Clearing the Bad Air

Having signed up for a stint as the Health Coordinator for an NGO, I have no right to complain. Nonetheless, sometimes I feel like my days are devoted, in one hour increments, to all the scourges of modern Africa: a morning spent in a staff meeting on HIV/AIDS and calling a supplier about hookworm drugs, an afternoon of Yellow Fever, teenage pregnancy and overpopulation. All that’s missing, and I’m sure one day this will land on my agenda, is the horde of locusts to which I will devote exactly one hour of my time.

This week has stood in contrast to the ADD of Health Catastrophes. My attention has been devoted, almost wholly, to malaria. A group of volunteers has arrived from the US to work with us on a malaria survey and a public education campaign in Humjibre, as well as the distribution and retreatment of bed nets. For two weeks, it is Malaria Malaria Malaria here.

As well it should be, given the scope and impact it has. Malaria is caused by an infection of tiny parasites, transmitted by the bite of the female anopheles mosquito. The parasites enter the liver, then after an incubation period, spread to the bloodstream where they wreak havoc, causing problems that start with a fever and degenerate from there. What is perhaps most striking about the disease is its dual nature: it can be both banal and terrifying. To the adults of a nearby village, Suroano (“On the River Bank” in Sefwi), malaria is foremost a simple economic problem. The disease strikes them several times per year, disabling them for weeks and sending them for expensive treatment at the clinic. Here in Humjibre, virtually everyone has had malaria, and it is spoken of in much the same way we speak of the flu.

Yet malaria can be frighteningly dangerous. It preys on society’s most vulnerable: the very young, the physically weak and malnourished and, most of all, those without access to healthcare. For healthy adults, a course of pharmaceutical treatment and a week of bed rest is usually all that is needed to fight off the disease. But for babies and young children, and even adults who do not get treatment quickly, the disease can be overwhelming: the intense fever degrades the body’s organ system and can eventually disable the nervous system, causing seizures, comas and death.

Malaria is the single most important disease in the world, and except for a few years when the Plague ran wild, it always has been. Malaria has existed for as long as homo sapiens have, and it has taken its toll on us. By one estimate, fully half of all the people who have ever entered into this world have exited it because of malaria. It is a historical oddity that most of us will not only go through life without contracting malaria, but will never even meet someone who has. This is a disease that once made Washington, D.C. virtually uninhabitable, and killed more Civil War soldiers than did enemy bullets. Its footprint stretched far out of the tropics, from Europe (its name is Italian for bad air, the supposed source of the illness that would strike Rome every summer), across Asia to the United States.

Now it is has been sequestered. It exists in much of Latin America and southern Asia, but its stronghold is Africa, where the most virulent strain, plasmodium falciparum, predominates. It is here that malaria claims about 90% of its victims. The tactics of eradication- the filling in of swamps and drying of wetlands, the construction of secure homes, the improvement of sanitation and construction of closed sewers- which worked so well in Europe and the American South nearly a century ago have either never been employed or have failed here. For those with the money to afford it, chemical prophylaxis has always offered some measure of protection. Malaria, however, with its long history of interaction with humans, has become adept at outflanking these defenses. Quinine and chloroquine, two stalwarts, are nearly obsolete now, with most strains of malaria having become resistant.

Nevertheless, fifty years ago, it looked like malaria could be totally eradicated, even here: the spraying of DDT to keep mosquitoes out of homes cut sharply into the prevalence of the disease in Africa. Then, in a post-Silent Spring world, such spraying campaigns fell out of acceptability, and the disease came roaring back. In the intervening years, scientists have found anopheles that are resistant to DDT, which means spraying is no longer a silver bullet. So Africa remains, as badly afflicted by malaria as ever, a reminder of the time when we were all in malaria’s peril. The problem, however, has taken on grotesque proportions: there are regions of the continent with average annual infection rates above 100%, as many people contract it multiple times in a year.

Here we are, then, in the second century of our battle against malaria. We have returned to what worked last century, trying to reshape the environment rather than directly attacking the parasites or the mosquitoes. However, it is not with bulldozers and thousands of miles of cement that it is being reshaped. It is with simple nylon netting. If you cannot get rid of the mosquitoes- and in this environment, you cannot- you must create a barrier against them. The battle has become one of getting mosquito nets into the houses, shanties, shambas and kraals of sub-Saharan Africa and getting the residents of these homes to sleep under the nets.

The first task is difficult. Bed nets cost about $6 each, so equipping a large family with nets could cost $24, nearly a month’s pay here. The second task, however, is equally daunting. Our survey is designed not just to determine who will get the 50 new nets we plan to distribute, but will also follow up with past recipients of nets, to make sure they are using them properly. We fear they have not. Partly, this is because bed nets are uncomfortable. It is stifling to sleep under a net, and the hot, unventilated rooms that most people sleep in are stifling enough already. There is also a degree of acceptance of malaria. It has always been in the community, and so people feel a certain complacency. Finally, bed nets are not foolproof- like other methods of prevention, they only lower the risk and frequency of infection. A foot kicked out from under a net is susceptible to bites, and anyway, the nets obviously only work during the times you’re actually in bed. If, after some period of bed net usage, someone falls sick again, he is much less likely to put up with the annoyance of sleeping under the net.

This is not to say it is impossible. In Suroano, about 1,000 of the village’s 1,500 people sleep under bed nets, which were provided by us for free. We know that they still use them because community health workers come and inspect the homes to make sure that the nets are still hung and in working order. The people report that childhood mortality has decreased, as has the number of days lost to the disease and the amount of money devoted to curing it. The cash savings have been reinvested in building the infrastructure of the village. Of course, this required not just a huge influx of cash, but also the dedication of the town, from the chief and elders on down. We’re working toward that here in Humjibre, but it’s going to be tough. It might even take more than a whole week’s attention.

Turning on the Lights in Muoho

There was most of a village crowded under that tin roof, or trying to press their way in. Five hundred people, from toddlers to nanas, squeezing into a space meant for a few dozen. Dusk was falling on Muoho, and for once there was electricity in the air. Quite literally.

It was not the presence of us obrunis that attracted the villagers, though once they arrived many certainly gaped at the foreigners. It was not the Peer Educators who attracted the villagers, though once the play about good and bad marriages began, the audience was in stitches. No, what brought the crowd was a bad Nigerian movie- the same bad Nigerian movie, in fact, that I panned last week.

It did not really matter that The Staff of Odo is a bad film, with stilted dialogue and paper-thin characters; after all, it is in English, a language which only a handful of people in the crowd could really understand. The crowd came just for the spectacle of it: the boom of the speakers we had rented, the video projected across the 5’X6’ whiteboard we had brought with us from the library in Humjibre. These were new things to Muoho.

Occasionally National Geographic or something like it will publish satellite photos of the world taken during nighttime, showing where the lights have been turned on and where they have not. Europe, the US and Japan are bathed in white, and most of the rest of the world is speckled or splotchy. In general, where there are people, there are lights. Then there is Africa: a few veins of light in South Africa, a spot here or there denoting the city lights of Nairobi, Lagos or Luanda, but otherwise it is indeed the Dark Continent.

Muoho is one of those countless dark places on the map. Perhaps it was the decision of some bureaucrat in Accra or Takoradi, or the District Assembly in Bibiani or the chief in Bekwai, maybe it was the work of a contractor skimming off the top and not finishing a job, or the result of a World Bank loan that never quite came through; whatever the reason, Muoho has been bypassed by electricity. Humjibre, three miles to the east, has electricity. Bekwai, three miles to the west, has electricity. Muoho, however, is a village of gas lamps, of tinny battery-powered radios, of early bedtimes.

What this means, if you’re a small NGO with a generator and the fuel to power it, is that you have a more-or-less captive audience for your message. So we rolled up to Muoho in a creaking 14-seater van, with 18 people, two 5’ speakers, an amp, a mixing board, lights, the 5’x6’ white board we took from the library, a laptop and a projector. If we passed through an American town with this retinue and hardware, we could be mistaken for a down-on-its-luck multi-racial rock band, but down-on-their-luck multi-racial rock bands don’t get the sort of reception we did. By the time we were setting up, there were a hundred people gathered under the tin roof of the open-air meeting place. By the time we put some hiplife songs over the sound system, there were three hundred. By the time we beamed the movie from my laptop onto the board, there were five hundred, and we had to stop the film shortly thereafter to make announcements to prevent a crushing or stampede. Even when we interrupted the movie so that we could get to real purpose of our visit, the educational play, the crowd pressed in. We had them hooked.

I feared a riot when we stopped the movie for good. We had played about fifteen minutes of it, interrupted it for the Peer Educators’ drama, and then played another forty minutes. It was getting late, though, and there remained at least an hour left on the film before we found out the secret of Odo (those of us, that is, who understood enough English to know that Odo had a secret). After much hand-wringing, we decided to pull the plug. There was no riot, however; people took it in stride and stayed in place as we stopped the movie, removed the lights, packed up the speakers, lit up the darkness with the sparks of poor electrical connections being undone. Then, eighteen of us piled back into the fourteen-seater van and left Muoho to its gas lamps, its tinny battery-powered radios, its early bedtime.