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throughout the country. The diseaseappears a year after the unfortunatevictims have drunk contaminatedwater, when adult worms, whichmeasure two to three feet long, beginemerging through the painful blistersand ulcers they create, usually on theleg or foot, though the wormssometimes emerge through the skin onany part of the body. There is no curefor the infection, but the disease isusually resolved after a few weeks ormonths, when the worm has finishedemerging. Victims do not becomeimmune to the infection.

Much of the significance ofdracunculiasis derives from the factthat the disease cripples working-ageadults as well as children, for periodsaveraging one to three months, in largenumbers (up to 30 per cent or more ofa village's population), at the mostcritical time of the agricultural year(planting or harvest, or both,depending on the local epidemiologyand the crops grown). For example, areccnt study funded by UNICEF in anarea of 1.6 million people in south-eastern Nigeria showed that the lossesin profits from rice production alone.due to the incapacitation of localfarmers by Guinea worm, exceed $20million dollars annually. Schoolabsenteeism may be more than 50 percent during the 'Guinea worm season'in such areas. Few dcaths are causedby Guinea worm directly, but itsometimes kills because many wormsemerge in a person simulLaneously, orthey emerge through a critical organsuch as the spinal cord, or because ofsecondary infection like tetanus in theopen wound caused by the worm.

Unlike some othcr equally horrible

....,NONINFECTED

INFECTED INDIVIDUAL

INDIVIDUAL

LIFE CYCLE OFGUINEA WORMDISEASE

Memorandum of Understanding inLagos, Nigeria with the FederalMinister of Health of Nigeria, and arepresentative of the Bank of Creditand Commerce International (BCCI)to begin assisting a national GuineaWorm Eradication Programme inNigeria. The agreement with Nigeria,which apparently has more Guineaworm than any other endemic country,was similar to those for nationalprogrammes that Global 2000 andBCCI were already assisting inPakistan since 1986, and in Ghanasince December 1987.

Guinea worm prevalenceAbout 10 million people arc estimatedto suffcr cach ycar from Guinea wormdisease, which is only contracted bydrinking contaminated watcr. Over100 million arc at risk from thedisease, in rural endcmic areas ofIndia, Pakistan, and about 19 Africancountries. In Nigeria, Ghana andBurkina Faso, Guinea worm occurs

Target 1995: Guinea worm eradicationby Dr Donald R. HopkinsThe complete eradication of Guineaworm is finally in sight. Currently, it isestimated that there are 10 millionsufferers each year, mainly living inIndia, Pakistan and 19 Africancountries. Donald Hopkins discussesthe different ways to control, andultimately wipe out this debilitating andpainfu I disease.SHORTLY AFTER opening thesecond African Regional Conferenceon Dracunculiasis (Guinea wormdisease) in Accra, Ghana in March1988, former American PresidentJimmy Carter visited the villages ofDenehira and Elevanyo near Accra.Both villages were highly affected atthe height of the local Guinea wormseason, and within an hour, Me Caner,who is the chairman of Global 2000,Inc., a non-profit organization at theCarLcr Presidential Center in Atlanta,Georgia had seen dozens of peoplesuffering from the disease. Perhaps themost graphic was a young woman whohad a Guinea worm emerging from herbreast. These two villages with acombined population of less than1,500, experienced over 400 cases ofthe disease in 1988.

Control measures, includingeducating the villagers to use cloths tofilter their drinking-water, and use oftemephos (Abatc) donated by theAmerican Cyanamid Company forthese two villages (to kill thcintermcdiate host of the parasite in thcwater), began soon after PresidentCarter's visit. Three borehole wellswere completed in the villages byJanuary 1989, COUrlesy of Global2000/ BCCr, the Bank of Credit andCommerce (Ghana) Ltd., andUNICEF. By the end of 1988 Denchiraand Elevanyo should be frcc, or almostfree, of the disease.

The day before seeing his firstactual cases of the disease ncar Accra,the former US President had signed a

Donald R. Hopkins is the Senior Consultantat Global 2000, Inc. The Carter Center, 1Copenhill, Atlanta, Georgia 30307, USA. DrHopkins' new address is 1840 N. HudsonAvenue, Chicago, Illinois 60614, USA.

6 WATERLINES VOL.8 NO.2 OCTOBER 1989

infections, Guinea worm can becompletely prevented by usinginformation and technology which isalready available. The best way toprevent Guinea worm is to promotethe availability and use of safe waterfor drinking in affected villages. Thisis the most expensive intervention, buthas the advantage of being apermanent solution to the problem,and of preventing other importantdiseases besides Guinea worm. AUNICEF-assisted rural water supplyproject in Kwara State, Nigeriareduced the average prevalence ratesof dracunculiasis in 20 villages from59.6 per cent in 1983-4, to 11.3 percent in 1986-7; the rates in three of thevillages were reduced to zero in thesame period, from 62.0 per cent, 52.7per cent, and 44.8 per cent. There arcnow many other such examples of theimpact of rural water supplies onGuinea worm.

Priority to Guinea wormvillagesThe case for giving priority to villageswith Guinea wonn for new sources ofsafe drinking-water is compelling.Because villages with Guinea wormsuffer all the other negati veconsequences of not having safe water,such as increased incidence ofdiarrhoeal diseases, for example, inaddition to having Guinea worm, theyarc by definition worse off, onaverage, than all other villages that donot have safe drinking-water.Secondly, villages with Guinea wormare a small minority of all villageswithout safe water, and thus it ispractically feasible to provide water tothem first, or early in the process ofreaching out to all unserved villages.In Nigeria, for example, the Global2000-assisted programme has shownthat of the estimated 90,000 villageswithout safe water, only about 6,000have Guinea worm. Finally, because ofthe unique opportunity they present toimprove rapidly health, agriculture,and school attendance, by eliminatingGuinea worm, the endemic villagesoffer the best return on investment inthe rural water supply sector. It ispossible, for example, that Nigeriacould recover the total cost of itsGuinea Worm Eradication Programmewith a year after eradication isachieved from the resulting increasesin its agricultural yields alone.

So far, only India and Nigeria haveestablished a national policy ofpriority to villages suffering fromGuinea worm for provision of safe

water supplies. Like India andPakistan, Nigeria also recentlycompleted a highly successful nationalvillage-by-village search for cases,which found over 650,000 cases of thedisease in that country. Healthauthorities there now know whichvillages have the infection, and willprovide that information to the ruralwater supply agencies to help them toimplement the new policy. In themeantime, efforts arc now under wayto train people in Nigeria's endemicv illages in other ways to preventGuinea worm.

Even before safe water can beprovided to all affected vilIages,residents can still be helped toeliminate Guinea Worm through healtheducation. Villagers in affected areasneed first to understand that they aregelling the infection from theircontaminated drinking-water, and thatthey themselves can prevent theinfection by keeping people withemerging worms from entering thedrinking-water source to contaminateit in the first place, or by boiling theirwater (if they can afford to) or filteringit through a fine cloth. By such meansalone three villages in Burkina Fasoreduced the annual incidence ofdracunculiasis from 54 per cent, to 37per cent and 24 per cent, respectively,to zero in only two transmissionseasons. Use of (temephos) Abateapplied in concentrations of one partper million at four to six-weekintcrvals to kill thc intermediatecyclops vector in stagnant opensources of drinking-water is a thirdway to control the infection.

Mobilizing villagesAnother recent example of the efficacyof mobilizing villagers to act againstthis infection is the village of Kali, inTogo. With the assistance of WorldNeighbors, an American NGO,villagers in Kati (population about3,000) were gradually helped withhealth education, and with theconstruction of six wells. From a totalof 928 cases in 1981, Guinea wormwas reduced to 263 cases in 1983,seven cases in 1985, and no cases in1988.

National health education efforts inGhana's Guinea Worm EradicationProgramme received an impressiveinauguration in June] 988, when thehead of state, Flight Lieutenant JerryRawlings, spent eight days visiting 2]endemic villages in the highly affectedNonhern Region teaching villagershow to prevent the disease. 'Guineaworm,' he said 'is a disease of

underdevelopment.' Improvements inthe surveillance of the disease inGhana is seen in its statistics: whilethe country reported 4,717 ofdracunculiasis to the World HealthOrganization in 1986, 18,398 werereported in 1987, and 71,767 cases in1988.

Soon, the two vilIages visited byPresident Carter in Ghana will also befree of Guinea worm. Otherselsewhere will be, too, if political,health and water supply authorities actquickly and rationally to give priorityto such villages in rural water supplyprojects. In the meantime, however,suffering villagers should be helped torecognize that they can attack thisproblem themselves, by notcontaminating their drinking-watersupplies when they have Guineaworm, and by discouraging theirneighbours from doing so; by filteringor boiling all potentially contaminateddrinking-water; by co-operating tobuild or raise money to construct asafe source of drinking-water; byusing safe water for drinking when itis provided; and by spreading theword, to tell their neighbours andfriends where this disease comes from,and how to avoid getting it.

The Ghanaian Guinea WormEradication Programme has set itselfthe goal of eliminating the diseasefrom Ghana by 1993. The target year[or its elimination in Nigeria is 1995.India and Pakistan intend to eradicateit by 1990. There is no reason why thisdisease could not be eradicatedglobally by December 1995. It oughtto have been eradicated before now. ~

Ghanaian woman sufferer.

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