With the show having just ended and the possibility of myriad new readers
turning to the books for the first time, this is what I hope will be the first
of a series of posts combining my loves of medicine and its history with A Song of Ice and Fire. In this first post, I wish to consider a moment from Fire and Blood which was for a time was perhaps the most discussed topic in the ASOIF community the death of Princess Aerea Targaryen.
For those unfamiliar with the event, I will briefly recapitulate it here.
Frustrated by her controlling yet emotionally distant mother the princess sought to return to her uncle’s court in the capital stole Balerion, called the Black Dread (the oldest and largest of the Targaryen family dragons). The two then disappeared for approximately a year. Upon her return, the princess was incredibly thin and more strikingly had a fever high enough to be felt through plate armor. Over the next few hours, her skin burned to the consistency of pork cracklings; smoke came from her mouth, nose, and her genitals and her eyes cooked within her skull until they burst. When the princess was lowered into the tub of ice, fiery parasites resembling worms with human faces and hands emerged. Both within the world of the book and in the fan community the prevailing theory regarding the source of this malady was an encounter with contaminated water during the course of the princesses’ doubtlessly harrowing journey.
When I first read this account including its theorized means of
transmission a few months ago, one disease immediately jumped to the forefront of my mind. The appropriately named Dracunculiasis or little dragons. Also called Guinea Worm, this is a parasitic malady by the nematode Dracunculus medinensis largely in tropical and subtropical regions. Much like what is believed about Aerea’s condition, contaminated water lies at the root of the disease. Consumption of copepod is ingested by a mammalian host, leads to its dissolution allow the D. medinensis larvae migrate through the wall of the intestine, and mature into adults. Roughly three months after infection the male and female of the species are able to meet and reproduce. While males die within the host the female migrates to the host’s subcutaneous tissue. Around a year after infection, the female causes the formation of a blister on the skin’s surface, generally on the lower extremities, though occasionally on the hand or scrotum. When the blister ruptures, the female slowly emerges over an extended period causing extreme pain and irritation to the host. It is this stage of the disease that earned the disease its name. When the host submerges the affected body part in water seeking relief the female expels thousands of larvae into the water. From here, the larvae infect copepods, continuing the lifecycle.
Fortunately, unlike in Westeros, we have been effective in responding to Guinea Worm. The Guinea Worm Eradication Program (GWEP) began in 1980 and has been led by the Carter Center since 1986. When this latter effort began there were an estimated 3.5 million cases of dracunculiasis worldwide and an estimated at-risk population of 120 million people. This potentially susceptible group lived across 20 different countries, 17 of them on the African continent. These countries were Benin, Burkina Faso, Cameroon, Central African Republic, Cote d’Ivoire, Ghana, India, Mauritania, Niger, Nigeria, Pakistan, Senegal, Togo, Uganda, Yemen, Angola, Chad, Ethiopia, Mali, and Sudan. According to the Carter Center’s latest statistics, there were 30 confirmed cases in 2017 and 11 in 2018. These cases were found in Angola (1), Chad (7), South Sudan (3). Other nations currently considered endemic such as Ethiopia and Mali have reported no cases as of August 29st of 2018. Despite the failure to meet the original 2009 goal of eradication the guinea eradication program still presents a powerful success as it reduced rates by 99.99914% (using 2017 confirmed data).
A number of strategies underlie this dramatic reduction. The first pillar of the response is case reporting and containment. This success is achieved through careful surveillance and reporting. The next key point is water safety, which encourages the treatment of potentially contaminated drinking water. The Guinea Worm Elimination Program (GWEP) gives fine-mesh cloth filters to households to strain out the infected copepods (tiny “water fleas” too small to be clearly seen without a magnifying glass) from contaminated drinking water. People who travel or work away from the household might not have access to filtered water, so they are given individual pipe filters. These devices are used like straws to drink water from unsafe water sources. A third key aspect is vector control. The vector for GWD is the copepod. To this vector, the GWEP puts a measured amount of approved chemical larvicide into the water sources that are suspected to be contaminated. The last import aspect of the effort continues to be education and community mobilization control particularly with the discovery of non-human mammalian and fish vectors which requires new approaches such as including thorough cooking, burial of fish entrails and preventing entrails consumption by dogs. All these efforts are all the more important given that treatment remains incredibly rudimentary consisting of literally removing the female worm with a stick gradually over several sessions (as rupture leads to a potentially fatal immunologic reaction), an approach often believed to be the root of the symbol of our own field the rod of Asclepius.
I hope you have appreciated this brief discussion of one of the most interesting recent moments in ASOIF and a disease as it stands on the brink of elimination.