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T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

june 21, 2007

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some to have been the “fiery ser- pent” described in the Old Tes- tament as torturing the Israelites in the desert. The global Dracun- culiasis Eradication Program spearheaded by former President Jimmy Carter and the Carter Cen- ter has now reached its final stag- es (see graph). This accomplish- ment is unprecedented — the only disease previously eradicated was smallpox, not a parasitic disease — and it has been achieved through grassroots public health initiatives involving thousands of village volunteers.

Thanks to the two-decade campaign against guinea worm disease, the global incidence has fallen from an estimated 3.5 mil- lion cases in 1986 to 25,217 in

2006.1 A slight increase in the reported incidence during 2006 is attributable to improved detection in newly accessible areas of south- ern Sudan.1 The eradication pro- gram has reduced the number of countries with endemic dracuncu- liasis from 20 in 1986 to 9 in 2006 (with 5 of the 9 having reported fewer 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 dis- ease was endemic have signed a WHO Geneva declaration pledging to wipe out the parasite by 2009.2 Whereas massive funding is fun- neled into campaigns to eradicate poliovirus, to control malaria and tuberculosis, and to prevent the

spread of human immunodefi- ciency virus, guinea worm disease is about to be eradicated without any drug therapy or vaccine. Its demise will be proof that people can be persuaded to change their behavior through innovative health education.

Dracunculiasis is transmitted to humans through drinking wa- ter contaminated with microscop- ic copepods (water fleas) that are infected with larvae of the worm. About a year after a person has become infected, adult female worms emerge from the skin (usu- ally 1 to 3 emerge simultaneously, but as many as 40 have been doc- umented to emerge from a given person in a season). If the emerg- ing worms make contact with wa- ter, they expel larvae into the water, which copepods ingest, be- ginning the cycle anew.2 The emer- gence of the worms, which can be more than 2 ft (0.6 m) long, is painful and often incapacitates

The Tail End of Guinea Worm — Global Eradication without a Drug or a Vaccine Michele Barry, M.D.

Guinea worm disease, or dracunculiasis — Latin for “affliction with little dragons” — is a plague so ancient that it has been found in Egyptian mummies and has been proposed by

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people for 2 to 3 months. Hu- mans are the only reservoir, and there is no effective anthelmintic agent or vaccine. Infection can be prevented by filtering drinking water through finely woven cloth, which removes the copepods; by killing copepods and larvae with temephos applied to open ponds; by educating villagers about not entering sources of drinking wa- ter; or by providing clean drinking water from safe sources such as borehole wells or hand-dug wells. In areas where guinea worm is en- demic, the parasite often predom- inantly infects women, who tend to do most of the washing and the gathering of water for house- holds. During planting or harvest season, dracunculiasis has some- times been reported in more than half the population of a given village.

The global eradication cam- paign began at the Centers for Disease Control (CDC) in 1980 and was then adopted as a subgoal of the United Nations International Drinking-Water Supply and Sanita- tion Decade (1981–1990).3 Since 1986, the Carter Center has led the effort with the help of the CDC,

the WHO, the United Nations Children’s Fund (UNICEF), the Bill and Melinda Gates Foundation, and many other donors and non- governmental organizations, as well as governments of the coun- tries where guinea worms are en- demic and thousands of village volunteers. Working with this public–private coalition, the Car- ter Center has been able to initiate village-based surveillance, health education, and distribution of cloth filters and to provide larvi- cides and solicit operational sup- port for the digging of wells.

The Carter Center provides fi- nancial and technical assistance

to national guinea worm pro- grams that include participants from ministries and from non- governmental organizations, tra- ditional leadership, political lead- ership, and village volunteers; these programs put eradication activities and surveillance into motion and empower communi- ties to provide clean drinking wa- ter. When the eradication program encounters an impasse, those in- volved often deploy unusual tac- tics. At a 1989 lunch with Edgar Bronfman, the Seagram’s liquor heir, President Carter explained the technique of filtering copepods out of water, demonstrating with a damask napkin. Bronfman, who held a major stake in the DuPont chemical company, had DuPont scientists develop the tough fine mesh that is now used to filter water. In Uganda, the eradication program has employed elderly men as “pond caretakers” to guard ponds against contamination by worms emerging from people.4 When infected people are identi- fied at a pond, the caretakers as- sist them with water gathering, preventing contamination of the water, and distribute nylon filters for ongoing prevention. Cash re- wards are sometimes offered to those who report cases or to in- fected villagers who agree to be

The Tail End of Guinea Worm — Global Eradication without a Drug or a Vaccine

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quarantined while the worm is emerging; often such persons re- ceive free care and food during that period.4

Water sources are monitored, and the level of coverage by con- trol measures is reported month- ly or quarterly to heads of state, who are also given documenta- tion listing areas free of guinea worm. The WHO has convened an International Commission for the Certification of Dracunculia- sis Eradication to certify coun- tries that have eradicated the parasite.

Such a transnational global campaign for improving health requires a nuanced understand- ing of global health diplomacy. Faced with one of the most im- posing barriers to eradication of guinea worm — the civil war in southern Sudan — Carter nego- tiated a 4-month “guinea worm ceasefire” in 1995, which also allowed public health officials to kick-start Sudan’s onchocerciasis control program.3 Inadequate se- curity in other countries where guinea worm disease is endemic, inadequate political will on the part of national leaders, and the absence of a “magic bullet” treat- ment have all presented challeng- es to the eradication program. Health care initiatives have had to

be linked with diplomatic efforts to overcome these challenges.

Much has been written about the inadequacy of “vertical,” sin- gle-disease programs that fail to focus on widespread reductions in poverty, on infrastructure de- velopment, and on the broad- based provision of primary care. But the Dracunculiasis Eradica- tion Program is leaving a legacy of development in sync with the United Nations Millennium De- velopment Goals. It has helped to improve the quality of water sources for communities that previously lacked access to clean and safe water, created jobs for the (often elderly) unemployed, and empowered volunteers, fre- quently inspiring them to pur- sue health-related employment. In communities where guinea worm was endemic, networks of women have been created for ed- ucation campaigns; Ghana alone has 6500 female Red Cross volun- teers assisting in the program, and in Benin newly created women’s clubs have helped to stop trans- mission of the disease.3 School ab- senteeism has decreased as fewer children have become infected. Research in Mali had linked a 5% decrease in production of two food crops to guinea worm disease, and the annual economic losses due

to guinea worm in three rice- growing Nigerian states was es- timated to be over $20 million, but now agricultural productivity has improved.5 Thus, this vertical program has been shown to com- bat poverty, hunger, and even il- literacy (by decreasing school absenteeism), as well as to em- power women — all Millennium Development Goals.

In an era when unprecedented global health funding is being di- rected toward vaccines and drug therapy, guinea worm eradication has been successful on a modest budget of about $225 million for the entire 20-year campaign. It has done so, according to Dr. Don- ald Hopkins, vice president for health programs at the Carter Center, by relying on the old- fashioned public health tactic of educating people about changing their behavior. With its charis- matic leader practicing global health diplomacy, a public–pri- vate coalition has been able to empower a marginalized, infect- ed population to slay its not-so- little dragons. An interview with Jimmy Carter and Donald Hopkins is available at www. nejm.org.

Dr. Barry is a professor of medicine and global health at Yale University School of Medicine, New Haven, CT.

The Tail End of Guinea Worm — Global Eradication without a Drug or a Vaccine

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Dr. Cyril Nkabinde, an intern at Prince Mshiyeni Memorial Hospital in Durban, South Afri- ca, grew up dreaming of becom- ing a doctor — an ambition he inherited from his mother, whose own dream had been thwarted by apartheid. Nkabinde’s goal of working as a family physician in rural KwaZulu-Natal has kept him on track, even as he’s watched medical school class- mates depart for business careers and superiors quit medicine be- cause of a chronic lack of health care resources. Now, as he pre- pares to marry a fellow physi- cian, Nkabinde realizes that his dream may not be achievable.

“The hope is to go into a rural or public setting,” he says, “but if we have kids, it definitely won’t be a long-term thing. Obviously, we would have to provide for them — schooling and so on — and the best case is for us to be in the city.”

Dr. Gloria Mfeka, Nkabinde’s fiancée, recently completed her mandated year of community service in rural Bethesda Hospi- tal. She notes that though rural work can be rewarding, its dif- ficulties can also be overwhelm- ing for a young physician. “If we got the bare necessities in outly- ing hospitals, like an ECG ma- chine . . . that would make a

world of a difference. In the out- lying hospitals, to get CD4-count results there’s a 6-week waiting list. . . . It’s just crazy.”

The pressures on Mfeka and Nkabinde ref lect a global prob- lem that is finally receiving at- tention from donors and inter- national agencies: a critical shortage of health care workers in many parts of the world. Al- though this shortage is not new, recent international efforts to vaccinate children and to fight human immunodeficiency virus (HIV) infection and AIDS, ma- laria, tuberculosis, and other dis- eases have brought it into sharp- er focus. Donors are increasingly realizing that without enough trained workers to deliver drugs, vaccines, and care, pumping mon- ey into projects will not have the desired effects. “Even if you have the medicine, the vaccines, and the bed nets, you need the health workers to deliver the service,” says Manuel Dayrit, director of the Department of Human Re- sources for Health at the World Health Organization (WHO). “With the experience of the last few years, where you have had huge global funds move into an activity to provide resourc- es . . . we’ve found that the bottleneck is really the delivery.”

Africa has been hit the hard- est by the crisis: according to

The Tail End of Guinea Worm — Global Eradication without a Drug or a Vaccine

Patients Waiting to Be Seen at the HIV Clinic at Bethesda Hospital in Rural KwaZulu- Natal Province.

Providing the Providers — Remedying Africa’s Shortage of Health Care Workers Pooja Kumar, M.D.

Dracunculiasis eradication: global sur- veillance summary, 2006. Wkly Epidemiol Rec 2007;82:133-40.

Dracunculiasis eradication: Geneva dec- laration on guinea-worm eradication. Wkly Epidemiol Rec 2004;79:234-5.

Hopkins DR, Ruiz-Tiben E, Downs P, Withers PC Jr, Maguire JH. Dracunculiasis eradication: the final inch. Am J Trop Med Hyg 2005;73:669-75.

Rwakimari JB, Hopkins DR, Ruiz-Tiben E. Uganda’s successful Guinea Worm Eradica-

tion Program. Am J Trop Med Hyg 2006;75:3- 8.