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Worms, Wisdom, and Wealth: Why Deworming Can Make Economic Sense

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Worms, Wisdom, and Wealth: Why Deworming Can Make Economic Sense Review Worms, wisdom, and wealth: why deworming can make economic sense Donald A.P. Bundy1, Judd L. Walson2, and Kristie L. Watkins3 1 Human Development Network, The World Bank, Washington, DC 20433, USA 2 Departments of Global Health, Medicine, Pediatrics, University of Washington, Seattle, WA 98104, USA 3 The Partnership for Child Development, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London W2 1PG, UK For those of us who have had worms, getting rid of them contemporaneous effects of deworming on health and edu- seems a good idea, and multiple studies demonstrate cation outcomes as well as long-run effects on adult earn- the simplicity and benefit of deworming children. In the ings [by projecting geographical panels (cohorts) forward past decade or so, there has been a dramatic increase in 50 years]. These results confirm the contemporaneous efforts to provide inexpensive deworming medications, observations and show that school age children in areas but at the same time there have been calls to re-evaluate with higher hookworm infection showed greater increases the impact of deworming programs. In this review, we in school attendance and literacy measures after interven- examine the history of deworming and explore the evi- tion. No significant effects were found in adults. The dence for effects of deworming on health, on child difference-in-difference follow-up of long-run cohorts indi- development, and on economic returns. Important poli- cates both a marked increase in education quality (rather cy conclusions include that a paucity of randomized trial than quantity) and a substantial income gain in the most data suggesting benefit does not equate to a lack of heavily infected populations. The scale of effect is such that benefit and that a greater emphasis on documenting the hookworm infection rate may have accounted for such benefit should be pursued. around half of the literacy gap and up to 20% of income differences between the North and South of the USA at the A little history time of the study. Large-scale deworming programs emerged as popular (and The results of the Commission were interpreted as populist) programs at the beginning of the 20th century, suggesting an important role for worm infections general- and their popularity has grown as treatment and program ly, and were followed by Rockefeller-supported campaigns design have become more efficient and better understood. in several low-income countries. Although the deworming campaign in the USA was among the last to be conducted High profile, early success in the USA in a high-income country and was followed by a lull in At the beginning of the 20th century, the Rockefeller interest in these diseases of the poor, interest in these Sanitary Commission, later to evolve into the Rockefeller diseases resurfaced on the public health agenda as a result Foundation’s International Health Board, began its hu- of the Second World War. manitarian work in the USA by examining claims that the wealth disparity between North and South was accompa- Deworming ‘This Wormy World’ in 1947 – not an option nied by similar disparity in health and that worm infection When the President of the American Society of Parasitolo- in particular might be a cause of underdevelopment. gy entitled his inaugural address ‘This Wormy World’, he Hookworm, then infecting 40% of Southern school chil- was reacting to an important post-Second World War dren examined, was identified as the ‘Germ of Laziness’ phenomenon [5]. In his words, ex-servicemen were coming [1], a phrase from the early days of germ theory, which ‘...back from the Pacific...to homes widely dispersed might today be translated as ‘an infectious agent resulting throughout the [continental USA]...to live a lifetime in in a reduced ability to work or study’. In response, the familiarity with the strangely sounding names of their Commission initiated large-scale, population-based treat- distantly-acquired helminthiases’. A similar phenomenon ment (using oral thymol) and hygiene education programs was also being experienced in Europe [6–8]. [2,3]. Stoll lamented that the treatment control ‘tools...are in Remarkably, the Commission also implemented com- need of sharpening’ and lists the most effective anthelmin- prehensive monitoring and evaluation programs that tics then as hexylresorcinol, chenopodium (fern extract), measured both health and education outcomes, and sub- and tetrachlorethylene – all characterized by poor efficacy sequently reported important effects on anemia and edu- and worrisome toxicity. Suddenly, the diseases of the poor cation over the 5 years of the intervention. So good was the were arriving in the lands of the rich and the available record-keeping that some 100 years later a comprehensive treatments were largely ineffective. re-analysis has been possible. Bleakley [4] has assessed the New approaches to deworming lead to new policies Corresponding author: Watkins, K.L. ([email protected]). Keywords: deworming; evaluation; impact; Cochrane Review; benefit; growth; Stoll’s call for a world-wide effort to control worms was not cognition. possible with the tools then available, but would resonate 142 1471-4922/$ – see front matter ß 2013 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.pt.2012.12.003 Trends in Parasitology, March 2013, Vol. 29, No. 3 Review Trends in Parasitology March 2013, Vol. 29, No. 3 over the following decades as new drugs and new program These donations have had broad impact, increasing the designs began to emerge. cost-effectiveness of deworming and heightening the at- Three developments converged to bring deworming tractiveness of deworming programs within public health back on to the agenda. First, the steady emergence of systems. new anthelmintic drugs – particularly benzimidazoles – These international developments in policy and tech- with greater efficacy and better safety profiles prompted nology led to dramatic increases in the number of individ- the WHO to re-activate a program of research and control uals receiving deworming medications around the world in human intestinal protozoan and helminthic infections and were underpinned by a growing body of evidence [9]. These drugs are considered safe enough to be delivered assessing the benefits of deworming. without individual diagnosis [10], and a recent systematic review of Randomized Controlled Trials (RCTs) shows that The effects of worm infection and the consequences of they are highly efficacious in terms of cure rate and, even deworming more so, in reducing infection intensity and thus transmis- Multiple studies have explored the impacts of worms on sion [11]. health, the consequences for the physical and intellectual The second development was the application of ecologi- development of children, and the long-run effects on indi- cal theory to helminthic diseases [12,13], from which viduals. Below we summarize the existing evidence and emerged new evidence that worms could be controlled discuss some of the strengths and limitations of these data. much more cost-effectively by programs designed to take The evidence includes traditional medical trials, but there advantage of the population dynamic characteristics of is also important evidence from other methods and evi- macroparasites, such as age-specific infection, overdisper- dence in the social science literature, particularly economic sion, predisposition, and transmission externalities literature, to be considered. [14,15]. The final development was a shift in public health Evidence from medical trials perspective with the growing success of child survival The Cochrane Library has recently published a systematic programs [16], and the recognition that the successful review of randomized controlled trials of deworming [23], efforts to reduce mortality needed to be supplemented using well-validated methods and expanding upon a pre- by efforts, such as deworming, aimed at supporting the vious systematic review [24]. The Cochrane Collaboration continuing development of surviving children, especially is a well-respected source of information for evidence- through a more integrated and multisectoral approach to based decision-making for medical interventions, combin- public health [16–18]. This human development agenda ing systematic search methods with strict selection criteria was the prime motivation for the highly successful national in order to minimize bias and enhance objectivity. The deworming programs in Japan and Korea. review concludes that available evidence suggests signifi- The convergence of these three key developments led to cant benefit of deworming on both weight and hemoglobin significant changes in international policy. The WHO gave in children with confirmed worm infection. The authors greater emphasis to deworming in specific age groups, note that there were not sufficient quality data available to especially preschool children, school age children, and determine the effect of deworming on cognitive function in women of reproductive age [19], and in 2001 the World children with worms. These findings are important be- Health Assembly declared the explicit goal of ensuring that cause they support the efficacy of deworming for improving 75% of all school age children in endemic areas received nutritional and hematologic outcomes in children with treatment (see: http://www.who.int/neglected_diseases/ worms. mediacentre/WHA_54.19_Eng.pdf). In addition to recogni- However, the review also analyses data from studies
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