Killing the Worm

Photographs by Peter DiCampo Disease eradication hasn't had a success since smallpox in 1979. Now, Guinea worm disease-in which a three-foot long worm burrows through its victim's body-is holding out in just a few African countries. The quest to wipe it out is slow and controversial, but the finish..

Photographs by Peter DiCampo

Disease eradication hasn't had a success since smallpox in 1979. Now, Guinea worm disease-in which a three-foot long worm burrows through its victim's body-is holding out in just a few African countries. The quest to wipe it out is slow and controversial, but the finish line is in sight.

Mariam Inusa sits on a low wooden stool, shivering a bit in the cool morning air. Two men crouch at the young girl's feet, next to a pail of water, and put on latex gloves. Her father stands behind her, ready to grab her arms. Mariam pulls up the printed piece of cloth that is wrapped as a skirt around her waist and legs. Emerging from a small hole in her swollen left knee is a thin white worm, six inches long, caked in blood, and dangling toward the ground.We are in Savelugu, a town of about 30,000 people in northern Ghana, 300 miles up from the country's Atlantic coast in West Africa. It is a flat town, dotted with baobab and acacia trees and bisected by a single paved road-two lanes of blacktop running north to south. Traffic is light. Sometimes a cargo truck rumbles by, but donkey carts and diesel-chugging cars and vans are more common. Mariam, tall and shy at 15 years old, lives here with her extended family in a cluster of one-story cinder-block buildings that stand around a courtyard of packed earth. Goats mill about, bleating at one another. A group of old men sit on a bench, shelling peanuts. Health workers have been visiting Mariam for about 10 days now; they have become part of the family's regular morning routine.CLICK FOR VIDEOWarning: includes scenes of a Guinea worm extraction.[good width="560" height="316" image=""][/good]Video by Austin MerrillThe health workers have, in fact, become a routine part of life for the entire community. The two men tending to Mariam-one Ghanaian, the other an American from Ann Arbor, Michigan-are part of an international, multi-organizational effort tasked with ridding the planet of Guinea worm, one of a handful of diseases in developing countries currently being singled-out for eradication. If they're successful, Guinea worm will be only the second disease ever to be eradicated. The first, smallpox, was wiped out nearly 30 years ago. The number of Guinea worm cases has dropped by more than 99 percent in the last 20 years, but it persists in remote parts of Africa. And as health workers fight to snuff out the last of the disease, their struggles to overcome local customs, community needs, and even dissent among global health experts demonstrate just how difficult and controversial disease eradication can be.Mariam's infection began about a year before her health-worker visits. Some time during Ghana's dry season in early 2007, she drank from a pond that was infested with a kind of water flea that feeds on Guinea worm larvae. Once humans ingest the fleas, the larvae penetrate the wall of the lower intestine and spend the next several months developing into worms. They tunnel through the body as they grow, producing an acid that ultimately forms a blister under the skin. When the victim, in an effort to relieve the burning pain, enters a pond to cool the infected area, the worm bursts through the skin, releasing millions of new larvae. The larvae are then eaten by the fleas, and the disease's life cycle continues. In most cases the worms exit from the lower legs, but they can come out anywhere-fingertips, eye sockets, breasts, genitals.Know officially as Dracunculiasis (Latin for "little dragon"), Guinea worm is an ancient ailment. Traces of the disease have been found in Egyptian mummies, and some believe it was the "fiery serpent" that plagued the Hebrews in the Bible. The pain is so acute that today it keeps children out of school and adults out of work, but since the disease is rarely fatal, it has gone through much of modern history without drawing serious attention from the global medical community. And in the same way that yellow fever and malaria fell off the priority list once they disappeared from Western countries, Guinea worm, afflicting people thousands of miles from New York or London or Geneva, was easily ignored.But Donald Hopkins, a tropical medicine specialist and alumnus of the smallpox fight, wanted to change all that. He was used to long odds-he entered medical school at the University of Chicago in 1962 as the only black student in his class after growing up in Jim Crow Miami. By the mid-1980s he was acting director of the U.S. Centers for Disease Control and Prevention, and he was eager to apply what he'd learned from smallpox to a new disease. In 1986 he convinced Jimmy Carter to make Guinea worm eradication a primary goal of the newly formed Carter Center, a nonprofit agency that would soon be known for mediating conflict, promoting democracy, and improving public health care in places like Haiti, Nicaragua, and Liberia. Because he was particularly interested in the world's lesser-known crises, Carter considered Guinea worm a perfect fit, and he hired Hopkins to lead the Guinea worm program. There were 3.5 million cases of the disease in the world when Carter and Hopkins joined forces; there are fewer than 10,000 today. The Carter Center has spent $260 million battling Guinea worm. The target date for its eradication is next year."That may slip a year or two, but I don't think much more than that," says Hopkins, who won a MacArthur "genius grant" in 1995 for his work against Guinea worm and is now vice president of health programs at the Carter Center. A fit and intense man who looks younger than his 66 years, Hopkins shuttles frequently between the center's headquarters in Atlanta and his home in Chicago, and travels to Africa whenever he can. "We're almost to the point of going out and handcuffing the last few cases to each of us to prevent transmission."The first country to knock out Guinea worm under the center's guidance was Pakistan in 1993. Kenya followed suit the next year, and then India in 1996. Over the next 10 years, eight more countries were added to the list, and four new ones-Ethiopia, Côte d'Ivoire, Burkina Faso, and Togo-reported no indigenous cases in 2007. Nigeria, Mali, and Niger still have a few hundred cases among them, but the last real bastions of Guinea worm are Sudan and Ghana.Savelugu is at the epicenter of Ghana's Guinea worm fight. An outbreak there in January, 2007, produced 533 of the country's 1,005 reported cases for that month-a one-year increase of 500 percent. The spike was the result of an unusually severe dry season in early 2006 that forced residents to get water from fewer ponds. Guinea worm victims entered those ponds to relieve pain or fill their buckets, resulting in high levels of contamination.Meanwhile in Tamale, a city of 300,000 people about 15 miles south of Savelugu, the municipal water system was falling apart due to poor maintenance and leadership. Tamale had piped clean water to several communities in the region. When its pumps failed and pipes broke, those who had relied on public spigots were suddenly forced to drink contaminated pond water. The disease spread, though no one would know it until many months later.When the outbreak hit, the Carter Center teamed up with Ghana's national Guinea worm eradication program and other agencies like UNICEF and the World Health Organization. "We doubled our efforts," Hopkins says. "We began warning Ghana in 2006 that already it was a standout among its three neighbors-Côte d'Ivoire, Burkina Faso, and Togo. Then it was even more isolated in 2007 when those countries reported no cases. Ghana finally started to get serious as a result of a lot of publicity and embarrassment."

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