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When People Come FirstCritical Studies in Global Health$

João Biehl and Adriana Petryna

Print publication date: 2013

Print ISBN-13: 9780691157382

Published to Princeton Scholarship Online: October 2017

DOI: 10.23943/princeton/9780691157382.001.0001

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A Salvage Ethnography of the Guinea Worm

A Salvage Ethnography of the Guinea Worm

Witchcraft, Oracles and Magic in a Disease Eradication Program

(p.207) 8 A Salvage Ethnography of the Guinea Worm
When People Come First

Amy Moran-Thomas

Princeton University Press

Abstract and Keywords

This chapter takes the program for the eradication of the guinea worm in northern Ghana as a launching point from which to examine the different epistemologies at work in global health initiatives. It teases out the ways in which the local landscape of health care is changed and imagined through such initiatives, and the ways in which people actively engage with them, transforming biology and magic into heuristics for one another. By collecting remnants of worm stories, traditions still remembered but no longer believed, fading memories, or chance moments, the author in part seeking to critically document a seminal moment in public health—a field with a notoriously short memory—in hopes that the experiences gained from this historical eradication program may hold lessons for future policy efforts. It is also an attempt to create a record of the living guinea worm itself, the human struggles it has crystallized and fragments of stories from the people, politics, and places it traveled through for centuries.

Keywords:   Ghana, guinea worm, global health, public health, health care, disease eradication programs

This is a story about a hard-fought health campaign against a centuries-old pathogen, a program now nearing its final goal of global eradication. Yet it is also a story full of conflicting priorities and values, and the laden paradoxes of humanitarianism at play as medicine breaches boundaries not normally thought of as permeable.1

Or at least, that is one way of saying that on the morning when the Ghana Guinea Worm Eradication Program sent two team members to a small dam in the village of Taha to put treatment chemicals in the community’s drinking water—hoping to interrupt the plague of three-foot-long guinea worms that for centuries had emerged from farmers’ legs and bodies every harvest season—they were met at the waterside by an angry crowd of local men armed with cutlasses and knives.

“They believed the worms were in their blood already, that people were just born with them there,” a longtime Ministry of Health official explained to me in 2009. We were walking slowly through the September heat as he recounted the event, weaving between reckless goats on the dirt road that cut through Taha’s clusters of earthen homes. “They thought it (p.208) was witchcraft that made the worms come out. The guinea worm mainly comes during harvest season, you understand, and so a lot of people believed that someone had sent them this worm as a curse to keep them from their fields.” He shook his head. “That year, there was an issue of timing … and then people thought it was the ABATE chemical itself that woke up the guinea worm. They thought the water treatment chemical was causing the worm instead of killing it.”

The Ghana Health Services expert nodded, adjusting the top button on his official program shirt. It was made of beige cloth patterned with images of a turbaned woman filtering her drinking water for guinea worm alongside circular icons of the program’s supporters, set against blue background tessellations of gently curling worms and their tiny crustacean vectors. “So that is why they threatened the lives of the program team who came to their village to put ABATE chemical in the water,” he recalled distractedly, scanning his cell phone contact list for the local guinea worm volunteer’s number so that he could be summoned for my interview.

When discussing African histories of magic and witchcraft, anthropologists tend to automatically think back to E. E. Evans-Pritchard’s classic 1937 monograph, Witchcraft, Oracles and Magic Among the Azande. From a wealth of ethnographic detail, Evans-Pritchard extracts a famous observation: that when the Azande spoke of causality they were not trying to figure out how something happened (in his example, how a granary house collapses on a person); rather, they were appealing to unseen forces to figure out why it happened to that person specifically. Indeed, throughout my fieldwork in Northern Ghana, local people’s understandings of accountability, causation, and fate were often permeated by a similar logic;2 it was common to hear questions like “But if it comes from water, then why did I get guinea worm when the others drinking from the same dam did not?” Seeking answers to such questions of “why,” many people in the past—and some even after twenty years of worldwide eradication efforts—would visit oracles to determine whether the worms were messages from “the ghosts,” usually meaning their ancestors, or sent through witchcraft by an evil person wishing them harm. But perhaps more unexpectedly altogether, on that day in Taha, the villagers’ answer to the question “why” suddenly shifted to the eradication campaign’s own treatments instead.

(p.209) I want to use this emblematic moment in Northern Ghana as a point of departure for this essay, to address the knotted social, political, and medical understandings that collided on that day. We begin with a question buried at the heart of this conflict. In the minds of these Dagomba farmers, what fields of meaning were in play to allow scientific chemicals to take the place of supernatural explanations for guinea worm with such ease?

I observed that these colliding fields—humanitarian interventions for guinea worms, on the one hand, and local understandings of them in the rural West African communities where this public health campaign is unfolding, on the other—at times also give way to unexpected but deeply meaningful resonances. Such unlikely congruencies, alongside the more obvious conflicts over the meaning of these worms, demand to be explored side by side—perhaps shedding light on the political forces, intricate ecologies, and cultural histories that have shaped the tensions surrounding guinea worm eradication, even as the parasite itself may finally disappear from this earth.

Ghana recently celebrated a tentative victory over guinea worm: not a single case was reported in the country in 2011. There were only 1,060 remaining guinea worm cases in the entire world in 2011, spread across just four countries: 8 in Ethiopia, 12 in Mali, 10 in Chad, and 1,030 in South Sudan (Carter Center 2011). This progress suggests that guinea worm is now firmly poised to be the second disease (and first parasite) to ever be eradicated from the world. There are already numerous articles and even a forthcoming documentary film that depict this pending historic moment as a celebration of inspirational success. Yet, as an anthropologist, my aims here are somewhat different. I examine the campaign’s progress from a premise perhaps more attuned to the way Ghanaian moral philosopher Kwame Anthony Appiah summarizes his own work: “Everything is more complicated than you thought” (2008:198). There are entangled social relations and challenging questions within this unfolding story that often fall outside the clean lines of policy agendas or headlines, what historian Nancy Leys Stepan might call “useful ambiguities” of eradication policy (2011). It is in the democratic spirit of critical inquiry and probing debate that I sketch some of these multiple sides and perspectives, attending also to the tough questions being asked by people on the ground and the ethical ambiguities of technological tools. In this way, this chapter unfolds at (p.210) uneasy interstices, trying to offer an ethnographic snapshot that lets messy situations remain messy: showing thought-provoking setbacks occurring side by side with equally thought-provoking successes. It considers the complexities of biology in relation to local environments, as well as the shifting rationales and difficult choices of prioritization that face both international and state actors with limited budgets—and it maintains that dissonance within local communities evinces not “cultural barriers” or “superstitions” to be overcome, but deep-seated questions and critical insights that require careful listening.

Salvage ethnography has been a bad expression in anthropology for decades, associated with heartbreaking legacies of colonialism and the extinction of entire peoples. Such anthropologists once documented and “salvaged” whatever remaining bits of information they could about a culture before it faded forever. But this particular opportunity for salvage ethnography presents us with a rare celebratory moment—it signals the end of a parasitic disease, rather than a dying people perched on the brink of extinction. By collecting remnants of worm stories, traditions still remembered but no longer believed, fading memories, or scrap-chance moments, I am in part seeking to critically document a seminal moment in public health—a field with a notoriously short memory—in hopes that the experiences gained from this historical eradication program may hold lessons for future policy efforts. But I also mean to create a record of the living guinea worm itself, the human struggles it has crystallized and fragments of stories from the people, politics, and places it traveled through for centuries. For there are certain knowledges and societal practices that will die along with this worm, a signifier whose deep and even conflicted social meanings deserve to be remembered in all their complexity.

Guinea Worm in the History of West Africa

Some information about the parasite itself will help set the epidemiological stage for the struggles that follow. For people unaccustomed to seeing it, guinea worm is a visually spectacular disease. Its life cycle in humans begins when a person drinks water containing microscopic Cyclops3 crustaceans, known as copepods or “water fleas,” which have themselves ingested tiny guinea worm larvae. Inside the human stomach, gastric acid (p.211) dissolves the water flea’s exoskeleton and liberates the captive guinea worm larvae, which then penetrate the human intestinal wall. Over a slow two-week migration, the nascent filament-thin larvae travel beyond the peritoneal cavity and into the thorax or abdominal muscles, where they remain until reaching adulthood, nourished in their growth by the bodily fluids they ingest.

When the male and female worms reach sexual maturity about one hundred days after they are first swallowed, they seek each other out to mate in a strange subcutaneous romance: neither of them will survive the ordeal. The male worms usually die not long after mating,4 their boneless corpses eventually encapsulated by the soft muscle tissues surrounding them. Meanwhile the impregnated female worms continue their migration and gestation until they are a full year old, by which point they have developed into thin white worms about three feet in length. Before emerging from the body, these female parasites slowly move through the host’s muscle planes, dissolving a pathway through human muscle and tissue. The entire body cavity of each female guinea worm is filled with her uterus, which contains up to three million embryos. Her pregnant body is literally on the verge of rupturing by the time she reaches the skin’s surface. There, the female worm causes a break in the skin by provoking a blister, usually emerging from the host’s feet or legs (boring out of lower limbs remains the worms’ best chance of being submerged in a pond, which offers some slim chance of survival to their progeny). Guinea worms do, however, occasionally emerge instead from wayward locations such as tongues, ears, and eye sockets. The searing sensation that accompanies guinea worm blisters typically drives their victims to seek water to soothe the burning pain,5 which is key to the parasite’s evolutionary strategy—immersion in cooling water causes the blister to burst and leaves the female’s anterior end extruding through the host’s raw tissue, where contact with water induces a contraction in the waiting mother worm.6 She spews hundreds of thousands of first-stage larvae from her ruptured uterus and through her head in her final act. Her pale body bursts like a popped balloon and she dies in the birthing process (Cairncross et al. 2002; Hopkins et al. 1993; Ruiz-Tiben and Hopkins 2006).

In a world where most sickness manifests via invisible pathogens and ambiguous symptoms, the dramatic appearance of this affliction has contributed greatly to the charged meanings ascribed to it. Certainly it (p.212) allowed the worm to be understood as a distinct disease entity centuries before the advent of microscopes or germ theory. Guinea worms have been found in the bodies of Egyptian mummies, and scholars argue that the biblical “fiery serpents” that plagued the fleeing Israelites in the Old Testament book of Numbers were in fact guinea worms (Grove 1994:694). Historians have even theorized that the caduceus emblem of a snake wrapped around a rod, still a symbol of the medical profession today, originated from what remains the most effective treatment for an emerging worm: wrapping it around a stick to ensure it cannot retract back into the skin, and reeling it out inch by inch over a period of several days. (While commonly attributed to Asclepius, the renowned Greek doctor and patron deity of medicine, the caduceus symbol actually predates this demigod and can be traced back to ancient Mesopotamia).7 These winding techniques remain important today, because it is critical not to break off the guinea worm before it fully emerges, which could cause a potentially lethal secondary infection. Although they often leave lasting exit scars and can cause great pain with their emergence, it is quite rare for guinea worms themselves to actually cause death.

The Guinea Worm Eradication Program still uses a version of this treatment today, in its specially designated “case containment centers,” where people with emerging parasites are brought. The first time I witnessed a guinea worm emergence in person, it was coming out of an eight-year-old boy’s foot. He looked as though he was trying not to cry in front of the other children waiting for their bandaging, but he still shrieked in pain when the Japanese volunteer tugged gently on the worm, adding the length of its body that she had pulled out to the glistening-wet coil resting near his toes. I had always pictured the guinea worm writhing, but it drooped out of his foot like a limp noodle.

Yet despite several weeks of intense discomfort and pain that the worm’s emergence caused, many adults in Ghana took the experience in stride. Some even went about their daily work, coping with the worm secretly rather than following the treatment and isolation recommendations of the eradication program. “There are those who run away and hide on their farms when we try to give them treatment,” explained Dr. Andrew Seidu Korkor, a deeply reflective man from Bole who heads Ghana’s National Guinea Worm Eradication Program. “They do not think it is an (p.213) emergency, because everyone knows it won’t kill you. To them, it is just part of their lives.” The worm even became such a naturalized fixture in the seasons that its absence from the body caused spiritual concern, as one Ghana health services program official told me with a laugh. “I remember when we went to Diare. One man said that for him, the guinea worm was in his blood and if every year it doesn’t come out, that’s when he knows something is wrong. So if it doesn’t come one year, then he has to consult the ghosts to ask why.”

Indeed, for many in Northern Ghana, guinea worm was once thought of not only as a common feature of people’s lives, but as an intrinsic part of their anatomy. The long-standing belief that guinea worm lies latent in human blood from the time of birth—a perception common in many parts of West Africa (Bierliech 1995; Brieger et al. 1996)—made more sense to me after a field visit one day, when the program truck stopped in a small Gonja village called Kampong to check on a reported case of guinea worm. We walked past women reclining on the ground and stirring pots of shea butter with bare hands, to the house of the concerned man who had notified the program. He emerged from a nearby yam field wearing a prayer cap and Islamic robe, which he pulled up to reveal a thick worm-shaped bulge on his thigh. The Ministry of Health worker poked at it, and after some observation announced it was just a varicose vein.8 “You can tell because it doesn’t move when you touch it,” he explained.

The fact that diagnostic ambiguity between human veins and worms continues today evokes older West African associations between the guinea worm and blood. But the recurring notion that the guinea worm can be an intrinsic part of a person also reveals deeper working ideologies of the body and self, which allow the physical resemblance between worms and veins to take on such layered meanings.

In his two-part series “Worms Are Our Life,” anthropologist P. Wenzel Geissler explores outlooks on experience and the human body in a Luo community of rural Kenya, charting how local people’s understandings of coexistence with worms are often dramatically different from the biomedical paradigms of elimination promoted in nearby schools and hospitals. Writing about intestinal parasites, Geissler describes his Luo acquaintances’ efforts to placate the worms in their bodies and to read the parasites’ actions as meaningful signs to be negotiated—a phenomenon, (p.214) he points out, that is common in various local knowledge systems.9 He then fits this recurring image into a broader understanding of social ties and life processes:

In this view, ‘lives’ overlap, grow into each other. And the action of the worm in the stomach has its place in this overall process of life, as has the decay and disintegration of the corpse, decomposed by the worms, turning to soil … life and death are not analogous to order and disorder, but included into one orderly process.

(Geissler 1998a:74–75)

His words contextualize the widespread Luo belief that worms are a latent and even intimate part of the human body as an element within a different way of understanding life’s arc—one that sometimes blurs the distinction between inside and outside, and phenomenologies of self and other, just as the boundaries between the living and the dead can also become profoundly blurred.

In Ghana, those who once considered emerging guinea worms a sign from their ancestors did not fear the parasite as a symbol of death, but rather often respected it as an angry message from their honored dead, a white finger from another world searing through them in the flesh. A 2006 New York Times article described a similar situation in Nigeria, where former head of state General Yakubu Gowon (who led the Nigerian military in the Nigeria-Biafra civil war of 1967–1970) traveled with other dignitaries to a small village called Ogi to personally pour ABATE larvicide into a guinea-worm-infected local pond. But just past the tall grass that surrounded the water’s edge, he met a group of village women who had formed a human wall around the sacred pond. “‘They had colors rubbed on their faces to show resistance, like Indian war paint,’ a Carter Center field officer said. ‘They were chanting songs of their refusal.’ The women shouted, ‘This disease is a curse from our ancestors, it has nothing to do with the pond water! If we let you touch anything, the ancestors will deal with us. We heard them crying all night’” (McNeil 2006:2).

The view of guinea worm as a potentially sacred ancestral message mingled and, at times, overlapped with other perceptions of the parasite in Northern Ghana. Another set of perceptions that persisted during the eradication campaign related to fears that the worms were sent as dark curses from a witch, wizard, or other ill-intentioned person who (p.215) possessed a dangerous magic (like the guinea worm itself, such powers are sometimes said to run in families and to be inherited at birth through the intrinsic bodily matter of witchcraft substance).10 There was not a systematic distinction between these dense repertoires, seemingly contradictory views of the worm as a messenger from ancestors, a consequence of drinking unclean water, or a curse from an ill-wisher; each case was interpreted according to many contingent factors, including the social background of the victim and the timing and context of the worm’s emergence. For example, as a handsome young program worker from Accra told me, it was not surprising that local parents immediately suspected witchcraft when their daughter had twenty-eight worms emerging from her at once, their sinewy white bodies crawling out of her arms, legs, and face simultaneously. The majority of the guinea worm cases were much more subdued, however, and interpretation could be ambiguous. Uncertain cases could be brought to oracles in the hope that divination would reveal the worms’ underlying cause.

People’s continuous struggles to determine the reasons behind the guinea worms’ appearance bring us back to Evans-Pritchard’s legendary observation about Azande ascriptions of accountability, magic, and the logic of causality. But as Didier Fassin responds to humanitarian programs’ expectations that he will give “‘cultural keys’ for interpreting ‘resistance in the population’”: “the analysis should encompass the entire intervention scene—not just aid recipients but the association and its members” (2010:40). In other words, in order to understand how the Guinea Worm Eradication Program’s own biomedical treatments suddenly became enfolded in some Dagomba farmers’ accusatory answer to this question of why, we must first turn to a reading of the health campaign’s own history.

A Social History of the Guinea Worm Eradication Program

Guinea worm became a global health priority during the “International Drinking Water Supply and Sanitation Decade” of the 1980s, when the World Health Assembly’s steering committee resolved that the worm’s eradication would stand as a lasting legacy of their efforts. Since the guinea worm’s survival depends on people first drinking infected “water (p.216) flea” vectors, which are easily visible even to the naked eye and can be strained out with any common cloth, and then, later, submerging their blistering ulcers into a water source, the disease should be extraordinarily easy to interrupt with even the most basic standards of water sanitation. Guinea worm once existed in the Americas, but spontaneously died out as water supplies improved. For this reason the World Health Assembly assumed that eradicating the parasite would be a natural consequence of improved water supplies, and an index of their success toward achieving their primary goal to bring clean water to every village in the world (Brieger et al. 1997:354; see Yacoob et al. 1989). “The Water Decade provides a vehicle aimed already at insuring disease-free water,” UN health expert Dr. Peter Bourne wrote in the early eighties (Bourne 1982:3). “[I]f the Decade is only 6–7 percent successful in achieving its overall goal it should still be sufficient to eliminate guinea worm” (Bourne 1982:2).

At the time, Bourne was both a top UN spokesman for the world water project and a former adviser to President Carter, then fresh out of his presidential term. When he met with Carter to discuss the possibility of collaborating on the effort, the former president was looking for a cause to which he might dedicate himself. Among the materials about world water problems that Dr. Bourne brought with him that day, “‘He had slides of guinea worm to show me,’ Mr. Carter [later] said. ‘I was intrigued’” (McNeil 2006:3).

Another legendary figure in guinea worm eradication had also opened discussions with Jimmy Carter’s White House as early as 1977. Public health expert and US Centers for Disease Control (CDC) veteran Dr. Donald R. Hopkins11 was involved in the landmark smallpox campaign in the 1960s, the first (and, at the time this is being written, the only) campaign to ever successfully globally eradicate a disease. At a time when dracunculiasis was rarely mentioned in public health domains, Hopkins believed that it would be possible to make guinea worm the second disease to be eradicated from the world. With a reputation for quiet dedication and unassuming genius, Hopkins initially established a program for guinea worm at the CDC in 1980, and he remains a driving force and lead expert behind the eradication campaign today—in fact, many in public health circles associate his name with guinea worm eradication just as strongly as they do Carter’s. By 1987, Hopkins and Carter had officially joined forces. Today, the powerful coalition against guinea worm led by the (p.217) Carter Center also includes key partners such as the CDC, WHO, Unicef, and the Bill and Melinda Gates Foundation, alongside many national governments and agencies. Hopkins has become Vice President of Health Programs at the Carter Center, and Jimmy Carter refers to him as one of the “few heroes in my life” (Bristol 2008).

If the guinea worm cause found a champion in Carter and his colleagues, the nascent Carter Center also found a perfect totem in the guinea worm. This choice of focus forever politicized the worm and simultaneously solidified Carter’s new foundation under its banner. Yet it also fundamentally changed the deepest premise of the original campaign, for the first time transforming the guinea worm into a primary policy target unto itself, rather than a secondary index of the underlying issue of water purity. This policy prioritization perhaps evinces a blurring between symbolism and epidemiology, for although guinea worms are strikingly monstrous in image, they do not actually cause death, in contrast to many other diseases in Northern Ghana that do. Indeed, local people quite frequently pointed this out, expressing confusion about the program’s dedication of major resources to a disease that many did not consider among their most important health issues. The group of Nigerian women who drove General Gowon away from their guinea worm–infested pond also expressed such concerns, shouting at him, “Why don’t you go treat AIDS instead?” (McNeil 2006:2).

In Northern Ghana, where I often waited for buses at the Tamale station, many surfaces were plastered with bright red–rimmed decals of the parasite emerging from someone’s foot, edged with the words “GUINEA WORM IS A MEDICAL EMERGENCY.” Such urgent messages were once printed on stickers, backpacks, and T-shirts distributed throughout the region, reminders of the fact that it took years for the campaign to convince many people with guinea worm that they needed treatment (Watts 1998). Publicity articles often refer to guinea worm as a “forgotten disease of forgotten people,” but, interestingly, it was often the “forgotten people” themselves—rather than private donors or health institutions—who for long years remained unconvinced that their disease was urgent enough to require medical intervention. Indeed, in statistics tracking the leading causes of death and disability among the world’s most marginalized poor, guinea worm would not make the list (World Health Organization 2009a). Yet parasites can be poignant symbols of death and (p.218) danger even when they do not scientifically cause it, as anthropologist Mary Douglas notes: “worms belong in the realm of the grave, with death and chaos” (1966:56).

Extracting a worm from the human body has long represented the quintessential act of healing in medicine. Ethnographic accounts the world over—from New Guinea (Hoeppli 1959) to South Carolina (Hyatt 1978)—tell of witch doctors healing complex sicknesses as well as economic misfortunes by removing worms from their patients. Georges Canguilhem uses a similar example in the opening of his famous work The Normal and the Pathological: “Magic brings to drugs and incantation rites innumerable resources for generating a profoundly intense desire for cure. Sigerist has noted that Egyptian medicine probably universalized the Eastern experience of parasitic diseases by combining it with the idea of disease-possession: throwing up worms means being restored to health” (1991:39, emphasis added). This figure also appears in Claude Lévi-Strauss’s essay “The Sorcerer and His Magic,” where the more potent sorcerer marks his power precisely by his ability to produce “a bloody worm,” and his approach is considered more efficacious than that of other healers because “he presents them with their sickness in a visible and tangible form” (Lévi-Strauss 1963:176). However unconsciously, this dramatic symbol of removing a living parasite from the body imagistically elevates the impact of such a health intervention in the eyes of observers. But at what point does the symbolism of a disease overtake other rationalities in establishing policy priorities?

Of course, few policymakers would be comfortable with the idea that symbolism impacts how they allocate funding. Their own powerful forms of cryptic evidence furnish other rationales and justifications. When institutional priorities began shifting away from the Water Decade’s infrastructural projects and toward a “targeted” campaign that made eradication a goal unto itself, health economists argued that the guinea worm not only emblematized inequality through its link to disease-ridden water (a symptom of poverty), but directly contributed to its pathologies (as a significant cause of poverty). Through extrapolations and economic rate-of-return equations, they predicted that eradication of the parasite would make local agriculture significantly more productive and profitable (by eliminating the days or weeks when the worm kept farmers from their fields), thus shifting local economies and bringing rural poverty a key step closer to alleviation (p.219) (Belcher et al. 1975; Cairncross et al. 2002; Centers for Disease Control 2011a; Voelker 2007).12 But poverty is a tangled and often-unresponsive condition. According to the World Bank, farming productivity in Northern Ghana remained painfully stagnant during the years that coincide with guinea worm eradication efforts, marked by low and inconsistent crop yields that experts believe are linked to holes in local infrastructure and to insecure markets for selling what food products are grown (World Bank 2011:52–53). In fact, the number of people living on less than a dollar a day in Northern Ghana has actually increased by 0.9 million since 1992 (World Bank 2011:7), when the guinea worm campaign was in its first years of outreach there. Whatever profoundly complex factors are now sharpening the inequalities that have long marked the region, these recent figures suggest that the slow decline of the guinea worm—while clearly meaningful for other reasons—has not yet been able to make a statistically visible dent in the deep-rooted problem of poverty for the farmers of Northern Ghana.

Yet the parasite’s evocative image of decay has undeniably captured the public imagination to a rare extent and has gathered major health policy momentum, propelling the guinea worm campaign into one of the most widely publicized and multipartnered eradication efforts in history. The program’s long-standing international media popularity likely also derives in part from the broader biomedical ideas about worms that were already in play, a semiotic dimension that Wenzel Geissler also examines in his “Worms Are Our Life” series. After detailing Luo ethnomedical ideas of worms, Geissler then probes and denaturalizes biomedical understandings of parasites to reveal them as equally culturally laden:

[B]iomedical concepts identify order with the maintenance of borders, which protect the vulnerable inside and the identity of the person and externalize and exclude other living things. The relationship to creatures transgressing these borders is conflict, in which both health and the order of life is at stake, and in which moral constructs of “good” and the fight against “evil” are evoked. … Worms are conceptualized as the enemies of order and a threat to bodily functioning … they have to be fought and possibly eradicated.

(Geissler 1998a:75, 70)

Surely the eradication campaign drew strength from these sorts of preexisting biomedical conceptions of worms, as well as from the international publicity generated by such a grotesquely photogenic nemesis. (p.220) The Carter Center’s first active tallies of guinea worm showed hundreds of thousands of unreported infections in some of the poorest corners of Africa. In light of how shockingly hidden the disease had formerly been during eras of passive surveillance, the guinea worm was also transformed into a potent symbol of neglect that could be remedied. There were almost 180,000 cases of guinea worm tallied in Ghana during the first official counts of 1989 (Hopkins and Hopkins 1992), the year that the national program launched in partnership with Ghana Health Services. The Carter Center was still called “Global 2000” then, and their multimillion-dollar backing, coupled with numerous partners and donors, was essential to the program’s extensive reach into every community in rural Ghana where the parasite was endemic. A dedicated rotation of program field officers canvassed cities, crossed rivers in dugout canoes, and set off down narrow dirt paths so rough they could be traveled only by motorbikes, gradually making contact with even the most remote communities. “Sometimes people would tell us it was the first time they had ever seen a government vehicle in their village,” Dr. Seidu said of the program’s four-wheel-drive trucks, which have small black and blue emblems of the guinea worm emblazoned on their doors.

Going after the guinea worm as a single-target issue meant a dramatic change of tactics from the World Health Assembly’s original vision. Instead of funding expensive clean water projects, the new program would focus on distributing straws that filtered only guinea worm larvae, and on establishing an unprecedented network of community volunteers to monitor and report developing cases. Yet after nearly fifteen years of applying these tactics, an explosion of guinea worm in a northern village called Sang still qualified this Ghanaian community as the most guinea-worm-ridden place in the world, and program workers began to consider integrating more comprehensive water-purification methods there. Although the Carter Center typically does not fund water projects directly, they had strong partnerships with other NGOs that did.13 With the Guinea Worm Eradication Program helping to coordinate advocacy, a mechanized borehole well system was finally built in Sang. “You used to see everyone in this village sitting under trees with their worms coming out. But we got the well and cases fell to nothing, nothing,” a community volunteer from Sang told me. Dr. Seidu was also impressed with the dramatic results that clean water provision produced in the long-problematic village. “I have (p.221) seen the worst guinea worm villages turn on a dime once they have good water,” he told me firmly. “It is something to think about.” A similar view has been expressed by people who received cloth water filters from the guinea worm eradication campaign in Nigeria, as William Brieger and his colleagues at the University of Ibadan (1997) reported in the article “Eradicating Guinea Worm Without Wells: Unrealized Hopes of the Water Decade.” They documented the campaign’s success at reducing guinea worm in Nigeria, but also discussed the persistent human health risks of a backdrop where only 14 percent of rural citizens at the time had access to safe water (74 percent of residents in hamlets drank only unclean pond water, and another 11 percent had wells that had become dysfunctional). In this context, “people accept the filters reluctantly and continue to ask when the government will provide them with wells” (Brieger et al. 1997:359).

Indeed, in contrast to the widespread enthusiasm that borehole wells and other clean water projects have generated, the reception of the program’s individual water filters has been ambivalent in Ghana as well, and their success at times markedly uneven. I will always remember the first time that I saw a guinea worm filter in its local context. It was in the town of Savelugu. I was sitting on a bench under an acacia tree, talking to some men with the help of a translator. When I mentioned my interest in the guinea worm, a tall, wiry young man signaled to his wife and said something enthusiastically in Dagbani. She disappeared behind half of a green fence, and returned holding some small objects in her extended palms.

It took me a minute to recognize the Carter Center’s signature guinea worm straw, with their stylized eagle logo imprinted on the shiny black plastic tube. The nylon cord—which in theory could be strung around a farmer’s neck as he worked in the fields, with the attached filter at the ready if he needed to take a sip from a nearby pool—was deeply folded at regular intervals, in that factory-fresh way that made it clear this cord was being unfurled for the first time. Eagerly scanning the faces of the older men as he explained how to use the straw, its owner theatrically demonstrated how to put the filter in his mouth, using a wriggling finger to represent the guinea worm that could not fit through its mesh. After a few minutes he gently passed the straw to me for inspection, then shook open the larger cloth filter with a dramatic flourish.

The second filter was edged with shiny cloth surrounding a wide mesh square made of synthetic fabric once donated by Dupont Corporation. (p.222) The nylon mesh was so clean and new that its white weave gleamed almost silver in the hot midday sun, still deeply creased in perfect, fresh rectangles after months (or years?) of storage. Such cloth filters were designed to be permanently stretched over the tops of the clay vessels in which a family’s water was stored, to catch the tiny crustaceans that, if swallowed, might infect the drinker with guinea worm. I was puzzled as I watched the man’s elaborate pantomime of how to employ devices that he himself had clearly never used. This technology had some significant value to him, I thought, but it wasn’t a use-value.

The demonstration over, he carefully refolded the cloth filter and tucked the pipe filter’s necklace cord back into neat loops and handed them both to his wife, who returned them to their designated hook on the earthen wall of their home. The unused filters hanging by the door reminded me of the placement of protective medicines in Dagomba households, which are carefully collected only to be positioned strategically in the house (usually hung in the doorway or buried in a corner of the room), other times worn on the body (often around the neck, along with herbal bundles or Qur’anic-verse-inscribed scrolls tucked in slender leather tubes only slightly smaller than the guinea worm tube filter hanging from its lanyard). In Northern Ghana, the efficacy of such traditional protective medicines is not understood to derive from their daily use; instead, it is the simple fact of their possession that matters (Bierlich 2007). Looking at the unused guinea worm filters draped with such care in a Dagomba family’s doorway, I began to wonder: Were these biomedical artifacts the talismans of a new century?

An informal questionnaire administered by Ghanaian leadership in the eradication program in 2009 found that 55 percent of people kept their guinea worm filters in the bedroom. A head Ghanaian program administrator, who had helped to organize the unofficial mini-survey in a few villages of the Northern Region and cared deeply about figuring out why local people acted in ways he could not understand, shook his head as he read the survey results to me. “The bedroom!” he repeated. “That doesn’t make sense. Why would they keep the filter in their bedroom?” The second most popular storage place, favored by 26 percent, was hanging on the wall. Another 11 percent declined to answer. Less than 3 percent reported actually keeping it on their water pot, where guinea worm filters are supposed to remain stretched for daily use.

(p.223) At the time the survey was taken, individual water filters and education about them had been a centerpiece of the guinea worm eradication campaign in Ghana for exactly twenty years. But when asked why they used the filters, 54 percent of people had no answer.

A Case of Competing Magics

The familiar term “magic bullet” in public health discussions refers to an intervention’s reliance on single-target medical technologies (such as chemical formulas, mosquito nets, or guinea worm filters), without focus on integrating these biomedical objects into more contextual, ecological, or holistic health care interventions (cf. Biehl 2007; Cueto 2007). In the public health seminars and policy lectures I attend at the Woodrow Wilson School, this phrase is bandied about frequently, often with air quotes and usually with critical implications.

But for a moment, I want to take this terminology seriously at face value. After all, the label “magic bullet” comes startling close to the “magic ammunition” (Evans-Pritchard 1937:180) that Azande witch doctors use to symbolically control danger and sickness. This is not to deny that public health’s “magic bullets” do have obvious biomedical applications and technological capacities, but rather to question why they are sometimes treated by health officials as having value and efficacy beyond their observable worth, as if their distribution alone somehow taps into a distant all-protective power regardless of how they are used in practice. Such uncanny resonance with ritual manipulation deserves to be taken seriously. An Azande witch doctor shoots a magic “missile” and extracts a beetle from his patient’s forehead (Evans-Pritchard 1937:179). Under what social conditions or political constellations can a health campaign distribute a “magic bullet” and expect to remove a worm?

Of course, this is a question that extends far beyond the realm of guinea worm and reverberates throughout the global health arena today. Elsewhere in Ghana, a study of river blindness showed that rates of the disease were not going down despite a major “vertical” campaign there. For unknown reasons, 75 percent of the people given ivermectin drugs by the campaign were not taking them, even though the pills would have prevented this crippling blindness, caused by the tiny microfilarial parasites (p.224) of a larger parasitic worm (Kutin et al. 2004). During a visit to Princeton in winter 2009, another top Ghanaian medical doctor and health researcher spoke eloquently about the “cultural barriers” he has seen during his decades of applied research. He told us that the malaria bednets distributed to be draped protectively around pregnant mothers and their newborn children were occasionally reallocated within the household, noting particularly that they were sometimes rolled up and tied around the head of a husband as he slept. (Interestingly, this style of male headdress is uncommon but highly symbolic in Northern Ghana. Or at least, the only man I ever met who had a rolled cloth circled like a crown around his head was the paramount chief of Kumbungu, who presided over his court of attendant chiefs in a red La-Z-Boy-style recliner.)

Yet such status-steeped and sometimes supernaturally meaningful applications were hardly the only instances of biomedical objects being used in ways that their public health creators had not intended. There were also some cases where they were simply not used at all, as when polio vaccines were rejected by parents who feared rumors of sterilization, or mosquito nets were found tightly rolled in the corners of huts where children died tragically of malarial convulsions. Other times these health devices were put to highly functional sideways purposes; off the banks of Lake Bosumtwi, I once saw two small boys wading in waist-deep water with a mosquito net, trying to catch tilapia.

These divergent local uses of biomedical objects ranged from the profoundly tragic to the dazzlingly creative, but they all had one thing in common. The objects all came from “magic bullet” campaigns, where the seemingly misused devices were distributed in a vacuum of ongoing infrastructural development (usually by outsiders who departed from the village shortly afterward), leaving the health technologies to circulate unmoored in the intricate capillaries of preexisting knowledges and meanings.

It is therefore no coincidence that these magic bullets at times become embedded precisely in local magical systems, traveling in sideways directions. While donors and public health officials are perpetually puzzled by local people’s “noncompliance” with such potentially lifesaving technologies, the recipients of these devices were often equally perplexed by the strangers who arrived abruptly in their villages and disappeared within hours, leaving behind the manufactured traces of their concern: fogs of (p.225) insecticides, the banal lace of synthetic bednets, or plastic filters subtly etched with corporate logos, like illegible glyphs on artifacts from some distant world. It is no wonder such objects sometimes came to be imbued with meanings of power and danger, even when unused and simply possessed.

Interestingly, Carter Center officials and other proponents of guinea worm eradication often speak of the program’s interventions as “a low-tech venture” (Bristol 2008), because the disease is now on the cusp of eradication without a drug or vaccine (Barry 2007). (There has never yet been a vaccine developed to prevent a known parasitic disease, a fact that marks a major tactical difference between guinea worm and the smallpox virus eradication campaign.) In fact, I imagine that some guinea worm program members might be taken aback that I consider some of their campaign cornerstones as “magic bullets.” Yet I want to suggest that a closer look at these objects begins to complicate taken-for-granted notions that such intervention tools are simply “low” technologies, assumptions that become part of a rhetoric that forecloses deeper questions. The copepods that carry guinea worm are unusually large for a water-borne disease vector, measuring more than one millimeter in length (Muller 2005:522). This means that any cloth, even an ordinary T-shirt, can serve as an effective water filter against guinea worm larvae, a preventative measure long known in many parts of the world. As far back as 1666, one author in Beirut wrote of guinea worm: “The way to avoid this worm is to drink only wine or, if water is used, only such as has been carefully filtered through linen” (Grove 1994:713).

Guinea worm thus has the rare distinction of being a tropical disease that the majority of people living in extreme poverty already had the technical tools to prevent—most any piece of cloth would do. I wondered what it meant that the Carter Center’s guinea worm filters looked distinctly like a piece of more specialized technology, when they had more or less the same medical efficacy as a T-shirt would. (DuPont scientists had developed a tough nylon mesh for the cloth guinea worm filters [Barry 2007], which would last longer and drain faster than cotton—fine enough to catch copepods, but too porous to strain out any other pathogens, such as microscopic vectors of fatal water-borne diseases.) Yet the novelty of the specialized-looking device may have served a double purpose. Perhaps it created a space for new behaviors, helping community health education (p.226) to take root in the minds of both policy officials and program recipients—almost as a kind of branding. Certainly the sleek, logo-imprinted guinea worm filters carry with them an aesthetic of science. But for all the tremendous efforts and resources entailed in developing and manufacturing the synthetic filters in an American laboratory, and in hiring campaign staff to distribute them to remote villages around the world and spend years educating people about their use, it remains a somewhat painful fact that the filter’s wide mesh can protect against only a single disease, and one that rarely ever threatens human life. A different type of water filter—ceramic, for example—distributed through the same channels to the same households could have prevented guinea worm and at the same time protected against the many other, far more deadly pathogens that often inhabit guinea-worm-infected waters (Brieger et al. 1997). Among these are polio, cholera, typhoid, hepatitis A, various intestinal worm infections, and the common diarrheal diseases that kill 1.5 million children in the world each year. Given this context, the eradication campaign’s choice to develop specialized water filters that protect only against a single water-borne disease might be viewed as a downright iconic example of “magic bullet” technology.

A similarly complex story could be told about the ABATE chemical formula widely applied to dams and ponds, which kills guinea worm larvae but is not designed to purify the unclean water that local people then must continue drinking. The larvicide is now donated to guinea worm eradication efforts by the BASF chemical group, a corporation which (among its many diverse products) sells active ingredients to the pharmaceutical industry (BASF 2012). ABATE is BASF’s particular brand-name of the generic drug temephos, an organophosphate larvicide; competing corporations have also produced versions of the compound under the trade names Abat, Abathion, Biothion, Bithion, Difennthos, Ecopro, Nimitox, and Swebate. By inhibiting cholinesterase enzymes in the brain, blood, and nervous system, temephos interferes with the functioning of the central nervous system and causes insect vectors to die before reaching adulthood. At much higher exposures (via accidents or spills, for example), temephos can produce the same effects in humans, overstimulating the nervous system and causing difficulty breathing, nausea, incontinence, convulsions, coma, respiratory failure, and death (National Library of Medicine 2011). (p.227) Indeed, it was not always easy for campaign workers to estimate the liquid volume of an irregularly shaped body of pond or dam, an important step in mathematically calculating the precise dose of ABATE needed. I was told of a case in Northern Ghana where many fish in a particular village’s pond died after an application of ABATE, suggesting that the water was accidentally treated with a significantly higher dose than that needed to kill copepods. The local community was deeply and understandably concerned by this incident. Temephos has also been widely used in other global health campaigns over time, such as efforts to eradicate malaria and river blindness, and several insect vectors have already developed drug resistance (Polson et al. 2010; Rodríguez et al. 2002; Tikar et al. 2009). One study in Ghana found that the S. sanctipauli blackflies (which carry river blindness) in a body of water that had never even been directly treated with the formula already had a fivefold drug resistance to temephos (Osei-Atweneboana et al. 2001). These flies had genetically mutated and developed inverted chromosomes that allowed them to survive the larvicide’s neurological effects—an evolution suggesting heavy levels of temephos saturation in the environment over generations. In this light, the guinea worm campaign’s focus on applying ABATE to local dams and ponds is perhaps not a case of a “low-tech” getting-away from drugs, but instead a displacement of the “magic bullet” chemical’s entry point: in the absence of an effective pharmaceutical treatment, the environment itself becomes medicated.

In addition to the scattered threats that villagers occasionally addressed to health workers administering larvicide to their drinking water (as in the situation in Taha where this story began), the guinea worm’s sheer persistence over the years testifies to the fact that many people did not use their painstakingly distributed household filters as instructed. Despite continuing campaign efforts and a consistently high demand for the program’s fashionable filters, the guinea worm in Ghana actually increased from 1994 to 1995, from 1998 to 1999, from 2001 to 2002, from 2002 to 2003,14 from 2005 to 2006, and from May of 2006 to May of 2007 (World Health Organization 2005:6; Centers for Disease Control 2007: 4). In a 2007 trip report, former president Carter even stated that “in our Guinea worm eradication effort, Ghana has been our worst disappointment” (Carter 2007). But in the face of mounting proof that (p.228) the technological tools at their disposal had limitations on the ground when it came to comprehensively addressing guinea worm disease without funding to build clean water projects, the Ghanaian program was faced with an exceptionally challenging task: to make the available tools work anyway.

This required constant and creative negotiations, careful surveillance networks, and most of all a renewed attention to the underlying social contexts and community relations through which the program’s distributed objects inevitably made their way. For example, ABATE chemicals usually rested at the center of the few more menacing conflicts that the program experienced—such as the rare but significant occasions when people came out and actively resisted attempts to apply ABATE to their water, or kept the locations of their ponds hidden from the campaign workers trying to treat them. Over time, the eradication program learned that the best way to quell such fears was to organize a community demonstration in which murky water collected from a local source would be combined with clear water in a glass jar and shaken, allowing people to see for themselves the white copepod vectors bobbing and swimming in the jar (Hopkins and Ruiz-Tiben 2011). If ABATE larvicide could be called a “magic bullet” solution on account of its vertical emphasis and chemical technology, then perhaps such demonstrations could be likened to showing people how a magic trick works. After such evidence-based demonstrations, community trust and lines of communication were generally much improved, and local people were less suspicious of the chemicals poured into their water. (After all, the Oxford English Dictionary’s [2010] definition of “magic” specifies that it usually involves “the use of an occult or secret body of knowledge.” What better definition could there be of technology when it is left unexplained and enigmatic?)

Conflicts over the guinea worm program’s technological tools were not always of this nature. At times they reified existing social differences, and even made new ways of addressing them possible. Bierlich reports that senior wives in Northern Ghana sometimes hoarded the household guinea worm filter as an object of prestige, forbidding junior wives to use it to prepare the family’s drinking water in their absence (1995:506). Even in the case of Taha’s conflict, it is notable that most of the farmers who stormed the water’s edge with cutlasses that afternoon were younger men, who by voicing their suspicions of the ABATE chemical’s dark purpose (p.229) were also posing a challenge to their elders who had consented to its application. At work here are basic human motivations and power struggles, old as time, which technology made negotiable in surprising new ways.

But there is still the underlying fact that somehow, when ABATE chemicals were first applied to the dam in Taha with secrecy reminiscent of a sorcerer mixing a potion, the local villagers themselves embraced this observation. They enfolded ABATE (perhaps already a vehicle for symbolic authority) into their preexisting beliefs about the paranormal causes of guinea worm as another interchangeable unit of magic. In this sense, perhaps it is these Dagomba farmers’ assumption that their own systems of magical causation were so plainly permeable to the eradication campaign’s paraphernalia that ultimately attests most loudly to the existence—and the potential risk—of the campaign’s magic bullets. Although devices such as guinea worm filters were designed as a quick fix to eliminate the parasite without costly infrastructural development, in Ghana “the programme stagnated for a decade” (Cairncross et al. 2012) and spanned more than twenty years. In this longue durée, supernatural suspicions and other very meaningful community concerns began to accumulate around the magic bullet technologies that were designed to eradicate a water-borne disease without providing clean water.

Yet to their great credit, program workers recognized the need to step outside this volatile overlap in order to move the campaign onto firmer shared ground. During my visits in 2008 and 2009, I observed government actors fight for clean water systems for communities even though usual Carter Center policy did not directly fund this strategy, painstaking national negotiations that resulted in a major new addition to the program staff in Northern Ghana: an “emergency response team” to assess water conditions and repair broken-down borehole wells. I was also impressed by many of the daily ins and outs of community relations (jokes, translations, compromises, return visits, village soccer games, and non-Muslim campaign workers who fasted during Ramadan as a mark of solidarity with coworkers, for example). I sometimes wondered to myself whether the campaign seemed to be making headway not because of its vertical blueprint but rather in spite of it, as behind-the-scenes swerves and human ties fiddled with the vertical model at its edges and remade its meanings on the ground—processes of trial and error that economist Angus Deaton might call “endless tinkering.”

(p.230) Reflections in the Twilight of the Guinea Worm

The office walls of the guinea worm program’s headquarters in Tamale were plastered with worm “forecasts” for the year. Side-by-side poster boards painstakingly charted each parasite that emerged in black or red marker, month by month and district by district. These charts documented the gradual effects of program workers’ persevering outreach as, one pond at a time, one village at a time, guinea worm slowly began to disappear from Northern Ghana. When I first visited the office in 2008, alternating ones and zeros dominated the forecasts, the hand-drawn binary code of guinea worm’s last stand. But by the following summer, most of the cells in the chart’s grid were filled with zeros.

In a back room of the air-conditioned office, a young Carter Center consultant spoke surprisingly fluent Dagbani for a twenty-eight-year-old from the American Midwest. For almost seven years he had worked tirelessly for guinea worm eradication efforts. Behind the desk where his laptop rested, there were numerous plastic vials, each filled with a single, long white worm suspended in clear liquid. “They are waiting to be sent to Atlanta for DNA testing,” he explained, adjusting his glasses.

At the weekly staff meeting later that day, ambiguity over the identification of various parasitic worms became a major point of discussion. Now that Ghana was down to its last cases, it was important to differentiate the actual guinea worm from any look-alike that might emerge, such as the white “mother worm” of onchocerciasis that can grow over a foot in length, nestled in a hard nodule under its host’s skin. Looking at the picture one program worker displayed on his laptop of a recently emerged false guinea worm, an example of the parasites that should not ultimately be tallied on the program charts, I thought fleetingly of the villagers with guinea worm who once used oracles to tell them whether they were responsible for the worms because of their own wrongdoings. With genetic sequencing and its digital divinations, the eradication program workers also needed to discern whether or not certain worms were their own responsibility to be counted.

Perhaps one might see in this a poetic analogy in which bioscience relies on its own secret knowledge. But meanwhile, the surrounding villages’ traditional markers of occult magic had been equally reconfigured (p.231) by the biomedical logic of guinea worm prevention. Where village elders had once guarded sacred oracles and shrines (Bierlich 2007), now locally respected villagers were hired as guinea worm “dam guards” by Ghana Health Services and paid a monthly salary to sit by the water’s edge and make sure that no one stepped into the water—or, in cases where a borehole well existed, that no one drew drinking water from the dam. The punishment for doing so was a fine payable at the chief’s palace, the dam guard I met one afternoon told me sternly, leaning heavily on his gnarled wooden staff. Yet even those villagers who had initially resisted such program efforts were increasingly grateful to be rid of the guinea worms that many had believed were painful but inevitable parts of their lives (and indeed of their bodies) for so long. “Once I had guinea worms coming out of me for a whole year, one after one after one,” a man in Diare told me. “I could not farm, and weeds killed all of my corn. It was so hard to feed my family. Now,” he shrugged as he shelled peanuts onto the cement floor, “I am free.”

But even when the worm’s life cycle is biomedically understood and locally reframed as itself the culprit, its intimacy and even its absence remained layered with other social meanings for such villagers. False or suspiciously unverifiable reports of guinea worm sprang up in places thought to have eliminated the parasite—247 such false reports were logged in Ghana in 2011 alone (World Health Organization 2012:185). People learned that they could use the politicized worm to make claims for long-needed clean water supplies. Missing worms became a sign that sickness of all kinds was not inevitable, and eventually might be eliminated from their lives—but also that it took certain channels of foreign partnerships and funding to do it. “I hope the Carter Center cures malaria next,” one village volunteer told me. “That’s the only way it will be fixed, if the Carter Center does it.” He also credited the Carter Center for giving him a blue bicycle that, it turned out, had actually been donated by Unicef.

In August and September of 2009, the last months I spent in Ghana conducting this fieldwork,15 the country reported only one case of guinea worm each month—for the first time in history. The last known case in Ghana to date was reported the next year, in May of 2010 (Richards et al. 2011). A Carter Center 2011 “Guinea Worm Wrap-Up” newsletter reported that “after … over four million cloth filters, more than one million (p.232) pipe filters, 72,000 liters of ABATE® Larvicide; at least nine ministers of health and nine missed target dates, we are confident that Ghana’s Guinea Worm Eradication Program has finally achieved the demise of the worm” (2011). With the hard work of the program, the gradual incorporation of water projects, and long-term community relationships finally paying off, the worldwide eradication of guinea worm has been predicted for 2013—a date certainly to be taken as a hopeful estimate, given that eradication was also predicted in 1990, 1993, 1995, 1998, 2000, 2005, 2008, 2009, and 2011. Yet eradication does seem imminent, with only 542 cases reported worldwide in 2012 (despite an unexpected outbreak in Mali), down from an estimated 3.5 million cases in 1986 when the Carter Center first began its campaign.16 Most of the remaining cases of guinea worm are found in postconflict South Sudan, where Carter once managed to use his diplomatic sway to negotiate a “guinea worm cease fire” so that nylon filters could be delivered safely. An experimental barter system there now encourages local peddlers to deliver guinea worm water filters and larvicide in exchange for gum arabic, a hardened tree sap they can use to make sale items such as watercolor paints, cosmetics, and shoe polish (Voelker 2007:1857). A feature film about guinea worm eradication, Foul Water, Fiery Serpent, was recently released, narrated by Sigourney Weaver. The movie poster depicts three African women balancing water vessels on their heads against a glaring red sunset, with a tagline reading, “IT’S NOT OVER UNTIL THE LAST WORM IS GONE.” “Weaver’s narration, given her role in Alien, seems oddly appropriate,” eminent parasitologist David Molyneux wrote in a recent Lancet article (2010:947), adding that guinea worm eradication, in his view, means removing one of “the true ‘alien monsters’ from planet earth” (948). There is even a “Save the Guinea Worm Foundation” that has sprung up online with the mission statement of protecting the parasite against extinction. It purportedly seeks elite members known as “the Preservers” to volunteer themselves as guinea worm hosts and give the “world’s most endangered species” a chance to continue its life cycle within their own bodies (2009).

But as this ancient disease nears the end of its time on earth, there is also cause for reflection. Parasitic worms by their very nature breach intimate human boundaries (Douglas 1966; Gardenour and Tadd 2012), which is exactly what makes the ways people struggle to understand them such a revealing microcosm of health cultures and local histories—and (p.233) so it is not surprising that the guinea worms emerging from people’s flesh became a battleground for much bigger social and political conflicts, raising questions of how to cure17 and whose responsibility it is to heal, and even metaphysical issues about where life ends and death’s parasitic hold begins.

As we drove away from Sang that day, it was not hard to believe that the village had once been the most heavily guinea worm–infected community in the entire world. I stared out the window at sights familiar in Northern Ghana, prayer calls echoing from the low plaster spires of neighborhood mosques, clusters of mud huts contrasting with the brilliant colors of women’s head scarves. Mothers balanced enamel bowls of yams on their heads and stepped between burning piles of trash with babies slung on their backs; everywhere, beauty and decay folded into each other. A Brong Ahafo Region health student named Alfred sat next to me in the backseat of the Guinea Worm Program 4 × 4, writing in his notebook. He had accompanied us for the day as part of his summer rotation, and had helped me enormously that afternoon to translate my questions into a rephrased half-pidgin that my interviewees could better understand. Suddenly he tapped me on the shoulder and shyly handed me a crumpled paper where a poem was written in blue ink. When I asked if I could include parts of it in the essay I was writing, he smiled and painstakingly recopied it for me on a fresh sheet of notebook paper in the neatest handwriting he could manage as we bumped down the unpaved road back to Tamale.

  • They say I am a blind old worm from Guinea
  • But I say to them, look not unto my whitish nature
  • And claim me holy
  • You don’t know me, I am not from the gods
  • I can do much worse things to mankind.
  • I bet you do not even try to memorize
  • My Christian name when I mention to you
  • I am called Dracunculus medinensis
  • The ancient hero, I manifest myself in man,
  • From drinking water containing my cyclops.
  • There my ruling power begins internally.
  • The rupturing of the blister releases
  • My new generation into the world.
  • (p.234) [Local] practitioners with their knowledge about me,
  • Have they not asked the oracles
  • How I managed to live successful with my victims?
  • I slaved them,
  • Made them unable to go to farm or work.
  • When man sees me at the shore of the body,
  • They maltreat me
  • By forcibly pulling me out with their hands.
  • Because they know who I am.
  • I only say to them, treat me gentle, gentle.
  • If you want to eliminate me,
  • Follow these rules of water sanitation:
  • Boil water before you drink
  • Never send blisters into streams
  • Treat all infected persons
  • Report any case of me to a health worker.
  • Then you won’t see me again.
  • I say watch out.

—Alfred O. K., age twenty-two (Kintampo Rural Health Training School)18

The worm’s-eye view from which the poem is written—besides revealing the author’s own imaginative force—also creatively reframes the guinea worm as the agent of disease, with the parasite itself denying all connections to local healers, oracles, and gods. Although the poem was ostensibly written as a teaching tool, by that afternoon in 2009 there were barely any cases of guinea worm left in Ghana. But in Alfred’s school of rural health training, guinea worm seems to have become akin to a case study of how to overcome entrenched local beliefs about health.

More than that, the complex perspective that Alfred frames here with his own creative spark—a parasitic voice both scoffing and ancient, caught in the midst of a battle of human misunderstandings, simultaneously uttering a didactic death wish and a last battle cry—casts the worm as a forceful actor in these contested stories, as something deserving of being considered not just as a vector, but an ethnographic subject in its own right. For in the end, this account is not about anything so simple as (p.235) two sides colliding. It is the much more intricate story of how these forces unpredictably mingled and slowly changed each other—the worms acting too, their unexpected persistence and very gradual disappearance conveying something that neither the health workers nor the local villagers could fully articulate to one another, as the mediating parasites themselves were all along exerting a force of their own (Serres 1982).

Many of the issues discussed here will outlive the guinea worm. These Dagomba communities will likely continue to fear other traces of witchcraft, divine new ancestral messages. Their families will continue farming peanuts and tubers, in poverty and in hope of better things ahead. Some lucky villagers will now have clean water systems (at least until locally irreplaceable grommets and gears begin to malfunction). Others have new roles as village health volunteers, a brittle network that will perhaps inflect claims to other futures. It will be interesting to see how long guinea worm filters continue hanging, talisman-like, in villagers’ doorways and bedrooms.

With equally staunch hopes for things ahead, the majority of dedicated guinea worm campaign workers will go on with bolstered résumés to work for other tropical disease programs, perhaps trachoma control or malaria eradication, collating data and likely distributing new “magic bullet” pills and devices in other poor regions of West Africa. In this sense, neither side will likely reevaluate its ritual forms, or lose its faith. Still, this moment when guinea worm eradication allowed public health officials’ and Dagomba villagers’ respective technological and ancestral magics to cross paths can help us glimpse the risks, causalities, and potentials that these diverse groups of people see in each other, as refracted through “the other” living within us. For whether in reverence or disgust, nostalgia or triumphant defeat, the trajectory of humankind’s largest bodily worm is a history worth remembering—inseparable as any parasite, it is our history too.

As for the guinea worm itself, it is not so clear where its story will definitively end. Although the parasite is not medically recognized as having any animal reservoirs (this niche historically being filled by the guinea worm’s veterinary counterpart Dracunculus insignis), genetic sequencing recently showed that a guinea worm living in a dog in rural Ghana was, in fact, the human worm Dracunculus medinensis. Over time, several countries officially certified as free of guinea worm, from India to Uzbekistan, (p.236) have also reported cases of human guinea worms found living as secret refugees inside the bodies of dogs and raccoons.19 No one can say with certainty whether this is random accident, elegant adaptation, or if the last surviving guinea worms are patiently waiting to return home.20


(1.) I am extremely grateful to Ghana Health Services, the Ghana Guinea Worm Eradication Program, Ministry of Health personnel, and members of the Carter Center in both Tamale and Atlanta for their early support of this research. This ethnographic description of the campaign’s social complexities and cultural ambiguities—anthropological interpretations that are mine alone, and for which I accept full responsibility—are offered here in the spirit of mutual care and critical inquiry, with respect for their dedication and difficult work. This research was approved by the Ghana Health Services Ethical Review Committee and the Princeton University Institutional Review Board. Fieldwork was funded in part by the West African Research Association, the Princeton Center for Health and Wellbeing, the Princeton Health Grand Challenges Initiative, and the Princeton Development Grand Challenges Initiative. An American University Dean’s Research Grant also supported related archival work in its earliest stages. I thank João Biehl, Carolyn Rouse, Jim Boon, Carol Greenhouse, Joseph Amon, Ari Samsky, Erin Kane, Pat Moran-Thomas, and the participants in the “When People Come First” workshop for their thoughtful readings. Warm thanks to the Department of Anthropology at Princeton, and to Andrew Seidu Korkor, John Gyapong, Mr. Suly, Alfred O. K., and the many people in Tamale and the surrounding villages of Northern Ghana who shared their hospitality, reflections, and experiences with me.

(3.) This genus has technically been subdivided into three: Mesocyclops, Metacyclops, and Thermocyclops. The guinea worm larvae go from stage 1 to stage 3 within the bodies of these copepods, further complicating the guinea worm’s intricate life cycle.

(4.) The male guinea worm’s life cycle is significantly shorter than that of the females—although neither the male nor the female guinea worm survives beyond the birth of their first-stage larvae. Such short life cycles are of course hardly exceptional in the lower animal kingdom.

(5.) The guinea worm’s Latin name, Dracunculus for “fiery dragon,” comes from this trait.

(6.) The blister is caused by the release of a few larvae into the subdermis, so the bursting of the ulcer can occur even if the guinea worm never reaches water.

(8.) This resemblance is also the reason guinea worm was historically once called not only the “medina worm” but also the “medina vein” (Grove 1994).

(p.237) (9.) Some other interesting ethnomedical texts about perceptions of general worm diseases include Vecchiato (1997), Green (1997), Zondi and Kvalsig (1996), Reis (1994), Nichter (1989:164–65), and Hoeppli (1959).

(10.) For those interested in further reading about the social histories of Dagbon, see Bierlich (2007), Staniland (1975), Palmer (2010), and Tait (1963). J. Goody (1962), E. Goody (1973), and Hawkins (2002) examine the micropolitics of the supernatural elsewhere in Northern Ghana. The geography of these accusations also reflects profound north-south inequalities and regional imaginations that persist in Ghana (see Goldstone 2012; Parker 2006; Pellow 2011; World Bank 2011); for a comparative view of the occult from southern Ghana, see Meyer 1998; Gray 2005; Parish 2000. Of course, these realities in Ghana today are part of much larger permutations in occult politics emerging throughout neoliberal Africa. For a sampling of this vast ethnographic literature, see Apter 1993; Ashforth 2005; Austen 1993; Bayart 1993; Comaroff and Comaroff 2001; Ferguson 2006; Geshiere 1997; Masquelier 1999; Mbembe 2003; Schmoll 1993; West and Sanders 2003.

(11.) In Northern Ghana, some villagers spoke at length about President Carter’s local visits, but many had not heard of Don Hopkins by name—yet another reminder of the divergent meanings, myths, and characters that global health campaigns hold for different people (Global Health Chronicles 2009; also see PBS 2006).

(12.) In 1997, a team from the World Bank and the Carter Center estimated that the economic rate of return for guinea worm eradication would be an impressive 29 percent (Kim et al. 1997). As Cairncross et al. detail (2002), attempts to estimate the economic impact of guinea worm disease have often relied on multiplying the number of days of labor lost by the mean production value per day, despite criticisms that such equations do not factor in what policymakers call “coping strategies” (see Paul 1998). But as Cairncross and colleagues also note, such economic arguments have been effective at galvanizing national policymakers in many African countries, whether or not these calculations were ultimately accurate.

(13.) See Carter Center 2004; Hopkins 1992:630; Huttly et al. 1990. In South Sudan, 444 of the 463 villages reporting guinea worm cases in 2011 did not have a single source of safe drinking water (World Health Organization 2012:184).

(14.) In 2002, the Yaa-Naa of Dagbon was killed, and the isolated pockets of political insecurity that followed the chief’s death surely also impacted the Guinea Worm Eradication Program’s success rates during that time, as in 1994–1995 (see MacGaffey 2006). Yet the repeated annual increases in guinea worm disease over more than a decade are not simply reducible to these chieftaincy disputes either, although American campaign workers frequently glossed setbacks in this way. The political instability in Northern Ghana was thus very different from that in the Sudan, where decades of violent military conflict have embroiled millions of people, dramatically affecting all areas of health care delivery. This tumultuous history is the primary reason why most of the remaining cases of guinea worm are found in South Sudan (see Hopkins and Withers 2002).

(15.) On a brief methodological note, I spent four months in Northern Ghana preparing for and conducting this ethnographic research on Dagomba community health issues between 2008 and 2009, including four weeks spent working closely (p.238) with the Guinea Worm Eradication Campaign itself. During this time I attended program staff meetings, visited the Tamale Case Containment Center during daily bandagings of emerging worms, interviewed the National Program head and various staff members, and visited numerous endemic villages with the program’s field officers, sometimes observing their regular field activities and other times conducting my own interviews with guinea worm volunteers and local community members. Like much salvage ethnography, this period of anthropological engagement was much shorter than would have been ideal, a time frame with obvious shortcomings. I relied on whatever scraps of ethnographic information I was able to gather during these brief trips, as well as on the deep local knowledges and guidance of campaign workers themselves. By the time I was ready for a full year of intensive dissertation research, the guinea worm had already been eradicated from Ghana.

(17.) In public health circles, debates about eradication rage on (especially see Cueto 2007; Henderson 2012; Rinaldi 2009; Stepan 2011). Those who support eradication point out the obvious long-term benefits of ridding the world of even a single disease once and for all. Having such a popular “targeted” aim also increases public and donor support, giving the campaign a more compelling storyline. Meanwhile, advocates of disease “control” rather than all-out eradication argue that building sustainable health systems should be the goal rather than campaigns, which cost a great deal of extra money in the final push of surveillance; in efforts to isolate a country’s final cases, the guinea worm campaign has occasionally resorted to paying up to US$112 per “hanging worm” (World Health Organization 2012:185; see Rwakimari 2006:5). Yet on the ground in northern Ghana, eradication meant something different still (see Carter Center 2006).

(18.) I had to condense his original text at certain points and omit a few lines for reasons of space here, with much gratitude to Alfred for sharing his poem and for giving permission for its inclusion in this essay.

(19.) Cairncross et al. (2002) provide an insightful overview of this literature on the history of guinea worm infection within animal populations, and Muller (2005) reviews this apparent incident of a human species of guinea worm living in a dog in Ghana. Bimi et al. (2005) describe the breakthrough genetic sequencing tools of 18S-rRNA used to differentiate D. medinensis from D. insignis, including their finding from Ghana that suggested the guinea worm extracted from a dog was in fact the human worm D. medinensis. The authors additionally document reports of human guinea worm in dogs in Mauritania and a donkey in Mali. See also country-specific accounts of D. medinensis infection in animal populations of formerly endemic areas, including Pakistan (Muhammad et al. 2005), Uzbekistan (Litvinov and Litvinov 1981; Litvinov and Lysenko 1982), and India (Lalitha and Anandan 1980).

(20.) Obviously, guinea worms do not have the affective capacity to consciously wait with patience, and this expression is a figurative reference to the evolutionary accidents and persistent force of nature over time, which often thwart or outlast (p.239) human efforts to decisively predict and fully control disease. By playing here with the way that the guinea worm has already been anthropomorphized by various actors in this story, I mean to suggest that versions of the social complexities and conflicting priorities that unfolded during this eradication campaign will repeat themselves in other times and places; if not for guinea worm in Ghana, then for guinea worm in South Sudan—and one day in the future, when guinea worm is finally eradicated, this story will resurface again within the tales of numerous other diseases for which eradication has proven a more elusive goal than anyone expected, as polio and malaria take their place as the next frontrunners on the global eradication agenda. Even smallpox, the disease so often pointed to as proof that eradication is truly possible, has recently returned anew to intervention debates: there is now talk about resuming public smallpox vaccinations, owing to concerns that the eradicated disease could be intentionally reintroduced as a biological weapon (Carter Center 2002; see Hopkins 2002 [1982]; Henderson 2009). With epidemiologists already constructing contingency plans and control scenarios in case the only disease ever to have been successfully eradicated from the world someday returns, it is worth wondering whether a similarly unexpected plot twist may one day present itself in the wake of guinea worm eradication. (p.240)