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Sudan's war and eradication of dracunculiasis

2002; Elsevier BV; Volume: 360; Linguagem: Inglês

10.1016/s0140-6736(02)11806-x

1474-547X

Donald R. Hopkins, P. Craig Withers,

Syphilis Diagnosis and Treatment

Donald R Hopkins is Associate Executive Director of The Carter Center. He was previously Deputy Director of the Centers for Disease Control and Prevention, where he initiated the worldwide campaign against dracunculiasis. P Craig Withers Jr is Director of Programme Support for the health programmes of The Carter Center. He was the Center's resident technical adviser in Sudan 1995–96. “You can bring whatever you like here. If this war continues, it will mean nothing.” This quote from an exasperated village elder in the Nuba Mountains area of Sudan says it all. Although incidence of dracunculiasis (Guinea worm disease) has been reduced by 98% from an estimated 3·5 million cases less than two decades ago, and seven of the 20 countries that were endemic for the disease have already eliminated the infection, most of the remaining patients are in southern Sudan, and the worldwide eradication campaign cannot be completed until Sudan's civil war ends. People get dracunculiasis by drinking contaminated water from open ponds. 1 year later, the 1-m long worms (Dracunculus medinensis) emerge through the person's skin. As a result of the pain caused by the emerging worm, many villagers are unable to farm or attend school for 2 or 3 months. When people with emerging adult worms enter water, the parasite discharges thousands of microscopic larvae into the water, where some are eaten by tiny water fleas (copepods), and become infective to people. This parasite must pass through people, so when transmission to humans is interrupted, D medinensis will be eradicated forever. People do not become immune, and there is no treatment or vaccine for dracunculiasis. The disease can be prevented, however, by teaching villagers not to enter water when a worm is emerging and to filter (or boil) water from such sources through a finely woven cloth; by treating contaminated ponds with Abate (temephos); and by providing protected hand dug wells or bore hole wells. How did we get to this impasse between eradication of Guinea worm and civil war in Sudan? The worldwide campaign to eradicate dracunculiasis began at the US Centers for Disease Control and Prevention in 1980. The current conflict in Sudan is almost as old, having resumed in 1983 after a 10-year respite. Sudan's war is Africa's longest, bloodiest, and most neglected conflict. Mostly because of the war, Sudan has reported a half or more of all cases of dracunculiasis in the world yearly, beginning in 1995 and increasing to 78% of all remaining cases in 2001. The difficulties of implementing any public health programme in southern Sudan are formidable. Sudan is as large as the USA east of the Mississippi River. The land in the southern part of the country is vast, much of it is flooded for months during the rainy season, and there are few roads or other infrastructure. Additional difficulties caused by the war include mass movements of displaced people, restricted access to known or suspected endemic communities, disruptions in activities and loss of personnel, and increased costs because of the need to airlift supplies. Of these challenges, only the geographic and climatic constraints are inherent. Pitted against these difficulties are many dedicated Sudanese health workers on both sides, and their allies from international organisations. Since former USPresident and Nobel Laureate Jimmy Carter negotiated a 4-month “Guinea Worm Cease-Fire” in 1995, the Carter Center has facilitated coordination of operations and reporting on Guinea worm activities from both sides, from offices in both Khartoum and Nairobi. Nairobi is the headquarters for dozens of non-governmental organisations (NGOs) that are active in rebel-held regions of southern Sudan. Both sides participate in quarterly coordination meetings, which are held alternately between Khartoum and Nairobi. The Guinea Worm Cease-Fire allowed health workers access to almost 2000 endemic villages, and to distribute over 200 000 cloth filters, to effectively inaugurate the Sudan Guinea Worm Eradication Programme (SGWEP). Whereas the strategy during the earlier stage of the worldwide campaign had been to wait until Sudan's civil war ended before engaging the programme there, the 1995 cease-fire showed that much could be done despite the war. Indeed, the newly emboldened Sudanese programme distributed even more cloth filters the next year, without a cease-fire, than it had in 1995. By 2000, the SGWEP was aiming to interrupt transmission of dracunculiasis in all eight northern states where it still occurred, and sought to focus efforts aimed at stopping transmission in the south in three “emphasis states” that were mostly under the control of one side or the other then: Upper Nile, Lakes/Buheirat, and western Equatoria. Despite all the constraints, the SGWEP distributed over 600 000 cloth filters a year for use in households between 1996 and 2000, and over 800 000 in 2001. In 2001, the programme also distributed more than 7·8 million “straw filters” for personal use—enough for every person at risk of the disease in Sudan. The straw filters allow individuals to always filter potentially contaminated drinking water, even when they are away from home. The effect of the straw filters is being assessed in 2002. Almost two-thirds (3921) of the 6040 accessible endemic villages in Sudan reported one or more cases of Guinea worm disease in 2001. However, another 2500 villages are known to have reported cases since 1995, but are currently inaccessible. Of the endemic villages that are accessible, 84% have a resident healthworker or volunteer trained in prevention of dracunculiasis, 85% received health education about the disease last year, 62% had cloth filters in all households, 61% had at least one source of clean drinking water, and Abate was used in 2%. Twenty NGOs are now implementing Guinea worm eradication activities in southern Sudan. With Sudan's increasing share of the remaining dracunculiasis cases in mind, the major external partners (The Carter Center, WHO, UNICEF) requested the government of Sudan to host the yearly meeting of all endemic countries in March, 2002. The President of Sudan presided over the opening ceremony of the conference, which was attended by President Carter, former Nigerian head of state General (Dr) Yakubu Gowon, two former Sudanese heads of state, Sudan's Minister of Health, and more than a thousand other healthworkers, mostly from Sudan. All 20 endemic countries were represented, including several ministers of health. Sudan's head of state unveiled three postage stamps to commemorate the occasion. The conference also provided an opportunity for President Carter and staff of the Carter Center's Conflict Resolution Program to engage in political discussions with the Sudanese leadership about ending the war. After leaving Khartoum, President Carter visited a rebel-held region and later met with the leader of the main opposition group (Sudan People's Liberation Movement). In seeking to help the search for peace in Sudan, The Carter Center is drawing on its involvement in health that began with an agricultural project in Sudan in 1986, and now includes cooperation on dracunculiasis, onchocerciasis, and trachoma. Before negotiating the Guinea Worm Cease-Fire, President Carter sought to negotiate a cease-fire in 1989 and then negotiated the “Nairobi Agreement” between Sudan and Uganda in December 1999, which led to restoration of diplomatic relations between the two countries. The recent efforts by the new US administration and some European countries to help negotiate an end to the Sudanese conflict provide a basis for hope that the war in Sudan may be ended soon. In our opinion, at this stage of the SGWEP, temporary cease-fires or days of tranquillity are only useful to the extent that they are confidence-building steps toward the main goal, which is ending the war altogether. For all the SGWEP's successes so far, dracunculiasis cannot be eradicated from Sudan until Sudan's civil war is ended. (With an incubation period of 2 weeks or less, and a vaccine, it may be possible to eradicate polio from Sudan before the war ends, but it will be hard to prove it. Smallpox was eradicated during Sudan's brief decade of peace.) We estimate that it will take 3–5 years to completely eradicate dracunculiasis in Sudan once the war is settled. Until then, the actual and potential costs to Sudan, its neighbours, and supporters of the eradication campaign will be substantial. They include the costs (now about US$2 million per year) to maintain the programme in Sudan; costs of maintaining surveillance to detect cases exported from southern Sudan to northern Sudan and to neighbouring countries; costs if an undetected case re-establishes transmission in Ethiopia, for example; and the costs of maintaining WHO's International Commission for the Certification of Dracunculiasis Eradication for the additional years. The need to address this public health problem is being used as a diplomatic tool in Sudan, and diplomacy is urgently needed to facilitate public health work in the war-torn country.