At the Old Swimming Hole, a Vicious Cycle ThrivesBy DONALD G. McNEIL Jr.

KWA’AL, Nigeria —The pond was aboutthe size of a school swimming pool,except it was surrounded by dry mudpocked with hundreds of hoofprints.

A herd of goats was at one edge, drinking and defecating in the same spot.The sun was going down behind a thorntree, backlighting 50 naked boys splash-ing one another in the warm dusk.

Where a colonialist romantic wouldhave seen a landscape of native inno-cence, I saw a horror movie: there wereworms in the brown water invisibly digging right through the boys’ skin.

Kwa’al is a market village that existsonly because the region’s red dirt tracksmeet a paved road here. Each morning,women walk in with sacks on their heads:potatoes, onions and cabbages that theypile by the road, hoping to earn $3 or so.It is rural and traditional; a nearby villageis famous for the dogs it raises for meat.

Kwa’al is also a “schisto village.” Athird of its children have blood in theirurine because of schistosomiasis, a parasitic disease transmitted by watersnails. Also known as bilharzia, it is thesecond most common tropical disease in Africa, after malaria. Stuck to the mudwall of a building is a Health Ministryposter showing a silhouette of a squat-ting boy staring down, troubled, at thescarlet stream running out of him.

The blood is just a red flag for the realproblem: children with heavy infestationsof the worms, known as schistosomes,are stunted and do poorly in school.

An hour in Kwa’al is a mural of para-sitology: a living schematic of how thelife cycle of a human boy intersects the

life cycle of a waterborne worm and thefinancial cycles of global public health.

When a team from the Carter Centerand a pediatric parasitologist from theCenters for Disease Control and

Prevention, Dr. Frank O. Richards Jr.,drove into Kwa’al at 5 p.m., after a long day visiting villages at the ends ofdirt roads, the local health volunteersbegan a demonstration of their pre-

vention techniques.As one man lectured some local chiefs,

using a flip chart to explain the worm’slife cycle, the children lined up at a smallwood table. Their names were jotted in a notebook, and their heights measuredon a stick with yellow, green, blue andred bars. Those who reached yellow, 35 inches tall, were handed one pill. The

tallest children were handed four, whichthey swallowed with a cup of waterdipped from a cooking pot.

In the West, doses are figured by thechild’s weight. But scales get broken, and

TUESDAY, NOVEMBER 2, 2004

Children in Kwa’al,Nigeria, waited to bemeasured and thenwere given a dose of the deworming drug praziquantelaccording to theirheight. They areinfected by swimmingin contaminated water.

For the boys, parasites in the

water mean bloodin the urine.

Photographs by Vanessa Vick for The New York Times

CASES WITHOUT BORDERS

marked sticks are easy to make. And allthe children were so thin that height indi-cated weight accurately enough.

Unlike the nearby dog village, Kwa’al is Muslim—a prayer meeting with a loudspeaker at a mud mosque a fewyards away nearly overpowered the lecturer —and Ramadan had begun. The children had to get dispensationfrom daytime fasting to take their pills. Insome areas, health programs just shutdown for Ramadan; at night, Nigeria’sroads are too dangerous.

Almost all the children in line wereboys. The volunteers survey schoolchild-ren, and Muslim girls here usually stayhome, so surveys may miss them. Butboys also have many more worms. InAfrica, girls fetch water, but boys swim.

Meskwal Yusuf, a 15 year-old wholooked 10, said he was “very happy’’ toget his dose.

“I could see red in my urine, and mypenis pained me,” he explained. “I toldmy father. He told me people would comeand bring drugs free, so I should notworry.’’ The pills were praziquantel,which kill virtually all the worms. Theycost 7 cents apiece. They are cheapbecause they’re generic, made by com-panies in Germany, Cyprus and SouthKorea. (In 1983, when only one companymade them, the pills cost $4.44 each atpharmacy prices.)

But the companies are not willing todonate the pills, so charities must buythem. The Carter Center can afford200,000 a year—enough to treat sixcounties in central Nigeria.

According to a 1995 study by Dr.Michael Reich of the Harvard School ofPublic Health, it would take 423 millionpraziquantel pills a year to treat schisto-somiasis worldwide. Together, the threedrug companies make only 89 million.

“When you hear that, you realize thevalue of the donations from Glaxo andMerck and Pfizer,” said Dr. Richards, theC.D.C. consultant.

(Pfizer, Merck and GlaxoSmithKlinedonate millions of their patenteddeworming and antibiotic drugs, whichcan cost several dollars each in Americanpharmacies, to programs fighting otherparasites.)

Because of the chronic praziquantelshortage, the World Health Organizationrations it: any village where fewer than 20 percent of the school-age childrenhave blood in their urine gets no treat-ment. “Imagine that in Manhattan, if a kidshowed up with blood in his urine,” Dr.Richards said.

In any village where 20 to 50 percent of the children have bloody urine, only

children get pills. And in any villagewhere more than 50 percent have symptoms, the whole village gets pills.

In Kwa’al, 36 percent do. When thehealth volunteer took questions, severalparents said they had blood in theirurine, so why didn’t they get pills too?

Those were the rules, the volunteersaid.

“I’m a pediatrician,” Dr. Richards said. “I’d love to blanket these areas.When you treat kids, their growth ratesincrease and their academic performanceimproves. But our position is W.H.O.’sposition. We’re not breaking groundhere.” We jumped back in the truck tofind the swimming hole, about 100 yardsdown the road.

Dr. Richards bent down to pick up atiny snail. It was in a quarter-inch ofwater, but he used a leaf, not wanting to dip even the tip of his finger in.

“You can’t keep a kid from urinatingwhen he swims,” he explained. “The eggsare in the urine. They infect the snailsand develop into a form that invadeshuman skin—a sharp head and a tail,sort of like a sperm. The head goes in,the tail snaps off, and it sets up shop inthe human. Then, when it releases itseggs, they burrow their way through the body to reach the bladder.”

He added, pointing to the youngsterssplayed out in six inches of water,“That’s why the boys have the heavyinfections. They’re lying there soaking up the schisto.”

As if a lifeguard had shouted, the boysall came running out of the pond at once,toward me. I was standing near wherethey had dropped their shirts and shorts,but the piles were so dirty they mighthave been cow patties.

The last one out was limping on astick, his back bent sideways. “Look,” Dr. Richards shouted. “Polio.” More thanone plague had visited Kwa’al.

As they dressed, I recognized Meskwal and others I had seen at the pill table. They had run here fasterthan we had driven.

Did the water, I asked, make their skin itch? Yes, they answered. It meantthat new parasites were digging in.

I asked them if they realized that this was how they got the blood in their urine.

“Yes, we know,” Meskwal said. “Ourparents tell us not to come. But as thereis no water in the river, this is the onlywater we have to bathe with. This is theonly way we can wash our clothes.”

As long as boys like water, schistoso-miasis will never be eradicated. Theworld is not ready to provide chlorinated

pools, and even a widely heralded UnitedNations plan from the 1980’s to provideclean wells in every country never cameclose to reaching its goals.

Instead, we settle for control: for a few thousand lucky boys, an annualdeworming that does not cure, but substantially cuts their parasite load, giving them a chance to grow up—andoutgrow the swimming hole.

Article © 2004 by The New York Times. Used with permission.

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