N’DJAMENA, Chad — Dr. Ernesto Ruiz-Tiben’s days on the front lines of the guinea-worm wars often end with a dinner of what is commonly called poulet bicyclette — chicken so lean and muscular that it could ride in the Tour de France.
But before anyone on his team eats, one tradition must be honored. Dr. Ruiz-Tiben raises a beer: “To the demise of the worm!”
“To the demise of the worm!” cry all in attendance, clinking glasses.
It is a ritual he has followed for decades, ever since becoming the chief strategist in the war against the Guinea worm run by the Carter Center, the global health philanthropy established in Atlanta by former President Jimmy Carter.
At age 78, Dr. Ruiz-Tiben still makes as many as six field trips a year, mostly to what he calls “places at the end of the road.” Reaching them can mean driving for days in 110-degree heat over kidney-jolting dirt tracks and sleeping in rustic guesthouses where frequent power failures mean sweltering nights passed in oven-hot, bug-filled rooms.
Asked why he does it, Dr. Ruiz-Tiben shrugged. “Because that’s where the action is — not in the capital city. People want to just snap their fingers and pouf, the worm is gone. That’s not going to happen.”
In the villages, he asks questions. Where do you get drinking water? What do you eat? How do you cook it? What does your dog eat? How far from home does your dog wander?
And he launches studies. Dogs get tracking collars; motion-sensing cameras are mounted near ponds; fish and frogs are caught, ground up and tested for worm larvae.
Though he is often quiet in large gatherings, Dr. Ruiz-Tiben can be scathing about those he views as obstacles to success:
“Air-conditioned epidemiologists pontificating about things they don’t understand.”
“World Health Organization people who like the great salaries and benefits but don’t like to work.”
“African men who treat their women like donkeys, letting them walk three-quarters of a mile with 40 pounds of water on their heads while they sit under the trees playing dominoes and getting drunk.”
At the same time, he has plenty of patience for the worm’s victims. He holds trembling children who fear they are in trouble as he asks, through a translator, how they were infected with a worm. He pats dogs that have been held down so worms can be drawn from their paws.
Dr. Ruiz-Tiben grew up in Ponce, Puerto Rico, sailing small boats. He describes himself as something of a juvenile delinquent. Hitting neighbors’ electrical transformers with a slingshot “is what got me sent to military school.”
In 1965, he got into parasitology “by serendipity” — also, he wanted to avoid going to Vietnam. He enlisted in the United States Public Health Service and was attached to a Centers for Disease Control and Prevention laboratory in San Juan.
He met his wife there; in Puerto Rico, nature abhors a bachelor. “The married ladies at the lab made me their project,” he said. “They invited me to go bowling, and that’s how we met.” They are about to celebrate their 50th anniversary.
He started off fighting schistosomiasis, a worm disease also known as bilharzia that is transmitted by water snails. He later switched to dengue, the mosquito-borne virus that causes “breakbone fever.”
He learned field work on assignments to Egypt, Liberia and South America. “You’ve got to pay attention to detail, to see what people are actually doing that spreads the disease,” he said.
His team does exactly that in Chad. The scientists are trying to understand why over 800 dogs have gotten Guinea worm, and apparently not from drinking water, as humans do. He suspects the dogs eat an intermediate host, possibly frogs.
After 26 years with the C.D.C., ultimately as head of its worm-disease division, he has seen his share of public health fumbles — for example, calling the agency decision to fight dengue by spraying San Juan with pesticide at treetop level “an ecological disaster” for bees and beneficial insects.
And he remembers the ugly years in the 1980s, when the C.D.C. was trying to stop AIDS, but many politicians were indifferent. “They saw it as God’s wrath on homosexuals,” he said. “The White House wouldn’t let the C.D.C. describe the reality.”
“Only Koop was willing to talk rationally about it,” he added, referring to the former Surgeon General, Dr. C. Everett Koop.
In 1991, Dr. Ruiz-Tiben retired, then joined former C.D.C. directors like Dr. William Foege and Dr. Donald R Hopkins at the Carter Center.
Global health was in dire shape then. AIDS in Africa seemed unstoppable and was driving a rise in tuberculosis. Malaria was surging as resistance to pesticides and drugs increased. The Bill and Melinda Gates Foundation had not yet injected billions of dollars into the game.
Some leaders favored what Dr. Ruiz-Tiben called “the magic-bullet approach”: trying to give clean water to the whole planet. But the cost — wells, dams, aqueducts and pipes for billions of people — was impractical.
Others wanted to tackle the most neglected diseases, like Guinea worm, elephantiasis and river blindness. The C.D.C. could not get funding for that, he said, so President Carter took up the cause.
It’s been a long struggle, and rarely an easy one.
Dr. Ruiz-Tiben has never had malaria. (His breakfast ritual is: “Everyone take their malaria pill?”) But he has been hospitalized with amebiasis.
He has never been taken hostage or held at gunpoint. The center’s local teams keep their ears to the ground, and the anti-worm program is popular. But there have been some close calls on rutted highways with trucks and drunken drivers.
His most dramatic moment, he said, was in a city in Ghana to which President and Mrs. Carter and center board members had come for a ceremony with Ghana’s health minister.
Suddenly, about 400 locals with worms erupting from their bodies arrived seeking help.
The city had let its pipes decay, forcing inhabitants to buy water from carts, and some sellers had filled their tanks at infested ponds. But city officials immediately blamed the victims, saying, “These stupid people will drink water from anywhere.”
As the medical teams worked furiously, Mr. Carter “went ballistic” with local officials, Dr. Ruiz-Tiben recalled. “That day was the turning point for Ghana,” he added. “After that, they got serious.”
The end is in sight for the Guinea worm, but not near. The W.H.O. demands at least three years with no cases before certifying a disease eradicated.
“I’ll need to retire at some time,” Dr. Ruiz-Tiben said. “My job is to train people to take over.”
President Carter is now 93, has recovered from a serious bout with cancer, and is caring for his wife, Rosalyn, who is facing cancer too. Their grandson, Jason Carter, is now chairman of the center’s board.
“President Carter has said he wants the worm gone before he is,” Dr. Ruiz-Tiben said. “We may not be able to fulfill his wish, but we’ll do the best we can.”
“But if we hadn’t done this campaign, there would have been 80 to 90 million cases by now. So whether or not we eliminate the worm, this campaign has done a lot of good.”
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