Kristen Moore-Sheeley's Nothing but Nets brings to life the history of insecticide-treated nets (ITNs) and demonstrates how and why they evolved from a luxury item rarely used in Africa to a ‘cornerstone of global malaria control’ (p. 14). Moore-Sheeley uses the history of ITNs as a vehicle to explore the interplay between science, policy and implementation of evidence-based global health interventions. The book acknowledges the impact of ITNs in malaria control and the innovative research that accompanied their growth while not shying away from the shortcomings of the widespread use of this tool. Nets have become synonymous with malaria control and have become the tool that people think of as effective, inexpensive and portable; this book addresses how that perception came to be.
The book is a close-in study of an object, a tool described as ‘evidence-based’ and expected to be effective everywhere. Yet Moore-Sheeley shows how much local context remains important. Nets are not equally effective everywhere and local conditions often explain a great deal. Nothing but Nets shows readers how political, financial and social factors shaped the use of ITNs. As a historian, Moore-Sheeley carefully attends to the history of this object, and the global conditions and global health discourses that allowed nets to become ubiquitous. She does a good job considering ‘the ways that shifting historical circumstances have shaped understandings of these technologies, their physical attributes, and their application over time’ (p. 4).
The book presents the history of ITNs across Africa through five main chapters organized around key events in the research, policy making and implementation of ITNs. Throughout, Moore-Sheeley focuses primarily on Kenya, which was a key site for ITN work and where the largest bed net efficacy trial was held in the 1990s. The bulk of her sources refer to the East Africa anglophone region, and she skilfully weaves in commentaries and personal experiences next to official research reports and epidemiological data. These come from Kenyan residents and scientists, community health workers and malaria control advocates involved in ITN research.
Chapter 2, ‘The biomedical technology: from Kenyan particulars to global universe’, focuses in on a large-scale ITN trial in Siaya, Kenya, run by the US Centers for Disease Control and Prevention (CDC) and the Kenya Medical Research Institute (KEMRI). The chapter illustrates how labour-intensive and complicated ITN research was and reinforces the importance of local circumstances. The chapter concludes by showing how complex results were flattened when they were shared outwards. One of the trial's key findings – the importance of considering local context – was overshadowed by the low cost and overall efficacy of the nets. Trials such as those in Siaya, and the overly simplified results that were publicized and widely shared, helped to create the insecticide-treated nets as an object with universal applicability. Similar studies positioned nets as the only logical choice to utilize in malaria interventions, as an ‘evidence-based’ tool. In the case of the Siaya study, rather than explaining research results in the frame of local distinctions and the need to tailor solutions to local realities, insecticide-treated nets were offered as the latest, greatest, newest tool.
While the chapter (and the book as a whole) is well written, and while clarity conveys a great deal not just of content, but also about missed opportunities in the realm of global health, it left these readers feeling melancholy. First, because the Siaya study is an example of how research results are often overly simplified and selectively reshaped. Too frequently data are discussed as a singular category that has clear meanings, rather than recognizing that meanings are assigned to data all the time. Second, because insecticide-treated nets continue to be presented as a magic bullet in the fight against malaria. The grand idea that a single tool will be able to resolve complex health problems around the world has a long history in global health and its precursors of international health, tropical medicine and colonial medicine. To nurture such naive hopes about technological solutions is a common pattern within global health. Too many global-health practitioners remain enthralled by the idea that a single vaccine, pill or tool can solve deeply complex, locally specific health issues that are often deeply entwined with local social and cultural conditions. This book lays bare these tendencies without offering simple solutions.
This book is carefully researched and draws on archival materials, oral histories and fieldwork in Kenya. All of the expected archives (and then some) were consulted, which included the World Health Organization, the World Bank, the US Agency for International Development, the United Nations, the London School of Hygiene and Tropical Medicine, the Centers for Disease Control and Prevention and the Kenya Medical Research Institute. Another valuable source of knowledge comes from thirty oral-history interviews conducted with scientists, health officials, malaria control advocates and community health workers on their perspectives of ITN research and development. Moore-Sheeley also integrates a handful of interviews with residents from four sites in western Kenya to discuss their understanding and lived experiences with ITNs. Finally, time spent in Kenya allows the author to comment on local ITN use, advertisements and methods of distribution.
This book would be well suited for undergraduate or graduate courses on a range of topics including global health, STS, the history of medicine and African studies. It is easily digestible and thought-provoking, and provides a detailed history of ITNs and malaria control efforts in an engaging way. We also hope that those involved in malaria control efforts and policy making can find time for this important work.
