say it hurts most at night, when the village is dark and quiet and
there is nothing to take the mind away from the slender, whitish
worm emerging from an open sore on the skin. Lukas, a young yam
farmer in the Nkwanta district of Ghana, West Africa, slaps a dirty
cloth at the flies swarming around a raw area on his leg as he describes
the pain, saying he cannot sleep and is unable to work. When he
had Guinea worm disease four years ago, he did not know what caused
it; he thought his very village was the reasonthat this was
simply a place where Guinea worm happened, as it had happened to
his family and his ancestors before him. Now, thanks to Emorys
institutional partner, the Carter Center, and several University
alumni, he understands that the worm comes from the villages
stagnant, untreated water sources.
community lies in one of the most remote regions of Ghana, twelve
teeth-rattling hours over a dusty, rutted road that winds north
from the capital city of Accra. When trucks carrying visitors from
the Carter Center approach at sunset one evening in early February,
curious children come running from brown mud huts, all smiles, wearing
a mystifying assortment of items: a Barbie pajama top, striped pants
with one leg cut short, a bright swath of kente cloth, a filthy,
frilly dress, or just a coating of red dust. A glance inside the
huts reveals these children sleep on dirt and probably have never
used an indoor toilet. Skinny goats and bedraggled chickens wander
among them, picking their way around the cooking fires and the trash
that litters the ground. Despite their apparent lack of almost everything,
including safe water, the children shriek with laughter at images
of themselves on a square-inch digital camera screen.
Howard 97Ox-99C (at left, with Nwando Diallo), coordinator
of public relations for the Carter Centers health programs
and the lead organizer of this trip for staff and media, quickly
attracts a crowd of friendly locals with her fair skin and tall,
slender build. She points out that a half-dozen of the villagers
were visibly infected with Guinea worm; many others bear its scars.
This is the second time Howard has traveled to Ghana for the Carter
Center, which has been battling Guinea worm here since 1988. The
first time I saw an actual, live Guinea worm, I cried, she
Nkwanta district villages and others like them in northern Ghana
are among the last one percent of endemic Guinea worm areas on earth.
These have been called the worlds most forgotten people, which
may explain why developed countries have paid little attention to
Guinea worm disease despite its almost primeval loathsomeness. But
part of the mission of the Carter Center, founded in 1980 by former
U.S. President, Nobel laureate, and Emory University Distinguished
Professor Jimmy Carter and his wife, Rosalynn, is to address those
far-flung afflictions largely ignored by other non-government organizations.
ancient Guinea worm parasite, while not usually fatal to its human
hosts, can grow up to three feet long inside the body before emerging
slowly through a blister on the flesh. The disease is contracted
by drinking water that contains the microscopic Cyclops flea, which
eats and carries parasitic Guinea worm larvae. In the hosts
stomach, the flea is broken down, leaving the male and female worm
larvae free to cruise undetected through the body until they find
one another and mate. The male dies, while the impregnated female
grows not fat but long before emerging blindly into the African
sunshine some nine months to a year later, typically on the lower
limbs. The emergence of the fiery serpent causes a painful
burning sensation, often sending victims to the nearest water source
to soak the sore, which begins the cycle anew: when it hits the
water, the worm releases thousands of new larvae.
all its wiliness, Guinea worm can easily be stopped by filtering
the tiny fleas out of contaminated water and keeping infected persons
away from water sources. Efforts by the Carter Center, along with
the Centers for Disease Control and Prevention (CDC), the United
Nations Childrens Fund (UNICEF), and the World Health Organization
(WHO), have helped reduce the incidence of Guinea worm disease worldwide
from about 3.5 million cases in 1986 to fewer than thirty-three
thousand reported in 2003. All the remaining cases are concentrated
in thirteen African countries, the majority in Sudan, where civil
war has made eradication attempts difficult. When Guinea worm is
gone, it will be the first parasitic disease to be eradicated and
the first sickness to be eliminated globally without a vaccine.
harbors the second-highest incidence of Guinea worm disease, with
some 25 percent of the current known casesa challenge that
prompted the Carters to pay a visit there in February along with
WHO Director-General Lee Jong-wook and UNICEF Deputy Executive Director
Kul Gautam. Despite the Carter Centers early success in Ghana,
the eradication program has been stalled for nearly a decade, with
an increase in cases in the last three years. The Carters
highly publicized appearance was meant to draw international attention
to the countrys high rate of Guinea worm disease and make
a serious push for increased eradication efforts.
departed en route to Accra Tuesday afternoon with a mixture of anticipation
and trepidation, Carter wrote on February 3 in an electronic
journal of the trip, which included stops in Mali and Togo. Ghana
was the first country in which Rosalynn and I ever visited endemic
villages, and well never forget seeing two-thirds of the total
population incapacitated with the disease, many of them lying around
under shade trees unable to walk. With our personal involvement and
strong support from the national government, there were only 8,432
cases six years later, in 1994. There has been stagnation in Ghanas
efforts since then, and in the last three years the number of cases
reported has risen from 4,739 to 8,283.
graduate Stephen Becknell 00C-02MPH (left) has
lived and worked in the problematic Nkwanta district for two years
as a technical assistant with the Carter Centers Global 2000
Guinea worm eradication program. Despite the lack of electricity,
telephones, e-mail, or reliable roads, Becknell says he likes working
at the community level because Thats where the action
wanted to do field-based work, said Becknell, a lean young
man with wild, bushy black hair and intense, piercing eyes. I
just like being outside, trying to work with the local people, building
a strong team. I did it at Emory through Habitat for Humanity and
Outdoor Emoryit seems very natural to me.
of Becknells job is trekking to remote areas by bike, boat,
and on foot if necessary to search out cases of Guinea worm so they
can be recorded and treated. His thorough surveys have resulted
in a spike in the reported district case numbers, with more than
five hundred new cases discovered in January alone. Much of the
region Becknell oversees has virtually no potable sources of water
such as wells or drilled boreholes, so convincing people to consistently
filter the surface water they use is his best hope for a significant
reduction in Guinea worm transmission. He has helped train more
than forty Ghanaian zone coordinators, who in turn coach hundreds
of grassroots volunteers to educate people on how to prevent Guinea
has come up with creative ways to communicate the Carter Centers
health messages, such as hosting festive evening programs in which
educational skits are combined with music and dancing. He anticipated
the Carters visit would bring added weight and importance
to his work in the eyes of influential local leaders.
change is hard, Becknell said. In our country, millions
die every year from smoking and eating fatty foods. One of the biggest
indicators of success here is when someone asks me a question because
they want to change their lifestyle. Seeing real changes in attitudes
can really give a sense that what were doing is working.
days before the Carters arrival, Jantong-Wura Ewontogmah Saaka
(left), chief of the northern village Dashei and eighteen surrounding
villages, welcomed guests from the Carter Center who had come to
help prepare for the prestigious visit. The Carter delegation was
scheduled to inspect a water site in Dashei, attend a community
celebration, and then proceed to nearby Tamale, a good-sized town
in northern Ghana, for a meeting with national health officials
to discuss the progress of Guinea worm eradication strategies.
in a flowing turquoise robe, wearing a striped hat and round, dark
sunglasses, the shrunken old chief sat enthroned in his hut on a
stack of grimy cushions, his wrinkled feet propped on a scarred
leather ottoman. Saakas hut was larger than most but not exactly
opulent; besides some ceremonial objects adorned with feathers and
fur, his only observable possession was a huge, plastic, battery-operated
clock, set to the correct time, hanging above his open doorway.
The ticking clock, arguably meant to keep the chief to some sort
of schedule, seemed an ironic presence in Africa where time is famously
told visitors he was preparing for the arrival of his friend,
Jimmy Carter. He is praying his friend will come and leave
safely, translated his linguist, through whom all the chiefs
communication is funneled. He is grateful [Carter] is coming
so he will see for himself that there is no clean water.
had hit on one of the toughest obstacles to eradicating Guinea worm
in Ghana: the people, understandably, want good water, not filters
and instructions. But because clean water is scarce in many parts
of Ghana, particularly during the dry season from October to March,
the Carter Centers eradication strategy relies heavily on
water filtering. Digging deep wells and boreholes is one solution,
but the process is costly and time-consuming, and boreholes can
fall into disrepair.
with the support of more than a dozen governments and private partners,
the Carter Center has provided millions of white cloth filters to
households in endemic areas, handing out nearly a half- million
last year in Ghana alone. They also have distributed some nine million
plastic pipe filters in Africa, which are worn around the neck on
a string and can be drunk through like a straw. Another component
of the eradication program involves treating stagnant water sources
with the chemical Abate, which kills Guinea worm larvae but is not
effective in large bodies of water.
people say, We will eradicate Guinea worm when you dig a deep
well, Carter said in a press conference during his visit.
The government should dig more boreholes. But
you dont have to have a borehole to eradicate Guinea worm.
In many nations, we have completely eradicated Guinea worm without
digging a single well. This requires education, teaching people,
and surveillance. . . . The strategy works completely, but the number-one
dependence has got to be on the filter cloth.
strategy may be simple, but implementing it in a place where no
one wears shoes or a watch can prove maddeningly difficult. The
roadblocks to success are many and varied, from government resistance
to village superstition.
major underlying flaw in Ghana, said Ernesto Ruiz-Tiben, technical
director of the Carter Centers Guinea worm eradication program,
has been poor supervision of the village-based health workers.
In the last two or three years weve tried to correct the problems
by providing additional resources to help create a cadre of personnel
below the sub-district levels that allows for much better supervision
. . . including technical advisers, both Ghanaian and ex-pats, to
help strengthen intervention. We have also provided funding for
additional vehicles, extra staff, and cloth filters enough to cover
every household. In our view, Ghana has all the resources needed
to have effective surveillance and the means to contain transmission
from each case.
Vaughn 94Ox (left), a technical assistant for the program,
lives and works in the areas surrounding Tamale. She spends most
days bouncing in a white truck from village to village on roads
the same red hue as her native Georgia clay, trying to mark tasks
off an ever-changing Guinea worm to-do list. She might spend hours
locating a chain for a volunteers motorcycle or waiting for
the proprietor of Tamales lone pharmacy to return so she can
stock up on gauze for a Guinea worm containment center.
can have ten things I want to get done, and if I get two of them
accomplished, thats a really good day, Vaughn says.
a young, pretty, white woman working in rural Ghana, Vaughn has
to be tough. Once, when she had spent an entire day watching Guinea
worm extractions and a long, tangled worm suddenly spilled out of
the incision in a boys ankle, she passed out, coming to a
few minutes later as anxious faces hovering above her blocked the
hot African sun. Another time the water reservoir at her tiny house
ran dry on a Friday afternoon, leaving her without water for the
weekend. She went to Tamale and bought dozens of sachet waters,
clean water in plastic bags about the size of a Ziploc baggie. You
learn to be resourceful, she says.
offices in Tamale as a home base, Vaughn works closely with a web
of local Carter Center staff and volunteers and with members of
the Peace Corps and the Red Cross to monitor Guinea worm in her
district. The day before the Carters visit, Vaughn drove to
Diare, one of the villages she oversees, to check on the area containment
center, a makeshift clinic where infected residents are encouraged
to stay until the Guinea worm has emerged. Thirty-seven cases had
been reported at the Diare center in January.
only treatment for those with emerging worms is to keep the afflicted
area clean and bandaged to prevent infection, wrap the worm around
a matchstick, and carefully turn it a little each day. The process
can take as long as two months, depending on the length of the worms
and how many are emerging; people have been known to host more than
fifty worms at once, although to have more than a few is rare. Breaking
an emerging worm will cause it to pull back into the body, where
it will die, calcify, and possibly cause deformities.
Abukari or AA, a district coordinator for the eradication
program, greeted Vaughn in Diare, where he was treating the days
Guinea worm patients. An old woman, cradling a shriveled arm that
she explained had been crushed in a long-ago lorry accident, quietly
described the pain of the worm as unbearable. A boy
with enormous eyes, who looked to be about three years old but was
said to be six, was visiting the containment center for the first
time with a Guinea worm emerging from the top of his foot. When
AA tugged gently at the stringlike worm, the boy began to cry helplessly;
his mother, standing by, put her hand to her mouth and looked away.
After his foot was cleaned and neatly bandaged, he received candy,
but he never smiled.
challenge, says AA, is convincing people to alter their behavior
permanently. How do you get the people to change their attitude?
he says. They untie the bandage, they say it was too painful.
You go to a dam site and say, dont go in the water, and the
next day they will be there again. But eradication will take the
commitment of everyone. When your neighbor is sick, you are all
sick. One person cannot achieve an aim without everyone.
recently, most of the volunteers trained in Ghanas Guinea
worm eradication effort were men. But about two years ago, the Red
Cross in particular began to teach women how to prevent the disease
in their communities. Women are the ones who fetch water for their
families each morning, often walking several miles during the dry
season to scoop from a pond that might supply several villages as
well as wild animals and livestockmainly bony cattlewho
roam freely in and around the water. The women typically use a calabash,
or bowl-like gourd, to fill a fifteen-gallon metal tub, which they
then help one another to hoist up to the coiled cloth on their heads
for the walk back home. In the evening they must make the trip again.
hundreds of women in rural Ghanaian villages are charged with helping
to make sure the water used in their compounds is Guinea worm free.
They show others how to fit the cloth filters, which resemble white
shower caps for giants, over the lip of the large clay drums used
for water storage in the villages, then pour the pond water through
them. The volunteers also inspect the filters for holes and help
replace them when needed. They have become a sort of cadre of Guinea-worm
police, visiting designated households regularly to make sure the
water is being filtered before use. Their uniform is brilliantly
dyed kente clotha welcome splash of color against the backdrop
of drab dust and scrubby trees.
Alid, a forty-two-year-old woman with clear eyes and a strident
voice, spends three days each week visiting houses to check them
for Guinea worm. She said she was chosen for the role by her community
because they knew she could do it; she is hardworking, and she loves
Diare. Her people filter well, she says, because she used to stand
and look at them while they filtered ita significant incentive.
She also monitors the dam, Diares water source, to make sure
no one with Guinea worm enters it and that no one drinks straight
from it. When I am at the dam, no one will enter the water,
she says proudly.
Amadu Dauda (left) is a former Guinea worm volunteer who was promoted
to area coordinator in Vaughns district. The two work together
almost daily, and Vaughn is frequently invited to share the evening
meal with his family. In khaki pants and a crisp white shirt, Buzaza
manages to look cool despite the withering heat; he carries a CDC
backpack and rides a sporty motorbike, with a stack of filter cloths
bungee-strapped on the back, to five or six villages each day. His
fourteen years of work in the eradication program recently earned
him an award for being the best coordinator in the district.
said that Guinea worm is embarrassing to Ghana, that
he would be ashamed if someone in his family contracted the disease.
But apparently not everyone feels the same.
you go to a house and ask if they are filtering, they can filter
very nicely for you to see, but they dont practice it,
he said. Because of this, you cant sleep.
Buzaza is optimistic about the success of the Guinea worm program,
especially since adding women volunteers has made a great difference
in his ability to monitor cases in his area. The women report new
cases to him every day. He described a woman who came to one of
his containment shelters with twenty worms and stayed forty-four
days. When she was released, her husband and children came to him
to say thank you.
was very happy, Buzaza says. She said, was there some
magic? She thought Guinea worm was from witchcraft. Now she knows
it is from water.
has become a personal dream for Buzaza, and he had high hopes for
President Carters visit the following day. President
Carters visit is very, very important, he said. His
coming will let all of us work harder, we will overwork ourselves
to eradicate Guinea worm in northern Ghana. When the worm is gone,
we will be very, very happy. We will grow and be fatter.
the morning of the Carter delegations arrival, the hot Saharan
wind, the harmattan, blows ceaselessly across the field near
Dashei, rippling the pond where the Carters will watch a water filtering
demonstration. The ground has been dampened to control the dust, but
clouds still billow behind the convoy of fifteen SUVs rolling across
the grass toward the site, looking as out of place as a line of donkey
carts plodding down Atlantas busy Peachtree Street.
and Mrs. Carter, their son Jeff, WHO Director-General Lee Jong-wook,
and UNICEF Deputy Executive Director Kul Gautam gather at the edge
of the water to watch a village woman and Red Cross volunteer demonstrate
how to collect and filter water. Leaning forward, Mrs. Carter, wearing
a salmon-hued suit, straw hat, and large sunglasses, helps her scoop
the water into a metal tub. A little boy, wearing the local school
uniform of orange and brown, then shows the visitors how to use
the pipe filter around his neck, kneeling on the rocks in the shallows
to drink right from the pond. Soon this muddy watering hole will
dry up completely, and the women of the village will have to walk
fourteen miles for water each day.
Dashei, the Carters visit Guinea worm victims at the containment
center, stopping to talk to several of them in a concerned, unhurried
way. When questioned, Carter later wrote in his journal,
even the youngest ones would show us scars on their arms and
legs from infections during previous years. Forty percent of all
cases are children. The Carters watch a class of children
being educated about the disease. Another group of schoolchildren
sings a song for the guests with the chorus, Guinea worm,
go away. They wear T-shirts that say: I want to be in
school. I dont want to have Guinea worm again.
have come here on many occasions in the past to visit your great
country, Carter later told a group of reporters. This
time, we have come almost exclusively to address the problem of
Guinea worm disease. Still this morning, when we visited the village,
we were saddened, with tears in our eyes, to see this terrible worm
coming out of little childrens bodies. This is unnecessary.
the center of Dashei, excitement is mounting as a thousand villagers
make ready for the Durbar, the celebration planned in honor of their
special guests. The crowd, which includes dozens of area chiefs
in colorful, locally woven regalia, sits on benches around a large
arena of red dust in a setting that brings to mind an American-style
rodeo. Traditional African dancers shake a tribal rhythm with belts
around their anklesinstruments which once would have been
made musical with dried beans or seeds, but now rattle with lengths
of light metal chain. Signs and banners proclaim, Welcome,
President Carter. You have brought us hope.
Carter delegation takes their seats on a shaded platform and speeches
are made by each leader, including Ghanas Minister of Health,
before has a president of the United States stood on this ground,
Afriyie says. The government of Ghana takes the issue of Guinea
worm very seriously.
Carter takes the podium under the blazing sun, a ripple of respect
and applause seems to bring the crowd to attention.
has wonderful people joining us in this effort to eradicate Guinea
worm, Carter tells them. I want to especially thank
the women of this country for the wonderful work they have done.
year I want to receive a report on this community that says there
is zero Guinea worm, Carter continues. All of you are
our brothers and sisters. We care for you. We wish you well. We
want you not to have Guinea worm in the future.
he speaks, Carter is presented with the traditional attire of an
area naa, a chief, and given the name Jantong Malgu-Naa, the
development chief. He readily dons the striped robe and hat;
now the real celebration will start and continue on into the night,
long after the Carters have boarded their plane for Accra.
the drumming grows louder, President Carter begins to trot and spin
around the dust circle at his hosts urging, shaking a long
hair whiska symbol of great authorityover his head.
The people of Dashei shout their approval as, with a red face and
a wide grin, the newest naa begins the dance