In India, a Small Pill, With Positive Side Effects

New York Times, Opinionator

April 4, 2012

On a cool February morning in north Delhi, India, 35 third graders sat at small desks in a spartan but tidy classroom. They wore blue school uniforms and listened as their teacher asked in Hindi if they had had intestinal worms.

A third of the children raised their hands, including 9-year-old Arjun Prasad. He sometimes felt stomach pain and weakness — symptoms of severe infection — he said. A few minutes later, Arjun and his classmates were given deworming pills, and took them during the class. They were among the 3.7 million children in Delhi who have taken the pills as part of a recent campaign in India’s capital to stamp out the widespread but neglected ailment.

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Intestinal worms are pervasive in the developing world and can have devastating effects. But there is growing awareness about how easy and inexpensive it is to treat worms, as well as surprising longer-term socioeconomic benefits. Research shows deworming to be extremely cost-effective: you get a lot of bang for your buck.

Two economists, Michael Kremer of Harvard University and Edward Miguel of the University of California, Berkeley, found that deworming reduced school absenteeism by 25 percent in a sampling of schools in Kenya and that regular treatment could lead to an additional year of attendance — all for  $3.50 per student, far less than subsidies, meals, free bicycles or other incentives to keep kids in school.

Children who are regularly dewormed earn over 20 percent more as adults and work 12 percent more hours, while those infected are 13 percent less likely to be literate.

Worms affect 600 million school-age children worldwide and cause diarrhea, anemia, internal bleeding, malnutrition and other debilitating symptoms. These blood-draining parasites stunt physical and mental growth, sap energy and can leave a child too weak to attend school. Hookworm, whipworm and roundworm are soil-transmitted helminths, so low-income people who live in unsanitary conditions or don’t wear shoes are particularly susceptible.

The chewable pill, mebendazole, which the Delhi schoolchildren said tasted like peppermint, costs just 3 cents. It is safe, easy to administer in schools (teachers can be trained to do it) and costs 50 cents per child to distribute twice a year. Within a few days the pill flushes worms out of the body.

The Delhi campaign followed others in India. Bihar, an eastern state for years practically synonymous with poverty in India, last year dewormed a staggering 17 million schoolchildren  — nearly double the population of Sweden. Andhra Pradesh, in southern India, distributed deworming tablets to 2 million children in 2009.

Today, worms are considered a disease limited to poor countries; that’s one reason they are neglected by donors and policy makers. But a century ago, worms were pervasive in the American South. The philanthropist John D. Rockefeller financed a 1910-15 deworming campaign in 11 Southern states after testing showed average hookworm infection rates of 40 percent among school-age children. Rockefeller’s $1 million donation paid for deworming for 400,000 children, as well as hygiene education. This led to eradicating widespread hookworm infection in the United States. Hoyt Bleakley, an economist at the University of Chicago’s Booth School of Management, estimated that childhood hookworm infection led to 40 percent less income earned in adulthood. School attendance also rose substantially after deworming.

If giving deworming pills to schoolchildren is so easy and effective, why haven’t more large-scale programs taken off? In fact, rolling out mass deworming programs, especially in infamously bureaucratic and corrupt India, is a huge logistical feat and a notable act of political will.

The first challenge is lack of awareness. Worms are so common in the developing world that they are considered a part of childhood by the poor and are usually left untreated. Ironically, because worms are easy to treat, donors tend to think governments don’t need help introducing campaigns. Worms also do not directly kill large numbers of people, though they contribute to malnutrition and diarrhea. Diarrhea is an insidious illness that kills 1.5 million children worldwide each year — more than AIDS, malaria, and measles combined.

Another challenge is lack of advocacy. Intestinal worms are one of 17 neglected tropical diseases that affect 1.2 billion people worldwide, and include elephantiasis, leprosy and trachoma. These diseases are “largely silent, as the people affected or at risk have little political voice,” said Margaret Chan, director general of the World Health Organization, in a 2010 report.

While worms are inexpensive to treat, they are expensive to diagnose. Last year, 3,600 stool samples were collected from Delhi children and tested in government labs and hospitals. The study found that the average infection rate in Delhi public schools was 16 percent, but as much as 83 percent in one slum — high enough to spur the citywide campaign.

But deworming has other advantages, too. School-age children are most at risk for worms, so schools are an established network to distribute tablets. In contrast, many vaccines should be given to infants and toddlers who are too young for school; parents have to be motivated enough to have babies vaccinated. Some vaccines must be refrigerated — no small task in hot countries with sporadic electricity and remote villages — and must be administered or injected by trained health workers.

Diseases that afflict the poor give little incentive for investment in new or better treatments. Fortunately, deworming’s low cost made it possible for GlaxoSmithKline and Johnson & Johnson to pledge annual donations of 400 million and 200 million albendazole pills, respectively.

Deworming tablets are widely used (they are sold over the counter in India) and don’t carry the political and ethical sensitivities of vaccines. They are generic, so patents are not an issue. Students do not need parental consent to take them, thus decreasing bureaucracy.

Ultimately, political will and dogged organization are vital for mass deworming. Big Indian cities have populations larger than entire countries, so deworming requires intensive logistical support. In Bihar alone, children in 67,000 schools were dewormed and nearly 140,000 teachers and 20,000 health workers trained.

In Delhi, three ministries — education, health and women and children’s development — all had to work together. To add to the complexity, Delhi government schools are run by three entities — state and two municipal governments — and deworming also happened at government health centers for the poor, called anganwadis.

Deworming programs require surveillance, monitoring and evaluation, training of health workers and teachers, and education about sanitation and hygiene, as well as worms.

Coordination in India was spearheaded by a global campaign called Deworm the World. In 2007 the Harvard economist Kremer helped start Deworm the World after the World Economic Forum in Davos, where he and other “young global leaders” were asked to come up with concrete ways to tackle global problems. (Kremer is president of Deworm the World.)

For a year and a half, Deworm the World lobbied government officials in Delhi to get approvals and plan the campaign. In Bihar, it took less than a year of talks and planning to introduce the state’s deworming campaign. The head of Bihar’s government, Chief Minister Nitish Kumar, has been commended for his social initiatives since taking office in 2005. Once Bihar health officials were convinced about deworming, they took on the project.

The key to sparking interest from governments was compelling evidence based on more than a decade of research in Kenya by Kremer and Miguel. Kremer’s interest in Kenya goes back to 1985 when he taught at a secondary school there for a year after graduating from Harvard.  (He didn’t get worms but he did get malaria and giardia.)

Some 20 years later, he and Miguel led a team of about 30 researchers to track down Kenyans who received deworming pills as children through a Dutch nonprofit program. They carved out a subsample from 30,000 dewormed children and tracked down more than 5,000 young adults. Ten years after deworming, many of them had moved and were scattered in Uganda, islands in Lake Victoria and even London. “Finding information was quite a process,” said Kremer from Boston, in a phone interview.

Miguel noted in a phone interview from California that in the 1990s it was rare for economists to do long-term tracking. “You need resources and a team that sticks with it year after year.” He added, “We were persistent and slightly obsessed.”

In the 1990s, even in the world of development economics, worms were a second-order health issue behind the likes of polio and malaria. “Some people scratched their heads and said, ‘What are you doing’?” Miguel recalled.

When they presented their results in Kenya around 2002, government officials including prime minister Raila Odinga became interested in deworming’s low cost and a blueprint to implement programs through schools. (Deworming’s quick and low-risk political mileage must surely also appeal to politicians.) Kremer explained, “It’s the evidence that gets people involved. They think, ‘Here’s something we can do. We can fix it.”

In 2009, with help from Deworm the World, 3.6 million children were dewormed through Kenyan schools. Today, the fact that tens of millions of children in Kenya and India are getting treatment is “mind-blowing” said Miguel.

However, the deworming campaigns are just one more important step. Momentum must be sustained; children should take deworming pills twice a year for several years if infection is high. “It’s key for all stakeholders involved to not just do it once and walk away,” said Alissa Fishbane, managing director of Deworm the World, in a phone interview from New York.

After Kenya’s deworming campaign in 2009, there was a ministry-wide freeze the next two years. But this January in Davos, Prime Minister Odinga of Kenya promised to deworm five million children annually until 2017. Bihar is readying for the second round of deworming this May, and Delhi has pledged another deworming day this summer. “Government will take this on, they won’t take it halfway,” pledged Kiran Walia, Delhi’s minister for women and child development, in an interview in Delhi in February.

Others hope lofty promises are fulfilled. Back in a poor section of north Delhi, mothers with young children crowded inside an anganwadi health center to receive deworming pills. Gita Gulati, a 50-year-old center supervisor, watched from a narrow lane between brick homes. “This program should have been started earlier,” she said.

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