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Sidebar:
A disease of poverty and progress
Senegal at a glance
The Diama dam in Senegal was built to bring progress to the West African
country. Instead, it brought an epidemic of schistosomiasis, as insidious
but preventable parasitic disease.
In 1998 author Kohar Jones, then a senior at Yale College, traveled to
Senegal to investigate the links between dams and the spread of schistosomiasis.
Without
clean water and sanitation, the river becomes kitchen, laundry and bathroom,
promoting an ongoing cycle of infection and reinfection.
In Mbagam, a rice-farming village on the Senegal River, workers wear awkward
rubber boots and take yearly doses of praziquantel to ward off infection
with schistosomiasis.
A drought in the 1960s and 1970s drove cattle herders off the dry plains
of the Sahel and into the cities. In response, the Senegalese government
and its neighbors resolved to spur agriculture and economic development
by building dams along the Senegal River. Development, however, remains
elusive.
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“The silent scourge
of development”
More than two decades ago Yale public health experts warned that dams
along the Senegal River would bring disease. A Yale medical student’s
research finds that their predictions have come true.
A letter from Senegal.
Article and photographs by Kohar Jones, M.D. ’05
In the Senegalese village of Mbagam, health worker Fatou Kine Manga fines
those who enter the waters of the Senegal River. Despite her warnings
to others, Manga admits to breaking her own rule. “Even me, I go
to the river!”
Snails that carry parasites lurk there, threatening infection with
schistosomiasis. This debilitating chronic disease attacks the poorest
of the poor—those who, like Manga, lack access to clean water and
sanitation and rely on infected water for drinking, cooking, cleaning
and bathing. Poverty and schistosomiasis are rampant in Mbagam, both despite
and because of the dams along the Senegal River.
I arrived in the West African nation of Senegal in September 1998,
on my 21st birthday, to examine the health effects of the dams for my
senior essay at Yale. This research would later become the topic of my
medical school thesis, as well. For two months I lived in the capital
city of Dakar, the westernmost point of Africa. Described by a friend
as a miniature version of Paris—after a bombing—downtown Dakar
had multistory apartments with ornate wrought-iron railings and crumbling
facades. Outside the skyscraper that housed the West African Bank, I dropped
change on the blankets of beggars with polio. At the West African Research
Center, as part of my study abroad program, I studied the country’s
economics, politics and culture.
For my monthlong field project, my instructor in the indigenous
language of Wolof encouraged me to follow in a Yale tradition and study
schistosomiasis along the Senegal River. Twenty-one years earlier, he
proudly told me, he had been the interpreter for a Yale team studying
the potential effects of the dams on human disease. Wilbur G. Downs, M.D.,
M.P.H., led the team, which included Herbert S. Sacks, M.D., HS ’53;
George A. Silver, M.D., M.P.H.; Eric W. Mood, M.P.H. ’43; Robert
B. Tesh, M.D.; and Curtis L. Patton, Ph.D. My Wolof teacher’s enthusiasm
sparked my own. When the director of the nongovernmental organization
Environment and Development Action in the Third World asked me to conduct
an informal field survey on whether schistosomiasis would limit the socioeconomic
development of the Senegal River region, I gladly agreed.
Sugar fields, rice paddies and near-desert
That November, I left the city for the Sahel, the region south of the
Sahara, to begin my survey. Two months after the rainy season, the Sahel
was already tan and dry. Herders wearing the traditional wraparound headdresses
of the Pulaar people drove thin cattle over the land. Barbed wire prevented
the herds from encroaching on the irrigated plots that nurtured dreams
of agricultural development.
From the sugar cane boomtown of Richard Toll I continued a few
kilometers downstream to Mbagam, a rice-farming village. My hosts were
a prosperous farming family, wealthy enough to own a latrine and a mosquito
net for guests. There was no electricity, but at night we gathered with
villagers in a neighboring compound to watch television—powered
by wires connected to a car battery—under the stars on a dirt floor
next to cows. A relative of these neighbors lived in France, where he
washed dishes and sent his wages home to support the family, pay the taxes
and buy the car that provided power for the flickering images that allowed
the villagers to dream of a different life.
The dams along the Senegal River also fed hopes of a new life.
Omar Niang, president of the village farming cooperative, praised the
dams for doubling the rice harvest. But standing next to a pump that transported
water from the river to the rice paddies, he noted the negative aspects.
Workers wore uncomfortable plastic boots for protection from infected
water, and they all took the anti-schistosome drug praziquantel. “Everything
has a good side and a bad,” he said.
Schistosomiasis, named “the silent scourge of development”
by the World Health Organization in 1998, is the bad side of dams. It
follows water development projects that create the perfect habitat for
the snails that carry the disease (See sidebar).
In 1994, less than 10 years after the dams were completed, Mbagam
had a disease prevalence of 91 percent. About 2,500 villagers joined the
estimated 200 million people worldwide who are infected with schistosomiasis.
The other 9 percent joined 400 million people around the world at risk
of infection.
The dams and the disease they brought emerged from Senegal’s
colonial legacy. Senegal, the former jewel in the crown of colonial French
West Africa, became independent in 1960 but maintained close trading ties
with France. In 1968, however, France stopped subsidizing the dominant
peanut economy just as a drought hit sub-Saharan Senegal. Both peanut
farmers and nomadic herders saw their economies and lives devastated.
Villagers flooded the capital cities in search of work, and starving masses
threatened to undermine political stability. In 1972, amid widespread
famine, Senegal adopted French colonial plans to dam and irrigate land
along the Senegal River.
With its neighbors Mali and Mauritania, Senegal formed the Senegal
River Development Organization (Organisation pour la Mise en Valeur du
fleuve Sénégal—OMVS). Dams provided hope for a desperate
population. The massive hydroelectric Manantali Dam in Mali promised both
electricity and a link between landlocked Mali and Atlantic trade routes.
The small Diama Dam at the mouth of the river, between Senegal and Mauritania,
would prevent salt water from creeping up the river bed during the dry
season, allowing for two harvests of rice each year. Unfortunately, reality
never matched the hopes.
By 1988 the dams were completed, but the promised new civilization
never came to be. Following the dictates of Structural Adjustment Programs
(SAPs) of the World Bank and International Monetary Fund, which demanded
a balanced budget, Senegal dismantled and privatized its national health
system and agricultural agencies just as they were needed most. Senegalese
economists wryly renamed the SAPs “the Suffering of the African
People.”
Disease comes to Richard Toll
During my month surveying schistosomiasis, my base was in Richard Toll,
home to the Senegal Sugar Company (Compagnie Sucrière Sénégalaise—CSS).
My new home became the gated Cité Cadre, where electricity generated
by the burning of sugar cane stalks powered the air conditioners of the
expatriate and Senegalese managers of the CSS, who directed development
in the region. It was a city on a hill, separated from the center of town
by a scattering of neighborhoods and the tall green waving stalks of irrigated
sugar cane.
Trucks carrying molasses and sugar cubes to Dakar rumbled along the paved,
two-lane National Route, dodging horse-drawn carriages, pedestrians and
the occasional cow. The paychecks of the sugar cane workers supported
a bustling market, a regional economic magnet. Electric lines strung overhead
connected cement block homes. Two water towers were under construction.
A latrinisation program promised to sanitize the town. Richard
Toll was the model of agroindustrial development for the nation.
But development had already brought disease. In 1986, the completion
of the Diama Dam blocked the saltwater tongue of the Atlantic. Freshwater
snails migrated from a nearby lake through a sugar company canal and into
the fresh water of the Senegal River, where their population exploded.
The human population of the sugar boomtown was also exploding. From 10,000
when the CSS was founded in 1972, Richard Toll’s population had
more than quintupled by 1988, to an official 50,000 (but closer to 75,000)
residents, largely due to immigration. Urban amenities had not kept up.
An infected migrant worker is believed to have brought the parasite to
Richard Toll. The CSS canals became ground zero in a massive schistosomiasis
outbreak.
Although there had been 50 isolated cases of intestinal schistosomiasis
among migrant workers between 1970 and 1980, before the dam was built,
in January 1988 Diokel Dieng, a government health worker in Richard Toll,
diagnosed a new case of intestinal schistosomiasis along the Senegal River.
By the end of the year, he had found 29 cases. By the end of 1989, there
were nearly 2,000. By August 1990, a full 60 percent of the population
of Richard Toll was infected with intestinal schistosomiasis. And it spread.
By 1998, schistosomiasis had infected hundreds of thousands of people
in the Senegal River region. In many towns and villages, as in Richard
Toll, the prevalence rates were just shy of 100 percent—only the
youngest children, who had not yet had extensive contact with infected
water, remained free of disease. It was the largest public health problem
facing the region, greater than the looming threat of AIDS and the constant
presence of malaria—and all because of the ecological changes wrought
by dams and irrigation.
Still, when I asked Aboubakry Gassama, M.D., the head of the CSS
health services, whether schistosomiasis would limit socioeconomic development,
he said no. Although most workers were sick with schistosomiasis, there
were enough healthy migrant workers desperate for a paycheck to replace
them. The limiting factor, he said, was the lack of financial resources
to irrigate the land around the river. (Of the 600,000 acres that planners
had hoped to irrigate by 2000, only 75,000 were in use—the same
number that had been irrigated 10 years earlier). This was not to say
that schistosomiasis wasn’t a problem. Of every 100 workers waiting
on benches that lined the clinic’s long concrete hallway, nursing
machete wounds from the fields or parasitic lesions from the Senegal River,
Gassama estimated that all but two had schistosomiasis. “If people
don’t do anything, then in 10 years they are indisposed, and in
30 years they are dead,” he said.
Return to the States
From Mbagam, I took a donkey cart to the main road to catch a car rapide
to the regional capital of Saint-Louis to take a sept place (a
seven-seated old Peugeot) back to Dakar to catch my plane home—a
century’s worth of development compressed into 24 hours. Descending
through the cloud cover over New York City, I appreciated the rains that
watered the gardens that provided food for farmers and industrial workers
alike. I returned to New Haven, where libraries serve as cathedrals of
knowledge and the sum of human experience could be consulted to shape
future planning. medline provided information about schistosomiasis and
disease outbreak in Senegal. Patton, a professor of epidemiology (microbiology)
and one of the original Yale researchers, provided the team’s reports.
The schistosomiasis epidemic, I learned, could have been prevented.
In 1972, when the OMVS decided to develop the Senegal River, the link
between dams and disease was well-established. Nevertheless, dam planning
progressed with minimal attention to public health concerns.
In 1978, the Yale researchers warned development planners that
schistosomiasis was a “serious public health problem” that,
without adequate control measures, “might be aggravated by irrigated
agriculture. … inhibiting both agricultural and economic development.”
They recommended a disease surveillance team to track outbreaks and implement
immediate control measures. They “strongly urged” that Senegalese
groups with “considerable experience” as well as “the
necessary trained personnel and mobile units to carry out such work”
conduct the health surveys. The only reason the Senegalese weren’t
already doing this work was that they were “rather short of funds
and supplies.”
Unfortunately, as budgets contracted under the SAPs, the recommendations
were ignored. Nothing was done to avert the preventable outbreak of schistosomiasis.
And a generation later, I arrived in Senegal to ask if schistosomiasis
would limit the socioeconomic development of the river region. After my
first visit in 1998, I made three more trips to Senegal, with support
from the Fund for Investigative Journalism and the medical school’s
Office of Student Research, to explore this question. There was no easy
answer, I found. It depended on how you defined development.
For individuals struggling to become masters of their own destiny,
schistosomiasis severely limited their progress to greater personal and
economic freedom. Sick, they could not work. Without work, they could
not pay for health care, school expenses for their children or even food.
For industries struggling to make a profit, schistosomiasis had
little impact. There were always healthy workers to replace the sick.
The limiting factor for economic development was simply the lack of local
money to invest in irrigation, factories and industry. Foreign investors
shied away from supporting further irrigation at the edge of a desert.
Instead of boosting macroeconomic indicators, the dams ushered
in an era of epidemic infectious disease. Poverty trapped villagers in
an endless cycle of infection and reinfection. In retrospect, Patton described
it as an “extraordinary example of poor planning.”
The Yale team’s recommendations—disease surveillance,
strengthened health systems, implementation of available measures to control
disease—remain apt today. Health planning must be part of all development
planning.
In Mbagam, where four spigots provided water for up to 3,000 people,
Manga continued to violate the very rules she had set to protect the health
of the villagers. “Only four flasks a day,” said Manga, bemoaning
the daily ration—about eight gallons for each household of up to
30 people. “That’s not enough water for sure. You have no
choice but to enter the river. It’s the financial means that we’re
missing. Above all, the means.” YM
Kohar Jones, M.D. ’05, is a resident in family practice at
Middlesex Hospital in Middletown, Conn. She plans to publish her medical
school thesis under the title Germs of Progress: Schistosomiasis in
Senegal and the Ethics, Politics and Economics of International Health
Research and Development in the 20th Century.
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