Guineaworm : the fiery serpent / Thomas Verghese

INDIA Guineawonn - the fiety serpent by Or Thomas Verghese Director, National Institute of Communicable Diseases, New Delhi ][ n a remote village in the arid district of Barmer in Rajasthan, a man descends into a step- well - the only source of drinking water in the village. Using a rope, he dips a conical, sieve-like contraption into the shallow water while a few village women look on curiously. After a minute, he lifts the contraption, a funnel-net, and the water drains through the sides of the sieve. Unscrewing a nipple with a wire mesh attachment at the bottom of the funnel-net, the man carefully examines the wire mesh. He repeats this process twice in different parts of the step-well. Satisfied, he climbs up, makes a mark on a map and adds an entry in the register he carries. A thousand kilometres to the south, in a village in the Bijapur district of Karnataka, another young man - 20 under the watchful eyes of his superior - pours an emulsion he has prepared in a plastic bucket evenly into the pond, using a plastic mug. After emptying the bucket, he washes his hands and records the date on a nearby rock while his supervisor makes an entry in a register. A third stranger greets a villager sitting under a tree in front of his thatched hut in Madhya Pradesh, the largest state of India. After exchanging pleasantries, the visitor explains the purpose of his call. He then examines the villager and finds an ulcer on his leg which he cleans and dresses with a bandage. He examines the other members of the family too, talks to them all for a few minutes, makes an entry in his register and moves on to another hut some distance away. These three functionaries in differ- ent parts of India all belong to the health departments of state governments, and all are involved in India's national guineaworm eradi- cation programme. They are carrying out the strategy of vector control and active case detection aimed at elimi- nating this debilitating disease from the 3,596 affected villages in six states, accounting for a total of 7,881 cases. Dracunculiasis or dracontiasis, caused by the nematode worm Dra- cunculus medinensis, is considered to be a very ancient disease. Indeed guineaworm is believed to be the "fiery serpent" referred to in the Bible. Sixteenth century European travellers The camel-powered watercart is pic- turesque - but how safe to drink is the water? WORLD HEALTH, September-October 1990 noticed the disease in Guinea-Bissau, in West Africa, hence the name guineaworm. At present, 19 African and four Asian countries are con- sidered endemic for the disease. The most severely affected countries in Africa are Burkina Faso, Ghana and Nigeria. The major foci in Asia are India and Pakistan. Scarcity of water facilitates the spread of the parasite. The fully developed worm can measure 60 to 100 centimetres in length and about 1.5 cm in diameter, and lies under the patient's skin, usually in the legs. When such an infected individual wades into a pond or a step-well - usually the source of drinking water for many households and sometimes for an entire village - literally millions of larvae can be discharged into the water. These are swallowed by the tiny crustacean Cyclops commonly present in the water. These infected creatures enter the bodies of other people who drink water from the same source and presently die, releasing the worm larvae. The larvae in turn develop until the fully grown guineaworm is living in the subcutaneous tissue of the new host. The cycle is repeated. Guineaworm infection causes a number of disabilities, not least the ugly ulcers where the adult worm emerges from the body. It rarely causes death, but the economic loss in man- hours because people cannot go to work and children cannot go to school is substantial. The most important factors in the transmission of the disease are the presence of guineaworm sufferers, who consequently infect drinking water sources, and the presence of the Cyclops vectors. This is particularly the case in endemic rural areas where water scarcity is chronic. Safe drinking water So in its efforts to eradicate the disease, India has adopted the combined strategy of providing safe drinking water, active surveillance, vector control, health education and personal treatment. Three active searches carried out in the endemic states between 1980 and 1981 revealed more than 12,000 cases of guineaworm. By 1984, nearly 40,000 cases in 12,840 villages of seven states were on record. Now three well-planned active searches in all the endemic villages are organized each year, in April, June and Novem- ber. Since humans are the only known reservoir of the infection, identifying all active cases will help to control its WORLD HEALTH. September-October 1990 transmission. The ideal preventive method would be to provide safe piped water. The Technology Mission on Drinking Water, run by India's Ministry of Agri- culture and Rural Development, has given priority to the endemic villages. It also provides assistance for converting unsafe water sources such as ponds and step-wells into safe draw-wells with protective parapets around them. These kinds of measures may take some time. So other means are used to render the water safe, both at the water source and before a family drinks it. Sources likely to contain infested Cyclops are treated regularly with T emephos, a chemical lethal to the vector but safe for human beings. And all households in the endemic areas are provided with double nylon mesh strainers and advised how to use them to eliminate the vector. If such measures are to be success- ful, people have to be made aware of WHO/Ajoy Sil (WHO photo competition ently) © Many families still use unsafe water sources, so they have to be made aware of the risk of guineawonn and shown how to treat the water before they drink it. the disease, how it is transmitted and the simple preventive actions that must be taken by those at risk. This is done through a health education campaign using posters, pamphlets and the mass media. The impact of these channels of communication on the rural poor and illiterate - who are the main target group - is limited. So the health educators make widespread and successful use of such folk media as songs, drama productions and group meetings. In order to achieve the goal of guineaworm eradication, the concerted efforts of a number of agencies will be needed. The departments of health, 21 Guinea worm public health engineering and water supply, as well as the mass media and publicity at central as well as at state levels all have to work in close coordi- nation. The National Institute of Communicable Diseases in New Delhi, which is the nodal point for the Guineaworm Eradication Programme and is responsible for planning, carry- ing out and evaluating eradication activities, holds frequent meetings with these agencies. A crash programme for training the personnel of these departments has also been started. With assistance from WHO, ten epidemiological teams have been deployed in the six endemic states to supplement the state health services and to monitor the pro- gramme. They help to identify any gaps in the activities and offer guid- ance to the state governments in carrying out effective programmes. Task force The Indian programme is now in its eighth year. A Task Force consisting of public health experts and engineers regularly reviews the programme and recommends mid-course corrections whenever necessary. An independent evaluation of the programme, first carried out in 1985, has now become an annual feature. These appraisals highlight weak areas needing more attention, and strong areas for con- solidation. The preventive activities of the Eradication Programme have been well received by the community. But by the very nature of its transmis- sion, guineaworm is mainly preval- ent in remote and difficult terrain where there is a perennial scarcity of water and poor communication facilities. Health workers often find it difficult to reach such areas to carry out their work. Despite some weaknesses, the Pro- gramme has shown very encouraging results. From 39,792 cases in 12,840 villages in 1984, the number of cases had declined by 1990 to 7,881 in 3,596 villages. In Gujarat, only six imported cases are on record now. Rajasthan, on the other hand , accounts for more than 60 per cent of the case-load today, and there are calls for intensifying efforts in that region. The target year for achieving "zero guineaworm · incidence" is 1991. Though this might have to be post- poned slightly, a deterrriined and coor- dinated effort by all the concerned agencies can bring about the eradi- cation of this disease from India in the very near future. • 22 MONGOLIA A process of renewal by Dr Rinchin Arslan Senior Medical Officer, Directorate of Science and Manpower Development, Ministry of Health and Social Services, Mongolia T he health status of the people, their well-being and their cultural level are not only major indi-cations of progress in a society; they are also an important pre-condition for further economic development. This is why the ultimate objective of social, economic and health development policies in Mon- golia is for everyone to attain the highest possible level of welfare and well-being. This is the starting point of national strategies for Health for all. Some 60 per cent of national income is at present devoted to the non-production sectors, including health. The health sector alone receives around nine to ten per cent of the national economy. In addition, resources used mainly for building new health institutions or buying vehicles and equipment are devoted to the health sector from national income (the capital investment fund) . Over the last decade, the health budget increased at a lower rate than that of total national income. But with external aid support, it proved possible to ensure some progress in health development; the numbers of medical institutions, doctors and hospital beds increased significantly, different types of medical care (including specialised care) were introduced, and health services were made more accessible to the whole population. Nine visits a year Mongolia now has 27.4 doctors, 118 hospital beds and 87.3 paramedi- cal workers per 10,000 population. Every citizen makes an average of nine visits to the doctor each year. There are around 60 general or specialised city and township hospitals, more than 350 provincial hospitals, and 1,337 feldshers (primary health care workers). Physicians trained in the main specialities provide medical services to the entire population. New technology and new diagnostic and curative methods are being introduced into practice, using sophisticated equipment, and these contribute A feldsher paying house-calls among the distinctive rounded tents of nomadic herdsmen in Mongolia. W ORLD HEALTH, September-October 1990