Speaker 1: When I was a young boy, I had two uncles.
Speaker 1: Both were heavily infected with guinea worms, and back then,
Speaker 1: no one here knew how guinea worm was transmitted. People
Speaker 1: would become infected and we just kept wondering why. During
Speaker 1: those years, we had some communal fighting, fighting between communities
Speaker 1: amid South Sudan struggle for independence. One day, fighting erupted
Speaker 1: in the evening, so everyone in my village ran away,
Speaker 1: but my uncles could not run, so they crawled to
Speaker 1: the garden to hide because no one could carry them.
Speaker 1: My mom could not carry them, and I had lost
Speaker 1: my dad during the struggle, so we had to leave them.
Speaker 1: There weren't any options. We just cried. So warfare comes
Speaker 1: and fighters raid our cows and kill some people and
Speaker 1: then go back where they came from. After that, when
Speaker 1: the people came back, we found that my uncles were gone.
Speaker 1: They had been killed. If it were not for guinea worm,
Speaker 1: they would have just joined us and treked away from
Speaker 1: the danger. So I say that it was guinea worm
Speaker 1: that killed them indirectly. When I was young, I could
Speaker 1: not understand how the guinea worm killed my uncles, But
Speaker 1: as time goes on, I have come to know this
Speaker 1: is our story. Later, we were living at a refugee
Speaker 1: camp and we were given pipe filters from the Carter Center.
Speaker 1: I didn't know why people were given pipe filters, so
Speaker 1: I refused to use mine. My mom is educated and
Speaker 1: she told me these were for guinea worm. And now
Speaker 1: she began to tell me this story, and I finally
Speaker 1: could see the connection between the guinea worm and the
Speaker 1: loss of my uncles. I said, okay, there are people
Speaker 1: that are working for this, and that was when I
Speaker 1: committed to working for guinea worm eradication. Because guinea worm
Speaker 1: had done something bad to me, and even if it
Speaker 1: had not been me, what of the rest of the community.
Speaker 1: That's what inspired me to work for the eradication of
Speaker 1: guinea worm. So I went away to school and when
Speaker 1: I came back, I looked for this work. When I
Speaker 1: found the man who would be my director, I told
Speaker 1: him I will never let you and my country down.
Speaker 1: I just need to relate to my community and see
Speaker 1: how this guinea worm is cruel to my community. I
Speaker 1: want my community to be free, and that's why you
Speaker 1: see I am doing this work. It is very difficult.
Speaker 1: If you want to work for guinea worm, you need
Speaker 1: to leave the good things in your life behind and
Speaker 1: become part of the community. That way, you come to
Speaker 1: understand the dynamic of how to help the community to
Speaker 1: eliminate the guinea worm. And that's been very effective. I've
Speaker 1: been there and I've worked, and I've seen how the
Speaker 1: guinea worm can go to nothing, and I have hope
Speaker 1: that one day we will be free and able to
Speaker 1: say that guinea worm is gone. It will be a
Speaker 1: very great achievement. I thank the Carter Center for helping
Speaker 1: us achieve it.
Speaker 2: Wow. That was that was Wow? That was an amazing story. Yeah.
Speaker 1: Yeah, so that was from Daniel deng Uh and he
Speaker 1: wrote that story called guinea Worm Killed My Uncle's which
Speaker 1: we found on the Carter Center blog. So that's who
Speaker 1: that was from. Yeah. Hi, I'm Aaron Welsh and I'm
Speaker 1: Erin Allman Updyke.
Speaker 2: And this is this podcast will Kill.
Speaker 1: You And if you haven't guessed, today we're talking about guinea.
Speaker 3: Worm, guinea worm tricculasis. I am really excited for this episode,
Speaker 3: which I know we say that every episode.
Speaker 1: Episode, but we're always excited, So it's always always excited.
Speaker 3: If you like, it's been a while since we've done
Speaker 3: a parasitic disease, so that's always interesting, you know. And
Speaker 3: the other reason that I'm super excited for this episode
Speaker 3: is that we have an incredible guest.
Speaker 2: Yes, we were.
Speaker 3: Fortunate enough to interview Sarah Urian, who is the senior
Speaker 3: Associate director of the guinea worm eradication program at the
Speaker 3: Carter Center.
Speaker 1: How amazing, I know.
Speaker 2: So we got to talk.
Speaker 3: With her a bit about her experiences on the ground
Speaker 3: as well as some of the more like, you know,
Speaker 3: the logistical finer points of how eradication is actually achieved.
Speaker 2: So keep an ear out for that later in the episode.
Speaker 1: Yeah, we're really excited about it. But first, oh, what
Speaker 1: what time is it?
Speaker 2: I think it's I think it.
Speaker 3: It must be quarantininey time. If I'm not mistaken, you're right.
Speaker 1: I just it's quarantine time. I checked my watch and everything.
Speaker 3: Well, Aaron, what are we drinking this week?
Speaker 1: We're drinking the Littlest Dragon.
Speaker 3: I love this name, so but it does require maybe
Speaker 3: a bit of explanation. Just so, the species name for
Speaker 3: guinea worm is Dracunculus medinensis, and dracunculus means little dragon,
Speaker 3: and so it's like the littlest dragons.
Speaker 1: The Tiniest Little Dragon.
Speaker 3: A cute name for a not so cute worm. I
Speaker 3: have to admit it's not the cutest of worms.
Speaker 1: You know. Are there cute worms out there?
Speaker 2: Absolutely?
Speaker 4: Oh?
Speaker 3: Okay, yeah, I don't know anybody, but I'm sure I'm
Speaker 3: sure that there are.
Speaker 1: Like oceanic worms. Actually, there's some cute ones in the ocean.
Speaker 2: Yeah, yeah, okay.
Speaker 3: Anyway, the Littlest Dragon. The Littlest Dragon is actually quite
Speaker 3: a delicious cocktail. So it has blue currosow, it has
Speaker 3: a rum pineapple juice cream of coconut, and the most
Speaker 3: crucial part is that you garnish it with a toothpick
Speaker 3: with a sour gummy worm wrapped around the toothpick for
Speaker 3: reasons that will become clearer later in the episode.
Speaker 1: Yes, and we'll post the full recipe for that quarantini
Speaker 1: as well as our non alcoholic plusy Brita on our
Speaker 1: website This podcast will Kill You dot com and all
Speaker 1: of our social media channels as well.
Speaker 3: Yes, so, I think we have a couple other pieces
Speaker 3: of business to take care of.
Speaker 2: We do so.
Speaker 1: First of all, I finally checked our po box after
Speaker 1: months of not going to the post office because of
Speaker 1: Corona and I'm thrilled for we got a couple of
Speaker 1: really really kind presents that we wanted to say thank
Speaker 1: you for. So First, I want to say thank you
Speaker 1: so much to Kira, who sent us not only the
Speaker 1: most adorable sweet just the sweetest letter, but also a
Speaker 1: handmade like Matt coaster for our quarantinies that looks like
Speaker 1: the coronavirus.
Speaker 3: Oh my gosh, it is incredible. Kira, Thank you so much.
Speaker 3: It's so sweet of you. And yeah, that letter made
Speaker 3: us like, oh, it's just like we're like, we.
Speaker 1: Don't deserve this.
Speaker 2: This is too nice.
Speaker 1: And also, thank you so much to Melanie who made
Speaker 1: us handmade masks with little germs on them.
Speaker 3: Oh my gosh, they're so cool. Thank you so much
Speaker 3: Kira and Melanie. We appreciate It's so very much, so.
Speaker 2: Much, really amazing.
Speaker 3: Well, I think the only other business is that we've got,
Speaker 3: you know, merch as per usual. Good to this podcast
Speaker 3: We'll kill you dot com and click on the merch tab.
Speaker 1: Shout out to Abigail Irvin Penner, who designed all of
Speaker 1: our new merch. We love it so much.
Speaker 3: Oh my gosh, I'm I mean, I'm obsessed seriously, and
Speaker 3: we also have a Bookshop affiliate account, so you can
Speaker 3: find all of the books that we talk about on
Speaker 3: our podcast there and also good Reads list, so check
Speaker 3: those out.
Speaker 2: You can find all of those things on our website.
Speaker 1: Awesome, is that all? I think that's all excellent. Shall
Speaker 1: we dive right into the biology of this little worm?
Speaker 1: Let's do it right after this break. Guinea worm or
Speaker 1: as you mentioned aaron, Dracunculus medinensis, right.
Speaker 2: I think that's how you say it.
Speaker 1: I even googled how to make sure I pronounced dracunculus
Speaker 1: properly because I've never been able to pronounce it. But
Speaker 1: everyone knows I have issues with pronunciation.
Speaker 2: What do you mean? Cough cough.
Speaker 1: Anyways, Dracunculus medinensis is a nematode or a roundworm. So
Speaker 1: this is the same phylum as hookworm. This is our
Speaker 1: second nematoad. Gotta love them, Gotta love them, that's their tagline.
Speaker 1: So okay, because this is a complex parasite, we obviously
Speaker 1: have to start with the life cycle.
Speaker 2: Okay, excellent.
Speaker 1: We're gonna start with the first stage, larva, so that
Speaker 1: when we end this cycle will end with the human
Speaker 1: part of the life cycle. Okay, Okay, So the first
Speaker 1: stage larva, if dracunculus are tiny dragons. These are the
Speaker 1: tiniest dragons, the babies. They're found in water sources, fresh
Speaker 1: water or brackish water sources. They swim and they thrash
Speaker 1: about in this water the way that worms like to do.
Speaker 1: And then they find tiny little copa pods. Okay. A
Speaker 1: copa pod is a little crustacean think plankton from SpongeBob.
Speaker 3: They're really cute, really cute.
Speaker 1: Yeah, they're very adorable. These copa pods swallow this first
Speaker 1: stage larva of the guinea worm, and then within the
Speaker 1: body of the copa pod, the larva kind of burst
Speaker 1: out of their stomach and begin to develop and grow.
Speaker 2: Question.
Speaker 3: Yes, I know, it's starting early. Okay, So the first
Speaker 3: stage larva it is ingested by the copapod. Does it
Speaker 3: have any movement towards the copa pod, like you know
Speaker 3: what I mean? Does it have any directional movement?
Speaker 1: They have certainly movement. I don't know if they have
Speaker 1: directional movement towards copapods. I didn't see anything about that
Speaker 1: in the literature that I read. But that's a really
Speaker 1: interesting question. Okay, gotcha Okay, so now they've molted, they've
Speaker 1: grown inside of this copa pod, and then a human
Speaker 1: comes along and fills up their water container from the
Speaker 1: well or the pond or whatever that this copa pod
Speaker 1: has been living in, and they've been walking for a while.
Speaker 1: So they take a big old swig of that water
Speaker 1: and they swallow these tiny little plankton copa pods, and
Speaker 1: then inside our stomach, the human stomach, the copopods die
Speaker 1: because of all of the acid, and they're obliterated, and
Speaker 1: the larva come forth, burst free, survive somehow in our stomach,
Speaker 1: travel down into our small intestine, and then burrow their
Speaker 1: way out of the small intestine and into the wall
Speaker 1: of our abdomen.
Speaker 3: What it's terrifying. It is truly like the movie Ali, Yes,
Speaker 3: but just a little much smaller scale.
Speaker 1: The tiniest dragon of scale.
Speaker 3: Which is actually really funny because there's a documentary I
Speaker 3: watched which is narrated by a Sigourney Weaver about guinea worm.
Speaker 1: Yeah, oh my gosh, that's phenomenal. Okay, so now these
Speaker 1: tiny larval worms are in basically like the connective tissue
Speaker 1: layers of your abdominal wall, your belly wall, and there
Speaker 1: is where they will begin to mature into fully adult worms.
Speaker 1: And these worms have male worms and female worms, and
Speaker 1: they will mate and then the females will grow and
Speaker 1: grow and grow and become all full of millions of eggs.
Speaker 1: And this is a process that takes many, many months.
Speaker 1: And then over the course of these months, as her
Speaker 1: eggs mature into embryos, she will then travel down through
Speaker 1: our connective tissue, down and down and down to the
Speaker 1: lower limbs like your leg, usually your ankle or your foot,
Speaker 1: although she could travel anywhere because she's basically just under
Speaker 1: your skin, just like in the fatty tissue underneath your skin.
Speaker 1: And these little worms are migrating through down into your
Speaker 1: lower extremities. And then ten to fourteen months after somebody
Speaker 1: drinks these copapods, this fully engorged female worm, which is
Speaker 1: now seventy to one hundred centimeters long, that's up to
Speaker 1: a meter long.
Speaker 3: Very long.
Speaker 2: It's just very long.
Speaker 1: It started in like microscopic and now it's a meter long. Okay.
Speaker 1: Then they come all the way forth to the surface
Speaker 1: of your skin, and in doing so it produces a blister.
Speaker 1: And this blister is incredibly incredibly itchy, like unbearably itchy,
Speaker 1: and it's burning, and it's really uncomfortable, so much so
Speaker 1: that the only thing you want to do to try
Speaker 1: and stop the itch is submerge your foot in cool,
Speaker 1: cool water. So you find a pond and you do that,
Speaker 1: and as soon as your foot enters the pond, that
Speaker 1: worm contracts and she pushes up, and she bursts forth
Speaker 1: and literally pushes open part of her gravit uterus out
Speaker 1: of the blister, bursts open and expels upwards of five
Speaker 1: hundred thousand larval worms into the water, thus completing her
Speaker 1: life cycle.
Speaker 3: It's incredible, It is incredible. So seems like otherworldly. Absolutely
Speaker 3: seems like this is everything about it.
Speaker 1: Is mind blowing. It's it really is. Nematodes in general,
Speaker 1: I think are absolutely mind blowing creatures.
Speaker 3: Like I genuinely am fascinated by them.
Speaker 1: Same So I said that she bursts forth and releases
Speaker 1: all these larval worms, that's not the end of her story.
Speaker 1: That's just what happens the very first time that she
Speaker 1: comes into contact with water. But now she is partially
Speaker 1: freed from your skin. Literally part of this female worm
Speaker 1: is sticking out of you. And then every time that
Speaker 1: she's submerged in water, she'll release more larva, and the
Speaker 1: part that's outside of your body will kind of just
Speaker 1: shrivel up and die, and then a little bit more
Speaker 1: of her will emerge every day, every day, every day,
Speaker 1: until finally she is completely gone and has released I
Speaker 1: don't know, more than like three million larval worms into
Speaker 1: the environment.
Speaker 3: Whoa mm hm.
Speaker 2: It's a journey.
Speaker 1: Yeah, it's a real journey.
Speaker 2: Okay.
Speaker 3: So number one, what happens to the male? Ooh, great question,
Speaker 3: because he's just floating around in there somewhere.
Speaker 1: Pretty much just floating around. Yeah, you can sometimes get
Speaker 1: like a small inflammatory response from wherever he ends up,
Speaker 1: but usually he just sort of your body will just
Speaker 1: sort of calcify him, and then you'll just have a
Speaker 1: little like boop of calcium some deposit somewhere in your body.
Speaker 3: Nothing much does the where he ends up dying? Can
Speaker 3: that be problematic in terms of like if he ends
Speaker 3: up in a joint?
Speaker 1: Oh, Aaron, you are getting so far ahead. Okay, we'll
Speaker 1: just put a pin in it all right.
Speaker 3: My next question is how does the female know where
Speaker 3: to go?
Speaker 1: No? Idea, great question, I don't. It is the weirdest
Speaker 1: it is the weirdest thing, and all of the things
Speaker 1: that I read were She's just like, yeah, most of
Speaker 1: the time it's from the lower limbs, but it could
Speaker 1: be anywhere. I think that there's some thought that they
Speaker 1: travel in part along like lymphatic routes. So if they
Speaker 1: just get on the right lymphatic tract in your abdomen,
Speaker 1: a lot of your lymphatics are going to be draining
Speaker 1: down to your legs, or like your lymphacts from your
Speaker 1: legs are going to be draining up towards your abdomen.
Speaker 1: So it kind of makes sense they're if they're in
Speaker 1: your lower abdomen already that they just sort of end
Speaker 1: up going down to your legs. Gotcha, gotcha?
Speaker 3: Okay, And my other question pertains to the longevity of
Speaker 3: these worms. So good ten to twelve months, and that's
Speaker 3: typically just in correspondence with like a rainy, dry season
Speaker 3: in the places where these are most abundant.
Speaker 1: Probably good question, very good question. Yeah, So there is
Speaker 1: definitely seasonal dynamics in terms of transmission, but whether people
Speaker 1: are more likely to get infected in the wet or
Speaker 1: the dry season depends on where they live and what region.
Speaker 1: So in some parts of the world, transmission is highest
Speaker 1: during the rainy season if it's areas where people are
Speaker 1: primarily using ponds as their water sources that are otherwise
Speaker 1: dry during the dry season, right okay, But in other
Speaker 1: places that are maybe more wet in general, where you
Speaker 1: have step wells or other types of cisterns, then transmission
Speaker 1: tends to be highest in the dry season or right
Speaker 1: before the rainy season starts, at the very end of
Speaker 1: the dry season, because at that time the water quality
Speaker 1: supports higher numbers of copapods. The water is less turbid,
Speaker 1: and there's not as many streams washing things away, so
Speaker 1: the copapods aren't as dilute as they would be during
Speaker 1: the rainy season when water levels are high.
Speaker 3: That makes sense, isn't that ecology?
Speaker 1: There?
Speaker 2: You go? So cool, it's very interesting.
Speaker 1: Okay, but that didn't answer your question. So the worms
Speaker 1: live a long time?
Speaker 3: Yeah, yeah, I guess I'm thinking like other species of nematodes,
Speaker 3: they mature a lot more quickly, right, yeah, than that,
Speaker 3: And so I wonder whether it does seem to be
Speaker 3: more in correspondence with like the timing of the dry
Speaker 3: and the rainy season.
Speaker 1: Yeah, yeah, that makes sense because pretty much across the board,
Speaker 1: even though in some places it's the wet season and
Speaker 1: in some places it's the dry season. Either way, we
Speaker 1: definitely see seasonal trends, so that does make sense. Yeah, cool, yeah,
Speaker 1: all right, okay, so that was that was just the worm, right, right,
Speaker 1: that was just the life cycle of the worm. We're
Speaker 1: missing like the human part of it, right, These are
Speaker 1: humans that are being infected, So what the heck is
Speaker 1: going on in you? Let's find out tell me, okay.
Speaker 1: So for some people, the first sign of infection might
Speaker 1: be noticing the worm itself, right, just kind of beneath
Speaker 1: the skin, a few days before it emerges, kind of
Speaker 1: as it's traveling down. For others, and very commonly, it's
Speaker 1: kind of a more generalized kind of allergic type symptoms,
Speaker 1: so maybe hives, maybe a bit of a fever, some
Speaker 1: swelling under your eyes, kind of like you might think
Speaker 1: I have an allergy to something.
Speaker 3: But all of this would be still around the time
Speaker 3: of its emergence.
Speaker 1: Of its emergence, right, not of when you get infected.
Speaker 1: Pretty much, there's basically no symptoms when you first get infected.
Speaker 1: So this is a year after you drink the larvae. Okay,
Speaker 1: But for most people, the very first indication of infection
Speaker 1: is the blister. And like we said, already, eighty to
Speaker 1: ninety percent of the time, it's on the legs or
Speaker 1: the feet, and it usually starts pretty small, but it
Speaker 1: grows fairly rapidly. It can grow over a number of
Speaker 1: hours or over a couple of days. And the blister
Speaker 1: before it opens is sterile, So it's not filled with
Speaker 1: like puss and bacteria like a pimple kind of blister.
Speaker 2: Right, it's just clear.
Speaker 1: It's clear liquid, it's inflammatory fluid, and it's filled filled
Speaker 1: with larva worm. So the female starts to release larval
Speaker 1: worms underneath your skin as part of the formation of
Speaker 1: the blister.
Speaker 3: So we're not quite sterile, is it.
Speaker 1: Well, yeah, it doesn't grow bacteria, is what we mean
Speaker 1: by sterile. And what's so interesting is that it's not
Speaker 1: entirely clear, like pathologically what causes the formation of the blister,
Speaker 1: like whether it's the adult worm releasing enzymes that cause
Speaker 1: tissue death, or whether it's the embryos the larva themselves
Speaker 1: that are causing the tissue damage, which I think is
Speaker 1: really interesting that we still just don't quite understand.
Speaker 3: Well. I also think you know to jumping ahead a
Speaker 3: little bit, but that there's probably a lot that we
Speaker 3: don't know about the biology or the ecology of this
Speaker 3: simply because it's not directly relevant to the control right
Speaker 3: of the parasite exactly.
Speaker 1: I think there is so much of this that we
Speaker 1: just don't know because it hasn't been studied because we
Speaker 1: didn't technically need to quote unquote to get it under control. Right, Yeah, okay,
Speaker 1: So now you have this blister, and then it'll start
Speaker 1: to open. So very often it opens at first in
Speaker 1: contact with water, because that does produce in the female
Speaker 1: worm this intense contraction where she pushes herself forth. But
Speaker 1: it is possible to have the blister break open even
Speaker 1: if you don't put your feet in water. So now
Speaker 1: you have this female worm half sticking out of a
Speaker 1: wound in your foot, and basically the only way to
Speaker 1: get her out is to slowly pull her out in
Speaker 1: a process that can take usually at least a month,
Speaker 1: where you slowly twist the worm around a small stick
Speaker 1: yep And that's why we have a gummy worm in
Speaker 1: our quarantini.
Speaker 3: It is indeed, if anyone still even wants to make
Speaker 3: it after that, after the script.
Speaker 1: Of a worm coming out of your foot that you're
Speaker 1: wrapping around a stick slowly over the course of a month, Okay,
Speaker 1: And that is the best case scenario, right, That's not
Speaker 1: what always happens. More than fifty percent of the time,
Speaker 1: the wound itself is complicated by a secondary bacterial infection.
Speaker 1: And there's a whole bunch of different ways that this
Speaker 1: can happen. Okay. So when the worm is happily living
Speaker 1: under the surface of your skin, in your subcutaneous tissue,
Speaker 1: it's in this little worm house, Okay. So it forms
Speaker 1: like this little fibrous worm sheath around itself, and that's
Speaker 1: how it can move without getting stuck to your tissues,
Speaker 1: like because of our inflammatory response. Okay, whoa, Yeah, it's
Speaker 1: that really cool, which I think is probably part of
Speaker 1: why it takes so long to travel down, right, It's
Speaker 1: not just like swimming through. It's like slowly moving its
Speaker 1: little sheath within its sheath.
Speaker 2: Oh my god.
Speaker 1: Okay wow. Yeah, But once it starts to emerge and
Speaker 1: it breaks through our skin, then our inflammatory response can
Speaker 1: really start to kick in and it can form adhesions
Speaker 1: to the worm itself rather than the sheath, which can
Speaker 1: complicate the removal and make it harder because it's stuck
Speaker 1: to our tissues. So if the worm gets broken during
Speaker 1: the extraction process, because it's quite a fragile little worm,
Speaker 1: then what's left of the worm in your body kind
Speaker 1: of withdraws back into its little sleeping bag and it
Speaker 1: brings with it all the bacteria from the outside of
Speaker 1: your skin, so stapf oureus e, coal like anything living there.
Speaker 1: So then you can get deep tissue infections because of that.
Speaker 1: But you also could get an infection even if you
Speaker 1: don't break off the worm right, just because you have
Speaker 1: this open wound and it's on a place like your
Speaker 1: foot or your ankle that's in contact with like the environment,
Speaker 1: right right. Tetanus is also a very real and very
Speaker 1: common complication, so secondary infection with a Claustridium species that
Speaker 1: produces tetanus toxin and then you end up with tetanus
Speaker 1: because of this. So that's kind of the most common
Speaker 1: complication of guinea worm infection. But it's also possible, like
Speaker 1: you mentioned aarin in your jumping ahead, for the worm
Speaker 1: to get a little bit lost on its way to
Speaker 1: try and emerge, So whether that means it makes it
Speaker 1: to your skin, but for some reason can't quite penetrate
Speaker 1: through your skin, which can happen. Then what will happen
Speaker 1: there is the worm just kind of becomesied with our
Speaker 1: own immune response, which wouldn't be a problem if it's
Speaker 1: just like say, in the subcutaneous tissue of your abdomen
Speaker 1: or your arm, but if it's in an important organ
Speaker 1: like your pancreas or your heart, or like you mentioned,
Speaker 1: aaron in your joint space, then you could end up
Speaker 1: with arthritis. It can also lead to deep abscesses. So
Speaker 1: even though I said that this blister is sterile, quote unquote,
Speaker 1: quote unquote, if the worm begins to release the embryos
Speaker 1: or the larva in your deep tissue, it will cause
Speaker 1: a really dramatic inflammatory response, and that will lead to
Speaker 1: a serious abscess where you would find a lot of
Speaker 1: puss and white blood cells and things like that. You
Speaker 1: still wouldn't find bacterial infection, but it would be full
Speaker 1: of larva. Right, And so overall, the reported period of
Speaker 1: kind of incapacitation due to this infection on average is
Speaker 1: eight and a half weeks, but that range is from
Speaker 1: two to sixteen weeks or even longer, and it really
Speaker 1: depends on how many worms you're infected with or whether
Speaker 1: you get a secondary infection and things like that, because
Speaker 1: ps getting infected with one worm doesn't prevent you from
Speaker 1: getting infected with multiple worms.
Speaker 3: Right, there's no immunity, Yeah, exactly.
Speaker 1: So usually most of the time people get infected with
Speaker 1: like one to three worms that emerge at a time,
Speaker 1: but some reports have found up to forty worms emerging
Speaker 1: from one person at a time, which just sounds unimaginably awful.
Speaker 2: Yeah.
Speaker 5: Yeah, yeah, because yeah, even like I said, in the
Speaker 5: best case scenario where you have a worm that emerges
Speaker 5: without any complications or infection, this is.
Speaker 1: A very painful process. You're slowly winding a worm, a
Speaker 1: living worm, out of your tissue in your leg. There's
Speaker 1: nerve pain, there's itching, there's burning, it's it's extremely painful.
Speaker 3: Yeah, just even getting around, like even not just the
Speaker 3: process of pulling the worm.
Speaker 2: Out, but like walking.
Speaker 1: Yeah, it's really painful and challengery painful. Yep, that's it, Aaron,
Speaker 1: that's biology. Okay, do you have any other questions for me?
Speaker 2: I don't think so.
Speaker 1: Well. Good, So, Aaron, where did this worm come from? Why? Why?
Speaker 1: I didn't mention this? But it only infects humans for
Speaker 1: the most part. Why how did it find us? Where
Speaker 1: did it come from? What are we doing about it?
Speaker 3: What?
Speaker 1: Tell me everything?
Speaker 3: I can't wait to right after this break? All right,
Speaker 3: it's kind of funny that you ask me where does
Speaker 3: it come from? And why does it only infect humans
Speaker 3: and etc. Because, to be honest, I couldn't find a
Speaker 3: ton on the evolutionary history of it, except for just like,
Speaker 3: here's the phylogeny of these worms, and so, you know,
Speaker 3: to answer those questions, I don't really know.
Speaker 2: I know that it's been with humans.
Speaker 3: For a very very long time, and it actually does
Speaker 3: seem to infect other animals, maybe not as readily as
Speaker 3: it does humans, but the infection in dogs seems to
Speaker 3: be a problem that's contributing to some of the difficulties
Speaker 3: in the complete eradication. So yes, yeah, yeah, I don't know. Anyway,
Speaker 3: I'm sorry, I wish I had more. If anyone has
Speaker 3: any great evolution Dracunculus Menaden says, evolution papers, please send
Speaker 3: them our way.
Speaker 2: I'd like to know.
Speaker 3: Yeah, okay, So, but the history of guinea worm has
Speaker 3: got all of the other usual suspects mummies, fun etymology, imperialism,
Speaker 3: and more and it's maybe the most classic disease quote
Speaker 3: unquote that we've had in a while. Yeah, So if
Speaker 3: you're playing tpwky bingo, get your cards ready.
Speaker 1: I love it all Right, let's begin ancient Realm to.
Speaker 3: Rome, to ancient Rome. Actually, let's go back even earlier
Speaker 3: erin because this this worm seems to have been known
Speaker 3: to humans for basically all of written history.
Speaker 2: And it makes an appearance in you might guess the.
Speaker 3: Ebers Papyrus Ebers for virus. They go there, we go
Speaker 3: Bengo number one. That's from around fifteen fifty BCE, by
Speaker 3: the way, so it's.
Speaker 1: Very old, very old.
Speaker 3: And so researchers think that the rare and obscure verb dqr,
Speaker 3: which is just like all one word together, refers to
Speaker 3: the pulling and spinning of the worm for its removal.
Speaker 1: Huh yeah, just like they had a specific verb that meant.
Speaker 3: That, right, And so like researchers were like, well, it
Speaker 3: kind of looks like it's referred to with like a
Speaker 3: spindle against one's leg, but it's also meant to something
Speaker 3: beneath the surface, and so they think it refers to
Speaker 3: the removal of the guinea worm. Using that method, huh.
Speaker 3: And there's also evidence to support this, or to support
Speaker 3: at least the fact that guinea worm was present in
Speaker 3: ancient Egypt, because a calcified worm was found in a
Speaker 3: mummy of a thirteen year old female from one thousand
Speaker 3: BCE roughly who had died shortly after her lower legs
Speaker 3: had been amputated, oh right, which some researchers have speculated
Speaker 3: was done to try to save her from the secondary
Speaker 3: infections that you mentioned.
Speaker 1: Oh my cause by the worms.
Speaker 2: Wow.
Speaker 1: Yeah.
Speaker 3: And then of course there's the Biblical mention. So in
Speaker 3: the Old Testament in numbers twenty one to six, which
Speaker 3: is thought to have been written around the eighth century BCE,
Speaker 3: there's this line, then the Lord sent fiery serpents among
Speaker 3: the people, and they bit the people, so that many
Speaker 3: people of Israel died. And so this is where the
Speaker 3: worm gets its fiery serpent nickname that you've probably come.
Speaker 1: Across, so that they think is Dracunculus worm. Fascinating, uh huh.
Speaker 2: Yeah.
Speaker 3: And the Ebers Papyrus and the Bible aren't the only
Speaker 3: ancient texts to mention guinea worm. There's also talk of
Speaker 3: the worm in ancient Greece and ancient Rome. For instance,
Speaker 3: there's this from around forty six to one twenty CE quote,
Speaker 3: the people who live near the Red Sea are tormented
Speaker 3: by an extraordinary and hitherto unheard of disease. Small worms
Speaker 3: issue from their bodies in the form of serpents, which
Speaker 3: gnaw their arms and legs. When these creatures are touched,
Speaker 3: they withdraw themselves and insinuating themselves between the muscles give
Speaker 3: rise to horrible sufferings.
Speaker 1: One hundred percent guinea worm.
Speaker 2: One hundred percent.
Speaker 3: And it was Galen who gave the infestation its first name, dracontiasis.
Speaker 3: And one more thing.
Speaker 1: So you're getting to my favorite part yet, I think
Speaker 1: it might be right now, Okay, good, this might be it.
Speaker 3: I'm sure you've heard it said before that the staff
Speaker 3: of Esculpius had Asclepius, which is that symbol that you
Speaker 3: often see associated with medicine and medical things. It's basically
Speaker 3: a singular snake winding around a rod. It's been said
Speaker 3: that the snake actually represents a guinea worm.
Speaker 2: Some people hypothesize.
Speaker 1: That's my favorite. It's my absolute favorite. It's so much
Speaker 1: better than it being like just a random snake like
Speaker 1: it has to be guinea worm. Of course it's guinea worm.
Speaker 3: Well, there are there are other hypotheses, so before I
Speaker 3: get to those, the WHO logo actually has the staff
Speaker 3: of Asclepias on it, and side note a lot of
Speaker 3: the times you'll see and I was always confused that
Speaker 3: the caducius, which is like two snakes and the wings,
Speaker 3: that's actually something.
Speaker 1: Else, that's Hermes.
Speaker 3: That's Hermes, right, and so that refers to more like
Speaker 3: messaging or trade or commerce, information flow, et cetera. But
Speaker 3: the other thing that I think is really interesting about
Speaker 3: the staff of Asclepias or the rod of Asclepias is
Speaker 3: that Asclepias was this Greek god that was associated with
Speaker 3: medicine and healing, and so some people hypothesize that the
Speaker 3: snake was like part of the healing process is shedding
Speaker 3: of the skin and becoming like that renewal, and so
Speaker 3: that's why they think the snake might represent. Besides ginea worm.
Speaker 1: I don't like it as much.
Speaker 2: I'm just you don't have to like it.
Speaker 1: You're just the messenger.
Speaker 3: I'm just the hermes of Okay. So whether or not
Speaker 3: the rot of Asclepias truly represents guinea worm, it does.
Speaker 3: From all of these ancient references to the parasite, we
Speaker 3: can at least tell that it was pretty prevalent across
Speaker 3: the tropical and parts of the subtropical regions of the
Speaker 3: Old World. And while most of these ancient folks seem
Speaker 3: to recognize it as a parasite so as like an animal,
Speaker 3: a creature that has somehow invaded your body and is
Speaker 3: now causing you harm, others, including the famous Avicenna, weren't
Speaker 3: as convinced, instead claiming it was actually a vein gone awry.
Speaker 1: Interesting m hm. Yeah.
Speaker 3: He did give it a name that would stick with
Speaker 3: the worm until present day, though, the Medina sickness or
Speaker 3: the Medina vein, because apparently it was quite prevalent in Medina,
Speaker 3: which is a city in western Saudi Arabia.
Speaker 1: Like that funky called Medina.
Speaker 3: The funky worm from Medina. Oh okay anyway, So the
Speaker 3: scientific name of guinea worm, which was given by Linnaeus
Speaker 3: in the mid seventeen hundreds, is Dracunculus medinensis. So, as
Speaker 3: we mentioned, from the Latin draco meaning dragon or serpent
Speaker 3: and medenensis meaning from funky cold Medina.
Speaker 1: Wait, Draco means serpent like Draco Malfoyd meant literally serpent
Speaker 1: or dragon.
Speaker 2: Yeah.
Speaker 1: I never knew that, Okay, sorry.
Speaker 2: Yeah, no, I didn't know that either. Yeah.
Speaker 3: So basically its scientific name means little dragon from Medina.
Speaker 1: Okay, it's kind of cute. Yeah.
Speaker 3: As travel and trade expanded throughout the sixteenth and seventeenth centuries,
Speaker 3: reports of the worm became more numerous, as did hypotheses
Speaker 3: about its nature. Was it an animal or was it
Speaker 3: just part of your body? Its life cycle, and how
Speaker 3: a person became infected in the first place. And it
Speaker 3: was also during this time that it was first called
Speaker 3: guinea worm, as it was seen in super high numbers
Speaker 3: along the west coast of Africa. The Transatlantic slave trade
Speaker 3: also led to the introduction of the worm in parts
Speaker 3: of North, central and South America, but it doesn't seem
Speaker 3: that local transmission was sustained for very long after that
Speaker 3: mid eighteen hundreds, possibly because of environmental conditions, possibly because
Speaker 3: the right copopod species weren't there. I don't really know
Speaker 3: for sure, Okay, But throughout the eighteen hundreds and early
Speaker 3: nineteen hundreds, the rapid expansion of travel and in particular, colonization,
Speaker 3: led to a heightened interest in the parasite in India
Speaker 3: and parts of Africa, for instance, British officers reported seeing
Speaker 3: cases of infestation among the military serving there, and so
Speaker 3: as you might expect, this led to calls for doing
Speaker 3: something about this guinea worm problem. Although the association between
Speaker 3: the parasite and water had long been recognized, especially in
Speaker 3: places where it had been prevalent for basically all of
Speaker 3: human history, there still wasn't a very clear understanding of
Speaker 3: how exactly they were connected and whether there were any
Speaker 3: other players in the game. In the eighteen seventies, a
Speaker 3: Russian parasitologist named Alexei Faedchenko getting his start just as
Speaker 3: the field of parasitology was taking off. What an exciting time.
Speaker 3: We would never have been allowed to pursue this career.
Speaker 3: So Fedchenko was encouraged by leading hell mythologist Rudolph Lukart
Speaker 3: to look at the possibility that infected copa pods might
Speaker 3: be harboring the larvae of the worm in eighteen what
Speaker 3: now erin eighteen seventies they were.
Speaker 1: Like, hmm, pretty sure it's a copa pod.
Speaker 3: What well, So this guy, Rudolph Lukart, he had he
Speaker 3: had either discovered this or learned about this in another
Speaker 3: species of worm. Isn't that using copopods as an intermediate host? Yeah,
Speaker 3: it's yeah.
Speaker 1: Like I know that we've talked about like early discoveries
Speaker 1: like this before, but it is still blows my mind
Speaker 1: that people could figure out a life cycle as complex
Speaker 1: as this. Oh just you wait, oh gosh, okay, just
Speaker 1: you wait. Okay.
Speaker 3: So so yeah, So Fedchenko looked and sure enough, within
Speaker 3: some species of Cyclops copapods that he had found in
Speaker 3: contaminated drinking water, he found larval worms that he thought
Speaker 3: might be the intermediate stage of guinea worm.
Speaker 1: There you go, incredible.
Speaker 3: And then he was like, all right, you know what,
Speaker 3: Humans probably become infected when they drink water containing these
Speaker 3: infested copopods.
Speaker 1: Because that's logical.
Speaker 3: Yeah, And he was like, I'm going to try to
Speaker 3: show this experimentally, So I'm going to give some infected
Speaker 3: copapods to cats and dogs. But they never developed the infection.
Speaker 1: Mm, they didn't.
Speaker 3: And so his hypothesis just kind of sat there quietly
Speaker 3: in the parasitology journals for a couple of decades, while
Speaker 3: others argued that it infected humans by boring into their
Speaker 3: skin directly kind of like you know, a La hookworm,
Speaker 3: a La hookworm. Meanwhile, in Britain's colonies in Africa, guinea
Speaker 3: worm continued to pose a threat to productivity and political stability.
Speaker 1: Oh gosh.
Speaker 3: And so the Committee of the London School of Tropical
Speaker 3: Medicine asked, fresh out of medical school with basically no
Speaker 3: research training, twenty four year old parasitologist Robert Leiper, whom
Speaker 3: you may remember from Marcs to Semius this episode, I
Speaker 3: don't that's okay. I just remember the name and that's it.
Speaker 3: And now I'm wondering did I pronounce it differently in
Speaker 3: that episode? So anyway, they asked Leper to head to
Speaker 3: Accra and Ghana to learn more about the parasite so
Speaker 3: that it could be controlled. And he entered this field
Speaker 3: of conflicting hypotheses and big egos and made frankly incredible
Speaker 3: progress towards understanding the key components of the parasite that
Speaker 3: would allow for its dramatic to cline in prevalence over
Speaker 3: the next one hundred years. Wow, most of that decline
Speaker 3: was concentrated in the last couple decades. But anyway, first
Speaker 3: of all, he demonstrated that no the larval worms do
Speaker 3: not burrow into your flesh. He fed a monkey bananas
Speaker 3: that contained infested copa pods, and then he waited six
Speaker 3: months and carried out a post mortem that showed that, yes, indeed,
Speaker 3: there were some Dracunculus medinensis in the monkey. Next, are
Speaker 3: you laughing at the banana?
Speaker 1: Yeah, the banana. I don't know why that's so funny.
Speaker 3: I don't know either. I don't know either, Like.
Speaker 1: You can't just put it in his water, like, you've
Speaker 1: got to add it to the banana.
Speaker 3: That's what That's what made me include that that detail.
Speaker 3: I was like, it's not just feeding them infested copa pods,
Speaker 3: it's the banana.
Speaker 1: The banana.
Speaker 3: Well, And then next Leper ruled out that it was
Speaker 3: any other intermediate host besides copopods. He then decided to
Speaker 3: do a series of experiments showing under what environmental conditions
Speaker 3: the larvae can live, the timeline of their maturation, and
Speaker 3: he mimicked conditions of the human stomach. He made an
Speaker 3: acidic solution to show how the copopods are killed, allowing
Speaker 3: the larvae to burst forth and then continue their passage
Speaker 3: through the human body. He did this in what year now,
Speaker 3: nineteen oh five what on earth? And so From all
Speaker 3: of this, he concluded that quote, the young larvae must
Speaker 3: be discharged directly into fresh water soon after the parent
Speaker 3: worm has succeeded in creating a break in the overlying skin,
Speaker 3: and before the wound has become markedly septic. The embryos
Speaker 3: must find a cyclops Within.
Speaker 2: A few days.
Speaker 3: They must moreover, succeed in entering its body cavity. Five
Speaker 3: weeks later, they will have developed into mature larvae. They
Speaker 3: must therefore be taken into a human stomach, and, having
Speaker 3: been set free from their host by the gastric juice,
Speaker 3: reached the connective tissues by penetrating the gut wall.
Speaker 1: Wow, I mean everything. I described everything.
Speaker 3: And so basically, within two years of his arrival, the
Speaker 3: twenty four year old had essentially laid out in impressive
Speaker 3: detail the life cycle of this parasite.
Speaker 2: Also, he didn't stop there.
Speaker 1: They never do never.
Speaker 3: Lbird took this information and made recommendations for its control, basically,
Speaker 3: clean the water to eliminate the worm. He also stressed
Speaker 3: the importance of knowing the seasonality of infection, timing of
Speaker 3: dry seasons and wet seasons, and where people get water
Speaker 3: as crucial in knowing where and when water supplies are
Speaker 3: most likely to be infested.
Speaker 1: Oh my goodness.
Speaker 2: Uh huh.
Speaker 3: He also recommended filling in surface water and shallow wells,
Speaker 3: getting rid of step wells where people have to descend
Speaker 3: to get water, and instead using draw wells, artesian wells,
Speaker 3: or pipes from rapidly flowing streams.
Speaker 1: Wow.
Speaker 3: And finally, just the cherry on top, he suggested that
Speaker 3: certain fish species might be a great way to naturally
Speaker 3: control the copa pods and hence the disease.
Speaker 1: Oh my gracious, uh huh. Wow.
Speaker 3: And so all of this he did in a couple
Speaker 3: of years, and then he like wrote a couple of
Speaker 3: papers and then didn't do anything with guinea worm ever.
Speaker 1: Again He's like, I did it all. I'm done, guys,
Speaker 1: I solved it. Just do it.
Speaker 2: I mean, kind if.
Speaker 1: I mean he was wrong.
Speaker 3: Yeah, And so after that he just went to hookworms
Speaker 3: and shisto and wow, that was it.
Speaker 2: And yeah.
Speaker 3: So I think that's That's one thing that I find
Speaker 3: so fascinating about guinea worm is that so much of
Speaker 3: the information that we use today to control guinea worm
Speaker 3: is literally ancient, or at the very least like old knowledge,
Speaker 3: right like in over one hundred years old, over one
Speaker 3: hundred years old, sometimes over three thousand years old. Wow.
Speaker 1: Yeah.
Speaker 2: In the early.
Speaker 3: Nineteen hundreds, the development of certain arsenical treatments for other
Speaker 3: worm we parasites led to some researchers trying them out
Speaker 3: on guinea worm, but none worked very well or they
Speaker 3: caused greater problems because then the worm would die in
Speaker 3: a joint or something, and then, as you mentioned, all
Speaker 3: of the horrible effects that can come from that right
Speaker 3: like on its way down. And then even if those
Speaker 3: side effects weren't an issue, there was the aspect of
Speaker 3: getting access to any potential treatments and the financial aspect
Speaker 3: of that as well. The method described in the Ebers
Speaker 3: Papyrus from fifteen fifty BCE of winding the worm around
Speaker 3: a stick to remove it, that's what we use today
Speaker 3: twenty twenty, twenty twenty. I mean, that's incredible to me.
Speaker 1: Yeah. Yeah.
Speaker 3: The connection between water and the parasite was long known
Speaker 3: in the areas where the parasite has been historically most abundant,
Speaker 3: even while Western researchers were fighting amongst themselves over whether
Speaker 3: it was from water or from the grass or from
Speaker 3: this or that, and the larger scale control efforts that
Speaker 3: we use still follow the same principles that Robert Leiper
Speaker 3: laid out in nineteen oh seven, which brings me to
Speaker 3: the last part of the history, yes, the eradication campaign.
Speaker 3: Although by the early nineteen hundreds the information needed to
Speaker 3: make serious progress towards controlling guinea worm was there, the
Speaker 3: disease remained neglected for almost seven decades, receiving little to
Speaker 3: no priority in national or international health campaigns for many reasons.
Speaker 3: Certainly part of it was that the populations that were
Speaker 3: most affected were often poverty stricken in rural, hard.
Speaker 2: To reach areas.
Speaker 3: But another aspect is that there were or are often
Speaker 3: many other diseases that had higher mortality rates or prevalence
Speaker 3: or both, so this was just lower on a priority chain. Yeah,
Speaker 3: there were some regional eradication efforts made during those seventy years,
Speaker 3: and other places made larger infrastructural changes to the water
Speaker 3: supply that essentially eliminated guinea worm, even if that was
Speaker 3: not one of the primary intended goals. But it was
Speaker 3: only in nineteen eighty one when the United Nations added
Speaker 3: guinea worm to the United Nations International Drinking water supply
Speaker 3: in sanitation decade. It was only in that year that
Speaker 3: the pair site was featured in an international elimination plan HUH,
Speaker 3: and so the Carter Center was founded a year after
Speaker 3: this was added to this elimination plan in nineteen eighty two,
Speaker 3: and one of its goals was the eradication of guinea worm,
Speaker 3: a cause that former President Jimmy Carter became very interested
Speaker 3: in after a trip to West Africa in their early
Speaker 3: nineteen eighties in which he witnessed some of the devastating
Speaker 3: effects of the infection. With the Carter Center's involvement, in
Speaker 3: nineteen eighty six, the WHO added support to the campaign
Speaker 3: to eradicate the infection, but one of the biggest challenges
Speaker 3: in this plan was the lack of accurate surveillance data.
Speaker 3: A survey in nineteen eighty six revealed that the disease
Speaker 3: was endemic in twenty countries, most of which were in Africa,
Speaker 3: and there were an estimated three point five million cases.
Speaker 3: The economic strain caused by the infection, as well as
Speaker 3: the relatively inexpensive methods of control, led to both continued
Speaker 3: support of the initiative as well as rapid progress in
Speaker 3: the control of the parasite. Still setbacks occurred in the
Speaker 3: shape of logistical difficulties, political instability, financial or technological shortcomings,
Speaker 3: but despite these, within four years, the number of estimated
Speaker 3: cases fell from three point five million in nineteen eighty
Speaker 3: six to eight hundred and ninety two thousand in nineteen
Speaker 3: ninety and then in twenty fifteen, twenty two.
Speaker 1: Oh oh m hmm, okay, yeah, I know.
Speaker 3: There's more to There's no more to that story which
Speaker 3: you're going to pick up one. But and so, although
Speaker 3: you know twenty fifteen it sounds pretty great to only
Speaker 3: have twenty two cases, and each year seems to bring
Speaker 3: an article with the headline guinea worm radication.
Speaker 2: Could it be this year?
Speaker 3: But complete elimination has remained just out of grasp. And
Speaker 3: so Aaron, yeah, that's where I'll leave off and leave
Speaker 3: it to you, okay, to tell us.
Speaker 2: What's going on with guinea worm today?
Speaker 1: Right after this break so Erin, you asked for me
Speaker 1: to tell you what's going on with guinea worm today,
Speaker 1: but I'm not going to do that because, as we
Speaker 1: mentioned in our intro, we were fortunate enough to talk
Speaker 1: with Sarah Urian, the senior associate director for the Guinea
Speaker 1: worm eradication program at the Carterson who obviously knows a
Speaker 1: lot more than I do about what's going on today.
Speaker 1: So I am thrilled to introduce her and we'll let
Speaker 1: her tell us all what's been going on. Awesome.
Speaker 4: My name is Feri Urian and I am the senior
Speaker 4: Associate director for the Guinea worm eradication program at the
Speaker 4: Carter Center. And I started this job about a year
Speaker 4: ago following six years working with the Carter Center and
Speaker 4: the Guinea room eradication program in South Sudan, a few
Speaker 4: years as a technical advisor in the field and then
Speaker 4: my last three years in South Sudan as the country
Speaker 4: representative for the program in South Sudan. And so now
Speaker 4: here at headquarters work with the team here to provide
Speaker 4: support to the country programs in the remaining endemic countries,
Speaker 4: which is Chad, South Sudan, Ethiopia, Molly and now Angola.
Speaker 2: Awesome.
Speaker 3: Thank you so very much for taking the time to
Speaker 3: chat with us.
Speaker 2: We really appreciate it.
Speaker 3: So could you start us off by telling us a
Speaker 3: little bit about the history of the Guinea worm or
Speaker 3: radication program and sort of what kind of work was
Speaker 3: being done in the early days there in terms of
Speaker 3: systems that were put into place for surveillance or direct
Speaker 3: care and field work, those sorts of things.
Speaker 4: So guinea worm, though it's not a deadly disease, it
Speaker 4: does cause debilitating pain when it's emerging from the body
Speaker 4: and then also during the healing process, and particularly if
Speaker 4: there has been a secondary infection associated with the emergence
Speaker 4: of that worm. And so this disease is something that
Speaker 4: was devastating communities and there were even parts of West
Speaker 4: Africa where it was called the disease of the empty granary.
Speaker 4: And so with simultaneously we're having the success of the
Speaker 4: smallpox eradication campaign and the nineteen seventies, the global community
Speaker 4: was looking for what might be next. And so now
Speaker 4: you have guinea worm disease which is devastating communities, and
Speaker 4: it's also a disease that potentially meets the criteria for eradications.
Speaker 4: And also, you know, there was an assessment done by
Speaker 4: the World Bank where they determined that actually the cost
Speaker 4: of the eradication campaign would be less than the costs
Speaker 4: that are associated with the socioeconomic impact of not eradicating
Speaker 4: guinea worm. And I think that's a critically important part
Speaker 4: of that consideration, and there was also sufficient funding and
Speaker 4: sustained political will, and so with all of that factors
Speaker 4: and the devastating impact of guinea worm on communities, that's
Speaker 4: how it was taken on as the next disease to
Speaker 4: try to eradicate. When we talk about setting up a
Speaker 4: surveillance system to address guinea worm, we're talking about kind
Speaker 4: of two phases of guinea worm eradication. The first is
Speaker 4: breaking transmission and then the second is certifying a country
Speaker 4: as guinea worm free. And so currently, you know, we
Speaker 4: have gone from over twenty one endemic countries in Africa
Speaker 4: and Asia in the nineteen eighties to five. Now we
Speaker 4: have South Sudan, Molly, Ethiopia, Chad, and Angola that remain
Speaker 4: endemic for guinea worm and they are still working to
Speaker 4: break transmission. And so endemic countries have to establish active
Speaker 4: community based surveillance and the foundation of this community based
Speaker 4: surveillance structure is the village volunteer. So in every endemic village,
Speaker 4: the volunteer actually walks house to house on a daily basis,
Speaker 4: searching for possible cases of guinea worm and providing health
Speaker 4: education to the community residents. And then treating any potential
Speaker 4: cases of guinea worm that are detected. And these volunteers
Speaker 4: are also ported by a hierarchy of other health workers
Speaker 4: who support their work and the implementation of a package
Speaker 4: of interventions to stop transmission. But at this point we
Speaker 4: know now that we have a suite of interventions that,
Speaker 4: when applied together, can be successful in stopping transmission. And
Speaker 4: that includes searching for cases and treating them. And also,
Speaker 4: you know, another intervention is health education to the communities
Speaker 4: on transmission and prevention of guinea worm. We also distribute
Speaker 4: nylon filters so that the communities can filter their drinking water,
Speaker 4: and we've also over the years have developed a pipe
Speaker 4: or a straw filter and finally treating water sources with
Speaker 4: a chemical that's safe for drinking water. But that reduces
Speaker 4: the presence of cyclops in the water and therefore the
Speaker 4: population of effective guinea worm larvae in the water is
Speaker 4: about behavior change, and that requires a constant presence from
Speaker 4: program staff in affected villages, and it requires building trust
Speaker 4: and that's something that takes time and it's not going
Speaker 4: to be able to be bought with any amount of money.
Speaker 4: And so, you know, I think the success of this
Speaker 4: campaign is really credited to the endemic communities themselves and
Speaker 4: the actions that they've taken to stop guinea worm in
Speaker 4: their communities. And so after transmission is broken, the second
Speaker 4: kind of phase of the eradication campaign takes place in
Speaker 4: a country. And so after they've reported zero, they go
Speaker 4: three years without reporting another case of guinea worm, and
Speaker 4: then they can apply for certification as guinea worm free
Speaker 4: from the ic CD, which is the International Commission for
Speaker 4: the Certification of the Kunkliasis Eradication.
Speaker 3: Gotcha awesome? So, you know, one thing I wanted to
Speaker 3: ask was about how there are these certain large scale
Speaker 3: infrastructural changes that would make not only guinea worm eradication
Speaker 3: more possible, but would also greatly reduce the prevalence of
Speaker 3: other diseases, particularly waterborne infectious diseases.
Speaker 1: So how do you strike.
Speaker 3: That balance between investing in the underlying infrastructure, such as
Speaker 3: like a consistently clean water supply versus a more targeted
Speaker 3: approach like the use of those filters that you mentioned
Speaker 3: that prevent guinea worm transmission but not of other waterborne pathogens.
Speaker 4: So two things here. One, you know, the guinea worm,
Speaker 4: as you've said, the guina worm program has to remain
Speaker 4: targeted on guinea worm disease in order to be able
Speaker 4: to demonstrate success. But at the same time, the program
Speaker 4: is training and developing a group of volunteers and health
Speaker 4: workers who will be prepared to provide other health services
Speaker 4: once guinea worm is eliminated in that country And in
Speaker 4: some countries we've seen that these health workers and volunteers
Speaker 4: have gone on to be involved in programs such as
Speaker 4: river blindness or tracoma control, and in some places they've
Speaker 4: even been absorbed into the national Ministry of Health system
Speaker 4: once guinea worm is gone. So I think that's one
Speaker 4: good example of some of the effects of the campaign
Speaker 4: that are beyond just the targeted disease eradication. And the
Speaker 4: other thing is guinea worm because it was as a
Speaker 4: water born disease, the presence of guinea worm or endemic
Speaker 4: guinea worm endemic communities has been an opportunity to leverage
Speaker 4: access to safe water, and so the guinea worm program
Speaker 4: in many countries has been able to work with ministries
Speaker 4: of Water and UNICEF and others to prioritize certain villages
Speaker 4: or locations for provision of safe water. Because guinea worm
Speaker 4: is an indicator that safe water is not present in
Speaker 4: that location.
Speaker 3: Gotcha, Okay, yeah, that makes a lot of sense. So
Speaker 3: throughout the history of the program, there has been an
Speaker 3: absolutely incredible amount of progress made towards eradication, So for
Speaker 3: millions of cases in the nineteen eighties to just like
Speaker 3: you know, dozens in the last few years. So can
Speaker 3: you bring us up to speed a bit with the
Speaker 3: latest numbers and especially the biggest hurdles that remain.
Speaker 4: So, as you've said, since the nineteen eighties, we've seen
Speaker 4: a ninety nine percent reduction in cases, which is phenomenal.
Speaker 4: So we've had twenty one cases so far in twenty twenty,
Speaker 4: which is a fifty six percent reduction compared to the
Speaker 4: same period in twenty nineteen. And at this point in
Speaker 4: the campaign, really our biggest challenge is transmission in animals
Speaker 4: and mostly in domestic dogs in Chad. And just to
Speaker 4: give you a sense of the numbers, in twenty nineteen,
Speaker 4: we had almost two thousand infected dogs that were detected
Speaker 4: globally and only eleven that were detected outside of Chad.
Speaker 4: You know, we've talked about guinea worm being transmitted through
Speaker 4: drinking infected water but we also have some evidence that
Speaker 4: dogs in particular could be getting infected by eating aquatic
Speaker 4: animals or aquatic animal waste that contains effective larva. And
Speaker 4: so as we're tackling the problem with dogs, we've had
Speaker 4: to kind of think outside the box a little bit
Speaker 4: and try to tailor some of our interventions to better
Speaker 4: target dog infections. And so the program is also working
Speaker 4: with the communities to kind of figure out what works
Speaker 4: best in each location, but to provide supplemental food to
Speaker 4: the household so that to feed the dog with and
Speaker 4: then also access to veterinary care and good access for
Speaker 4: the dogs to exercise, and so far, you know, this
Speaker 4: is something that has been a very recent intervention, but
Speaker 4: we are encouraged by the twenty six percent reduction and
Speaker 4: dog infections in Chad that we've seen so far in
Speaker 4: twenty twenty. And so while we may not have all
Speaker 4: of the answers or a perfect intervention or a silver
Speaker 4: bullet just yet, we are excited about some evidence that
Speaker 4: these new interventions to target dogs might be working.
Speaker 2: It's yeah, it's it's fascinating.
Speaker 3: I think there's there's a lot to uncover there, which
Speaker 3: is really cool. And so the last question that I
Speaker 3: want to ask is about you. So how did you
Speaker 3: get involved with the Guinea worm or medication program? And
Speaker 3: I was wondering whether you could share with us any
Speaker 3: memorable experiences that you've had while working with the Carter Center.
Speaker 4: When I was doing my master's and public health at
Speaker 4: the Rolling School of Public Health University, there was a
Speaker 4: professor Stan Foster who had been a big part of
Speaker 4: the smallpox eradication campaign. And one day I was in
Speaker 4: his office. We were talking about something else, and he said,
Speaker 4: you know, I think you could do it. I said,
Speaker 4: do what he said, I think you could be a
Speaker 4: technical advisor for Guinea worm. And so a few months
Speaker 4: later I found myself signing up for a six month
Speaker 4: contract with the Guinea ram eradication program working in South Sudan.
Speaker 4: That turned into six years working with the program there
Speaker 4: and then now in this role here, a total of
Speaker 4: seven years later. And I think for me, you know,
Speaker 4: initially going into this, what interested me was that this
Speaker 4: really seemed like an opportunity to apply field at the gemiology.
Speaker 4: You know, you're collecting data and making decisions in real time,
Speaker 4: and it's really an honor and it's really a privilege
Speaker 4: to be part of a program and to work in
Speaker 4: places where the community has invited the program to work
Speaker 4: there with them, and the governments themselves indeed have invited
Speaker 4: the support of Carter Center and other partners in their
Speaker 4: national eradication campaigns. And so I think that level of
Speaker 4: discipline and diligence that's required from everyone in the program
Speaker 4: is really incredible.
Speaker 2: And to just.
Speaker 4: Imagine how many tens of thousands of volunteers and help
Speaker 4: workers around the world that have all displayed that level
Speaker 4: of commitment to support their communities to get rid of
Speaker 4: guinea worm is I think truly remarkable. And for me,
Speaker 4: as I said, has been a real privilege to be
Speaker 4: part of that.
Speaker 2: That was so great.
Speaker 3: Thank you so much, Sarah for taking the time to
Speaker 3: chat with me about guinea worm.
Speaker 2: It was great. I loved it.
Speaker 1: Oh, it was so great. It's how amazing that we
Speaker 1: get to interview people who have actual experience working on
Speaker 1: these things like that's incredible.
Speaker 2: It blows my mind.
Speaker 1: Thank you so much for taking the time.
Speaker 3: Yeah, it's kind of nice that we get to end
Speaker 3: this episode on a happy note. Yeah, it's not often
Speaker 3: that we get to do that when we discuss diseases,
Speaker 3: particularly neglect of tropical diseases.
Speaker 1: Yeah, it's a really thing. And do you know, we
Speaker 1: could actually make this episode even a little happier if
Speaker 1: we wanted to. We of course, did an episode on
Speaker 1: polio way back in was it twenty seventeen? I think
Speaker 1: it was, yeah, our first season. And there's been some
Speaker 1: new news on the polio eradication front that is absolutely thrilling.
Speaker 1: So we now are even closer to polio eradication because
Speaker 1: as of twenty twenty, the World Health Organization African Region
Speaker 1: has been declared free of wild polio. They haven't had
Speaker 1: a single case of wild polio on the continent in
Speaker 1: the last four years.
Speaker 2: That is remarkable.
Speaker 3: I mean, I know, to hear that it is on
Speaker 3: the verge of eradication is absolutely incredible.
Speaker 1: There's only two countries left in the entire world that
Speaker 1: are still left to be eradicated, Pakistan and Afghanistan. So incredible. Like,
Speaker 1: we're so close, We're so close.
Speaker 2: Oh that's very cool.
Speaker 1: Yeah, awesome.
Speaker 3: So is that should we dive right into sources?
Speaker 1: I think we ought to?
Speaker 3: Yes, okay, cool. So I read a few things. One
Speaker 3: was a couple chapters in a book called a History
Speaker 3: of Human Heal Anthology by David Grove. And then a
Speaker 3: few papers that I found super helpful were DQR Spinning
Speaker 3: in Treatment of Guinea Worm by Miller in nineteen eighty
Speaker 3: nine and by Taya at All twenty seventeen Guinea Worm
Speaker 3: from Robert Leiper to Eradication. And then I also wanted
Speaker 3: to shout out a couple of really interesting papers by
Speaker 3: Amy Moore and Thomas, one titled a Salvage Ethnography of
Speaker 3: the Guinea Worm and another called the Creation of Emergency
Speaker 3: and Afterlife of Intervention, and these I thought were very
Speaker 3: interesting discussions on sort of the merit of targeted approaches
Speaker 3: to disease eradication or elimination versus like a more integrative,
Speaker 3: bigger scale infrastructure approaches.
Speaker 2: Very very interesting papers.
Speaker 1: I feel like those are really sort of important discussions
Speaker 1: to have in the context of these kind of eradication campaigns.
Speaker 1: So AB definitely shout out those papers awesome. I have
Speaker 1: a number of papers for the biology as well. We'll
Speaker 1: post the full list of all of our sources for
Speaker 1: this episode and every episode on our website This podcast
Speaker 1: will Kill You dot Com. Just click on the episode's
Speaker 1: tab and you can find all of our sources there.
Speaker 3: Thanks again to Sarah for taking the time to chat
Speaker 3: with us about guinea worm, and also thank you to
Speaker 3: Emily for helping set that up.
Speaker 1: Yeah, that was really incredible. And thank you to Bloodmobile
Speaker 1: for providing the music for this episode and all of
Speaker 1: our episodes.
Speaker 3: And thank you to you listeners for still tuning in
Speaker 3: and listening to us talk about disease.
Speaker 2: We really appreciate it.
Speaker 1: We hope this could be like a small little ray
Speaker 1: of sunshine in your September twenty twenty.
Speaker 2: Yeah.
Speaker 3: Yeah, well okay, until next time, wash your hands.
Speaker 1: You filled the animals a