Analysis of eradication impacts.
Medicine and Society—the power of cooperative innovation and efficacy of community-based mobilization in eradication efforts.
The dracunculiasis eradication campaign is impressive in that compared to the publicity and monies funneling into the eradication of other diseases such as polio, malaria, tuberculosis, or HIV, guinea worm eradication is not only receiving fairly modest funding, but is occurring without a vaccine or curative therapy.8 Even more impressive is that eradication has continued even in the presence of civil strife and dwelling political support—an effort largely maintained by the tenacity of The Carter Center and its community-based health workers.
The DEP’s grass-root public health initiatives in Uganda, for instance—a coalition of public and private sectors consisting of NGOs, political and religious leaders, and village volunteers spearheaded by TCC—have provided ongoing operational support and funds for filtering cloths, larvicides, and borehold wells for empowered communities.9 Furthermore, innovative measures were adopted to bypass containment impasses. Elderly men were employed as “Pond Care Takers” to guard water sources against contamination and to distribute nylon filters. Surveillance was improved when case prevalence was decreasing by instituting a cash reward for new cases going to the identifier, the ill patient, and the village volunteer who treated the case. Moreover, voluntary institutionalization of contaminated individuals were rewarded by a free stay in the public health clinic with free food and a cash reward. In this way, Uganda managed to go from more than 125,000 cases per year to eradication in twelve years, from a budget of $5.6 million.10
The success of these innovative measures shows that future eradication of disease can be achieved without significant scientific advances. Through national and donor partnerships, realistic time frames and objectives, stable financing, and accurate monitoring and evaluation systems, DEC is able to change medicine’s reliance on curative therapy, shifting the focus to prevention.11 The impact is that by the steadfast “inch by inch” methods of the DEP, prevention is just as effective, if not more, than treatment of infectious disease.
At the heart of TCC’s eradication campaign lie village health workers (VHWs) who perform much of the grunt work in identification, surveillance, and prevention, and who are responsible for allowing communities to receive much of the positive externality associated with eradication. Because cases of dracunculiasis are rarely presented at health centers due to its debilitating effects and the ineffective treatment capabilities at these clinics, the motivation for utilizing a VHW system came from the fact that GWD is found in villages away from more industrial/urban centers. Such VHWs are selected through a variety of means, depending on the country of origin: in Burkina Faso, a pre-existing network of VHWs was mobilized and trained by local health staff; in Nigeria, VHWs were selected based on literacy in order to complete surveillance forms, although studies in Ghana indicate that illiterate VHWs are as reliable as literate ones.12 Furthermore, demographic qualifications were accounted for such as sex, as a married woman would be more reliable than men because they are less motivated by material rewards and less likely to leave their village, or for ethnicity, in cases where villages were inhabited by more than one ethnic group. Considering the logistic difficulty of visiting every village monthly and the fact that work is conducted by volunteers, village-based surveillance system is highly effective, with recent evaluations showing that VHWs accurately detect 95% of endemic villages.
However, a community-based system is not without challenges. The main preventative intervention is health education, in encouraging safe drinking or filtering. Although cloth and sieves were widely used to filter liquids before eradication efforts, the right type of cloth is necessary to cleanse the water from copepods. An important behavioral change was the introduction of cloth filters. In the early stages of eradication, cotton cloths were adopted, but in some cases the attractive design on the cloth led villagers to wear or hang it, and in other cases there were complaints about the time it took to filter, since the cloth would clog with sediment. A monofilament nylon cloth donated by Dupont Precision Fabrics through TCC is less susceptible to clogging, providing so popular that it has even been sold in non-endemic village markets.21
A community-based approach is also not cheap. Health education costs at least $110 per endemic village per year, while borehold wells costs $10,000 or more per village. Furthermore, motivating volunteers prove difficult at times, especially since monitoring 1,000 people takes at least two days. The result is that VHWs do not visit households routinely, relying on word of mouth. In Pakistan, VHWs were paid a salary to encourage diligence, but this could make the VHW reluctant to work himself out of a job. In Togo, VHWs keep some of the revenue sold from cloth filters. However, most countries prefer to give presents such as shirts, which can be a sign of status, often more important than monetary rewards. A survey of workers in Northern Ghana indicates that the most important motivation comes from improved social status and the progressive decline of GWD in their villages.13
The importance of these VHWs cannot be underestimated. Although the commitment of VHWs will be difficult to maintain as more villages cease to be endemic and that these community-based surveillance systems may be wasted as eradication becomes more realized, the solution is to combine dracunculiasis eradication with the monitoring of other health conditions, or to use these VHWs to help eradicate other diseases. VHWs, who make monthly visits to families in their villages, are extremely sensitive to changes in health conditions. This proves important for neonatal tetanus, for instance, where surveillance is required by people who know the families on a regular basis. In Burkina Faso, VHWs have spontaneously started helping immunization teams in identifying children to vaccinate, a consequence of keeping updated records of their surveillance forms. Dracunculiasis eradication is now becoming a case study for community mobilization, making it apparent that utilizing community members is not only more effective, but also more efficient in surveillance and prevention.22
Science and Technology—implications for future eradication efforts.
The major setback before implementing dracunculiasis eradication was the dearth of an antihelminthic medication or vaccine. Smallpox, the other eradicated disease, was successful through global adoption of a vaccinated cure. Dracunculiasis, on the other hand, would need to be eradicated entirely through prevention.
Initially, the WHA proposed three criteria to be considered before launching an eradication program: biological/technical feasibility, cost and benefits, and societal/political considerations.14 GWD can be eradicated for several reasons: first, there is no human carrier beyond a one-year incubation period; second, there is no animal reservoir; third, diagnosis of patient infections is marked by a highly conspicuous protrusion of the worm; fourth, transmission of the disease is seasonal, thereby facilitating the timing and effectiveness of control interventions; fifth, controlling outbreak is simple, using cloth filters or borehold wells; sixth, the disease is well recognized by the local endemic populace.6 The impact of the success thus far indicates that eradication by prevention is possible, given the ease of several other aforementioned factors.
Economics—cost-benefit analysis of GWD eradication.
The economic benefit of dracunculiasis eradication affects mainly the endemic countries, but the benefits are coincident and widespread: clean drinking water; the existence of a VHW system; prevention of disability; improving agricultural production and school attendance; fostering managerial, planning, supervisory, and monitoring skills; and perhaps most importantly, providing a tangible example of a successful eradication effort. All these factors are relatively immeasurable with the exception of agricultural production improvement. The World Bank estimates $1 billion in lost production of goods due to GWD each year, worsening poverty for entire endemic villages in West Africa.15 If occurring in the planting or harvesting seasons, food production suffers, where up to 40% of farm workers may be affected.
A study by Kim A., Tandon A., and Ruiz-Tiben E. et al conducted a cost-benefit analysis of the campaign, concluding that GWD eradication is calculated to produce an economic rate of return (ERR) of 29%.16 The study compared the increases in agricultural productivity resulting from the prevention of cases and projected this to eradicating the disease by 1998, with a conservative assumption of 5 weeks incapacitation (ranges from 2-16 weeks, average 8 weeks) caused by GWD. They also accounted for the fact that two-thirds of all cases reported represented those in the economically productive age group of 15-44. According to the World Bank, any ERR above 10% is a sound economic investment.
The caveats to the study come mainly from the high sensitivity of its assumptions. The most obvious fallacy is from their twelve-year project horizon (eradication was not achieved in 1998), and further sensitivity analysis shown that in the Sudan, where the disease is still high in prevalence, negative economic benefits will incur if eradication is not achieved by 2005. Although many positive externalities are not accounted for in the model, such as improved education, employment, and training, current models for the economic benefit of dracunculiasis eradication, as of now, are projected to have negative economic returns. The longer it takes for GWD eradication, the more economic cost the country and its associated NGOs will incur.
Society and Politics—support in times of war.
The most pressing challenge when it comes to politics and GWD eradication is maintaining support at the national level during the final phases of eradication. The fact is that DEC targets a very small proportion of the national morbidity burden in the poorest communities amongst the poorest countries in the world, and sustaining support has been complicated by logistic difficulties in supervising these remote areas. Furthermore, sustaining an eradication program for almost twenty years has strained funding sources, important for eradicating the remaining areas of disease. In Sudan, where civil war persisted for a decade, funding is a serious problem because of donor concerns that not much can be accomplished during wartime, and that societal and political support has to be mobilized both by the official government and rebel groups.17 Encouragingly though, interventions have been sustained in conflict environments, and cease-fires have been organized around the GWD eradication campaign—the impact being that health campaigns can simultaneously lead to improved health outcomes and political peace.
In Sudan, GWD cases have mildly decreased in the mid-1990s due to sporadic evacuations of international staff. However, in 2003-2004, Sudanese cases of GWD were reduced by 67%, ending the indigenous transmission of the disease in northern states in 2002. This effort was largely due to more than seven million pipe filters and 3.5 cloth filters for person protection, more than 100,000 health education sessions between 2002 and 2004, and $200,000 in first aid kits in 2003, made possible by a joint collaboration between TCC, the Humanitarian Action Campaign, and Health and Development International.18 This incredible success illustrates the power of societal and political support, impacting the support for eradication programs in the future by recognizing the need for collaborative efforts in accomplishing communal goals, even during political strife and civil unrest.