Frontline Workers Push Guinea
Worm Disease to The Brink Of Eradication
23
November 2017
Former U.S. President Jimmy Carter tries to comfort
6-year-old Ruhama Issah at Savelugu Hospital as a Carter Center technical
assistant dresses Issah's extremely painful Guinea worm wound. Photo by: The
Carter Center
ABU DHABI — When Northern Nigeria was down to its
last remaining cases of Guinea worm disease, Dr. Adamu Keana Sallau and his
team had to get creative. As the Carter
Center director for integrated health programs in the country’s Imo
and Abia States in Nigeria, Sallau knew that stigma and far flung geography
would made it difficult to spot infections — and every case had to be found to
end the disease.
A Hot Devil
Guinea worm disease weaves through much of human history, taking on names and local meanings as diverse as the countries it afflicted. The parasitic infection occurs when humans drink contaminated water. The worm enters the body and grows up to several meters long, before emerging through a painful burst in the skin. Patients are lured by burning pain to place the infection into the water, where the worm re-enters the water supply.
Today, the Carter Center and other partners support local health ministries, but always make sure the program is country-owned and operated.
Political leaders can also give the necessary backing and legitimacy for community health workers to adopt and adapt the fight to their own contexts.
Success, said Sienko, “often gets down to the village level.”
Awad Alla worked intrepidly throughout Sudan’s myriad conflicts, something he told Devex is increasingly the calling of frontline health workers. “You should be available and prepared for very extreme hardship conditions,” he said. “Otherwise, it will not work.”
Sallau came up with a locally tailored strategy.
Community members who shared information about a new case would receive 3,000
Naira ($8.50) as reward. But if the health workers found a case that hadn’t
been reported, they would take a goat from the village — equivalent to
about 5,000 Naira ($14) in wealth. Usually, it took just one goat for
communities to get serious about reporting, he said.
Last week, Sallau was among half a dozen other
frontline health workers honored for their roles in pushing Guinea worm to the
brink of eradication through the inaugural Recognizing Excellence around
Champions of Health, or REACH, awards. The awards were given by Abu Dhabi Crown
Prince Mohammed bin Zayed Al Nahyan at the Reaching the Last Mile global health
summit last Wednesday.
There have been just 26 cases of Guinea worm in
2017 so far, down from 3.5 million cases in 21 countries in Africa and Asia in
1986. Nigeria, the most endemic country, had 650,000 cases at its peak, before
dropping to zero in 2013.
If Guinea worm is eradicated, it would be just
the second disease after smallpox to disappear from the planet. The story of
that eradication is one of individual communities like the ones that Sallau
spent three decades of his life visiting. He and other health workers took
basic public health education messages and shaped them around local conditions,
beliefs, and narratives.
Dr. Nabil Aziz Awad Alla, a REACH honoree for his
work as former national program coordinator for Guinea worm disease eradication
in Sudan’s Federal Ministry of Health, summarized the keys to eradication
success so far: “Number one, political support is important. Number two, you
need strong and able leadership. Number three, all such programs should be
owned by the community,” he told Devex.
A Hot Devil
Guinea worm disease weaves through much of human history, taking on names and local meanings as diverse as the countries it afflicted. The parasitic infection occurs when humans drink contaminated water. The worm enters the body and grows up to several meters long, before emerging through a painful burst in the skin. Patients are lured by burning pain to place the infection into the water, where the worm re-enters the water supply.
The Carter Center began spearheading the efforts
toward eradication in 1986, including with a donation several years later from
the United Arab Emirates’ leader Sheikh Zayed Al Nahyan. While there was and
still is no vaccine or treatment for the disease, basic public health education
can break the worm’s life cycle, eliminating it from water supplies.
Doing so, however, required shifts in basic
community behavior that were not always an easy sell. Communities needed to
filter their water to avoid drinking the parasite, and then avoid the water
supply altogether when they had an active infection.
“At the beginning, most of the communities never
agreed [to treatment],” Sallau said. Some areas of Nigeria, for example,
believed that the drinking water supply was sacred and should be left untouched.
Others simply disbelieved that an infection that had existed for generations
could simply disappear.
“But gradually with health education and building
up trust and communication with the communities, we were able to put
interventions in place,” Sallau said. Among the keys, he said, was to reach out
to traditional leaders and seek their support initially.
In South Sudan, community mobilizer Regina
Lotubai Lomare Lochilangole, another REACH awardee, wrote songs explaining
Guinea worm to fellow residents and warning about the dangers of not filtering
water.
“The men in South Sudan don’t listen to women, so
it was a big challenge” to spread the message, she recalled. But results
started to convince the skeptics; as caseloads fell, “people now recognize whatever
I say.”
Political support
As with public health education, Guinea worm
eradication efforts have operated on the principle of going to people where
they are. Getting political leaders on board has been vital.
“There needs to be that strong political support
for what we’re doing,” Carter Center Vice President for Health Programs Dean
Sienko told Devex. “When you have a strong national program, tremendous things
can happen. … We have had presidents of countries and ministers of health out
in front of their populations, saying we need to combat these diseases.”
Today, the Carter Center and other partners support local health ministries, but always make sure the program is country-owned and operated.
In Sudan, another endemic country, political
backing proved critical to tackling the disease between the federal north and
the then-autonomous south. In the late 1990s, Awad Alaa and the ministry of
health signed a memorandum of understanding with their counterparts in the
south, allowing them to coordinate their work with Carter Center support, he
said.
Political leaders can also give the necessary backing and legitimacy for community health workers to adopt and adapt the fight to their own contexts.
Success, said Sienko, “often gets down to the village level.”
Peace and security
More than three decades after the eradication
campaign began, the Carter Center now says just one thing is needed to finish
the job. “Peace and security,” said the
center’s Guinea worm eradication Director Ernesto Ruiz-Tiben at the Reaching
the Last Mile Summit last week in Abu Dhabi.
The first “Guinea worm ceasefire” was arranged in
Sudan in 1995, when Awad Alla invited President Omar al-Bashir and former U.S.
President Jimmy Carter to a summit on the disease. Agreeing to halt conflict
between south and north Sudan, the initial three month ceasefire “was really a
good chance for us to start proper disease surveillance in the country,” he
recalled. The agreement worked so well, in fact, that it was renewed for a
subsequent three months.
Today, many of the last cases and affected areas
are in regions of turmoil or insecurity, where ongoing surveillance and
monitoring is difficult or at times impossible. South Sudan, for example,
hasn’t witnessed cases yet this year, but health campaigners are still cautious
in their optimism, worrying that the civil war there may have left cases
unspotted.
In Nigeria too, conflict has complicated health
work. Militants in the country's north, including Boko Haram, set up
checkpoints on the way to affected villages. Sallau worked to negotiate with
local leaders to let Guinea worm staff pass even when other wouldn’t be allowed,
he said.
Awad Alla worked intrepidly throughout Sudan’s myriad conflicts, something he told Devex is increasingly the calling of frontline health workers. “You should be available and prepared for very extreme hardship conditions,” he said. “Otherwise, it will not work.”
About the author
Elizabeth Dickinson is associate editor at Devex. Based in
the Middle East, she has previously served as Gulf correspondent for The
National, assistant managing editor at Foreign Policy, and Nigeria
correspondent at The Economist. Her writing also appeared in The New Yorker,
Wall Street Journal, New York Times, Politico Magazine, and Newsweek, among
others.
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