Voices Against Malaria

Fighting the deadly parasite in West Africa with stories, songs and nets.

Fellows Spring 2011

By David Taylor

June 20, 2012

Also published in the Johns Hopkins Public Health magazine, Spring 2012

Photo: David Colwell

Social Forces

During my first weekend in Bamako, I learned that in Mali, music means a lot more than Top 40. It’s a way of life. And the people who make music—including traditional West African storytellers, called griots, and the more recent wave of pop music stars—can be powerful agents for change.

Riding the capital’s dusty red dirt streets on a motorcycle one Sunday afternoon, I soon witnessed the griot tradition. Under a white tent spanning the middle of a residential block lined with mango trees, a local griot serenaded wedding guests, accompanied by several djembé, or Malian drums. The bride and guests laughed at the teasing story she sang about their families and origins, which she surmised partly from their names (akin to how we know baking professionals lie somewhere in a Baker family’s ancestry).

Societal changes of the last two decades have blurred the line between traditional griots born into the tradition by family, and others who choose to be musicians by trade. The professional musicians bring in new styles from jazz, blues and Latin music, but still perform traditional songs with griots at weddings and naming ceremonies.

Woven together with the playful banter, skewering satire and sage advice that these honey-toned singers have passed down for centuries are new messages—messages aimed at saving lives across West Africa. With the help of Voices for a Malaria-Free Future, a project of the Bloomberg School’s Center for Communication Programs active in four African countries, the singers have become the newest foot soldiers in the battle against malaria. They are reaching out with their artful blend of song and storytelling to galvanize public and private resources against a disease that claims nearly 700,000 lives a year, most of them in Africa and most of them children, according to WHO. (A February Lancet article offers a direr estimate, placing global malaria deaths in 2010 at 1.2 million.)

In malaria, the griots face a foe as adept at improvisation as they are. The constantly shifting malaria parasite can acquire drug resistance quickly, and a vaccine has remained elusive. That’s why Voices for a Malaria-Free Future, with Gates Foundation funding, has combined national dialogue and local action to change people’s behaviors. Claudia Vondrasek, who heads the project, told me they adapt their strategy to social forces already present in each country. Malians have used mosquito nets for decades, but typically only during the rainy season. So the project made a strategic choice to focus on widening net use for prevention. (According to WHO, full use of insecticide-treated mosquito nets in sub-Saharan Africa could reduce child mortality by 18 percent on average; that would save more than five lives per year for every 1,000 children under 5 who are protected.) The project also chose the cultural resources available in traditional griots and popular music as a key channel for behavior change communication (BCC).

Big Picture

Musicians showed the practical power of Mali’s music culture when the project started in 2006.

A bureaucratic logjam had kept nets warehoused in the capital for months. So the Voices staff mobilized a group of high-profile advocates—including top musicians, legislators and health officials—to film public service announcements, explains Mali country director Djiba Kane Diallo.

Salif Keita, Mali’s first world music superstar, brought results immediately. “We went together to the Ministry of Health and filmed,” recalled Diallo. “[Keita] stood in front of the Ministry of Health and said, ‘It’s almost the rainy season, so we need to give nets to people and alert them to use them.’ We made the PSA and aired it. A day or two later the Minister of Health herself called and said, ‘Okay, what do you need?’”

From that came an annual distribution of nets at the district and community levels, with more nets provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President’s Malaria Initiative. After the 2007 campaign provided treated nets to more than 2.8 million children, a survey showed that 80 percent of households with children under age 5 had treated nets. The next question: Would they use them?

Among the hurdles to fighting malaria, the biggest may be long-standing public acceptance of the disease. You need a powerful message to tackle a mountain that people have come to accept as part of the landscape.

Abdoulaye Diabaté, one of Mali’s most popular musicians, said, “I suffered too much from malaria.” He recalled the high fever and headaches, the vomiting and diarrhea and the repeating cycle of shivers and sweats through the night. “It was not just me, it was all children my age, catching the same illness,” he said. “We grew up that way, accepting the disease. We didn’t know it could be different.”

First, Voices of Mali enlisted top health officials to articulate the message to policymakers. These champions included Ogobaro Doumbo, who heads the Malaria Research and Training Center at the University of Bamako. Doumbo helped Voices sensitize legislators from Mali and 17 other countries across West Africa to how they could help, starting with increasing
the proportion of national budgets devoted to health.

One evening at Point G, a century-old hospital on a bluff overlooking the capital, Doumbo explained this high-level advocacy. To motivate public figures, Doumbo said, “you have to use an exact but simple message.” Malaria is a specific fever, he explains, and by improving diagnosis and prevention it can be beaten. Then he marshaled a compelling comparison: “This is equal to three to four tsunamis happening every year to African kids.

“Africa has lost a lot of Einsteins, a lot of Pasteurs, a lot of Bill Gateses because of malaria. So if you’re able to eliminate malaria, you will see it increases the general creativity in this country and the ability of people to innovate and bring science to make their own solutions.”

Doumbo added, “When you say that to parliamentarians, they listen.”

A Grassroots Shift

After focusing their message on national decision makers, Voices advocates needed to inform the public of policy changes and persuade them to adopt preventive care for pregnant women and appropriate malaria treatment. In 2009, the second phase launched the BCC component. Increasingly, Voices of Mali involved griots and popular stars to take the message to village-level action. Again, project staff trained the champions to deliver key messages in concerts and on radio spots. For example, for World Malaria Day they worked with Diabaté on the message that pregnant women need to get prenatal care. The lyrics of one song urged, “Pregnant women, please get your consultation prenatale, to be sure you receive your nets.” Local NGO affiliates created watchdog committees, with women and a representative each from schools and health agencies—six or seven people per village. The committees organized town meetings focused on how to avoid mosquito bites and the proper use of nets. “They also go gate by gate, family by family,” Diallo said, encouraging people to use their nets nightly, stressing the importance for children’s health.

Next door in Senegal, a national net distribution campaign coupled with BCC—led by a coalition of the National Malaria Control Program (NMCP), the Peace Corps and other organizations, including NetWorks, a CCP project—yielded big gains.

By January 2012 the campaign covered 10 of Senegal’s 14 regions and distributed more than 3.8 million nets. It had received a boost two years earlier from Youssou N’Dour, a Senegalese world music star, who grew up in a griot family and has crossed over with songs that weave in outside influences. “In Senegal, everybody knows Youssou N’Dour’s songs by heart. If you can get 8 million people to memorize these songs, we should be able to lead to a change in behavior,” observed Yacine Diop Djibo, who heads the NGO, Africa Speak Up. A song that N’Dour recorded with Viviane Chedid, titled “Our Society,” aired frequently on radio stations for months, with a refrain that in the Wolof language sounds danceable: “Our society is booming/ We stand strong and proud/ We fight malaria/ To finally kick it out of Senegal.”

As one of the key partners in the Senegal coalition for distributing the bed nets and getting people to use them consistently, NetWorks operates differently from the Mali CCP program, explains Joan Schubert, NetWorks team leader based in Dakar. With funding from the President’s Malaria Initiative, NetWorks has developed technical strategies for logistics, communications, and monitoring and evaluation, says Schubert. To monitor overall progress, NetWorks will track indicators annually, including the percentage of households with one or more insecticide-treated nets and the percentage of people who slept under nets the previous night. During home visits a week after the distributions, outreach workers look at how many nets were properly hung and used the night before. NetWorks also launched a 24-month qualitative study in January on the culture of net use; the study will help refine future communications work.

Senegal has seen a steep drop in malaria, from 1.5 million cases in 2006 to 175,000 in 2009, according to a 2010 NMCP study. Improved diagnosis (determining other causes of fevers) accounts for a large share of that decline, but the public campaigns appear to be having a remarkable impact. By January, more than 13,400 health workers and more than 1,200 traditional communicators had received NetWorks training on the message, “All the family, all year, every night.” In French it is known as the Trois Toutes campaign: Toute la famille, Toute l’année, Toutes les nuits.

In Mali, griots with Voices incorporated the message into their traditional performances. Performing at a wedding, they’d interrupt singing to say, “I need to talk with you about malaria.”  After the wedding, where gifts can include a mosquito net, the griot would urge, “Now please sleep under the net because it’s important.”

After I peppered Diallo with questions about griots, she called Abdoulaye Diabaté. “Bonjour, Papa,” she said, then eased into Bambara (another West African language). She succeeded in getting me an interview with this nationally famous musician for the very next day.

The next morning outside the Voices office I heard Diabaté bantering with the staff well before I saw him. Then the man with the resonant voice moved into the office with an easy grace, garbed in a flowing white robe and fez-like hat. Diabaté, who comes from a long line of griots, says: “A griot is someone who retains a lot in their head. For changing people’s thinking, you need people who retain a lot.”

He nodded toward the laptop nearby and his own two cell phones. “Now we have computers, we have phones, we have machines. Before, it was only the griot who had that function.” Yet even with these new technologies, he said, the griot retains authority as “the mouth of the people, the ear of the king.”

Like N’Dour, Diabaté straddles the line between griot and pop artist. His songs have long addressed social themes including illness, inequality and the role of science. He became involved in the fight against malaria through songs about his experiences growing up in the countryside, where, like other children, he suffered from malaria.

One night soon after, Diabaté deployed his charismatic blend of griot and Afropop rhythms at a fundraiser for a local youth association. He connected with his audience, young and old, as they shouted the lyrics to his driving song “Sere,” which addresses adolescent health and possibilities for the future.

As the hot season steamed into April 2011, Voices ratcheted up the awareness campaign leading to net distributions in western villages near Kayes. I found glimmers of the campaign in a bus station four hours east of the capital, where the lettering on one young man’s shirt read, “Free Africa from Malaria Now.” In a rural clinic several hours away, Dr. Karamako Nimaga explained that malaria was still the main reason for clinic visits during the rainy season.

As Mali emerged from a scant rainy season last November, Voices received Gates Foundation funding to focus on advocacy and private sector partnerships. In Mali, the high-end Azalai hotel chain committed to promoting use of mosquito nets among its employees and hotel guests; and Orange, a major cell-phone carrier across Francophone Africa, sponsors soccer tournaments to promote awareness in the countryside.

“For me, a Mali without malaria will bring a blossoming of cotton, millet and rice,” Abdoulaye Diabaté told me. Now I understood: Malaria strikes not just individuals but entire communities who manage the fields and run the fishing boats in the season when the haul is most fruitful. Diabaté said this was more than simply a fight to end an illness, as important as that would be. “People who are completely free of malaria can work in their fields, they can fish.” Then he added ruefully, “I don’t want my children to suffer from this disease and say, ‘Abdoulaye didn’t do anything.’

“A Mali without malaria is an abundant Mali,” he said. “That’s the hope.”