Thanks to Dr Scott Kellermann from the Uganda Nursing School Bwindi for submitting this article.

Burials of young children are the most common observance that we attend. We are, however, witnessing too many unnecessary deaths from malaria, and it is obvious that we need to engage in prevention.

Mosquito nets impregnated with insecticide have proved to be effective in many areas of the world. Education and widespread distribution of these nets is important in their success. We obtain an inexpensive source for these nets and consider giving them away. We meet with the abafumu (traditional healers/witchdoctors) and explain our proposal for free mosquito net distribution. The abafumu are not impressed and inform us that our plan will surely fail. They agree “if the nets are to be valued, then the recipients must contribute something to the cost of the nets”. I question this approach and tell them “in my world it would be unethical to charge an impoverished person for an item that can prevent her child from dying”. The abafumu insist that unless something is contributed, the nets will not be appreciated or used correctly. I reflect that I have commonly seen donated mosquito nets used for fishing, dresses and other attire. Actually a woman wearing a tastefully arranged mosquito net looks quite stylish.

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I agree with the abafumu’s plan, and we set the price at $1 for the nets, although more often we accept the trade of a bow, arrow or basket as payment. Several government officials and non-government organizations hear of our plan requiring payment and complain, “Don’t you white folks have donors who are willing to help poor African children?” These criticisms sadden us, but we agree to honor the advice of the abafumu.

When we travel to villages to discuss bed nets and how these nets can help to prevent malaria, the villagers are very skeptical. “Malaria cannot be stopped by a net,” they state.

“Why not?” I ask.

“Because malaria is caused by Stan!” they exclaim. I recall that Stan is one of their traditional small gods, a demon.

They continue, “When our young children contract malaria, they have shakes and jump around (seizures); this is obvious demon possession by Stan, and nets cannot prevent Stan from getting to our children.” I am stumped.

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I seek advice from our friends the abafumu. I state that we are having trouble distributing mosquito nets because the villagers believe that malaria is caused by Stan and that Stan can easily pass through the nets. The abafumu nod in agreement, “Stan is indeed very dangerous,” they concur. “Stan is the god of our ancestors. After the death of a relative, if adequate sacrifices have not been provided to Stan, then Stan will return to cause all kinds of illnesses, including malaria. Stan is very powerful and not to be angered,” they emphatically state.

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The abafumu are, however, willing to engage in a discussion. The medical students and I spend many hours discussing malaria with the abafumu. We take them to the hospital laboratory and show them what the parasite looks like under the microscope and explain in great detail the life cycle of the anopheles mosquito. The abafumu are very attentive and eventually agree that the mosquito is the culprit  and decide to assist as they all have witnessed children dying from malaria under their care. They help in organizing the villagers and agree to go to schools and public meetings to explain the necessity of using bed nets.

We survey our area and identify every child under the age of five and every pregnant mother. We are determined that all these non-immune individuals should be provided with a net. We launch our campaign and are surprised by the response. We begin by selling 100 nets per month, which quickly progresses to 1,000 per month. After two years we have distributed over 15,000 bed nets! We then notice a substantial drop in the hospital admission rates for malaria and a marked reduction in the number of outpatient cases presenting.

Our records indicate that in 2006 one to two children were dying of malaria every week at our institution. A decade later, after the vast majority of children in our area have received mosquito nets, to the hospital’s and abafumu’s delight, in a nine-month period not one child dies from malaria! When we investigate our laboratory records, we find a similar trend. A decade earlier, on any given day, our lab log would contain several pages of blood smears positive for the malaria parasite. In contrast now one page of the lab log contains multiple days of malaria smear records. Previously 40 percent of the hospital’s outpatient visits were due to malaria, presently just under 4 percent complain of malaria, a statistical analysis indicates that the prevalence of malaria has been reduced by over 90%! Malaria has not been completely eradicated, but many children now survive into adulthood because of the use of mosquito nets and the support and cooperation of the abafumu.

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