Creating a Worm Free Paradise: Establishing a Steady Supply of Albendazole for De-Worming Efforts in Southwest Honduras (2013)
Introduction to Honduras
Honduras, located between Guatemala and El Salvador to the north and Nicaragua to the south, is a Latin American nation with 7 million people (Factbook). It is also one of the poorest countries in the Western Hemisphere. Similar to many poor countries, Honduras faces numerous public health problems, especially in the rural parts of the country. For example, 63% of the population lives below the poverty line; seven out of ten Hondurans do not have access to sanitation nor basic needs such as a clean water supply (World Bank). Most rural villages lack access to medical attention within a four hour walk. Fifty-seven percent of rural Honduras has never seen a medical or dental professional in their lives.
The World Bank and the IMF declared Honduras to be one of the heavily indebted poor countries making it eligible for debt relief in 2005 (World Bank). Honduras, the second poorest country in Central America, suffers from extraordinarily unequal distribution of income, as well as high unemployment. Sixty-three percent of people earn below poverty rate and about one-third of the people are unemployed or underemployed (World Bank).
Honduras is particularly susceptible to natural disasters such as hurricanes, flooding and earthquakes. Drought and forest fires are also common. The country is yet to recover from the 1998, Hurricane Mitch, which caused such massive and widespread destruction, that it reversed the progress that had been made in the country over the past 50 years (ECLAC). Mitch obliterated about 70-80% of the crops and transportation infrastructure, (USGS) including nearly all bridges and secondary roads with losses estimated at $3 billion USD (ECLAC).
This combination of natural disasters and poverty has made Honduras a hot spot of tropical diseases and public health related illnesses. Healthcare employment is low in the country of Honduras, and even lower in rural areas that rely on traditional cures (World Bank). Poor sanitation and a weak healthcare system have allowed intestinal parasites to become an endemic problem in Honduras.
Problem
Due to lack of essential sanitation and medical support, people in Honduras have suffered greatly from diseases that are relatively easy to treat and many conditions involving intestinal parasites. Trematode worms, more commonly known as flatworms, nematodes, more commonly known as roundworms, and hookworms are the most prevalent parasite species in Honduras, which respectively cause schistosomiasis, gnathostomiasis or trichuris, and ascaris. These infections are problematic because they may induce diarrhea, flu like symptoms, itching, nausea, vomiting and headaches in the short term and cause anemia, fatigue, poor nutrition and stunted growth in the long term. In addition, the total eradication of parasites is the only way to get rid of parasitic diseases because they return if anyone in the population is still infected with parasites. The very nature of parasitic diseases makes them very hard to eradicate. According to a survey focusing on 320 children in rural communities in Honduras in 2011, 67% of the children were infected with the most prevalent intestinal parasite induced diseases, Trichuris (Soil-Transmitted Helminth Infections and Nutritional Status in School-age Children from Rural Communities in Honduras).
Despite the wide prevalence of intestinal parasites and difficulty of eradication, flatworms, roundworms, and hookworms can be effectively treated with medications that destroy parasites, such as albendazole, ivermectin, and mebendazole. In fact, one dose can clear an intestinal infection and protect the patient for up to six months. Therefore, many volunteers groups have tried to rid Honduras of intestinal parasites using these medications. Unfortunately, these groups have failed to dislodge parasites from many parts of the country. These failures can be attributed to three main shortcomings.
Status Quo Problem 1: Lack of Information on Population of Targeted Area
The foremost problem that many preceding attempts encountered was lack of information about patients in the targeted area. When groups of volunteers decide to rid a village of parasites, it is essential to choose one that has manageable population and is relatively isolated. All villagers have to be treated with the medication and interactions with non-villagers have to be minimal to avoid transmission of parasites from potential carriers. This basic information is needed when deciding if parasites can be successfully eradicated from an area. However, due to the small size and the secluded nature of rural communities in Honduras, the necessary information on target villages normally unknown and challenging to acquire. Additionally, a parasite’s life cycle involves not only the humans but also the environment, so parasite treatment has to be paralleled with an environmental approach that deals with water and soil contamination. If not, then the remaining population of parasites the in soil or water will re-infect the community. The relation of life cycle of parasites and environment will be further discussed, because this close relationship with the environment becomes one of main reasons why parasites are so difficult to eradicate. In general, simply bringing medication that is not enough to eradicate parasites and prevent reinfection.
Status Quo Problem 2: Lack of Sufficient and Consistent Supply of Drugs
Another problem that has caused failures in previous attempts is the absence of a continuous supply of the drug. Because of the six month cycle of reinfection, it is important that volunteers distribute the right amount of the drug during the proper time periods. In addition, the drug has to be stored in relatively cool temperatures with low humidity to avoid spoiling. So, volunteers tend to often bring the drug themselves to targeted villages. Due to the remote nature of the villages, volunteers are not always able to supply enough of the drug to prevent reinfection. This problem can be attributed to many explanations. One is lack of information, which is thoroughly discussed earlier. Another explanation is lack of method to transport enough amount of drug within six months. Currently, the most feasible method for transporting drug to the village is through volunteers manually delivering the drug to the targeted community. However, such methods force the volunteers to carry the entire responsibility of obtaining and administering the drug. Although the drug can be conveniently packed into a box, importing large amount of drugs often causes unnecessary suspicion in airports. Due to the inconsistency of the availability of the drugs, the eradication of parasites often failed.
Status Quo Problem 3: Cycles of Parasitic Re-infection
The final main reason the attempts ended in failure is the fact that eradication of parasites is often very challenging and requires constant efforts, which becomes evident considering the life cycle of parasites. Obviously, flatworms, roundworms, and hookworms are similar in that humans are an essential part of their life cycle. However, transmission of these intestinal parasites is unique for each species. For instance, flatworms tend to live in the bodies of freshwater fish until maturity and cause schistosomiasis by entering humans through skin penetration and then migrating through the venous system to the portal veins where the parasites produce eggs (Schistosomiasis Symptoms, Signs, Cause, Diagnosis, Treatment, Prevention and Prognosis - OnHealth). In the case of roundworms, they mature in the bodies of water fleas and cause gnathostomiasis, and infect people when they swallow infected water fleas or eat undercooked infected frogs, birds, reptiles, fish, and eels (Parasites - Gnathostomiasis (Gnathostoma Infection)). Therefore, contaminated water sources can continuously give flatworms and roundworms opportunities to re-infect community population. Lastly, transmission of hookworms originates from the feces of an infected person. If the eggs from feces are deposited on soil, they hatch into larvae, and mature into a form that can penetrate the skin. Therefore, hookworm can enter the body when one walks barefoot on contaminated soil, causing Trichuris (Animal Diversity Web). Hookworms can also be transmitted through the ingestion of larvae from uncooked food or infested water source. Since parasites depend on water for development and transmission the best way to eradicate parasites and prevent reinfection is the construction of a clean source of water.
Where to start
Nuevo Paraiso, a small village in the southwest, presents a microcosm of all the problems facing the country. It is one of the poorer villages in the country but has the opportunity for positive change (YSA). It is about two hours outside of Tegucigalpa and is home to Sociedad Amigos de los Ninos, a large healthcare network that has already been established but needs supplies to make a greater impact (SAN, About Us). Sociedad Amigos de Los Ninos was originally established as a home for Honduran orphans up to the age of twelve, but has expanded to incorporate so much more than that.
Sur Maria Rosa, a nun and an orphan herself, founded the organization and has raised 56,000 children at such Sociedad Amigos de los Ninos orphanages (FHC, Sister Maria Rosa). For this reason, she was a nominee for the Nobel Peace Prize. She works toward creating a brighter and healthier future for the children of Honduras. Beyond establishing multiple orphanages in different areas of Southwest Honduras and the capital Tegucigalpa, Sister Rosa has established several different clinics across the department of Paraiso. Sister Rosa is very open to newer forms of medication, especially those targeted toward treating common infectious diseases affecting the people of her area such as parasitic, bacterial and fungal infections (SAN, About Us).
These Sociedad Amigos de los Ninos clinics and medical camps are the ones that our project Creating a Worm Free Paradise plans on leveraging. The organization cannot reach its full potential, not because of a lack of labor or money but because of physical capital, specifically medical supplies. One of the biggest problems that Sociedad Amigos de los Ninos faces in Nuevo Paraiso is the treatment of reoccurring parasitic infections (YSA).
In Nuevo Paraiso, children constitute 40 per cent of the population and 52 per cent of them are part of single-mother families (FHC, About Us). These women struggle to raise their large families in the face of abject poverty. As a result, many conditions that you would expect to see in third world countries are seen multiplied in incidence in Nuevo Paraiso (Hope for Honduran Children). Most of the people have health problems relating to infectious diseases such as intestinal parasitic infections, respiratory infections, diarrhea, and fungal skin infections (Global Brigades). One of the largest problems is the cyclical nature of parasitic infections in the area mostly because of the lack of de-worming medication continuously available.
Part of the Nuevo Paraiso region is Flor Azul, an even smaller rural village with a very small population of about 300 (Ranganathan et al). This remote mountainside village suffers extreme droughts followed by disastrous floods. The people are extremely poor and employment is usually temporary during the cane picking season. There is no electricity. Accessibility to water, potable or otherwise, is a big problem in these areas and for most parts of Honduras (Pineda et al). The nearest water source is two miles away and the water must be transported on donkey back (Ranganathan et al). Flor Azul is one of the areas that are totally dependent on volunteer groups sent from Sociedad Amigos de los Ninos for health care. These groups often run out of medical supplies and do not have the supplies to treat everyone (Ranganathan et al). Many people have complained of stomach issues, mostly caused by gastrointestinal parasitic infections.
Call to action
As more and more citizens of Nuevo Paraiso, Honduras continue to suffer from parasitic worms, it becomes more difficult to combat the infections. Due to repeated use of dirty drinking water and disagreeable weather conditions, it is nearly impossible to eradicate the worms once and for all. Creating a Worm Free Paradise aims to come as close to this as possible. It is with your help, support, and investment that we believe we will be able to combat the issue facing so many people in this impoverished community. With your help, children will be able to have brighter futures, and parents will be able to support them, as we move towards a Nuevo Paraiso without worms.
Short-term goals
Our mission is to supply the population of Nuevo Paraiso with a reliable source of albendazole, in order to combat intestinal parasites. By centralizing albendazole purchasing, storage and distribution, we will ensure that volunteer groups operating in the area will have enough albendazole. Centralizing distribution will enable groups to carry the right amount of albendazole when they set off to their destinations. Our group will be responsible for obtaining albendazole, allowing volunteers to focus on their own missions. To achieve this goal we will partner with the local charity Sociedad Amigos de los Ninos. By working with local humanitarian groups, we can avoid setting up a new network for the distribution of albendazole (What to Expect). We can instead focus on procuring albendazole from sources in the United States and sending them to the Sociedad Amigos de los Ninos clinic in Nuevo Paraiso (About Sociedad Amigos de los Niños (SAN)).
Nuevo Paraiso was chosen as our area of operation because there are many humanitarian groups working in the area. Additionally, Sociedad Amigos de los Ninos operates a clinic in the area, which can be used to store albendazole and distribute it to volunteer groups. By limiting our scope to a small region we can better record the amount of albendazole being distributed and monitor who is taking the medication. The impact this program is having can be assessed by monitoring how much albendazole volunteer groups are distributing and by having volunteers ask villagers about the prevalence of intestinal parasites in their community.
Long term goals
If our initial operation in Nuevo Paraiso is successful, we could expand our area of operation to cover more areas where Sociedad Amigos de los Ninos operates. We could also partner with other humanitarian organizations that operate in Honduras and expand our focus to other regions of the country. Global Brigades, one of the humanitarian groups we will be supplying through Sociedad Amigos de los Ninos, operates in other countries (Where We Work). Global Brigades sends volunteers to Nicaragua, Panama and Ghana. We could easily supply these other locations with albendazole using a similar system to the one in use in Nuevo Paraiso. Even with in Nuevo Paraiso there is more our group could do in the future. Besides just providing albendazole, we could supply volunteer groups with other medicines that the villages might need. Scabies is also a problem in Nuevo Paraiso and even though the clinic is stocked with permethrin for treatment there is not always enough to go around. Permethrin is readily available in the United States and can be obtained in the same manner as albendazole. It can also be distributed using the same system we will be using to distribute albendazole. The storage fees we will collect from the volunteer groups using our service will be put towards developing a safe drinking water supply for the communities in Nuevo Paraiso. Since contaminated drinking water is one of the major causes of intestinal parasites, developing a clean supply of drinking water will help prevent future outbreaks of intestinal parasites. The creation of a clean water supply will also create jobs in the area since the system must be maintained and repaired from time to time.
Logistics
Our mission is to provide Nuevo Paraiso and its surrounding communities with an adequate supply of albendazole in order to combat intestinal parasites. Previously the various volunteers that visited Nuevo Paraiso were responsible for their own supplies of albendazole, leading to shortages. We plan to centralize the collection and distribution of albendazole to ensure that volunteers will be able to treat everyone. By centralizing albendazole distribution we remove the responsibility of obtaining albendazole from the volunteers and allow them to focus on other aspects of their mission. In order to supply the inhabitants of Nuevo Paraiso with albendazole we will be partnering with three groups, pharmaceutical companies and international charities, Sociedad Amigos de los Ninos in Nuevo Paraiso and the various volunteer groups that visit Nuevo Paraiso and the surrounding villages.
Pharmaceutical companies, such as, Johnson & Johnson will be our main suppliers of albendazole. Johnson & Johnson regularly donates albendazole to groups combatting intestinal parasites around the world. Johnson &Johnson has already pledged to donate 200 million doses of albendazole a year for de-worming initiatives (News). Many charitable organizations are dedicating to eradicating intestinal parasites all over the world. Organizations, such as, the Red Cross and The Global De-worming Inventory and Children Without Worms could supply us with albendazole as well (Global NGO De-worming Inventory).
In effect, our project acts as a supplier for low-cost parasitic medication to distributers by collecting it from companies and charitable organizations that lack demand. By increasing the access to demand, supply shoots up which would lower prices and increase access to medical care. After collecting albendazole from pharmaceutical companies and charitable organizations, it still needs to be shipped and stored in Honduras. Nuevo Paraiso is one hour away from Tegucigalpa and its airport. The albendazole will be shipped to Tegucigalpa, where representatives of Sociedad Amigos de los Ninos will pick it up. There, it will be transported to the clinic run by Sociedad Amigos de los Ninos in Nuevo Paraiso. This clinic will serve as the storage and distribution point for albendazole (About Sociedad Amigos de los Niños (SAN)). The clinic in Nuevo Paraiso is a major hub for volunteer groups before they head out to more remote locations. The staff at the clinic will be tasked with distributing the albendazole to the volunteer groups that pass by.
We will partner with volunteer groups, such as, Global Brigades to distribute the albendazole to locals. Global Brigades launches several trips a year to Nuevo Paraiso (Honduras). Many smaller volunteer and missionary groups pass through Nuevo Paraiso throughout the year. These groups normally distribute albendazole to the villages they visit. The volunteers pick up albendazole at the clinic at Nuevo Paraiso, depending on where they are head they will get the appropriate amount of albendazole. When they volunteers reach the villages they will distribute albendazole in a central location where everyone can seek treatment. The volunteers will distribute the albendazole to locals and will keep track of how many tablets they distribute and who is taking the medication. Each patient will be limited to one tablet of albendazole, which will have to be taken in front of a volunteer. The volunteers will be told to ask villages about parasites in the village, if the medicine is working and about the rate of reinfection in the village. In order to make our system sustainable we will charge a small fee of $50 per volunteer group for the use of storage and distribution system. This fee will be paid by Global Brigades or any other group that wishes to use our system. The money generated will be used to purchase more albendazole for future use and to create sources of clean water in Nuevo Paraiso and the surrounding villages.
When the volunteers return to from their trip they will send the information they collected to us. We will use this information to determine how much albendazole each village should receive in the future, determine who is taking the medication and to determine which villages are improving and which villages need more assistance. The data collected by the volunteers will be used to determine how effective our system is.
By centralizing and streamlining the way albendazole travels from the United States to Nuevo Paraiso, we will more effectively combat intestinal parasites in the area. In the long run the fee paid by volunteer groups that choose to use our system, will be used to construct new sources of clean water to better protect the inhabitants from intestinal parasites.
Partnerships
In addition to Sociedad Amigos de los Niños, and other community service groups, we will partner with other companies and organizations. Because albendazole is on the World Health Organization’s (WHO) Essential Drugs List, we are legally able to purchase and receive donations of the medicine to administer in Nuevo Paraiso (World Health Organization). Due to the fact that each individual diagnosed with parasitic worms must receive the one pill treatment running its course over six months, it is important to have quantities on hand for when they are infected again. In the past, this has been difficult to achieve. Service groups around the country have administered the drug for short periods of time, but they undoubtedly run out before everyone can receive their proper dosage, and more individuals develop worms after the groups have gone. It is our mission to provide a steady availability of albendazole, so that the citizens of Nuevo Paraiso are not dependent on the occasional service trip. For this to be possible, it is necessary to raise the funds, locate a steady supply of the medicine, as well as collaborate with existing organizations that have experience in the area, knowledge of the symptoms, and ways to diagnose. Additionally, we aim to work with local citizens so that they may gain employment in the effort as well.
There are many organizations whose collaboration could facilitate many measures while on the ground. These include The Global NGO De-worming Inventory, Save the Children, Children Without Worms, and the World Health Organization. It is with these organizations that we will be able to fundraise and acquire the adequate materials to maintain a steady supply of albendazole in Nuevo Paraiso. The Global NGO De-worming Inventory and the work and research they have done are crucial to the success of our mission (The Global NGO De-worming Inventory). Throughout the world, over 800 million children face the risk of contracting intestinal worms. Not only do these worms impact children physically, but they also inhibit opportunities to learn, grow, and work productively in society. Several Non-governmental organizations as well as Faith Based Organizations collaborate to find this data and find the resources people need. We are aiming to provide ground access and join these organizations with the community of Nuevo Paraiso.
The Global NGO De-worming Inventory collaborates with Children Without Worms (CWW), which is made up of a partnership between Johnson & Johnson and the Task Force for Global Health. We are interested in a partnership with this organization so that we may have access to albendazole as well as start-up funds from the corporation partnership. Through partnering with Johnson & Johnson, we are able to join an existing source of albendazole to assist in a disease they are currently combating (The World’s Children Free of Intestinal Worms).
Save the Children is a global non-profit organization that works in Honduras to combat issues such as poverty and hunger with children. Our mission will be a natural partnership with PROGRESA, a food security program within Honduras, for albendazole combats issues developed from dirty drinking water. Save the Children receives funding from the government, other companies, as well as donations, and a partnership with this organization would help to provide the funds for medicine for children. Additionally, Save the Children has offices throughout Honduras, allowing for greater access to on site availability (Official Site- Save the Children).
Funding
In order to keep our de-worming program running, it is crucial to maintain a steady flow of funds to cover the costs of purchase, shipping, and other onsite needs. We will receive pills from the Global NGO De-worming Inventory and Johnson & Johnson, but seek albendazole left over from hospitals around the country. Through grants, beginning with small grants from the World Health Organization, which has albendazole listed as an essential medicine, we will be able to get our project up and running. We will constantly look for donors, and will set up a website to raise awareness and allow anyone to contribute to the de-worming of Nuevo Paraiso.
Potential setbacks
The potential setbacks in this mission are largely due to the possibility of lack of funding and supplies. If there are delays in the shipments of products— which is a distinct possibility due to the remote location of Nuevo Paraiso— we may not be able to provide all individuals with the treatment that they need. Additionally, over time, weather has become far more extreme in Honduras with tropical storms causing excess rainfall (Trócaire). We need to anticipate times such as these, which could prevent access to Nuevo Paraiso due to altered flights and flooded roads. In order to prevent this from happening, it is crucial that we keep an emergency supply of albendazole on site from the onset, which may only be accessed in the case that a new shipment is delayed. It is important as well to maintain relations with donors, because their support is the key to the success of the mission. If funding stops, we are unable to pay for the medicine, shipping costs, and the upkeep of our site in Nuevo Paraiso, leading to the continued problem of untreated parasites.
Practical advantages
Right now there is no centralized system for the obtaining and distribution of albendazole. Each volunteer group is responsible for purchasing and transporting their own supply of the drug. Normally individual volunteers have to find their own supply of albendazole and transport it to Honduras. This system is inefficient since volunteers do not have the knowledge or resources to find the best supplies of albendazole. Large corporations, such as, Johnson & Johnson normally do not donate to individuals and give albendazole to organizations (News).
Since each volunteer organization that visits Nuevo Paraiso has its own system for obtaining and distributing albendazole there is no way of knowing how much albendazole is being distributed and no one knows exactly who is taking the medication. The lack of centralized distribution makes it difficult to gage the effectiveness of albendazole distribution in Nuevo Paraiso.
Our system will centralize the purchasing and distribution of albendazole in Nuevo Paraiso. By transferring the responsibility of finding albendazole from individual volunteers to our group, we can decrease the cost of obtaining albendazole. By partnering with the Global De-worming Inventory we can secure donations of albendazole from companies, such as, Johnson & Johnson. Corporate donations can be used to keep operating costs to a minimum. Shipping the albendazole directly to the Sociedad Amigos de los Ninos clinic in Nuevo Paraiso will centralize distribution and storage. Since many groups pass by the clinic on their way to more remote villages, volunteers can pick up supplies of albendazole at the clinic. In our system we will have volunteers record and track how much albendazole they are distributing and who is taking the medication. This data will allow us to predict how much albendazole villages will need in the future and determine how effective our system is.
The fee that we will charge volunteer organizations for using or distribution system will be used to fund the creation of clean water supplies in the area. A clean source of water is crucial to preventing outbreaks of intestinal parasites. With a clean source the inhabitants of Nuevo Paraiso will not need to rely on volunteer groups to combat intestinal parasites.
Social Benefit
Because of Honduras’s climate, lack of proper sanitation and medical services, intestinal worms are a major problem in poorer communities. Intestinal parasites can cause diarrhea, abdominal pain and weight loss in patients (Parasites - Taeniasis). In children severe infections can impede development and growth (Parasites-Ascarisasis). Besides improving the quality of life in Nuevo Paraiso, our program will allow children to grow and reach their full potential. The eradication of intestinal parasites will allow villages to improve their productivity. The money generated from volunteer organizations using our system will be used to obtain more albendazole and to construct clean water supplies in Nuevo Paraiso. The construction of clean water supplies will help prevent intestinal infections in the future and provide a long term solution to intestinal parasites. In order to make these water supplies effective in the long term, they have to be maintained and repaired by the local population. Locals will have to be trained to repair and monitor the water supply. This will create new jobs in Nuevo Paraiso and create workers with a skill set that can be applied in other villages. Our project can make an immediate impact on the prevalence of intestinal parasites in Nuevo Paraiso, while working towards a permanent long term solution. Water supplies created with our funds will provide jobs and skills to villagers in the area. Our project will improve social and economic conditions in Nuevo Paraiso.
Conclusion
There are problems in the status quo. The lack of information about critical regions of the world and the lack of steady and sufficient supply for an issue that is cyclical and recurring. Through centralizing and streamlining the process of how Albendazole gets to Nuevo Paraiso, we can better combat intestinal parasites in the region. A constant reliable supply of Albendazole will allow us to control or eradicate intestinal parasites in the Nuevo Paraiso. Albendazole can be obtained from companies, such as, Johnson & Johnson or from The Global De-worming Inventory and Children Without Worms. Working with Sociedad Amigos de los Ninos gives a secure area to store and distribute Albendazole. By centralizing the distribution and storage of Albendazole we can measure the prevalence of intestinal parasites in the region and gage the impact our system is having. The revenue generated by our project will put towards maintaining a continuous supply of Albendazole and creating a clean water supply in the area. A clean water supply is crucial to eradicating intestinal parasites in the long term. And in a town that is literally translated to mean “New Paradise”, eradicating intestinal parasites will bring Nuevo Paraiso one-step closer to fulfilling its name.
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