The Water’s Not Fine: Impacts and Eradication Efforts of Guinea Worm Disease in Sudan

A disease so ancient, the most prevalent medical symbols--the Rod of Asclepius--is said to depict its medical extraction; a creature so old that its calcified remains have been found in mummified remains of Egyptian's elite ("Guinea Worm Eradication Program"); a tiny, spaghetti-shaped parasitic nematode so terrifying that myths and legends have been told for millions of years of its curse over entire communities for a sinful offense (Melvin et al. 1997)--the Dracunculus medinensis, or Guinea worm, causes Guinea worm disease (GWD) and crippling pain for Sudan's farmers and students. Ongoing eradication campaigns in Sudan by non-governmental organizations (NGOs) have been hindered by political strife and societal traditions. This essay will discuss the impacts and eradication efforts of Guinea worm disease in Sudan.

Guinea worms have caused annual debilitating agony for millions of people in African and Asian countries since ancient times (Callahan 2008). The disease has been in decline since 1986, when infection rates totaled 3.5 million, according to the Carter Center (Callahan 2008). Pakistan, Kenya, India, and Chad all eliminated GWD in the 1990s, and Senegal, Yemen, and Cameroon also eradicated the disease as of 2006 (Mastony 2007). In December 2008, Kelly Callahan of the Carter Center reported the most current statistics to Scientific American: there has been a 99.7% decline in GWD cases since 1986, down to less than 5,000 cases in 2008, and of 20 countries originally reporting Guinea worm cases, only six currently still report incidences of the disease (Callahan 2008). Of the six still endemic countries, Sudan reported 61% of the 9,585 worldwide GWD cases in 2007, and 80% of 4,410 worldwide cases in 2008.

Guinea worm disease is almost completely isolated to poor, rural African communities without access to safe drinking water (Fact Sheet: Dracunculiasis - Guinea Worm Disease). Limited access to safe water supplies is directly coupled with poor sanitation, and, because these communities are poor--average income is US$810 ("International Peacemaking and Human Rights Programs - Sudan - CarterCenter.org")--they also have limited access to health care services (Callahan 2008). Currently, humanitarian organizations such as the Carter Center are making efforts to eradicate GWD in southern Sudan, after eradicating all indigenous cases of the disease in northern Sudan as of 2003 ("International Peacemaking"). Because Guinea worms burrow in the host's body for a full year before emerging and becoming infectious, all areas surrounding Sudan are at risk of recontamination until the disease is fully eradicated from the country. Uganda, Ethiopia, and Kenya are all especially at risk for re-endemism based on past migration patterns and disease monitoring efforts ("International Peacemaking").

How Guinea Worm Disease Spreads

Year after year, thousands of rural Sudanese farm workers are infected by the crippling Guinea worm by drinking standing water contaminated by tiny water fleas (copepods), which harbor the even smaller Guinea worm larvae. Human stomach acid digests the ingested copepods, but Guinea worm larvae resist these acids and continue to move through the digestive tract to the small intestine. There, the larvae are able to penetrate the intestinal walls and move into the human host's body cavity, where they mate. The female Guinea worms grow to between two and three feet long over a period of 10-14 months--the males are much smaller and only grow to one inch long, posing little risk for this debilitating disease (Fact Sheet: Dracunculiasis).

When fully mature, the female worms migrate throughout the body, typically emerging through the host's skin, usually somewhere on the lower extremities. The worm causes a painful, burning blister on the skin before rupturing 24-72 hours later. In many cases, multiple worms emerge from the host human's body at the same time. The most effective relief for the burning is to submerge the ulcer, and protruding Guinea worm, into water--usually into the same ponds that provide villages with the majority of their water supply. Submergence of the Guinea worm, however, causes it to release millions of larvae into the water, visible as a semi-opaque white liquid, which contaminates the water source and kicks off another worm life-cycle. Each time the worm is submerged in water, from the time it begins to emerge from the host until it dies several days after extraction, it expels more of the immature larvae, leaving every water source it encounters polluted with the next generation of Guinea worms (Fact Sheet: Dracunculiasis).

The only safe way to extract the worm from its host is by winding the worm around a small stick or gauze roll to slowly pull it from the ulcer--a process which takes days, weeks, or even months (Fact Sheet: Dracunculiasis). There is no medicinal cure for GWD, and surgical extraction is usually not possible--even simple medical supplies are scarce in the most endemic areas, such as rural southern Sudan ("International Peacemaking").

Societal Impacts of Guinea Worm Disease

As with many other diseases, GWD's affect is not isolated to the suffering of individuals. Adults who contract GWD are unable to work in fields and care for livestock and draft animals. According to the Centers for Disease Control, worm emergence typically occurs during planting and harvesting times, when field work is most crucial to a family's survival over the coming year (Fact Sheet: Dracunculiasis).

The Center for Disease Control also states that parents with active GWD can't care for their children in many cases, and often the children must work the fields in their parents' absence (Fact Sheet: Dracunculiasis). Even many healthy children are therefore unable to attend school for weeks at a time, and can fall so far behind that they are unable to catch up upon their return, often dropping out permanently. Active GWD also has been linked to missed immunizations for small children, when mothers are unable to bring children to the clinic for the vaccines (Melvin et al. 1997). The result that communities where GWD is prevalent also experience decreased agricultural production and more dropouts in the educational system, which then results in economic and societal burdens after many years of individuals experiencing sustained decreased productivity (Fact Sheet: Dracunculiasis).

Methods of and Hindrances to Eradication

There are several incredibly efficient methods to eliminate GWD infection among Sudanese populations. Use of well water for drinking and cooking water because it is not accessible to the copepods that transmit GWD infection, is the easiest way to reduce or eliminate transmission. Wells are expensive to build and maintain, and these costs prohibits their widespread use (Mastony 2007). It is also possible to treat standing water in ponds with regular applications of ABATE®, a larvicide which kills copepods (Fact Sheet: Dracunculiasis). In Southern Sudan, however, the widespread rain during their four-month rain season "renders makeshift roads impassable, creating such vast swamps that proper application [of ABATE®] is nearly impossible" ("International Peacemaking").

The most low-tech, cost-effective, and consistent way to prevent GWD infection is by filtering drinking water to eliminate the copepods. This can be accomplished using a finely woven cloth filter which fits over water pots. When water is poured through the pot and filter, the copepods are captured and eliminated from the water supply (Mastony 2007). Another filtration device is called a pipe filter. The pipe filter resembles a large straw with a filter cloth on the liquid end, which is also used like a straw, by placing the mouth over the non-filter end and siphoning water through the filter and pipe (Callahan 2008).

The filtering, however, is more complicated to implement than government-funded water treatment or well construction. It is a treatment that, to be highly effective, requires personal responsibility of every community member, and therefore demands widespread health education programs ("International Peacemaking"). In explanation of the Carter Center's mission, their website explains: "By providing education on the biological causes of the disease, the Guinea Worm Eradication Program helps people understand how to manage and prevent it, with the extra benefit of reinforcing sound health practices and building a sense of hope that people in endemic communities really are able to improve their own lives" ("International Peacemaking").

To accomplish more effective eradication of GWD, humanitarians from organizations such as the Carter Center and Peace Corps must also work with communities to overcome traditional myths surrounding GWD--myths that rationalize GWD infection as witchcraft, curses, and even as impossible physical anomalies such as loose tendons or veins (Melvin et al. 1997). Where community training about GWD has been provided to the Sudanese people, there was a direct reduction in GWD incidences ("International Peacemaking"). Retraining entire communities can be difficult, though, when access roads--troublesome to navigate even in dry weather--are washed out during the rainy season, such as the case in nearly all of southern Sudan (Callahan 2008).

Navigating such a large country in deplorable geographic and climactic conditions is difficult, and the civil war and political strife throughout Sudan create additional chaos, including "mass movements of displaced persons, restricted access to known or suspected endemic communities, disruptions in activities and loss of personnel, and increased costs because of the need to airlift supplies" (Hopkins and Withers Jr s21). Add to this the fact that GWD is rarely fatal, and the resources question is suddenly answerable: scant funding available for disease prevention has typically been applied towards malaria, tuberculosis, AIDS, and other deadly diseases (Callahan 2008).

When the Centers for Disease Control and Prevention (CDC) began a global campaign for the eradication of GWD in 1980, the First Sudanese Civil War had ended eight years earlier. When civil conflicts resumed in 1983, however, humanitarian access was limited--if not eliminated--once again, leaving the country and its citizens behind as GWD eradication continued throughout the rest of Africa and Asia (Hopkins and Withers Jr s21). Many humanitarian organizations were unwilling to send foreign aid workers to war zones to begin treatment and education campaigns, and suffering continued, with only one four-month "Guinea Worm Cease-Fire" in 1995, brokered by former President Carter and the Carter Center, in order to treat GWD and other diseases in more than 2,000 villages. Possibly as a result of the cease-fire, otherwise inaccessible Sudanese villages were able to move forward in the GWD fight in spite of the civil war ("International Peacemaking").

Since the end of the Second Sudanese Civil War in 2005, humanitarian organizations have met with increased access to southern Sudan and have a much better understanding of the affected communities and their needs ("International Peacemaking"). While the southern Sudan-based NGOs have not yet been affected by the current governmental retaliation against humanitarian organizations and foreign aid workers ("Sudanese gov't takes measures to safeguard NGOs in Darfur"), there is a chance that humanitarian organizations may choose to remove their foreign aid workers as a precaution against kidnapping and permit revocation, once again curtailing the community education programs so vital to the GWD eradication effort's success.

How Close is Eradication?

The eradication campaign of GWD has taken, to date, over ten years longer than originally planned by leaders such as Dr. Robert Hopkins (Mastony 2007). Their current campaign has produced positive eradication reports in 2008, and a large amount of good press in December 2008 and January 2009. With ongoing efforts from such groups as the Carter Center, UNICEF, the CDC, and the World Health Organization (Fact Sheet: Dracunculiasis), it is possible that GWD eradication is close at hand. The major factor for success in the Sudanese GWD eradication efforts is continued peace in the country, which seems to slip away each time GWD eradication is near. Considering that the elimination of GWD would be only the second complete elimination of a disease in human history, after smallpox (Callahan 2008), and the first disease to be eliminated based solely on community education campaigns, it is imperative that the peace be maintained for at least five more years--enough time to have two full seasons without infection or transmission of GWD. This would allow every remaining endemic community to take full ownership of the eradication campaign in a civilly ordered society, rather than the chaos of war.

Works Cited

Callahan, Kelly. "What is Guinea Worm Disease?" Interview with Coco Ballantyne. Scientific American. 8 Dec. 2008. 14 Mar. 2009 <http://www.sciam.com/article.cfm?id=what-is-guinea-worm-disease>.

"Guinea worm 'almost eradicated'" BBC News 6 Dec. 2008. 14 Mar. 2009 <http://news.bbc.co.uk/2/hi/africa/7768871.stm>.

"Guinea Worm Eradication Program." The Carter Center: Advancing Human Rights and Allevi-ating Suffering. Carter Center. 15 Mar. 2009 <http://www.cartercenter.org/health/guinea_worm/index.html>.

Hopkins, Donald R., and P Craig Withers Jr. "Sudan's War and Eradication of Dracunculiasis." The Lancet Volume 360 Supplement 1 (2002): S21-22. ScienceDirect. College Edition. Foothill College, Los Altos Hills. 14 Mar. 2009. Keyword: Sudan's War and Eradication of Dracunculiasis.

"International Peacemaking and Human Rights Programs - Sudan - CarterCenter.org." The Carter Center: Advancing Human Rights and Alleviating Suffering. 14 Mar. 2009 <http://cartercenter.org/countries/sudan.html>.

Mastony, Colleen. "Doctor without borders." Chicago Tribune 12 May 2007. 14 Mar. 2009 <http://www.chicagotribune.com/news/local/chi-070512guineaworm-story,0,6320481.story>.
Rod of Asclepius. Digital image. Guinea Worm Eradication Program. Carter Center. 14 Mar. 2009 <http://www.cartercenter.org/health/guinea_worm/index.html>.

"Sudanese gov't takes measures to safeguard NGOs in Darfur." ChinaView.cn 15 Mar. 2009. 15 Mar. 2009 <http://news.xinhuanet.com/english/2009-03/15/content_11016357.htm>.

United States. Center for Disease Control. Division of Parasitic Diseases. Fact Sheet: Dracuncu-liasis - Guinea Worm Disease. 14 May 1998. Division of Parasitic Diseases. 14 Mar. 2009 <http://www.cdc.gov/NCIDOD/DPD/PARASITES/dracunculiasis/factsht_dracunculiasis.htm>.

United States. Peace Corps. Information Collection and Exchange. Animation Skills (Not for Guinea Worm Only). By Carla Anike Melvin, Louanne Smith, Griffin Mwamba, and Patricia Bartlett. Washington D.C.: Peace Corps' Information Collection & Exchange, 1997. Animation Skills (Peace Corps). Aug. 1997. Peace Corps. 14 Mar. 2009 <http://www.greenstone.org/greenstone3/nzdl?a=d&d=HASHd406dd9704d392551bd5f8&c=edudev&sib=&ed=1&p.s=ClassifierBrowse&p.sa=&p.a=b&p.c=edudev>.