Guinea Worm Eradication: Celebrating A Humanitarian Legacy
We're on the cusp of an enormous global achievement. Guinea worm, a neglected tropical disease (NTD), has nearly been eradicated. A scourge to humankind across millennia, it's been postulated that the medical emblem with a snake wrapped around a staff is actually a Guinea worm. As with the fight against polio, this work has required decades of international coordination and mobilization in 21 countries across Africa and South Asia. UNICEF has been at the forefront of these efforts, bringing water, sanitation and hygiene (WASH) expertise to vulnerable, often remote communities. And starting in 1986, a powerful ally — former U.S. President, statesman and humanitarian Jimmy Carter, along with The Carter Center — played a key role in taking the fight to the next level.
It was a massive undertaking for a parasitic disease with which most Americans are unfamiliar, but Dracunculiasis, or Guinea worm disease, is debilitating and excruciating for those infected. It is contracted when people consume water from stagnant sources contaminated with Guinea worm larvae. Once a person is infected, during the year-long incubation period the worm grows and eventually emerges from a painful blister, most often in the leg or foot. By this time, the worm will have grown to about 3 feet long. The most widely used extraction method is to gradually wind the worm around a small, dirty stick; the entire process can take weeks, sometimes leading to secondary bacterial infections.
In Sudan in 2012, a Guinea worm is extracted from a patient's foot by wrapping it around a stick and carefully pulling it out. The process is carried out twice a day and can take weeks to fully remove.
It's during this period when contamination is such a huge risk, as Guinea worm sufferers would often seek to soothe their wounds by soaking their infected extremity in a shared stagnant water source, renewing the cycle and putting more people in danger.
Though the disease is not usually fatal, it can still have severe and widespread impacts on communities. 'It tends to emerge during harvest,' says Ida Marie Ameda, Global Malaria and NTD Advisor for UNICEF. 'It takes people away from farming. That's their livelihood.' If a child contracts Guinea worm, they could miss weeks of school. If a village is raided during times of conflict, those infected may not be able to flee to safety.
The consequences of an outbreak have always been evident, but the path toward eradication would require a clear plan and vision.
When it came to addressing Guinea worm disease, UNICEF's focus in the 1970s and early 1980s was primarily in India, which had the largest number of cases outside of Africa. 'India was the epicenter,' recalls Kul Gautam, former UNICEF Deputy Executive Director. 'There were seven states of India where there were 40,000 cases occurring of Guinea worm every year.' At the same time, WASH had become increasingly important in the country because of ongoing droughts, setting the stage for the pioneering work to come. A formal eradication program would begin in 1983.
UNICEF developed a multipart strategy to fight Guinea worm, beginning with a rapid increase in boreholes and improving access to safe water in rural areas. 'In India, UNICEF worked with local governments and private companies to manufacture several hand pumps,' says Gautam. 'There's a hand pump called India Mark II, which became very famous. That became the most widely used water pump in developing countries.'
A woman explains the life cycle of a Guinea worm, part of community education efforts in Rajasthan, India. In 1983, India launched the world's first national Guinea worm eradication program.
Temephos, a pesticide, was applied near these water points to help kill infected water fleas. And then, perhaps most important of all: 'awareness creation,' says Rupert Talbot, a former WASH specialist at UNICEF India. 'We had people going around village to village and monitoring the number of Guinea worm cases, alerting the authorities when one had been found.' Much of these efforts also focused on convincing communities, particularly in India's Rajasthan state in northwestern India, to close stepwells that so frequently led to Guinea worm exposure. Without this outreach, the WASH programs could only go so far.
These learnings would be invaluable as UNICEF and partners expanded eradication efforts to other countries. 'The name of the game is replication in all these programs,' says Talbot. 'It's advocating an approach, demonstrating the art of the possible, and then replicating it and taking your particular project to scale.' And through the years, progress would continue to be made in India; elimination would be certified by the World Health Organization (WHO) in 2000.
Archival photos from the 1980s show UNICEF-supported interventions to eradicate Guinea worm disease in Ethiopia, including community demonstrations on water filtration, left, and the construction of new wells.
In 1986, the fight against Guinea worm would receive a significant boost in profile. 'Jimmy Carter became very interested and involved, and he made it into a big focus for The Carter Center,' says Gautam. At that time, UNICEF and partners had brought to light that this was a persistent problem in several countries, and WHO had developed technical guidance and an eradication strategy. 'UNICEF, WHO, the CDC and Carter Center, those four organizations became the big organizations who were pushing,' says Gautam. 'Jimmy Carter's involvement made it possible for us to go to the highest levels of government.'
'He was an amazing statesman,' remembers Della Dash, a former WASH specialist at UNICEF Ethiopia. 'He was brilliant and intense. When he looked at you, there was nobody else in the world that existed. He was a 100 percent focused on you, what you were saying.' Carter's ability to win over world leaders would be instrumental in breaking down barriers in the years ahead.
Former U.S. President Jimmy Carter during his first visit to Ethiopia in 1993.
Meanwhile, UNICEF and partners were finding success with new approaches. For instance, in the mid-1990s, UNICEF used GPS units coupled with WHO-developed software to locate remote villages in Ethiopia with limited water sources, making them prime candidates for drilling new boreholes, or protecting springs where possible. 'The GPS devices were big and heavy, and they didn't have a very long battery life,' says Dash. 'But they were helpful as a tool to guide us in terms of program implementation and what intervention needed to happen in different areas.'
UNICEF staff based in impacted countries would communicate regularly, and convene periodically. "Once we met in Geneva, all 40 or so of us would look at the data together and figure out how to develop strategies to really address the challenges,' says Dash. These strategies were often focused on the different points at which the transmission cycle could be broken. This could mean digging more wells, or teaching people how to filter their water using mesh screen material. And as Talbot and his team had seen in India, community participation was essential. Della recalls how in Ethiopia's Gambela region in the west, her team would use GPS data to create maps that could be brought to village elders, who could then work with UNICEF to find potential sources of Guinea worm, stagnant ponds and the banks of rivers that could be treated.
All of this work was done in lockstep with The Carter Center. And as more countries moved closer to the elimination of Guinea worm, Jimmy Carter was there to provide both political support and pressure. By 2004, Ghana was starting to lose momentum, with a surging number of cases — prompting a meeting with Carter. 'When we went to see the president of Ghana, I found Jimmy Carter to be such a masterful advocate,' says Gautam. 'He said, 'Politically, this is something that you can do. It doesn't cost a lot of money. It requires your leadership. We can make it a success.''
It took many years and there would be setbacks, including a large-scale outbreak in Savelugu in 2008, but eventually the country's elimination efforts paid off.
During a 2004 visit to Dashie, a village in northern Ghana, (from left to right) the late former U.S. President Jimmy Carter, former Deputy Executive Director of UNICEF Kul Gautam and former Director-General of WHO Dr. Lee Jong-wook meet with a mother suffering from Guinea worm. Carter urged Ghana to take 'swift and immediate action' to reduce its number of cases and eradicate the disease.
In 1986, Guinea worm disease afflicted an estimated 3.5 million people. In 2024, there were just 14 provisional human cases across South Sudan, Angola, Cameroon, Ethiopia and Mali. But crossing the finish line is no small task.
Adam Weiss, Director of The Carter Center's Guinea Worm Eradication Program, was in Ghana to watch the last worm be pulled out of the last patient in 2010. And despite conflict and social unrest sometimes limiting humanitarian access throughout the region, the progress is still remarkable. 'We are starting to get closer and closer to not having the generation around that saw hundreds or thousands, millions of cases,' says Weiss. 'But the oral stories that have been shared have helped reinforce amongst younger generations that it's still real.' Now it's about maintaining motivation and vigilance.
That became especially true in 2012. It was then that it was discovered that Guinea worm was now much more endemic in domestic dogs than researchers had realized. 'That was a big shift and required all countries with support from the global program to kind of reimagine their own programming from being very human-centric to a more holistic approach, thinking about the ecology and the environment in a different way,' says Weiss. This meant going back and listening to communities and encouraging them to keep dogs from contaminating water sources; families and local leaders played a direct role in shaping surveillance systems and safety protocols.
As The Carter Center, UNICEF and partners adapt to these new circumstances and approach global eradication, what might the future hold? 'Success is bigger than just Guinea worm,' says Emily Staub, Associate Director of Communications at The Carter Center. 'It's that injection of humanity, the injection of being innovative and thinking outside the box, and what else can we do?'
Because of the eradication efforts, so many more communities have access to safe drinking water from wells drilled by UNICEF. In addition, practices and data collection methods learned from the Guinea worm program are being used by thousands of people around the world, to tackle new public health problems. 'I think President Carter was able to have high-level conversations with big agencies and governments to help them see that even though Guinea worm didn't impact people in countries like the United States, this work has had auxiliary benefits in other areas,' says Staub.
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