Guinea worm disease, or dracunculiasis — Latin for "afflictionwith little dragons" — is a plague so ancient that ithas been found in Egyptian mummies and has been proposed bysome to have been the "fiery serpent" described in the Old Testamentas torturing the Israelites in the desert. The global DracunculiasisEradication Program spearheaded by former President Jimmy Carterand the Carter Center has now reached its final stages (seegraph). This accomplishment is unprecedented — the onlydisease previously eradicated was smallpox, not a parasiticdisease — and it has been achieved through grassrootspublic health initiatives involving thousands of village volunteers.
Number of Reported Cases of Dracunculiasis Worldwide, 1989–2006.
Data are from the Carter Center.
Thanks to the two-decade campaign against guinea worm disease,the global incidence has fallen from an estimated 3.5 millioncases in 1986 to 25,217 in 2006.1 A slight increase in the reportedincidence during 2006 is attributable to improved detectionin newly accessible areas of southern Sudan.1 The eradicationprogram has reduced the number of countries with endemic dracunculiasisfrom 20 in 1986 to 9 in 2006 (with 5 of the 9 having reportedfewer than 30 cases each). The World Health Organization (WHO)has now certified 180 countries as free of guinea worm disease,and all countries where the disease was endemic have signeda WHO Geneva declaration pledging to wipe out the parasite by2009.2 Whereas massive funding is funneled into campaigns toeradicate poliovirus, to control malaria and tuberculosis, andto prevent the spread of human immunodeficiency virus, guineaworm disease is about to be eradicated without any drug therapyor vaccine. Its demise will be proof that people can be persuadedto change their behavior through innovative health education.
Dracunculiasis is transmitted to humans through drinking watercontaminated with microscopic copepods (water fleas) that areinfected with larvae of the worm. About a year after a personhas become infected, adult female worms emerge from the skin(usually 1 to 3 emerge simultaneously, but as many as 40 havebeen documented to emerge from a given person in a season).If the emerging worms make contact with water, they expel larvaeinto the water, which copepods ingest, beginning the cycle anew.2The emergence of the worms, which can be more than 2 ft (0.6m) long, is painful and often incapacitates people for 2 to3 months. Humans are the only reservoir, and there is no effectiveanthelmintic agent or vaccine. Infection can be prevented byfiltering drinking water through finely woven cloth, which removesthe copepods; by killing copepods and larvae with temephos appliedto open ponds; by educating villagers about not entering sourcesof drinking water; or by providing clean drinking water fromsafe sources such as borehole wells or hand-dug wells. In areaswhere guinea worm is endemic, the parasite often predominantlyinfects women, who tend to do most of the washing and the gatheringof water for households. During planting or harvest season,dracunculiasis has sometimes been reported in more than halfthe population of a given village.
The global eradication campaign began at the Centers for DiseaseControl (CDC) in 1980 and was then adopted as a subgoal of theUnited Nations International Drinking-Water Supply and SanitationDecade (1981–1990).3 Since 1986, the Carter Center hasled the effort with the help of the CDC, the WHO, the UnitedNations Children's Fund (UNICEF), the Bill and Melinda GatesFoundation, and many other donors and nongovernmental organizations,as well as governments of the countries where guinea worms areendemic and thousands of village volunteers. Working with thispublic–private coalition, the Carter Center has been ableto initiate village-based surveillance, health education, anddistribution of cloth filters and to provide larvicides andsolicit operational support for the digging of wells.
The Carter Center provides financial and technical assistanceto national guinea worm programs that include participants fromministries and from nongovernmental organizations, traditionalleadership, political leadership, and village volunteers; theseprograms put eradication activities and surveillance into motionand empower communities to provide clean drinking water. Whenthe eradication program encounters an impasse, those involvedoften deploy unusual tactics. At a 1989 lunch with Edgar Bronfman,the Seagram's liquor heir, President Carter explained the techniqueof filtering copepods out of water, demonstrating with a damasknapkin. Bronfman, who held a major stake in the DuPont chemicalcompany, had DuPont scientists develop the tough fine mesh thatis now used to filter water. In Uganda, the eradication programhas employed elderly men as "pond caretakers" to guard pondsagainst contamination by worms emerging from people.4 When infectedpeople are identified at a pond, the caretakers assist themwith water gathering, preventing contamination of the water,and distribute nylon filters for ongoing prevention. Cash rewardsare sometimes offered to those who report cases or to infectedvillagers who agree to be quarantined while the worm is emerging;often such persons receive free care and food during that period.4
Water sources are monitored, and the level of coverage by controlmeasures is reported monthly or quarterly to heads of state,who are also given documentation listing areas free of guineaworm. The WHO has convened an International Commission for theCertification of Dracunculiasis Eradication to certify countriesthat have eradicated the parasite.
Such a transnational global campaign for improving health requiresa nuanced understanding of global health diplomacy. Faced withone of the most imposing barriers to eradication of guinea worm— the civil war in southern Sudan — Carter negotiateda 4-month "guinea worm ceasefire" in 1995, which also allowedpublic health officials to kick-start Sudan's onchocerciasiscontrol program.3 Inadequate security in other countries whereguinea worm disease is endemic, inadequate political will onthe part of national leaders, and the absence of a "magic bullet"treatment have all presented challenges to the eradication program.Health care initiatives have had to be linked with diplomaticefforts to overcome these challenges.
Much has been written about the inadequacy of "vertical," single-diseaseprograms that fail to focus on widespread reductions in poverty,on infrastructure development, and on the broad-based provisionof primary care. But the Dracunculiasis Eradication Programis leaving a legacy of development in sync with the United NationsMillennium Development Goals. It has helped to improve the qualityof water sources for communities that previously lacked accessto clean and safe water, created jobs for the (often elderly)unemployed, and empowered volunteers, frequently inspiring themto pursue health-related employment. In communities where guineaworm was endemic, networks of women have been created for educationcampaigns; Ghana alone has 6500 female Red Cross volunteersassisting in the program, and in Benin newly created women'sclubs have helped to stop transmission of the disease.3 Schoolabsenteeism has decreased as fewer children have become infected.Research in Mali had linked a 5% decrease in production of twofood crops to guinea worm disease, and the annual economic lossesdue to guinea worm in three rice-growing Nigerian states wasestimated to be over $20 million, but now agricultural productivityhas improved.5 Thus, this vertical program has been shown tocombat poverty, hunger, and even illiteracy (by decreasing schoolabsenteeism), as well as to empower women — all MillenniumDevelopment Goals.
In an era when unprecedented global health funding is beingdirected toward vaccines and drug therapy, guinea worm eradicationhas been successful on a modest budget of about $225 millionfor the entire 20-year campaign. It has done so, according toDr. Donald Hopkins, vice president for health programs at theCarter Center, by relying on the old-fashioned public healthtactic of educating people about changing their behavior. Withits charismatic leader practicing global health diplomacy, apublic–private coalition has been able to empower a marginalized,infected population to slay its not-so-little dragons.
Source Information
Dr. Barry is a professor of medicine and global health at Yale University School of Medicine, New Haven, CT.
An interview with Jimmy Carter and Donald Hopkins is available at www.nejm.org.
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