Guinea worm eradication program by D.E. Desmyter

Assignment 10/2005 – 04/2006

D.E. DESMYTER (Belgium)

It has been quite an experience to work in Africa! My professional life in Europe is mainly focussed at streamlined efficiency, a maximum productivity rate and swift return of investment. Major difference of course between my home professional activities and those of Ghana with the Health Directorate is that in Europe I am a Business consultant, while in Ghana a Health & welfare consultant. Needless to say that comparing the two would be most irrelevant. It does tell a lot though about how I initially looked at my assignment in Ghana and how my mentality eventually evolved into a more unperturbed stance of professionalism.

It was strictly based on my interest in the Guinea Worm Eradication Program, that I finally decided to do my voluntary assignment in Northern Ghana. I must admit I have been most pleased with deciding to enter this program! Not only did my research before I left to Ghana conclude that this must clearly be one of the most interesting voluntary assignments currently available in Third World Development; but also discussing with other volunteers in Ghana about their assignments, made clear that I was most fortunate that I had decided to enter the GWEP team. With talking enthusiastically about GWEP to other volunteers, I apparently interested many of them in Tamale and Bolgatanga to follow me in the villages and to help me in Health Education and Advocacy. After introducing and training these people in Guinea Worm and GWEP General Principles of Conduct, we went together from village to village; from compound to compound and from school to school; every day of every week. I hereby introduced these individuals and their respective voluntary organisations to the program and urged them to deliver motivated and enthusiastic people to help GWEP reach its final deadline of 2007.

I must put emphasis on one most important pillar, which helped to create a strong and solid fundament for the success of this assignment with GWEP. Namely the cooperation I received from two very special individuals: Dawuda Issah from Kpawumo and Awal Iddrisu from Taha. After my introduction to the program in the District Health Directorate offices, I was most thankful to receive the confidence of the GWEP Management to be assigned to my own area of operations in the Taha-Kamina district. I received responsibility for 8 villages: Kpawumo, Taha, Gbalahi, Wovogumani, Wovogu, Gbrima, Kulaa and Kpintaliga. These villages were and are still the area of operations for Zonal Health Coordinator Dawuda Issah and Awal Iddrisu, Health Volunteer of Taha. From the very start I was most pleased to get acquainted to these people. These pleasant and humble young men were clearly the driving force for Health Operations in that specific cluster of communities with their deep insight and strong commitment in the health issues and other difficulties these communities are encountering on a daily basis. They were the people who vigorously and with strong emotional convincement, introduced me to the problems of the area. They were the people who every single day followed myself and the team of volunteers I had gathered, from early morning until sometimes late in the evening and sometimes even during weekends to lead me through the villages and translate my every word to their fellow villagers, chiefs and elders. Always happy and eager to help, even when realising that their personal life and family obligations were not easily to be fulfilled in combination with the intensity of this job. After all they both are farmers and entrepreneurs and they both had a family to run. Just like every other villager in the area. It was most astonishing to see them show up for work every day with a genuine smile on the face and ready to jump into action. I have rarely in my life seen such dedication and forthright altruism! I am absolutely convinced that, without these people, the Health Directorate would have its hands full in controlling these eight villages. Not only on the issues of Guinea Worm, but on health and welfare issues in general.

During the six months that Dawuda, Awal and I have combined our forces in these villages we have been able to, at least temporarily, change the mentality and understanding of most of the villagers towards Guinea Worm and other health issues that they are encountering on a regular basis. We visited every compound of every village on a weekly frequency to teach the landlords and their wives about health and how to elevate their well being and that of their children. Every visit started with a focus on Guinea Worm: filtering the water in the compounds and handling the filters for maximum safety and durability; meticulously checking every filter for holes and replacing them when deemed necessary; as well as asking for known cases in the village. If pipe filters were available, we also informed the villagers how to use them and we distributed these to people who went to farms and to fetch water. Usually we ended our visit with looking for other health issues and if necessary we took action for further follow-up. Sending kids who were at home to school was mostly the closing of each visit.

We visited every school several times to talk about Guinea Worm and other issues, both to the teachers and in a more educational voice to the children during class-room discussions and presentations; always changing the mode of communication, depending on the level and age of the public. As confirmation to the effectivity of our health education, we actually succeeded in putting these children in action: we saw them motivating their mothers and sisters in filtering the water, replacing the filters if necessary and in taking their own initiative to inform us or the village volunteer about possible cases or miss-conduct by infected fellow villagers. We trained the teachers and gave them tools and engaged them to repeat all this information on a regular basis to their pupils.

We worked in close contact and regular reporting towards every chief and his committee of elders, informing them thoroughly about Guinea Worm and the risks it brought to the well-being of their villagers and advising these opinion-leaders in how to handle the villagers for health issues. Regularly a village assembly was gathered when the situation dictated a more radical approach to protect the well-being of the whole village or to activate and correct people ‘with hard ears’.

We directed special attention to the Red-cross mothers of every village. Per village, we gathered and trained these ladies (learning-by-doing) in filtering effectively, washing and handling the filters for maximum durability and we urged them repeatedly to take action and go from compound to compound to check the quality of the filters and replace them if necessary. We organised them per village in sections, so each Red-cross mother could cover her section of the village at least twice a week. That was not too much to ask, since each of them only had a few compounds to cover. It took a lot of effort and pleading to the most motivated of the lot, to get them on the road to do what was expected of them. But I am happy to say that, at least in certain villages, we have succeeded in this set-up. I was delighted to see that red-cross mothers of Taha, Kulaa, Wovogumani, Wovogu and Gbrima were actively taking part in our efforts. By the last two months of my assignment, these villages had filters which were usually in a very good condition, because of their actions. That was clearly not the fact before!

We had noticed that during ceremonies and festivities such as naming-ceremonies, weddings, burials, chieftaincy ceremonies, etc invitees of numerous villages were gathering and massively fetching drinking water and distributing it amongst each other without filtering (a major point of focus!), we decided to attend these meetings as much as possible and urge the Red-cross mothers to take their responsibility. During most of these ceremonies, we actually had to take action and let the ladies clean out their water pots and filter the water, which they were not planning to do before we warned them. After some reluctance, we always succeeded in making them understand the importance of filtering that water. When attending the Chieftaincy crowning of the honourable new chief of Kpawumo in February 2006, I was most thrilled to see that a Red-cross mother of Taha, who was there during the festivities, was not difficult to motivate to take the lead and responsibility to transfer all the water into new pots, clean the contaminated pots and filter every gallon with strong dedication. Taha clearly has delivered some remarkable people!

It was much more difficult to motivate the village volunteers! Some of them were doing a minimum of effort, making sure not to leave a too broad gap of care for Guinea Worm, but I regret to say that most of them were absolutely passive and uninterested in the Guinea Worm issues. They were not taking any action whatsoever for Guinea Worm and sometimes neither for other health issues, overloading us with a most creative bunch of excuses. Though we have urged them repeatedly to change their stance and beg them to help us actively, usually the only task they fulfilled was storing the replacement filters and giving us the community health book for signing (if they were to be found in their compound). We were usually disappointed about their lack of interest and our powerlessness to motivate them to do better.

If a case was found, we jumped into action without delay, no matter what day or time it was. We contained and bandaged the case and thoroughly informed the infected person and the people in his/her compound about Guinea Worm, the procedure of treatment, possible pains and physical discomfort. Also how to handle the bandage and what precautions were expected of him/her. We strongly warned that person never to even come near the village water sources and especially not to enter them at any event. We immediately sweeped the whole village for possible other cases, while informing every villager that a case had been found and advising them to take their best care of filtering and we emphasized not to drink directly from the village water source(s). The moment I heard that someone with a blister or a hanging worm entered the water, after I had warned that person with great emphasis not to come near the drinking-water sources, I reacted diplomatic but always with immediate and strong determination to make sure that this person understood what he or she was doing wrong. My advocacy in these cases was always very clear and assertive. I did not accept any excuses and I was not afraid to take down their names and compound number and made sure that they understood that I would not hesitate to give this information to the chief of their respective village. I am glad to say that, after a strong second warning, I was not forced by any case to go and report to the chief, but I did come very near to it several times in Gbalahi!

The changes that we were able to bring were a direct result of our intensive work in the field and the serious stance we took to improve the overall health standards of these villagers. I’m sure though, that a likewise follow-up and continuation of this meticulous work is most advisable to keep these changes in existence. Six months was a considerable period for this achievement, but without a suitable follow-up, this change of mentality will slack before we well realise it. Therefore I would recommend The Health Directorate and The Carter Foundation to continue to work with motivated and suitable, independent volunteers and send these people out into the field! During my assignment I encountered too many people, which were connected to the GWEP, who were spending most of their time or at least too much of their time in the Health Directorate offices. Guinea Worm will never be eradicated from the office. Everyone should combine forces in the field because that’s where the problem is occurring!

Below you will find an overview of the villages which Dawuda, Awal and I, in kind cooperation with numerous other volunteers, have repeatedly covered. This overview will give a detailed view of our findings during the assignment, and will function as an unmistakable introduction for those who will take over to continue our work there. I’m sure Dawuda and Awal will be thrilled to receive more volunteers to help them with their work in these communities!

KPAWUMO

Number of Compounds: 25
Village Volunteer: Abdulsomed Fuseini
Zonal Coordinator: Dawuda Issah

This small village is the home of Dawuda Issah. When I started my assignment in October, the filters and general health mentality of the villagers were in a dreadful condition. Filters were full of holes, while still in use. In several cases there was no filtering being done at all. Gradually, through time and effort, the situation changed. Especially after advising Dawuda that he’d better take over the filter responsibility from the Village Volunteer, because no activity or interest was shown from this person for GWEP or other health related issues. The Red-cross mothers have shown little initiative, but due to the help of one highly motivated Red-cross mother from Taha, the neighbouring village, there were some slight improvements in activity. Repetitive personal advocacy changed the mentality of this village beautifully and by February-March most filters were in a reasonable condition, hanging well washed at the best place in the compounds! No cases have been recorded for this village, while I was doing this assignment. Neither were there cases in the years before that. The new chief and his elders have been well informed about Guinea Worm and they confirmed their dedication to keep this village Guinea Worm-free. I would recommend replacing the village volunteer because he has an absolute lack of interest in his responsibilities. I recommend the Health Directorate to consider officially appointing Dawuda as the Kpawumo volunteer, because I have the feeling that Dawuda has the tendency to shift responsibility to the inactive Village Volunteer.

TAHA

Number of Compounds: 152
Village Volunteers: Awal Iddrisu and Iddrisu Momuni

This sizable village was, just like Kpawumo, having a serious health mentality defect. It was clear from the start that little health education had taken place here, or at least there was little of that action left in the minds of the villagers. Though this village has two Village Volunteers, little was noticeable of Guinea Worm advocacy. This was a highly endemic community because of the number of cases in the year and years before my assignment. Taha was my base of operations for a considerable time. From the very start it was clear that no activity should be expected from Iddrisu Momuni. This man was almost never to be found in Taha and if he was there, he did not show any interest in his responsibilities nor did he ever show any activity for health-related issues. Awal Iddrisu, in the contrary to the other volunteer, was clearly the most active Village Volunteer. You could even call him the Village Volunteer for every single village in our area. This highly motivated and enthusiastic person is without a doubt the perfect example of how a Village Volunteer should be doing his work. It took a lot of effort though, to transform Taha mentality. It seems that Taha is a village of people with strong personality… and very hard ears! Remarkable persons such as Awal and the Red-cross mother (lady with the seamstress shop next to Awal’s little shop) were most welcome to work with and highly productive as part of the team. It seems though, that when they are not part of a project team, the individual initiative is much lower. Certain other families in this village were most difficult to handle. Especially the compounds 1 to 6 were carelessly stubborn. Throughout the six months of this assignment there has been no improvement noticeable for these compounds. They used filters with holes and didn’t understand or care to change them and they highly mistreated the replacement filters, succeeding in spoiling them in a days’ time. Several of these last mentioned compounds didn’t even bother to filter at all! They were not only a danger for themselves, but as well for the school in Taha because they are the closest buildings to the school and children from and in the school passed by on a very regular basis to drink the unfiltered water in their water pots! Numerous visits (sometimes three times a week!) and talks with the families in these compounds didn’t make any change at all. Until the end of my assignment these compounds stayed a major problem in Taha. This has been discussed with the chief, and promises were made to take action, but little action has been recorded until the end of this assignment! We went to Taha school three times: twice to talk to the teachers and inform them about Guinea Worm in general and mention the problem about the nearest compounds + urging them to place a water reservoir of filtered water, so the children in the school could take water right there; one time we went to the school to have a lengthy class discussion and presentation to the Taha children which were present in the school. I regret to say though that it seems that about half or more of the children in Taha are not attending school at all! We spoke to these children when covering the compounds, urging their parents to let their children attend school. We told them about Guinea Worm, and showed them Guinea Worm cases so at least they understood what we were talking about. These children were very active in chasing our team through the village and after a day or two they started understanding what we were doing there. They even started mimicking us and went from family to family to do their own advocacy about Guinea Worm, checking filters and replacing them when they noticed holes. It’s a good sign to see their commitment, but they should not be in the village during school hours. Taha was quite a piece of work but I was pleasantly surprised to see a total change starting from half January! All of a sudden, after months of worrying about what we could do more to motivate the Taha people to change their attitude, things improved very drastically! At first we couldn’t exactly put our finger on what was going on, but after informing ourselves with the villagers we found out that the Red-Cross mothers had finally ignited their engines. Every compound we covered, filters were in a perfect state and hanging at the best place to dry. This has continued at least until the end of my assignment and I honestly hope that this is still the case! Stubborn compounds 1 to 6 are still a problem though! During my assignment we had several cases in Taha, but the number as projected, based on historical data, seemed to have dropped considerably! Another proof of the stubborn ears of Taha villagers was the numerous cutback-cases. No matter how frequently we tried to make these people understand that they should not pull the worm hanging from their legs, they still stubbornly pulled it and of course had cutback after cutback. This village needs to be followed well, because I wouldn’t be surprised that their attention slacks in the very near future, once they understand that there is no regular follow up of our efforts. It is also recommendable to officially appoint Awal as sole Village Volunteer in Taha for the same reason as that for Kpawumo.

GBALAHI

Number of Compounds: 48
Village Volunteer: Mussah Mushee

This village has been a problem case from the beginning of my assignment. Of all the eight villages, we have put most effort in Gbalahi with the least improvement to be mentioned. The main problem is that there is no initiative that is coming from Gbalahi villagers. The village volunteer is absolutely not to be disturbed or talked to about health related issues, especially Guinea Worm. Though he seems an active member of the community, I regret to say he is absolutely not useful as Village Health Volunteer. It seems to me that this man has accepted too many responsibilities and has no further interest in taking more action then he is already doing. Selection of this person as Guinea Worm volunteer was not a good idea; that was clear from the start. The village Red-cross mothers I’m afraid are posing the same problem. I’m sure some of them could be motivated, if they were coached well, but there is no such thing as coaching to be seen. While training them it was clear that none of them even knew how to filter, or how to clean the filter. Looking for holes was too much to ask. We even saw several Red-cross mothers in Gbalahi, who were not filtering at all, while they should be giving the right example to the other villagers. Then we haven’t mentioned the school yet! The teachers corps in Gbalahi is not working at all, only sitting outside the school building for an hour or two, fiercely keeping the few present children quiet and leaving the premises around 11 in the morning. The head master was there about once a week, especially the day that he knew the school would be checked by a representative of the Ministry of Education. Unbelievably this man did not speak a word of Dagbanli, while he ought to be leading a school were Dagbanli is the only language of communication. The few times I met this person, he repeatedly came to ask whether we could help him to bring the children of Gbalahi to school. We have invested a lot of effort in trying to motivate these children and by making their parents understand why school is important for their development. Each time we heard the same story of these villagers: why would we pay for our kids to go to school, when they are not even teaching there?! And they were right! We have checked numerous times and confirmed. Even the volunteers are running away from this school! Delivering health education in this school was therefore not an easy job and only a few children were there to follow our advocacy. I can continue about Gbalahi like this for pages on end, but I see no added value to do so. It is clear that Gbalahi has a structural problem. Improvements are not to be talked of, the whole thing should be disbanded and rebuilt from the roots: a new Village Health Volunteer; selection of ten new and motivated Red-cross mothers; a new teacher corps and a new head master who is not afraid of his own school and enthusiastic enough to restart the whole school strategy with a new team. Throughout my assignment we have continued our work in Gbalahi with special focus to the many problems in this village. No matter how driven I was, this village was poking my eyes out. They just didn’t want to listen and laughed at us in our face! That was reason enough for me, though, to bite myself solidly into this bone of a problem. During these six months we’ve had several cases with very stubborn people, who didn’t mind the fact that they were repeatedly (!) infecting the Gbalahi water source. This was not only a problem for the village as a whole, but also for the uncountable people who are going to Gbalahi dam to fetch water during the peak of the dry season. We interviewed people coming from as far as Kalpohini, Kukuo and even Vitting to fetch water in the Gbalahi dam. While careless infected villagers walked in this water source, knowing that they had Guinea Worm, but just not caring at all. At the end of this assignment I had decided that this problem should be contained immediately before a new major outbreak in the surrounding villages would be inevitable during the following year. I called for a general village assembly. We met with the Chief and his full corps of village elders in an overfilled chiefs’ palace. I put my ultimate effort in slowly and clearly explaining them this important problem and advising them how to take action. These opinion-leaders listened and confirmed with great interest and understanding. The meeting was over after a good hour and without delay the chief ordered the elders and opinion leaders to take action. They were about twenty. They left the palace and spread out all over the village to advocate and warn the villagers about what we just had discussed. I was content to see that they took my pleading most serious and followed it up with immediate action. The chief promised us that they would do this on a regular basis. That was my last visit to Gbalahi, so I have no idea whether this action has made any effect.

WOVOGUMANI

Number of Compounds: 43
Village Volunteer: Yahaya Sibduo

This village was initially, during the first months, a problem. Filters were in a very bad state and many families were not filtering at all. It took us some time to motivate the Village Volunteer and the Red-cross mothers. We actually took a team of mothers with us, to let them see what was expected of them. Also the Village Volunteer was active part of our team from time to time. Important to understand is, that the team of red-cross mothers and the volunteer were established enough, that we actually were able to take them with us. This is not possible if you have to work with people with a lack of motivation like those of Gbalahi. By January we had reached a very satisfactory mentality change with these people, as well as with the villagers. During the last half of my assignment, we could very swiftly cover this village without many hiccups or mentionable problems. Filters were in a perfect state, hanging where they should be hanging to dry. The school Health education was also a major success with very active pupils doing an excellent job in the village itself while taking good care of their own health. This village has access to a dam with a remarkable quality of water, which it is sharing with nearby Wovogu. Though this village did a great job during the last months, strongly supported by the Red-cross mothers, it is very important to carry on the follow up to make sure that they continue the good work! It is also important to know that, once Gbalahi dam is dried up during dry season, people of surrounding villages are gathering at Wovogumani dam to fetch their water! No cases recorded in the last six months.

WOVOGU

Number of Compounds: 20
Village Volunteer: Alhassan Wumpini

This small village uses the same water source as it’s bigger brother, nearby Wovogumani. Just like Wovogumani, Wovogu needed dedicated attention. It was most pleasant working with a motivated Village Volunteer and some highly motivated Red-cross Mothers. Things improved drastically by January. Wovogu had found the path, which they needed to walk, and they liked it! The school Health education was a success. Except the sporadical hiccups, they did a great job in changing their mentality into health-respecting attitude.

GBRIMA

Number of Compounds: 33
Village Volunteer: Abdulai Nasam
Gbrima seems to be the most ‘sophisticated’ village, though it’s clear it has known more fruitful times in the past. Gbrima has succeeded in attracting quite a lot of investment from NGO’s and religious groups. It has a dam with high quality water and it is the only village with a functioning borehole, throughout the year. After dedicated attention during the initial months of the assignment, Gbrima was well on it’s way to show nothing but clean, perfect filters and devoted villagers. No cases have been recorded during the assignment. The Village Volunteer and the Red-cross mothers were reasonably fast in following our guidance. Covering this village was swift and successful in most of the visits during the last months.

KULAA

Number of Compounds: 61
Village Volunteer: Ibrahim Mammudu

Kulaa is quite similar to Taha. After months of focussed attention and advocacy we managed to transform the mentality of most families into reasonably acceptable behaviour with attention to their health issues. It took us some time to motivate the Red-cross mothers, but after a few months, at least some of them did what was expected of them. Some stubborn families continue to be a threat to the village health though and these will need more counselling. Several cases have been recorded during the assignment. One case seemed to be the grounds to sack one of the Red-cross mothers. This decision was taken by Health Directorate personnel, but I honestly have to admit I do not agree with the reasons for firing this lady. I did not wish to interfere in this process, as it happened without my immediate knowledge during a visit by health staff, which was not communicated to our team. I would like to emphasize that the decision for sacking this Red-cross mother is not acceptable on the grounds as concluded. My opinion is followed by both Dawuda and Awal, as well as by the Village Volunteer of Kulaa and Mr Salifu, District Health Coordinator. This Red-cross mother has also involved Red-cross mothers of other villages, who were following her in her defence for this unfortunate incident. Basically the decision to sack has demotivated many Red-cross mothers of Kulaa and other villages and the Village Volunteer of Kulaa. Neither do I appreciate the fact that actions were taken in an area, which was still repeatedly being covered by dedicated people; while uncountable other areas in the district were not attended to. At least a minimum form of communication would have been desirable. It makes no sense to keep all these people unhappy about that very dubious decision to sack this lady. At the end of the assignment Kulaa was on the right track, but dedicated follow-up is most advisable.

KPINTALIGA

Number of Compounds: 10
Village Volunteer: Salifu Fuseini

This tiny, isolated village has had its share of water problems. It basically has to count on the nearest Kulaa dam, several miles away from the village itself. Risks involved are undoubtedly the fact that Kulaa still is a highly endemic community, so there is a great risk for Kpintaliga villagers fetching potentially infected water. Though this village is very small, it demanded a great deal of effort to change the mentality of the villagers concerning filtering and handling their filters in an acceptable and durable manner. Main problem is the lack of active Red-Cross mothers and a passive Village Volunteer. Throughout the six months of covering this village, the quality of the filters had well defined ups and downs with regretfully many more downs then ups. The idleness of the Village Volunteer has been a point of discussion since the beginning. This person is not showed any interest, nor any activity whatsoever for health related issues. That is according to our findings the main reason why Kpintaliga is still a source for worry. Six months of thorough advocacy have proven to be unproductive. It is recommended to meet the Village Volunteer again and give him the choice: start work or leave the role to someone who actually is motivated enough to do what is necessary. I do not think there is a lack of other candidates; I do think it is the current volunteer who is merely protecting his honorary position in the community by painstakingly holding on to a role, which is not suitable for him in the first place. This small village needs dedicated attention by Health Directorate staff, because the current situation is not helping anyone.

Points of Focus

  • lack of communication by Health staff in the field;
  • irregular and inadequate distribution of health tools in the field;
  • too many meetings and ‘preparations’ in the office, while the problems are to be found in the field;
  • Gbalahi;
  • Kpintaliga;
  • Kulaa Red-cross mother issue;
  • regular follow-up of each of the eight above described villages;
  • overlapping action areas due to ineffective scheduling of health personnel;
  • theoretically there are numerous appointed volunteers in the field, but practically, little of these show interest nor a minimum of dedication to their responsibility (Why not downsize the number of volunteers and Red-cross mothers into an easily manageable number of highly motivated, well trained and well coached people?);
  • A well organised basis (fundament) for voluntary assignments just like this one! The world is packed with highly motivated and well educated, independent young individuals and idealists who would be most thankful to receive a chance like this to make a real difference. Free of charge!
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