We can get rid of guinea worm / by Donald R. Hopkins

We can get rid of Guinea wonn § hortly after attending the opening session of the Third African Regional Conference on Dracuncu- liasis in Accra, Ghana, in March 1988, former US President Jimmy Carter visited the villages of Denchira and Elevanyo, about 44 kilometres northwest of Accra. There, in less than an hour, the former US head of state (who is the chairman of Global 2000, a non-profit organization of the Carter Presidential Center in Atlanta, Georgia, USA) saw over a hundred persons suffering from Guinea worm disease, including a woman with a worm emerging from her breast. During the International Drinking Water Supply and Sanitation Decade ( 1981-1990), dracunculiasis, or Guinea worm disease, has received increasing attention as an environ- mental health problem that is speci- fically associated with polluted drinking water in certain rural areas. The con- tamination of drinking water by infected persons and the use of such contaminated water are the two human behaviours which allow the disease to perpetuate itself. As many as ten million persons are thought to suffer from the infection each year, in India, Pakistan, and 17 endemic African countries located in a belt from Senegal and Mauritania in the west to Ethiopia and Sudan in the 26 by Or Donald R. Hopkins Senior Consultant, Global 2000 east. Anything from 60 to 100 million inhabitants of endemic rural areas in those countries are at risk of the infection. The disease appears when the adult female Guinea worms, which are two to three feet long, emerge through the skin of victims about a year after the unfortunate person has drunk water containing the immature larval stages of the parasite. If the adult worm comes into contact with fresh water, as in a pond or step well, she discharges hundreds of thousands of larvae into the water. The larvae are ingested by a tiny crustacean or "water flea" called a copepod, where it develops into the stage that is infective for humans. When humans drink water containing copepods with infective stages of the parasite, the copepods are killed by digestive juices in the stomach, and the liberated larvae migrate into the abdo- men and mature in the tissues. After about one year, the fully grown female worm causes a painful blister to appear, usually on the lower leg. Victims seeking relief from the blister or entering fresh water for any other reason permit the worm to discharge larvae back into the water, thus conti- nuing the cycle. The adult worms emerge slowly and painfully over several weeks, and affected persons may be crippled for months. Worms may emerge from any part of the body, though most emerge through the skin of the lower leg, ankle or foot. There is no curative treatment, and infected persons do not develop any immunity to the disease. Although Guinea worm doesn't usually kill its victims - some die if the worm invades the spinal cord, brain, or heart, or if the ulcer caused by the emerging worm is contaminated with tetanus bacilli - it has enormous social and economic impact because of its crippling effects. Up to half or more of adult farmers are crippled for weeks by the emerging worms at the time of year when they must harvest or plant their crops. For the same reasons, large numbers of children are unable to attend school during the "Guinea worm season." So the disease exerts its negative effects on the health, agricul- ture and education of endemic areas. Three ways Yet it is entirely preventable. Teaching villagers to filter, boil and not to contaminate their drinking water, providing safe pipe-borne or borehole well water, and treating contaminated water sources with temephos (Abate), are three ways of stopping transmis- sion of the infection completely. By similar means (health education, and providing new or improving old water sources), the disease was eliminated from the southern part of the Soviet Union over 60 years ago. In 1989, the World Health Assembly declared the WORLD HEALTH, January- Feb ruary 1990 Former US President Jimmy Carter inspects the safe water supply - free from Guinea worm infection - in the Ghanaian village of Elevanyo. And right, examines the old, unsafe source. goal of eliminating Guinea worm disease as a public health problem from the world in the 1990s. Just how preventable Guinea worm is was demonstrated again recently in the two Ghanaian villages visited by former President Carter. Ghana began its national Guinea Worm Eradication Programme in December 1987, with the assistance of Global 2000, which works particularly with Third World countries in the fields of public health and the environment. Within days of Mr Carter's visit in March 1988, the Ghanaian Ministry of Health together with Global 2000 began working with the Department of Community Devel- opment of the Greater Accra Region to help the 800 inhabitants of the two villages, mainly subsistence farmers, to understand how the infection is spread and how to mobilise themselves to prevent it. The villagers constructed patas, or small sheds, near the drinking water sources so that persons with emerging worms could rest out of the sun until someone else gathered drinking water for them. A member of each house- hold was given a nylon cloth with which to filter their family's drinking water, and shown how to use it properly. The American Cyanamid Company donated 100 litres of Abate, which was used to treat the contami- nated water sources each month, beginning that May, and a geophysical survey was started. By January 1989, two borehole wells were completed in Denchira and one in Elevanyo, with funding from the Bank of Credit and Commerce (Ghana). UNICEF provided India Mark 11 handpumps for the three wells. The issue of Guinea worm disease and its prevention received national attention in Ghana in June 1988, when the Ghanaian head of state, Right-Lieutenant Jerry Rawlings, spent eight days visiting 21 affected villages in the Northern Region of the country, urging the inhabitants and their leaders to take personal protective measures against the disease. This highly visible attention paid to the problem by the head of state helped to convince political and medical leaders as well as the news media that this dreadful disease could be eliminated. In March 1989, a year after Mr Carter's first visit, the Executive Direc- tor of UNICEF, Mr James Grant, W ORLD HEALTH. J an uary- Fe bru ary 1990 officially "commissioned" the wells in the two villages. What he saw in a nearby village which was still in the grip of the infection so moved him that he resolved to involve his agency much more in the campaign against the disease. The former US President unveiled a commemorative plaque on the wells during a second visit to the villages in August 1989, by which time the number of cases had fallen from 133 in 1988 to only 14. In Ghana as a whole, improvements in surveillance of the disease have had the paradoxical effect of increasing the number of known cases (because more cases are being reported) , from an annual average of 4 ,500 cases reported to WHO between 1984 and 1986 to over 18,000 in 1987, and over 71,000 in 1988. Ghana aims to eliminate Guinea worm by 1993. Cases falling Meanwhile India, which began its national Guinea Worm Eradication Programme in 1980, reduced the number of · cases there from almost 45,000 in 1983 to about 12,000 cases in 1988. In Pakistan, the number of cases fell from an estimated 2,400 in 1987 to 1,111 in 1988. India and Pakistan, the only two remaining en- demic countries in Asia, both intend to eliminate the disease from their territory by the end of 1990. By then, all of the endemic African countries should have conducted national searches for cases. Nigeria conducted the first such search in Africa late in 1988, when it recorded over 650,000 cases. As of September 1989, at least six African countries were planning to conduct national searches for cases under WHO's techni- cal guidance and with the support of UNDP and UNICEF. Completion of that critical first step by the end of 1990 would be a fitting milestone at the end of the Water and Sanitation Decade, for which elimination of Guinea worm was originally selected as a sub-goal. Apart from the momentum that the Decade has helped to generate towards getting rid of dracunculiasis, Guinea worm in turn has given the Decade a very graphic, visible target with which to help people to under- stand the importance of safe drinking water, the benefits that can accrue from a better understanding of the environment, and the value of mobilis- ing the community to eliminate environmental hazards. • 27