. ITNs are simple to use, affordable and effective. During the first year of a study in the Gambia, the use of treated nets led to a 25 percent reduction in malarial mortality, a decrease in rates of parasitemia (parasites in the blood) and an improvement in the nutritional status (decreased anemia) for children 1 to 9 years old. I am optimistic Piron could see similar results.
By sunset, everyone in Piron has heard about the tubabu—the foreigner; literally, the white person, though as a Korean-American I am far from being what most Westerners would consider Caucasian. The villagers come by to greet me, stare at my every move and ask for all my possessions. Furakise di yan, give me medicine, is what they ask me most. It is customary for field groups to bring medicine when conducting research or educational programs in Mali.
A number of people have come by to ask for mosquito nets, not completely understanding that I’m not here to deliver donations, but to help create a net-treatment service that would allow villagers to take control of their own health. It must seem strange to them that I turn them away empty-handed. Although I am a student working on a small grant, being a tubabu makes me wealthy in the eyes of the villagers.
In an article, “The Economic Burden of Malaria,” John Gallup and Jeffrey Sachs summed up Malians’ predicament, “Poverty doesn’t cause malaria, but malaria does cause poverty.” The disease impacts fertility, saving and investment, worker productivity, absenteeism, premature mortality and medical costs. Malaria drains an estimated $2 billion in productivity per year in Africa.
In Piron, we first conduct an education program focused on malaria prevention so that people will understand the need for ITNs. While distributing questionnaires, I decide to visit Nouh’s family. When I turn a corner, I startle a small naked boy with a distended belly who jumps a foot in the air and runs, crying, to hide behind his mother. Many African kids are afraid of me, a person with skin so white and strange.
I see this little boy again, a week later, but he is too weak and sick to be scared. Nouh, who has finished a malaria education workshop, has treated his son, but even on the third day of treatment, the boy is still feverish. His body is a small hot furnace burning underneath dry, sandpapery skin.
Although we have been here little more than two weeks, our supply of injectable quinine, used to treat severe malaria, is almost gone. Nouh thinks we have none left, and because he does not want me to worry he says his son is much better. When I tell him we still have enough to treat a child, he admits that his son is still not well. He speaks soothingly to the boy, rocking him in his arms, as a health guide administers a shot in the boy’s thigh.
Although medications are beneficial in treating malaria, there is a precarious balance. Anti-malarial medications are toxic with extended use, and there are side effects. Mefloquine is contraindicated for individuals with a family history of mental illness because it can cause severe depression and hallucinations. Drug resistance is an inevitable problem, too, and many parts of Africa and Southeast Asia now have chloroquine-resistant malaria.
After several days I am disappointed because fewer than half of the villagers have come to have their nets treated. Nouh tells me not to worry. Everyone will come eventually. People just need time to see that ITNs work. I bear in mind the words of Ronald Ross, the man who discovered how malaria is transmitted. “This is a matter which is always ultimately in the hands of laymen—it is they, not the doctors, who rule the world.”
Treatment of nets will resume once the village decides on a price that can be sustainable in the long-term. The villagers need to charge enough money to buy more insecticide after I have gone.
There are many challenges to ITN distribution, acceptance and proper use. The season in which ITNs are introduced makes a difference in their effectiveness. Improper use, such as washing treated bednets more often than needed or with the wrong soaps, can limit their effectiveness. And although education and implementation of simple community-level ITN programs are the best solution to reduce malaria in the short term, global eradication can only be achieved if developing nations, developed nations and international aid organizations collaborate on long-term infrastructure improvement and vaccine development.
And regardless of how much money is thrown into malaria eradication, African countries need to be held accountable. Fifty heads of African states pledged to reduce tariffs and taxes on needed materials for malaria-control programs at an African summit in 2003. Only half of these nations have followed through on that promise.
Each time I return to Africa, I question my ability to improve the quality of life for people here. Did my work make any dent in their malaria problems? As Nouh and I go to see the village chief to say my goodbyes, I try to imprint upon my memory the sound of women pounding millet, the sight of children dancing—the taste of the strong black tea. In my reverie, I enter the village chief’s compound and almost run into him. He laughs and jumps effortlessly to his feet to bless me. Nouh stands there gaping: in all his adult years, he has never seen the village chief without his cane.
And if that is not enough, whom do I see running and laughing with his friends? Nouh’s son! I move to hug him, but he screams and runs away. Never have I been so happy to see a child scared of me.
MICHELLE RHEE, ’95, received her PhD in biological sciences at the University of Edinburgh in 1999. She is in her final year at the Stanford School of Medicine.
