The Last Guinea Worm: Carter, Kennedy, and a Victory for Person-to-Person Development

When Jimmy Carter announced last month that he has been diagnosed with brain cancer, the 90-year-old former president stated that it is his dying wish to see the last guinea worm die before he does. He may well get his wish.

The crippling disease once infected millions of people a year across a swath of the planet stretching from Senegal to India. Now thanks to the tireless work of Carter and others, there are only 14 guinea worm cases left on Earth — not even enough for a soccer match. Soon, the last of these terrible little creatures will die. It may die next week or it may die next year, but its demise is now all but inevitable.

When the last guinea worm dies, it will be just the third disease humans have eradicated, after smallpox and rinderpest (a cattle disease). It will be a victory for President Carter’s philanthropy, the Carter Center, which for years led the international campaign against guinea worm. It will also be a victory for President John F. Kennedy’s vision of person-to-person development, exemplified by the Peace Corps.

You see, guinea worm will be vanquished not by a medical cure or vaccine, like smallpox and rinderpest, but by the small heroism of millions of people in poor villages, convincing their neighbors to change their everyday behavior. I’m privileged to be friends with a few of those people, and I look forward to raising a toast in their honor.

Let me back up a bit. Let me back up fourteen years, to be precise, to a sweltering West African midday in 2001. I was in Boulporé, Burkina Faso, a little village on the austere Mossi Plateau 60 kilometers north of Ouagadougou, and a known epicenter of guinea worm.

I was a math teacher in the Peace Corps at the time, making the most of a weekend by accompanying my friend and fellow volunteer Christina Gomez-Mira to scout for sites for “Worm Week.” Christina was one of several dozen health volunteers tasked with the mission of eradicating Guinea Worm from Burkina Faso. At that time, per the Carter Center chart below, there were still about 50 thousand guinea worm cases worldwide, and eradicating them from Burkina Faso seemed a daunting task. Worm Week was a festival organized by Peace Corps Volunteers to fight the worm, in which health lessons and water-filter distribution were interspersed between free food, drinks, music, and dancing.

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Guinea worm is a painful and humiliating malady. It is ingested when you drink unfiltered water drawn from an infected pond. The waterborne larva grows inside your body for months into a thin, meter-long worm. After a year or so the worm, or worms, emerge from your extremities, slowly and painfully. The agony of the emerging worm is quenched by dousing the affected limbs in water, at which point the worms’ eggs are released to spread and hatch, ready to infect again.

The only treatment for the guinea worm is to coax it slowly from your body, twisting it around a twig millimeter by millimeter over the course of weeks, like living spaghetti around a tiny fork. If the worm breaks before it is fully removed, it dies, and its body hardens inside your limb into a debilitating residue that can cripple you for life. The image of a worm twisted around a stick is thought by some to be the origin of the rod of Asclepius — the symbol of modern medicine.

Preventing guinea worm is straightforward if you just follow two steps: first, don’t drink unfiltered water from infected sources. Wells, water filters, and larvicide help with this, as described in the case study on guinea worm in CGD’s Millions Saved (new edition coming soon). And second, if you’re infected, don’t dip your wounded limbs in the drinking water source.

Sounds easy enough, right? If everyone in a village follows those steps for a year, as we were attempting with Worm Week, the guinea worm disappears from the village. If everyone on the planet follows those steps for a year, the guinea worm will vanish from Earth. That’s exactly what’s about to happen. It was by no means inevitable.

Christina and I arrived in Boulporé by bicycle, under the blazing sun of the Sahel. Our hosts were expecting us, and they offered us a calabash of refreshing welcome water. We faced a conundrum—should we drink it? It was odd-smelling and a little chunky; not very water-like. Turning up our nose at their hospitality would have been the height of rudeness, jeopardizing our mission from the outset. On the other hand, by drinking infected water we risked acquiring a horrific and entirely preventable disease. How would we explain that to Mom and Dad back home?

We deliberated between ourselves in English before arriving at a compromise. We would touch the drink to our lips for a few seconds, but not swallow any of it. When we did so we were relieved to realize that the smelly liquid was not water at all, but zoom koom, a sort of runny yogurt. The villagers were a step ahead of us—they knew their drinking water was fouled and had offered us a reasonable alternative.

The discomfort we felt with the welcome water was just a warm up for what happened next. An elder asked if we wanted to see a guinea worm. Morbid curiosity got the best of us. We did. He summoned a young girl forward, who sat in the dirt before us. He instructed her to show us where a white spaghetti-string worm was protruding several inches from her foot. Here, come get a better look, he said, as he yanked the worm from her skin. The worm broke off, partially, leaving the rest inside her foot. Christina and I were mortified; the girl now faced serious disability for the remainder of her life.

We left Boulporé that evening. Ultimately we decided to hold Worm Week in a different village. I still remember the chant we made up in the Mooré language: nyiini yaa wenga, kuuli tond tenga! (The Guinea worm is bad, get it out of our land!). And when our two years in Peace Corps were up, we left worm-stricken Burkina Faso to pursue careers in the United States.

These days I work on climate change and tropical deforestation — big daunting issues with more bad news than good. I hope that within our lifetime we’ll be able to tame runaway deforestation, and turn a corner on climate change. So I find it inspirational to look back on humanity’s triumphs, when everyone came together to solve a common problem, like the ozone hole, smallpox, or guinea worm.

I thought about guinea worm recently in a seminar at CGD by Daniel Immerwahr, a professor of history at Northwestern University. It was an excellent presentation based on his book Thinking Small. He explained how in the 1950s and 1960s a vision of grassroots, person-to-person, teach-a-man-to-fish development extolled by The Ugly American swept through world capitals. This vision of development from the bottom up led to President Jawaharlal Nehru’s thousands-of-villages-strong community development program in India, and President Kennedy’s Peace Corps.

But after a few years, Immerwahr explained, this 60s-era brand of grassroots development fell out of favor as idealistic community development workers failed to budge entrenched village hierarchies content with the status quo. India’s community development program withered as quickly as it blossomed. Peace Corps endures, but has been dismissed as mired in the past by a colleague of mine who I nevertheless respect highly. These days experts are more inclined to attribute development to economic growth, or the right institutions, or political rights, or techno-fixes, or fairer rules of the global game, or straight-up cash. And I have little doubt of the importance of any of these things.

And yet, somewhere out there the last guinea worm is waiting to die. And when it does, the vanquishing of a disease that once hobbled millions of people will be a victory for grassroots, person-to-person development. Community health educators. Peace Corps volunteers. Wells and water filters. Millions of people across sub-Saharan Africa and South Asia who made small changes in their drinking and bathing habits, and convinced their friends and neighbors to do the same. Thanks to all of them, a dreadful scourge will soon be gone from Earth, forever.