issue 207 - May 1990
The fiery serpent and
the new party offices
The Water Decade turned a spotlight on a drinking-water disease which causes
weeks of agonizing debility. Elizabeth Obadina reports from the Nigerian front.
I don't think anyone can imagine,' says Professor Alphonsus Nwosu, how it feels to have a live worm crawling out of your body for the two weeks it takes to emerge. Every day you rub in oils and take something for pain. If you pull and the worm breaks, you will be severely poisoned, horribly ill. So you just keep coiling it round a stick until the whole thing is out. There is nothing I have seen that has a more agonizing and humiliating effect than guinea worm.'
Professor Nwosu is a tireless campaigner against the disease known in Biblical times as 'the fiery serpent'. In 1986 he was appointed Commissioner of Health of Anambra State in south-east Nigeria by the country's military rulers. Upon assuming office he launched a crusade against guinea worm (dracunculiasis), which is transmitted via drinking water. Guinea worm afflicts thousands of villagers in Anambra - especially in the rice-growing region of Abakaliki.
In the 1986/87 dry season, the crusade reached over 200,000 sufferers in Anambra. A health-education programme taught villagers that they had contracted their worms by drinking dense grey-green water from ponds shrunk by sun and drought and swarming with water fleas.
These tiny cyclops play intermediate host to the guinea-worm larvae. When imbibed by a human being, the larvae burrow through the stomach wall and sail around in the lymphatic system before emerging fully grown a year later. They can come out of the breast, tongue, genitals - anywhere, though they usually emerge from the leg. The pain of the ulcer drives the victim so plunge the affected part in cool water, starting the cycle of infection all over again.
A curse of the gods
Villagers in Abakaliki were initially sceptical that guinea worm came from drinking pond-water. His Royal Highness Igwe Nwenyi, one of the local traditional rulers, describes superstition and ignorance as the main barriers to the disease's eradication. Over half the 75,000 people in his 'kingdom' used to be crippled regularly for ten weeks every dry season.
'I learnt to boil my water as a child,' says Igwe Nwenyi. 'None of my family ever contracted the disease. But our people would not copy me. I am a Christian and 95 per cent of them are pagan. They believed the worm was a curse sent by the gods or a witch, that people were born with it and that it came out depending on whether a person had hot or cold blood.'
In 1988 and 1989, a programme of 400 new boreholes began operation in Abakaliki under the UNICEF-assisted Anambra State Water and Sanitation - 'Watsan' - Programme. A new protected water supply has made all the difference.
'Seeing is believing,' says Mr Aniogor Joseph, a local primary school teacher. 'We would tell our people the pond water was bad but they wouldn't listen. Now we have a borehole which is nearer and much more convenient. This year, we have just one case of guinea worm in school compared to over a quarter of our pupils last year. January is also harvest time, and in past years villagers would be on their beds. They can see the difference between pass and present.'
The Nigerian government was first alerted to the incidence of guinea worm 30 years ago by another professor, Sanya Onabamiro. He outlined how it might be prevented and cured but nothing was done. In 1990, with 653,492 counted cases in the country (there are probably many more) Nigeria has the largest guinea-worm problem in the world. It has been estimated that 50 million working days, 20 million school days, and $20 million in rice production are being lost so the disease. Around the world there are between 10 and 20 million sufferers in a poverty belt of 19 sub-Saharan countries, India and Pakistan.
According to Dr Luke Edungbola, co-ordinator of Nigeria's first national guinea-worm conference in 1985, there are a number of links in the chain of infection which can be broken. The most obvious is to provide a protected source of water, but measures to stop people wading in drinking-water ponds, to cover open sores, to treat water, and to filter it before drinking to remove the cyclops, are all good preventatives. In Anambra State, local by-laws now make it an offence for anyone with an open ulcer to wade in drinking-water sources. Commissioner Nwosu also organized the distribution of free bandages to cover wounds as well as local cloth for water filters.
'I wanted to show that it is possible to use indigenous capacities to cure a disease in this environment,' says Professor Nwosu. Experts agree that breaking the cycle of transmission can chase guinea worm from a community in only one year. 'If we solve the guinea-worm problem - which is technically an easy one - then with the enthusiasm we create we can tackle leprosy, schistosomiasis and even the main killer, malaria, which is very difficult to combat.'
Politics, even in guinea worm
But Commissioner Nwosu's campaign has run into political difficulties. The eradication of guinea worm has become inextricably linked with the provision of borehole water supplies, itself a highly charged political issue. In July 1989, Lagos witnessed the launch of 'Target 1995, Global Eradication of Guinea Worm' by ex-US President Jimmy Carter. US money poured into a programme drawn up by his Global 2000 organization, and Nigerian President Babangida pledged one million dollars.
The new attention to guinea worm led to an order from the Nigerian government that villages suffering the disease be accorded priority in the allocation of new boreholes. This decision drew bouquets from Global 2000 and brickbats from guinea-worm-free communities. Many such communities have since 'discovered' guinea worm in their midst in order so bring clean water closer.
Villagers are sceptical about health education; they want water supplies for convenience' sake. But the guinea-worm card has entered Nigerian water-supply politics, and everyone plays it. Eradication of guinea worm, like smallpox before it, is a popular global target, especially with big donors. UNICEF and the Nigerian Ministry of Health have made careful efforts so champion health education, sanitation and social development as part and parcel of borehole schemes. But there is a risk that these will be washed away in a gush of water, forgotten in a blaze of publicity declaring the imminent eradication of guinea worm.
Commissioner Nwosu's other problems are even more pernicious. Despite the high level of government commitment both to rural water supplies and guinea-worm eradication, within months the authorities were robbing Peter to pay Paul: a different government programme pulled rank. In Anambra, all funds on current account for Watsan and guinea-worm eradication have been diverted by the state treasury. They will now pay for the construction of office buildings to house new political parties being nurtured by the military rulers for when they relinquish power in 1992.
As a result, during the last four months of 1989 the Watsan and guinea-worm programmes in Anambra were suspended. In January, UNICEF-donated vehicles, maintenance workshops, and drilling rigs stood idle. Project staff had not received their civil-service salaries. No more boreholes were under construction, in spite of the 95-per-cent success rate of the drilling programme to date, and initial enthusiasm was wearing thin.
It is likely that the donor agencies will exert whatever pressure they can to put the programme back on the rails. In the meantime, in Abakaliki all Commissioner Nwosu's gains are being put at risk as even the distribution of bandages and supply of cloth filters has ceased. In the country with the world's greatest number of guinea-worm sufferers, a showpiece programme to eradicate the disease has ground to a halt.
Elizabeth Obadina is a regular contributor to the NI based in Lagos.
Testing the water
Geronima Mendez Espinoza lives opposite one of the two hand-dug wells in the village of San Nicolas, Boaco. Since the discovery that the well becomes frequently contaminated she has taken on the task of testing the water regularly and adding a prescribed amount of chlorine.
This village in the hilly, fertile province of Boaco is one of several whose water supply is being improved and its quality monitored under a project run by the Nicaraguan Institute for Water Supply and Sewerage (INAA) and supported by the Catholic Institute of International Relations.
In San Nicolas and around 230 other rural communities, INAA carried out field tests for bacteriological contamination, using a 'portable laboratory': the Oxfam DelAgua water-testing kit developed in England by the Robens Institute.
The survey of Boaco's water in 1986 produced alarming results. Less than one-quarter of sources - usually hand-dug wells with handpumps - were producing water fit to drink. Disturbingly, many contaminated wells had been dug only recently in a drive to improve water supplies. Construction standards were good but neglect had caused the structures to fall into disrepair. Pumps failed so people resorted to drawing water with dirty buckets. Fencing was usually poor and animals wandered at will, contaminating the area with their excreta.
It was at this point that a community education programme identified local inhabitants such as Geronima Espinoza and enlisted their help. Preventing misuse of handpumps and ssandpipes was one goal; getting the community to understand how to avoid the contamination of their water was another.
Water and health issues were presented to villagers in public meetings with films, videos and flip-charts. Where communities were receptive, water committees were elected to help INAA workers in repairing broken-down systems and a small tariff levied from each household to pay for parts and materials. Despite economic hardship, these small contributions were insisted upon to underline the community's responsibility for its own water.
While the systems were restored, INAA workers began routine monitoring of the bacteriological quality of all supplies. Where this monitoring revealed persistent contamination - as at San Nicolas - regular chlorination was begun, with users measuring chlorine by a simple method. Geronima and the other monitors take a water sample, add a tablet, and if it doesn't turn pink, add a certain amount of chlorine solution to the village well.
Although this seems a model of community development, resistance to chlorination was often very strong because users did not like the taste. Ines Gomez, who looked after the well at the other end of San Nicolas, was threatened with violence by some members of the village for what was seen as meddling and spoiling the water. In time, INAA staff visited and sorted things out.
In 1988, the lessons learnt from Boaco were incorporated into the national programme for water quality control. The five-year programme will cost two million dollars, with the Nicaraguan government covering 34 per cent of the costs. It is unlikely to be threatened by the recent change of government.