Photo Gallery: Battling the Guinea Worm
The President and the Nematode Jimmy Carter's Fight to Eradicate the Guinea Worm
When Jimmy Carter left the White House almost 30 years ago after a failed bid for re-election, he said that he faced "an altogether new, unwanted, and potentially empty life."
Now he is leaning back in his rocking chair, with roses blooming in the garden behind him. The autumn sun is shining through the window into his office in the Carter Center in Atlanta. His hair is snow-white, his back is crooked and he doesn't move as quickly as he used to. The former American president is now 86 -- and yet he says: "This is the best part of my life since the White House."
Carter is on the verge of achieving the greatest victory of his life, one that involves a terrible disease and Africa. And people like Ajak.
The older girls are singing together to drown out the piercing screams of the younger children. "Those who work for Jesus will have a long life," they sing. Ajak, a seven-year-old girl, is wearing nothing but a worn T-shirt. She is sitting on the bare concrete floor, her left calf immersed in a bucket of water. Her face is distorted with pain, but she doesn't make any noise at all. A little boy next to Ajak starts screaming. The other children sing louder.
A male nurse wearing rubber gloves is massaging Ajak's thin lower leg. There is a hole in the middle the size of a fingernail, and a whitish worm is poking out of the hole. It looks like a cooked spaghetti noodle.
Gasping for Breath
The Guinea worm can grow to more than a meter in length. It lives inside the human body, crawling around between muscles and bones. Eventually it tries to get out.
A boil appeared on Ajak's leg two weeks ago. Then the worm began to emerge. Since then, nurses have been carefully pulling at the worm every morning and every evening. It is lodged in the tissue, and each time it is pulled it emerges by a few more centimeters. Then the nurse wraps the part of the worm that's already outside the leg around a piece of gauze bandage and ties it to Ajak's leg. The procedure is so excruciatingly painful that the girl gasps for breath at each tiny jerk.
Today the nurse has managed to pull the worm out completely. Ajak looks down and smiles. There is a picture of Winnie the Pooh on her T-shirt, but Ajak doesn't even know what a teddy bear is. The little boy next to her is crying. There are three worms poking out of open wounds on his legs. A second worm has emerged through the skin of Ajak's left foot.
The quarantine station in Abuyong in the Awerial district of Southern Sudan, one of many run by the Carter Center, is surrounded by a wild savannah as beautiful as the Serengeti. But the lives of the people here couldn't be more difficult. There is no clean water, and there are no doctors or schools. The local residents grow sorghum and corn, using only hoes and machetes as implements. Walking is the only mode of transportation.
'Ugly and Horrible'
The isolation ward is on a patch of ochre-colored earth, surrounded by dry tree trunks. The treatment room consists of a concrete foundation with a corrugated metal roof. Ajak and the 13 other children sleep on pieces of corrugated metal siding. Nowhere in the world are there as many Guinea worms in the late fall of this year as in Awerial.
After the end of the Carter administration, Peter Bourne, the director of the National Drug Control Policy under Carter, took a position at the United Nations. During a later visit with his former boss, Bourne showed Carter slides of meter-long worms crawling out of human beings.
The disease, Carter says "is ugly and horrible and afflicts the poorest people on earth. There is no vaccine and no medication that it can be treated with. No one wanted to deal with this horrible, obnoxious disease."
The UN had just failed in its efforts to eradicate malaria, yellow fever and the hookworm. The Guinea worm was also considered a hopeless case. But Carter recognized the worm as a potential project. At the time, the Guinea worm afflicted three-and-a-half million people in Asia and Africa every year. The plague was called the "disease of empty granaries," because victims cannot walk and are therefore unable to bring in the harvest. "We knew that we might fail," says Carter. "We were willing to risk failure if we believed it was worthwhile."
Clean by Next Year
That was a quarter century ago. This year, the Guinea worm has afflicted only about 1,700 people worldwide, and it is believed that only 75 of them live outside Southern Sudan. "Ghana has eight, Mali has 49 and Ethiopia 18." Sitting in his rocking chair, Carter recites these numbers like a sports fan rattling off statistics. These numbers are his victory.
Carter has helped eradicate the worm in 16 countries. His experts believe that Ghana will be clean by next year, and Mali and Ethiopia in two years. In Southern Sudan, health authorities counted only half as many people afflicted with the Guinea worm as last year.
The only human disease that has been eradicated to date is smallpox, which the World Health Organization eliminated in 1980 with the help of a vaccine. The UN's polio campaign, on the other hand, has already cost $8 billion (€6.1 billion) and remains plagued by recurring setbacks. To date, Carter's campaign has cost only $300 million, which he says is money well invested. Bill Gates agrees. The founder of Microsoft has contributed $40 million to Carter's effort.
Breaking the Cycle
The Carter Center depends on donations and operates on a tight budget. In Abuyong, the men from the villages have built their own quarantine station. The Carter Center didn't pay wages for the work, but it did provide the workers with food, in the form of corn porridge and lentils.
The Center has sent 20 Western development experts to Southern Sudan. They live in tents in outposts like Abuyong -- in close proximity to creatures such as scorpions and cobras. The outposts are so remote that the aid workers rarely encounter people working for the more than 100 other private aid organizations in Southern Sudan.
It is still dark, and a hyena howls outside the camp, but Makoy Samuel Yibi is already waiting in front of his tent. He is tall, like most Southern Sudanese, and his three-day beard is peppered with the first white hairs. He is wearing pressed jeans, a polo shirt and black, low-cut shoes, not the kind of outfit that would suggest that he is about to start walking through the savannah in the searing heat.
Makoy, a member of the Mundari tribe, has ritual scars on his temples. He works at the Health Ministry in Juba, the capital of Southern Sudan, where he directs the eradication program. He is Carter's most important man in Southern Sudan. Makoy wants to find out why there are still so many worms in Awerial.
'Where Is Your Filter?'
He sets out with his helpers at dawn. Children are bathing in a pond next to the camp. White and purple water lilies bloom in the middle of the pond. It would be an idyllic sight for anyone but Makoy, who only sees the dangers lurking in the water. The tiny crustaceans that thrive in the standing water swallow the worm larvae and transmit them to people. Anyone who drinks from the pond can get infected.
A woman walks past Makoy carrying a full plastic canister on her head. "Mama, where is your filter?" he calls out after her. The Carter Center has distributed filters to everyone here and they are the most effective form of protection against worm-infested water. The woman says that she is only using the water to cool her date wine. Makoy rolls his eyes, not believing her. He encounters two other women with canisters at the pond, and although they have used their filters, they haven't rinsed them properly.
The filter is a round piece of material, about twice as large as a plate. It's easy to place it over the nozzle of a canister. An assistant pours pond water through a filter and then shakes the material that has collected on the filter into a water bottle. Makoy holds the bottle up to the rising sun, showing tiny white dots swimming around in the water, small crustaceans known as copepods, which are barely visible to the naked eye. The larvae of the Guinea worm develop inside the copepods.
"Want a sip?" Makoy asks, jokingly. The women shake their heads with looks of disgust. "The pond has to be treated with ABATE," says Makoy, "tomorrow, if possible." The larvicide is not toxic to humans, but it kills the copepods.
A Military Campaign
An army of 8,000 volunteers is running the eradication campaign with full-time workers referred to as field officers. Carter's battle is as tightly organized as a military campaign.
Each volunteer is assigned to 25 households, and each threatened village throughout the entire country has a worm commissioner, whose job is to immediately report anyone infected with the Guinea worm. It is critical that he prevent those who have become infected from cooling their legs in drinking water sources. The worm commissioner is also supposed to ensure that everyone has a black plastic drinking straw. A small stainless steel filter inside the straw filters out the larvae. A Danish firm makes the straws for the Carter Center. People wear them on strings around their neck and use them whenever they feel the need to drink from a pond when they are traveling.
Today, Makoy is working with health officer Solomon Kuol Adol. He assists the volunteers whenever they need help, such as when a village leader refuses to put ABATE in his pond because he doesn't want to disturb the spirit living in the water, when patients resist going into quarantine or when people carelessly throw away the filters.
For such cases, Solomon always has his flipchart on hand, a picture book for adults in a region where most people are illiterate. One image shows two village elders preventing a man from cooling his leg in a pond. A white worm is poking out of the man's leg.
Thousands of Larvae
When the worm drills through the skin, the patient experiences an unbearable burning sensation. Water eases the pain, which is why patients like to cool their feet in ponds. But the worm ejects thousands of larvae as soon as it encounters water. The copepods eat the larvae, and the cycle is completed when people drink the water. Once it enters the body, the worm passes through the small intestine and into the tissue, where it grows for about a year and then emerges through the skin, starting the cycle all over again.
Makoy's team is trying to break this cycle -- everywhere, if possible. If they succeed, the worm will have been vanquished. The human body is the Guinea worm's primary host.
When Solomon and Makoy reach the next hut, a teenage girl crawls under a blanket. "I don't have a worm," she mumbles. The 15-year-old had a worm in the summer and was in the quarantine station, and now she has scars on her leg from the incisions tribal people make when they try to pull out the worms. This often leads to dangerous infections.
The girl mutters: "What do you want from me?" Makoy asks her where she was last year, knowing that she must have ingested worm-infested water somewhere. The girl says that she was probably infected in the cattle camp. She shoots angry looks at Makoy and Solomon. "You people come here with chemicals and you pour them into our pond. Now the people are sick. What is the reason? I think you are the one responsible."
The Dangers of the Cattle Camps
Southern Sudan is the poorest country in the world. No other country has so much suffering, so little clean water and so many people who can't read or write. The civil war that raged here almost uninterrupted for half a century ended when a peace treaty was signed in 2005. In January, the south will vote in a referendum on independence from the north, meaning war could again be on the horizon if the north decides not to allow the south, where most of the country's oil reserves are, to secede.
In trying to convince villagers to use their filters, Solomon says: "Your filter is like your weapon. You would load your weapon before you go into battle." The people here, after all, understand the language of war. They have endured fighting, displacement and disease -- and the experience has made them stoic. Two million people died in the war, and those who survived are not afraid of a little dirty water. Makoy laughs: "Nobody normal here," he says.
Nevertheless, he hopes that the country will be able to derive new strength from a victory over the worm. "People could say that they themselves were the ones who obliterated the worm. The have control of their lives; they realize they can do something for themselves."
Makoy's next problem case is a pregnant woman. She walks with a limp as she struggles into the shade of a tree. Pus is leaking from bandages on both of her ankles, and there are flies on the bandages. But her mother-in-law refuses to let her out of her sight, which prevents Makoy from taking her to the treatment center, even though she looks terrible.
No Problem Getting Appointments
Makoy leads his team through the tall savannah grass, past acacia and mahogany trees. He also seeks out the parents of Ajak, the girl in the isolation ward. If there are only 1,700 cases left in the world this year, but if many of those cases are in the same family, there must be a problem in the family. Ajak's sister also had a worm this year, and Ajak herself had another worm last year. Makoy wants to know why.
Her mother, an emaciated woman, carries her youngest child in a goatskin bag under her arm. When addressed, she responds by complaining that Ajak is now unable to watch the baby. She says that at least the girl should bring some millet home from the quarantine station. When asked whether Ajak goes to school, she says: "Girls are sold here, so why should they go to school?"
The girl's father says that the worm is bad, because it prevents his family members from tending the goats and tilling the fields. "And then no one will be able to cook food, because we won't have any food."
Makoy says that he thinks of Jimmy Carter whenever he feels discouraged. "If he can devote himself to this problem at 86, just think of all the things we can do."
Of course, Carter deals with heads of state, not villagers. Back in Atlanta, he explains: "This is one advantage I have as a former president of the United States. I don't have any problems getting an appointment with any heads of state, be it a king or a president or a prime ministers or whatever."
Carter toys with his reading glasses and talks about how he visited Pakistan, the country where the Guinea worm campaign began. "I knew President Zia since he was president when I was and neither he nor his minister of health had ever heard of Guinea worm." Pakistan was worm-free five years later. It was Carter's first success.
In 1995, Carter even negotiated a cease-fire in Sudan so that his worm missionaries could reach the sick in relative safety. When the Carter Center needed membranes so that villagers could filter the crustaceans out of their water, Carter had dinner with a shareholder in the DuPont chemical corporation. At the table, Carter poured water through a napkin to show the man what he needed. DuPont then developed a fine-pored material that doesn't rot -- and has donated six million square meters of the filter material since then.
Carter convinced German corporation BASF to produce as much of the chemical ABATE as he needed. Today the World Health Organization and the United Nations Children's Fund (UNICEF) also support Carter's project.
Carter talks about an experience he had in Ghana that he hasn't been able to forget. A few years ago, he visited a small Ghanaian village where 350 of the 500 residents had Guinea worms. Some were so sick that they couldn't even drag themselves out of their huts for their important visitor. Carter saw an attractive young woman, perhaps 20, who looked like she was holding a baby in her arms. When he approached the woman to ask for the baby's name, he saw that she was holding her swollen right breast. A Guinea worm was protruding from the nipple.
Although the parasites usually appear on the legs, they can bore their way out of the body anywhere, even through the eyes.
'Work, Work, Work'
Sometimes Makoy is furious with his fellow Southern Sudanese. When he took a course on epidemiology at Emory University in Atlanta a few weeks ago, he saw that American businesspeople had donated money for a hospital. "And our own rich people? What have they done?" he asks.
Makoy was born 44 years ago, in a small village a few hundred kilometers from Abuyong. His father, a former soldier, sent him to school, which hardly anyone else did. "He said: work, work, work. He pushed me."
Makoy studied Public Health in Khartoum. Four years ago, he was promoted to director of the Guinea worm program. What happens when his adversary is finally eradicated? "Then I'll have made it. Then I will be done," says Makoy. "Then I want to be a good father." His wife and their four children live in Uganda and he sees them only once every few months.
After dinner on normal workdays, Makoy often walks back to his office in Juba, where he sits behind latticed windows after it gets dark outside. An energy efficient light bulb hangs from the ceiling as he pores over reports, looking for answers to questions like: Have his teams really detected every case? Where did the infected person become infected with the worm?
Makoy visits the cattle camp in Abuyong in the evening. In many tribes in Southern Sudan, everything revolves around cattle; cattle are the people's bank accounts. Anyone who wants to marry needs cattle. The young men in the region often don't have cattle, but they do have guns. Cattle theft is the most common crime in the region. Shooting is common, and entire clans sometimes disappear, making it extremely difficult for field officers to find the worm patients.
The Heat of the Moment
Last year, many of the sick became infected in cattle camps. The camps are a Southern Sudanese party zone, a place where people gather for wrestling matches and dancing, and where they drink Siko, a black date wine. In the heat of the moment, people sometimes forget to use their filters.
The camp near Abuyong is called Raka-Weng. Clouds of pungent, white smoke rise into the air. Children have dried cowpats and burn them to repel mosquitoes. The cows lie next to each other on the ground as children massage white ash into their hides and then rub the rest onto their own faces and bodies. Herds arrive from all directions, kicking up clouds of dust, led by spirited boys marching along with sharpened sticks in their hands. The cowherds move on after a few months, searching for the best pastures. They are constantly drinking from new, dirty water sources.
Makoy strokes one of the boys on the head. "He's exactly like I was," he says. "Six or seven years old, with white ash in the face, on my way to the next wrestling match." Cattle are so important to the Dinka and Mundari tribes that they name their children after the animals. Makoy means "cream-colored cow with brown spots."
Makoy praises every child carrying one of the Danish plastic straws around his neck in the cattle camp. Then, on the outskirts of the camp, he finds a dirty water filter that someone apparently used to carry ash. Makoy picks it up. He finds another one a few meters away, and then another.
Wanting to Set an Example
Despite the commotion around him, Makoy suddenly falls silent. In the end, he has picked up 50 filters. Furious, he makes his way to the Abuyong outpost. He has spent 13 hours walking through the bush today, but he still summons his team members to tell them: "We have a problem."
He wants to hold a meeting in Raka-Weng the next day, and he wants the health officers to focus on the filters. Early in the morning, a field officer calls together the cowherds with a megaphone, and they gather around him in a half-circle. The broken filters are lying on the ground. "What exactly do you think the Carter Center is doing here? It wants to help you stay healthy. And you misuse it." Then he picks up a filter and shakes it in the air. "If you don't load your weapon before a battle, you will lose," he shouts into the megaphone. "And when you misuse the filters, you'll also lose."
One of the leaders steps up to the front. His face is covered with white ash, giving him a frightening look. His wool cap is pulled down over his forehead. His name is Moses Majok Geng, he says, and he saw many people die when he was a fighter in the rebel army. Then he spits on his right index finger and wipes it across his foot, revealing a round scar on his dusty skin. "I had a worm this year," he says. "And even I, as a chief, went to the quarantine station." He says that he wanted to set an example.
Makoy leaves the next morning to return to Juba. Before going to his tent at night, he hears the cowbells from Raka-Weng, where Chief Moses Majok Geng believes in a better future. In the quarantine center, Ajak hopes that she will never see another worm crawl out of her body. For Makoy, the next day is another day in his fight against the Guinea worm.