Why Eradicate Guinea Worm?
Feasibility
Dracunculiasis is extremely easy to contain. First off, its vector is a water-borne copepod that can be filtered out with cloth. Secondly, the only way the larva enter bodies of water is through direct exposure. So, it infected people stay clear of bodies of water, they can’t transmit the disease. I will go much more into depth as to how this process into how this process ties into achieving eradication goals in the Methods section.
Cost-Benefit Analysis
In 1997, The World Bank came up with an “estimated economic rate of return of 29 percent” for the eradication program. How could this be? This data used sound research on all of the problems caused by Guinea Worm, such as those described in the socioeconomic section, but did not value this work nearly as highly as it should be.
Most importantly, as pointed out by Cairncross, The World Bank report forgets that the short term costs of eradicating guinea worm will have long term benefits. Unlike treating other disease, children wont just be able to go to more school for one year, the burden of dracunculiasis will be lifted off of them forever. Men will not just be kept out of bed for a year, but they will never be economically crippled by this nemesis of a nematode again.
In addition, there is great intangible benefit to eradicating a disease: it breeds excitement about global public health projects. The enthusiasm to treat guinea worm largely grew out of the success of the small pox eradication; who knows what success with Guinea Worm will lead to.
Funding:
Approximately 89 million dollars were spent on the eradication program between 1987 and 1998. The vast majority of the funding during this period came from Global 2000, UNICEF, and WHO. Towards the end of this period, funding began to slow. (World Bank)
Then, in 2000, The Bill and Melinda Gates Foundation donated 28.5 million dollars to the program (CDC), which was a far greater sum of money than had been spent in any one year on the program prior to then (World Bank).
Photo: The Bill and Melinda Gates Foundation
http://www.gatesfoundation.org/
This year, The Bill and Melinda Gates foundation pledged a 25 million dollar challenge grant. They gave the center 5 million dollars initially, and then promised to match other donations for a total of up to 20 million dollars. In response, the Canadian international Aid Agency donated 5 million dollars, and the Hilton Foundation donated 1 million dollars. This funding should help close out the eradication program (CDC).
 A note on Donald Hopkins
While these donors should be commended for their efforts, there are other individuals who must be commended; the dedicated individuals who decided to show the world why we should treat dracunculiasis, and did what it took to have eradicate Guinea Worm, and why it should be done. Chief among these individuals is Donald Hopkins, who “has been the spark plug on this for years” (William Foege). While working at the CDC, he and other passionate health advocates (such as William Foege himself) convinced Jimmy Carter and others to fight this terrible parasite. Thank you!
Photo: Donald Hopkins, M.D., M.P.H
http://cartercenter.org/aboutus/showdoc.asp?bioID=7&submenu=aboutus
History of Eradication Efforts:
As discussed in the Epidemiology section, guinea worm has been around for a long longtime. However, the eradication effort didn’t start until the 1980’s. The initial push was fueled by the passion of Donald Hopkins: “He’s been the real spark plug for this from the beginning”. He was supported by other passionate people from the CDC, who were spurred on by the recent success of smallpox eradication.
The early years of the Global Dracunculiasis Eradication Campaign were extremely successful, due mainly to the ease of control of the Dracunculiasis vector. This accounts for the eradication in all of the countries discussed in the Epidemiology section. Despite this ease, the target date for 1995 was not met, but whether or not it was serious goal is questionable. Again, the advocates of this program were working off of the excitement of smallpox eradication, as were their donors. Making a goal seem close gets people even more excited. This could have been an intelligent tactic.
In 1995, Jimmy Carter negotiated a “Guinea Worm Cease Fire”, which temporarily put the civil war on hold, and allowed Health workers to enter the dangerous region of Southern Sudan to care for the sick, and more importantly to spread out aid. Health Workers who previously could not access this region got to distribute over 200,000 cloth filters to 2,000 endemic villages, and distribute, to effectively inaugurate the Sudan Guinea Worm Eradication Program (SGWEP) This monumental cease fire shows the power of health care. It is likely that the desire to treat guinea worm played a role in the eventual peace treaty.
In the late 90’s, eradication pace slowed. Many countries were getting to the difficult part of reaching complete eradication status. At the same time, Sudan was still a haven for dracunculiasis, as the war impeded health worker access and prevented general sanitation. The Gates Foundation donated more money, as described in the Funding section, to try to tackle the last few in some countries, and work on the puzzle that is eradication in Sudan.
Methods:
Education
Education is the most important aspect of Guinea Worm eradication. Prevention is actually fairly easy, but first you have to get everybody on board. As explained in the Vector and Transmission section, the vector for guinea is transmitted through water. So, eradication programs focus on making sure people drink clean water, or at least filter dirty water, and on keeping infected people away from bodies of water. Convincing people to do this is dependent on teaching them that guinea worm is transferred through water. As Bill Foege, senior fellow of the Gates Foundation and ex director of both the CDC and the Carter Center, states:
“with each village you must provide persuasive health education so that people actually believe they are getting this problem from the water. With a 12 month incubation period it is not easy to accept this is due to something that people have been doing every day, namely drinking water. When I lived in Africa people had many explanations but usually involving something that they had encounter days before the worm emerged.”
Bill Foege (email correspondence; 5/25/05)
This education has primarily been accomplished by community health workers, who teach everyone in their villages about health issues.
In addition, The Carter Center recently (2003) instituted a program to use the radio to transmit additional information about Guinea Worm, and how to prevent its transmission. Carter himself spoke in the public service announcements, in addition to UN Secretary General Kofi Annan, and the Presidents of both Mali and Niger ( Carter Center – Health Programs).
Water Sanitation
Woman Filtering Water
Carter Center: http://www.cartercenter.org/doc1572.htm
Clean water is essential to riding the world of dracunculiasis. Dracunculiasis is only a problem where people have to drink dirty water. Fortunately, ridding water of the vector for dracunculiasis, the water flea, is easy. While microscopic, the flea is large enough to be filtered out with a simple nylon screen. The difficult part is convincing people to use these filtering clothes.
ABATE® Larvicide can also be used to clean bodies of stagnant water. It kills the copepods that carry dracunculiasis, leaving water safe to consume. This treatment method leaves less room for later human error leading to infection (Carter Center- Action Plan).
In addition to providing nylon filters, in 2001 The Carter Center distributed 9 million portable pipe filters (shown below) in Southern Sudan. They can be worm around the neck on a string, and allow people to drink from dracunculiasis infected water while on the move. ( Carter Center – Activities by Country: Sudan)
Carter Center: http://cartercenter.org/doc1255.htm
Borehole wells are also frequently used to prevent transmission. Jimmy Carter points out the problems with this method of finding clean water.
“It became increasingly obvious to me that a basic problem was that Ghana 's officials, from field workers to the president, considered the drilling of deep borehole wells as the primary solution to the Guinea worm problem. The common theme was "a deep well will eradicate our Guinea worms." Although highly desirable and much needed in every village, this is not the way to eradicate the disease. Extremely expensive and time-consuming, with no assurance of finding potable water in many areas, the borehole dream had become a substitute for simple filtering of each drink and keeping people with emerging worms out of the ponds.”
Jimmy Carter 2/9/04
Final Reflections From Africa: Web Log (Blog) Update
In addition, this method takes emphasis away from containment. All it takes is an infected person getting one drink, and the natural source of water is contaminated. This is an incomplete answer to a complex problem.
Identification and Containment of Cases
At first, intervention was focused just towards helping people protect themselves by filtering copepods out of their water. However, once case numbers went down drastically, emphasis shifted towards containing current cases, and keeping larva from getting into bodies of water. In order to eventually free water sources of dracunculiasis, cases must be identified extremely quickly, and sufferers must be kept from water sources. This is another task of the job of community health workers.
In addition to education, health workers have a few other methods of keeping infected people away from water. One is surgically removing the worm in its early stages, riding the body of the worm and larva. Another crafty method is raping the leg in a large bandage. While this doesn’t help treat the worm, it makes it less likely that an infected person will submerse their leg in the water. In addition, if the leg is submerged, it is less likely that larva will get into the water (WHO – Vector Control).
On the Importance of Community Health Workers
Red Cross Volunteers: Courtesy of Carter Center
http://www.cartercenter.org/doc1572.htm
Community Health Workers are an essential part of all three of these aspects of eradication programs. Without effective educators and leaders, eradication would not be possible. Sending in outsiders to do this work would not be as effective for a whole slew of reasons, including difficulty reaching different locations, difficulty communicating with locals, etc. Fortunately, this is a very respected position, and people in communities are interested in helping.
The Last Stand: Ghana and Sudan:
The Carter Center: http://cartercenter.org/healthprograms/program1.htm#table
There approximately 16 thousand cases of dracunculiasis remaining of the 3.5 million that plagued Africa and other regions of the world in the early 80s. The vast majority of them are located in Ghana and Sudan. Here, I will discuss why these two locations are still strongholds for the disease, and the prospects for complete eradication.
Ghana
Carter Center: http://www.cartercenter.org/doc1572.htm
Ghana has more reported cases of dracunculiasis than any other country (2 more than Sudan). Why is this?
Ghana was on track with other African nations until its funding was cut short in 1997. Ghana was only without funding for a few months, but they happened to be the months of greatest transmission (Cairncross). This had lasting effects in Ghana, and transmission rates doubled in 1999. Ghana is still crawling back form this problem; however, there is no reason why eradication can’t be achieved in Ghana.
Sudan
Since the beginning of the Guinea Worm Eradication Campaign, Sudan has been the hardest country to work with. The 20 year civil war made treating endemic areas in the south nearly impossible. The cease fire in 1995 did a lot of good, but without a stable treatment system, eradication is impossible.
Now that there is peace, it seems that eradication is possible. The reported incidences of guinea worm went down 65% between 2004 and 2003(calculation using WHO data). It seems that the final stumbling block to eradication may prove to be more of a speed bump.
However, there is an important confound that must be considered. While peace has been restored to the south, a terrible genocide is still being committed in the Darfur region ( Western Darfur). This has killed 180,000 people, and left 1.6 people internally displaced. Now it is the rainy season, and BBC correspondent in Darfur H ilary Andersson (sic.) reports that torrential rains fall on the camps at night (BBC). If these rains form ponds, or if ponds already exist in the camps (as they apparently do in other parts of the country) transmission would be extremely easy. Guinea worm has not been endemic to this region for years, but it is not out of the question that someone could carry it there, and it could get into the water.
USAID http://www.usaid.gov/locations/sub-saharan_africa/sudan/images/satellite/
Baring an unfortunate outbreak caused by this terrible humanitarian crisis, it appears that Sudan will be free of dracunculiasis in a matter of years, possibly as few as two (William Foege).
All other Countries
CDC: http://www.cdc.gov/ncidod/dpd/parasites/dracunculiasis/wrapup/word152.pdf
In order to clean up the last few cases we must keep up funding, and put much effort into case containment. Given the progress made in these countries, there is little reason to be concerned. Unless a war breaks out, dracunculiasis will be eradicated by the 2009 target date.
Lessons To Be Learned:
Secure a constant source of funding
If the Gates foundation had not decided to support dracunculiasis eradication, the outlook could be much more grim. While difficult, it seems clear that a constant source of money will make programs in the future far more secure, efficient, and economical. For example, the loss of funding in Ghana left more people infected, set the campaign back, and led to higher long term costs.
Harness the power of Communities
The Community Worker is a real hero in this campaign. They proved to be quite effective in educating the public and managing cases, and should be trusted in further campaigns.
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