Ordinary people can do extraordinary things.
That belief lies at the foundation of NetsforLife®'s philosophy which, in the last nearly five years, has changed the way many nations and health organizations combat malaria. The Episcopal Relief & Development-sponsored partnership's combination of net distribution with community education and organizing to foster a "net culture" among recipients also changes the communities themselves.
Still, on the April 25 commemoration of the fourth World Malaria Day, much work remains.
"This is not time to rest on our laurels," Presiding Bishop Katharine Jefferts Schori, House of Deputies President Bonnie Anderson and Episcopal Relief & Development President Robert Radtke said in a statement to mark the occasion.
Indeed, the World Health Organization recently described what it called the "fragility of malaria control and the need to maintain control programs even if numbers of cases have been reduced substantially."
NetsforLife®'s statistical achievements alone are impressive. The program has distributed 6.3 million nets (far ahead of its planned pace), trained more than 43,000 volunteer malaria control agents and directly or indirectly reached more than 35 million Africans in 17 sub-Saharan countries.
In its first phase, NetsforLife® distributed 1.5 million nets between June 2006 and September 2008. That was 500,000 more than its goal. In Phase II, which began in October 2008 and is planned to run through 2013, 4.8 million nets have been handed out thus far. At this pace, the program stands to meet its Phase II goal of distributing seven million nets two full years ahead of schedule.
And, even as NetsforLife® has changed the conventional thinking about malaria prevention, the program itself is changing as well. Its methods are being refined in order to combat more effectively the disease that is borne by an increasingly cunning foe.
"These insects are getting smarter every day," Dr. Stephen Dzisi, NetsforLife®'s technical director based in Accra, Ghana, said of the female anopheles mosquito. "Their habits are changing very, very fast."
From the beginning, NetsforLife® has bucked the conventional wisdom about malaria prevention, according to Dzisi and others. That thinking includes a conviction that professionals in health centers were the only ones who could collect accurate data on the disease and efforts at prevention.
In addition, many experts assume that people who caught malaria know everything they need to know about how and why they got sick. All they lack is a net under which to sleep. NetsforLife® says it is proving the problem is much more complicated.
People who live with malaria "may know [a lot of things about malaria], but all they know are the wrong things," said Dzisi, whose passion for fighting malaria comes from the memory of seeing his younger sister die of the disease when he was a four-year-old growing up in Ghana.
Malaria kills nearly one million people each year, most of them children younger than five years. Sleeping under insecticide-treated nets is a simple, yet highly effective way to reduce the incidence of malaria. However, it is not easy to convince people to sleep under nets.
NetsforLife® teaches people about malaria and why sleeping under long-lasting insecticide-treated nets is crucial to avoid contracting malaria. It encourages recipients to keep using the nets, in part by helping them understand that the decrease in the number of times family members get sick from malaria is related to the fact that they are sleeping under nets.
Its model of community education and mobilization, net distribution and follow-up have proven so effective that entire countries, such as Ghana and Liberia, have told other organizations that they cannot operate within their borders if they do not practice similar methods, Dzisi said. And, as Radtke told the church's Executive Council in February, "NetsforLife® has changed the way the entire global health community is thinking about how to eradicate malaria."
The change is happening because the agency's statistics show that its efforts have resulted in greater and more sustained net use. The global health community considers sustained use of nets to be "the holy grail" of malaria prevention, he said.
The NetsforLife® method takes lots of hard, sustained work, and that's where ordinary people wind up doing extraordinary things. For example, it was a stunning piece of logistical work during one week in May 2010 when 17,781 NetsforLife® volunteers spread out across northern Ghana to hang 655,369 nets. Equally stunning was the fact that during their work, those volunteers discovered nearly 30,000 nets that residents had received from other programs.
None had been hung because the recipients had never been told what to do with them. The program's volunteers hung those nets as well.
"What amazes us is the readiness of people to go the extra mile to ensure that these nets are available," said Cletus Asare, NetsforLife® program support and logistics officer, during an April 1 meeting in Accra. They do so "because they believe in it, they've seen it, they know the results and they're ready to sacrifice" to get the nets into people's homes and get them hung, he said.
The people have volunteered to work among their own communities to teach their neighbors about the causes of malaria and how they and their children can avoid contracting it. They use trucks and bicycles and canoes to reach those in need of nets. Once, in Liberia, volunteers carried nets on their heads for 68 kilometers to reach a village, Asare said.
The work doesn't begin with a nets distribution, and it doesn't end there either. Months before any distribution, NetsforLife® staffers and existing volunteers study the community to assess its incidence of malaria, its use of nets, its members most at risk and its barriers to medical treatment.
Local traditional, religious and political leaders are asked to describe how information is transmitted in their communities and how other behaviors in the community have changed. Those leaders are offered nets and their trust is earned and they begin to experience the resulting decreases in malaria incidents among their families.
Education geared to each community begins with the seemingly simple information about mosquitoes being the transmitters of malaria, that they bite most often at night and thus how sleeping under a net is crucial. There are also myths to be de-bunked.
Dzisi cited one that he said is claimed by 50-55 percent of women of child-bearing age in some countries: insecticide-treated nets have contraceptive power. The story goes that they are white men's way to make men sterile.
"You may send in all the nets in this world, they just won't use them" if that sort of misinformation is not addressed, Dzisi said.
Students become agents of change, learning skits and songs to take the nets message back home. Sometimes community gatherings – known in Ghana as durbars – are held to get the message across with music, dancing, plays about using nets, speeches and question-and-answer sessions. Net-distribution days are often festive events with more celebratory entertainment and speeches.
The community selects members to be trained as malaria control volunteers who will educate their neighbors, help them hang their nets and assist the program in monitoring and evaluating their use. The nets are often stored in the leaders' homes and the chiefs and other leaders take charge of the distribution.
Once nets are distributed and hung, follow-up visits occur periodically over the next two years. Volunteers revisit the approximately 20 compounds to which they are each assigned to talk to recipients to check on the continued use of the nets and to inquire about changes in the incidence of malaria.
"Without them, we can achieve nothing," said Moses Nanang, malaria program manager for the Diocese of Tamale's Anglican Diocesan Development and Relief Organization (ADDRO) based in Bolgatanga in Ghana's Upper East Region.
Dzisi said NetsforLife®'s monitoring and evaluation efforts are meant to be "very, very rural-centered and people-centered" and they depend upon getting data from "very ordinary people in the field," some of whom have little or no education.
"Even an illiterate mother can tell you that her children are getting less malaria" after they begin sleeping under a net, he explained.
And while NetsforLife® volunteers and staffers review records of malaria treatment at clinics, Dzisi said that the malaria-control community's traditional focus on only that data skews the picture of malaria. "You can only get data from people who come … and they are already sick," he said, adding that only about 40 percent of ill people come to clinics for treatment.
"You are missing out on a lot of [data about] attitudes and behaviors, and that is what you want to change to make the achievements sustainable," Dzisi said.
The volunteers fill out handwritten reports on their observations, which are usually collected during regional volunteer meetings. Eventually they make their way to the Episcopal Relief & Development office in Accra where the findings are compiled and analyzed.
Ensuring the sustained use of nets does more than reduce the prevalence of malaria. Communities with less malaria, NetsforLife® has found, send more children to school and have a more consistent food supply because fewer people are sick and unable to tend the fields.
And, the NetsforLife® method of organizing, training and evaluating brings added benefits to the community by building the residents' communal capacity to make group decisions and come together to solve other problems, according to Dzisi and the ADDRO staff.
The results are independently reviewed each year and their reports are "consistent with our findings," Dzisi said, that sustained net use results in sustained decreases in the incidence of malaria.
During a late March community gathering in Apodabogo in the Diocese of Tamale, a chief stood up during the question-and-answer period to ask when all the members of his community would get nets. His question "is not something you would have heard three or four years ago," Dzisi said, explaining that it shows a growing trust and understanding of the effectiveness of nets.
The chief's question also points to one of NetsforLife®'s current challenges. The first phase of the project targeted pregnant women and children five years and younger because of their acute vulnerability to malaria infection. As that phase was coming to an end, the World Health Organization changed its net policy to so-called "universal coverage."
WHO said its field research showed that targeted distribution reaches about 40 percent of a community. To be effective at controlling the spread of malaria, WHO advised that 70 percent of a community's residents must be covered with nets when they sleep.
NetsforLife® agreed and Phase II of the project is aimed at universal coverage. And, Dzisi said, universal coverage for NetsforLife® means retroactively universal. The communities that have gotten nets since 2006 will get more nets before Phase II ends.
Add to that plan the reality that many of the nets distributed during Phase I have passed their estimated three-year lifespan and need to be replaced. Those changes could increase the number of nets eventually distributed to perhaps 10 million, Dzisi said.
And then there's the mosquito and its changing behavior. While mosquitoes typically bite their victims between about 9 p.m. and 4 a.m., field research is showing that mosquitoes are feeding earlier, sometimes as early as 6:30 p.m. This raises the question of how to combat the insect during the hours when people are still outside.
And, the insects are now showing signs of feeding outside as well as inside and being able to breed in much less water, "which is a source of worry," Dzisi said.
Plus, mosquitoes seem to be changing their flight habits, perhaps because they are getting stronger. They are spending less time regaining their strength by perching on interior walls that might be treated with insecticide or nets. While NetsforLife® does not spray walls, other organizations do and Dzisi suggested that the program needs to coordinate with these efforts.
"One thing that's clear is single interventions will no longer be effective," he said.
Episcopal Relief & Development supports other programs in Africa aimed at creating self-sustaining communities. In a perfect world, NetsforLife® would run in tandem with those programs because sustainable development is fostered in healthier communities and healthier communities have a greater ability to tackle other problems.
"The average African household has several problems; malaria may be just one of them," Dzisi said. The other problems include access to clean drinking water and money to send children to school and to buy food.
Not all of the countries in which NetsforLife® operates benefit from Episcopal Relief & Development's other programs and not all of the ones that do have the agency's support also have a NetsforLife® operation, he said. Increasing the number of nets to be given away by the end of 2013 alone will cost more money than what is budgeted for Phase II of the program, Dzisi said.
Enter the NetsforLife® Inspiration Fund. At the 75th meeting of General Convention in 2006, the Episcopal Church endorsed what became the Millennium Development Goals Inspiration Fund, which raised more than $3.2 million in three years. In 2009, the church renewed that support by endorsing the NetsforLife® Inspiration Fund and contributing 0.7% its triennial budget as seed money (about $800,000) for the effort. The goal is to raise $5 million with the support of churches, dioceses, seminaries and other institutions around the church.
"Our job is to multiply that" amount by encouraging Episcopalians to contribute to the effort, Brian Sellers-Petersen, Episcopal Relief & Development director of church engagement, told the NetsforLife® staff during the April 1 meeting in Accra. The effort includes diocesan and congregational campaigns to raise money to buy more nets.
Dzisi acknowledged that the program is small by some standards. The 6.3 million nets it has distributed are just a sliver of the 289 million insecticide-treated nets that the WHO estimates have been delivered to sub-Saharan Africa in the three years ending in 2010. However, a representative of another malaria-prevention program during the meeting said that NetsforLife® "is always part of the conversation."
"The NetsforLife® team across the continent of Africa has really been a resource for us in the United Methodist Church," said the Rev. Gary Henderson, executive director of the UMC's Global Health Initiative, which includes its Imagine No Malaria campaign. "We have been learning from you."