Schistosomiasis (also known as snail fever or bilharzia) is a waterborne parasitic infection which affects more than 240 million of the world’s poorest people. Endemic in 78 countries across Africa, Asia and parts of South America, the disease leads to acute health complications and the deaths of an estimated 200,000 people annually.
Infections primarily affect the urinary and intestinal system, causing chronic ill health and in some cases death. Water-based activities such as swimming, washing and fishing make school-age children the most vulnerable, with infection responsible for malnutrition, absenteeism, and impaired intellectual development.
Children suffering from persistent and severe schistosomiasis infections are also likely to have chronic irreversible diseases later in life, such as scarring (fibrosis) of the liver, bladder cancer, or kidney failure.
Commissioned by Merck Group
German pharmaceutical, Merck KGaA, is a partner in the global campaign to eliminate neglected tropical diseases, spearheaded by the World Health Organisation. Schistosomiasis is one of 20 diseases targeted for elimination, a goal Merck has been committed to achieving since 2007.
As part of Merck’s ongoing education and donation programmes, photography was commissioned to highlight a community in Ethiopia impacted by schistosomiasis and the measures they are taking to eliminate it. The photography is being used by Merck and partners to support their schistosomiasis elimination communications throughout 2021 and beyond.
Field partner: NALA
NALA is a specialist Israeli NGO working to eliminate neglected tropical diseases. They operate in areas where parasitic infections are endemic to develop effective community-driven disease elimination programmes which are scaled and shared with other regions. NALA also provides expert technical assistance to the Ethiopian Federal Ministry of Health to help eliminate schistosomiasis and other neglected tropical diseases countrywide.
Bench Maji
Ethiopia
Bench Maji lies in the tropical south-west of Ethiopia extending to the border with South Sudan. With poorly developed infrastructure and a rainy season lasting nine months of the year, the area is a hotspot for neglected tropical diseases including schistosomiasis, a parasitic worm infection contracted through infected rivers and watercourses.
Mizan is the largest town in Bench Maji. It has a distinct frontier atmosphere and is an important trading centre for subsistence farmers and traders who travel in from miles around to buy and sell wares and produce. When the sun goes down, the town’s atmosphere changes as the youth gather late into the night.
The rainy season lasts for nine months of the year. But when the rains stop the damp air is replaced by dust.
Coffee farmers in South Bench
Bench Maji is best known as a coffee growing region supplying well-known brands in the west. But little of this coffee wealth seems to trickle down to the local people. Despite the obvious challenges of a subsistence lifestyle, families and the many local communities across Bench Maji share a strong bond and do their best to support each other.
The Ethiopian coffee ceremony is a regular part of community life, bringing friends and neighbours together. Invitations are wonderfully simple: if you smell coffee being roasted, you're invited.
Many families live in basic conditions. A mother prepares a fire for cooking. Today’s menu will include local turnips.
Very few people have access to clean running water in their own homes, so they use nearby rivers and lakes instead. This increases the risk of infection with schistosomiasis if the watercourse is contaminated.
It is difficult for children to avoid infections in this type of environment. Nine-year-old Manyazewal has a confirmed case of schistosomiasis. If left untreated the condition can lead to a series of acute health complications and knock-on effects impacting all aspects of his development.
Life cycle
Schistosomiasis infections occur when people come into contact with water contaminated by the schistosome parasite. These free swimming parasites burrow into the skin and move through the body. They develop into worms, lay eggs and cause damage to the bladder, kidneys and liver.
In areas where sanitation is poor and hygiene is a challenge, eggs from humans easily pass back into watercourses. There they hatch and the parasites burrow into certain types of snails, where they develop further. These parasites then leave the snail as free-swimming organisms in search of humans to infect. And so the cycle continues.
Solutions
Treatment is necessary to control schistosomiasis, but treatment alone cannot eliminate it. Long-term behavioural change is also necessary.
The World Health Organisation is recommending an integrated approach to eliminate schistosomiasis globally. Four of the key components of this strategy are:
TREATMENT
Providing testing and access to drugs for the communities who need it.
EDUCATION
Awareness to prevent infection, transmission and re-infection.
WASH
Developing sustainable access to Water, Sanitation and Hygiene.
VECTOR CONTROL
Measures to control snails that act as intermediary hosts.
For somebody so young, Ergoya Gebre’s position as deputy head of the Mizan health centre is considered unusual, and an inspiration to others in her community. When Manyazewal was brought to the health centre feeling unwell, it was Ergoya who arranged for him to be diagnosed and treated.
Schools in the area are reassuringly full, and are regularly visited by health workers to educate the children about health and hygiene. They are taught about schistosomiasis – how to recognise the symptoms; how to avoid contracting it; how to reduce transmission.
A stool-surveying team from Mizan Tepi university use humour to engage school children. They encourage them to provide a stool sample for testing to gauge the prevalence of schistosomiasis in the area.
Stool samples are prepared and assessed by the team back at the university. If schistosomiasis is considered to be a public health concern in a particular area, schools will be targeted for a mass drug administration (MDA) to treat all the children simultaneously. Below, health extension worker, Medina Ali Adem, informs students at Mizan No 2 School about an upcoming MDA.
In remote areas where literacy levels can be low, producing clear guidance on how to combat schistosomiasis can be a challenge. Local health extension workers meet to discuss illustration styles to ensure locally produced materials can be understood by all.
Advice around water is often followed, but it is not known if splashing water, which is impossible to avoid, can lead to infection.
On a hill near Manyazewal’s home, stands an experimental latrine. The floor is sloped so it can be washed by the heavy rains of the region. The latrine also incorporates a clever ventilation system operating on negative pressure in the pit to control odours and a fly trap to reduce local transmission of other diseases.
Once the design is perfected through consultation with the community, the latrines will be built by local people using materials that are easy to find and simple to maintain.
This inclusive community approach is essential to the success of any WASH (water, sanitation and hygiene) programme. In turn, these programmes are fundamental to the eventual elimination of schistosomiasis and other neglected tropical diseases.
Snails are intermediary hosts in the transmission of schistosomiasis. Despite having a reputation as slow movers, snails and their larvae can travel relatively large distances when washed down rivers on loose vegetation, making vector control a challenge.
Regular checks for the presence of snails in watercourses used by local communities are necessary, as illustrated by this government worker in Zanzibar. If the count is above a level considered safe, the water will be treated with a biodegradable molluscicide to control snail numbers.
Saturday afternoon is usually a time to relax in the villages. Woman prepare each other’s hair for church the following day, an important religious and social event for the whole community.
Pastor Getachew at the Mesertkiristos church delivers a traditionally enthusiastic sermon. Churches play a vital role in community cohesion and in rural areas have become trusted partners in the sharing of public health information, including information about the control of schistosomiasis.
Girls conceal their laughter during one of the sermon’s more humorous moments. Below: children gather by the back door during the sermon to watch the photographs being taken. They can’t resist posing for a picture, but do so in total silence to avoid attracting the attention of church elders.
Behind the many light hearted moments lays a real sense of faith under the leadership of Demissei Weldemariam, the head of the protestant church in South Bench. In the wider community where different faiths are practised, all religions are equally respected, a common trait across Ethiopia.
Following treatment, Manyazewal is recovering well. His mother, Mekides, tells us her son will soon be back at school.
Contaminated water continues to threaten communities around the world. But as global programmes to eliminate schistosomiasis gather pace, we can begin to see a future where Manyazewal and millions like him, will no longer be at risk from this disease.
Acknowledgements
Marcus Perkins and Merck KGaA would like to thank the people of Bench Maji, the Ethiopian Federal Ministry of Health, the Ethiopian Federal Broadcasting Authority and the individual health authorities in North, Central and South Bench for their guidance, permissions and assistance with this work.
We would also like to express our sincere gratitude to Dorin Turgeman at NALA, for her commitment and untiring support in the planning and execution of this project, and to Hailu Debebe and Asrat Meleko for sharing their invaluable local knowledge.
“These truly impressive pictures help us tell the story of the burden schistosomiasis imposes on local communities, and shows how we are working with partners to tackle this neglected tropical disease.
Merck committed itself to combating schistosomiasis more than a decade ago and these pictures are a crucial element of our work to raise awareness of this insidious disease, not only in affected communities but world-wide.”