Nobel Prize-winning peacemaker Jimmy Carter spent nearly four decades waging a war to eradicate an ancient parasite plaguing the world’s poorest people.
Rarely fatal but extremely painful and debilitating, Guinea worm disease infects people who drink water contaminated with larvae that develop inside the body into worms up to 3 feet long. The noodle-thin parasites then burst out, breaking the skin in the form of burning blisters.
Carter made Guinea worm eradication a top mission of the Carter Center, the nonprofit he founded after he and his wife, Rosalynn Carter, left the White House. The former president united public health experts, billionaire donors, African heads of state and thousands of volunteer villagers to work toward eradicating a human disease for only the second time in history.
“This will be the most exciting and gratifying accomplishment of my life,” Carter told the Associated Press in 2016. Even after entering home hospice care in February 2023, aides said Carter kept asking for Guinea worm updates.
Carter died on Sunday at the age of 100.
Thanks to the Carters’ efforts, the insects, which affected an estimated 3.5 million people in 20 African and Asian countries when the center began their campaign in 1986, have been brought to the brink of extinction. According to The Carter Center, only 14 human cases were recorded in four African countries in 2023.
The World Health Organization’s eradication target is 2030. Carter Center leaders hope this will be achieved soon.
That recently meant returning to Jarweng, a remote area in South Sudan in northeast Africa. The village of 500 people had not seen Guinea worm infection since 2014, until Ngong Aguek and his two sons drank swamp water during a visit in 2022. A fourth person also got infected.
“Taking out the worms is more painful than giving birth to a child,” Aguek said, pointing to the wounds where four worms had come out of her left leg.
The center’s staff and volunteers went door-to-door to distribute water filters and teach people how to inspect for dogs, which may also carry the parasite.
“If anyone is hurt, the Carter Center will help,” villager Matthew Maniel said while listening to a training session while checking his dog’s symptoms.
an audacious plan
In the mid-1980s, global health agencies were otherwise occupied, and heads of state largely ignored the disease afflicting millions of their citizens. Carter was still defining the center’s mission when public health experts who had worked in his administration approached him with a plan to eliminate the disease.
In 1979, it was just a few years after WHO declared that smallpox was the first human disease to be eradicated worldwide. Experts told Carter that Guinea worm could become another.
Dr. William Foege, who led the smallpox eradication program at the U.S. Centers for Disease Control and CDC before becoming Carter, said, “President Carter, with his political background, was able to do much more in global health than we could have done alone ” The first executive director of the centre.
Those who worked closely with Carter suspect that Guinea worm’s impact on poor African farmers resonated with the former president, who as a boy lived in a Georgia farmhouse without electricity or running water.
“Nobody was doing anything about it, and it was such a terrible disease,” said Dr. Donald Hopkins, the campaign’s architect who led the center’s health programs until 2015. From Guinea Worm Disease to Work.”
change behavior
There is no vaccine that prevents Guinea worm infection or any medicine that gets rid of the parasites. Treatment has changed little since ancient Greece. The emerging insects are gently wrapped around a stick and slowly pulled through the skin. It may take several weeks to remove an entire worm without breaking it.
So rather than scientific breakthroughs, the campaign has relied on motivating millions of people to change basic behaviour.
Activists from the central and host governments trained volunteers to teach neighbors to filter water through cloth screens and remove tiny fleas that carry larvae. Villagers learned to track and report new cases – often for a reward of $100 or more. Infected people and dogs were to be prevented from polluting water sources.
The goal was to break the life cycle of the worm – and therefore eliminate the parasite itself – in each endemic community, ultimately eliminating Guinea worm entirely.
The campaign became a model for combating a wide range of neglected tropical diseases afflicting poor people with limited access to clean water, sanitation and health care. Expanding its public health mission, the Center has supplied training, equipment and medicines that have helped 22 countries eliminate at least one disease within their borders.
Mali became the latest in May 2023 when WHO confirmed it had eliminated trachoma, a blinding infection. Haiti and the Dominican Republic are working to eliminate malaria and mosquito-borne lymphatic filariasis by 2030. Countries in Africa and America are trying to eliminate river blindness by 2035.
a personal mission
The former US president taking over the reins was a major boost for a non-profit that had been reliant on private donors to fund its initiatives.
Carter’s fundraising enabled the center to pour $500 million into fighting Guinea worm. He persuaded manufacturers to donate larvicide as well as nylon cloth and specially made drinking straws to filter the water. His visits to afflicted villages often attracted news coverage, raising awareness globally.
“He went to a lot of areas where people were suffering,” said Dr. William Brieger, a professor of international health at Johns Hopkins University who spent 25 years in Africa. “The kind of attention it brought to him for getting on the ground and highlighting the plight of individual people suffering, I think it made a significant difference.”
Carter saw the disease firsthand in 1988 while visiting a village in Ghana, where about 350 people were infested by worms. He approached a young woman who was seen cradling a child in her arm.
“But there was no child,” Carter wrote in his 2014 book “A Call to Action.” “Instead, she was holding her right breast, which was about a foot long and had a worm coming out of her nipple.”
Carter used his position to inspire other leaders to take on larger roles. Some heads of state became competitive, inspired by the center’s charts and newsletters that showed which countries were progressing and which were lagging behind.
insects in the war zone
In 1995, Carter intervened when the civil war in Southern Sudan made it too dangerous for workers to reach hundreds of hotspots. The ceasefire he negotiated enabled the Center and others to distribute 200,000 water filters and search more endemic villages.
Makoy Samuel Yibi, the young nation’s Guinea worm eradication director, said Carter’s efforts not only stopped transmission in much of South Sudan, but also built confidence in communities, resulting in a “significant peace dividend.”
In 1993, Pakistan became the first endemic country to eliminate human cases. India soon followed suit. Until 1997, the disease was not found in Asia. By 2003, recorded cases worldwide had dropped to 32,000 – a 99% decline in less than two decades.
Some setbacks discouraged Carter. While visiting a hospital full of afflicted children and adults amid a 2007 resurgence in Ghana, Carter publicly suggested that the disease should perhaps be renamed “Ghana worm”.
“Ghana was very embarrassed,” Hopkins said.
Ghana ended broadcasting within three more years. Even more inspiring: Nigeria, which once had the highest number of cases in the world, reached zero infections in 2009.
“He was a thunderbolt,” Hopkins said. “It was important throughout Africa, throughout the global campaign.”
till the last worm
Even after being diagnosed with brain cancer, Carter remained focused: “I would like the last Guinea worm to die before I die,” he told reporters in 2015.
Despite declining cases, total success has proven elusive.
Historic floods and years of civil war have displaced millions of people across Central Africa who lack access to clean drinking water. Nine of the 13 total cases reported in 2023 occurred in Chad, where infection in dogs has made it difficult to eliminate the worms.
“These planets are the most challenging places on Earth to operate,” said Adam Weiss, who has directed the mission since 2018. “You need eyes and ears on the ground every day.”
The campaign still relies on about 30,000 volunteers spread across about 9,000 villages. It may be difficult to remain vigilant now because cases are so rare, Weiss said.
“I would still like to think that we will beat that timeline,” Weiss said of the 2030 eradication goal. “The Carter Center is committed to this, obviously, no matter what.”