Schistosomiasis Control in Puerto Rico

Community Medicine & Health Education
Berry-Cabán, J Community Med Health Educ 2013, 3:7
Research Article
Open Access
Schistosomiasis Control in Puerto Rico-The Division of Community
Cristóbal S Berry-Cabán*
Womack Army Medical Center, Fort Bragg, North Carolina, USA
In the early 1950’s Puerto Rico began a 14 year program to eliminate schistosomiasis from the island. The Division
of Community Education (DIVEDCO) was created to bring together rising authors, artists, composers, and filmmakers
on the island to produce a series of materials– pamphlets, films, and posters– that educated the people about issues
such as health, public safety, democracy, literacy, and civic participation. One such pamphlet published was Bilharzia
that in 24 brief pages outlines the history, occurrence, reservoir, susceptibility, treatment, and control measures of
schistosomiasis on the island.
Keywords: Susceptibility; Schistosomiasis; Ccercariae
Schistosomiasis mansoni, known colloquially as bilharzia, came
to Puerto Rico with the slave trade [1-3]. At the beginning of the 20th
century, schistosomiasis was limited to several low-prevalence locations
in Puerto Rico (Mayaguez, Utuado and Aibonito) and the adjacent
island of Vieques an area of high prevalence. The change from a coffee
economy (that was precipitated in part by Hurricane San Ciriaco in
1899) to sugarcane cultivation and the subsequent construction of
large-scale irrigation systems, produced massive migrations of workers
from the mountains to the coastal regions [4]. As sugar cultivation
increased so did schistosomiasis.
Schistosomiasis is an infection with one of a series of related
trematode parasites that are endemic to at least 78 tropical and subtropical countries. Over 200 million people have this disease; 120
million of them have symptoms, 20 million have severe illness and
600 million others remain at risk [5]. Four species routinely infect the
human host. The majority of Schistosoma mansoni and Schistosoma
haematobium infections are found in sub-Saharan Africa. Schistosoma
mansoni remains endemic to parts of Brazil, Venezuela and the
Caribbean. Schistosoma mekongi is found in Cambodia and Laos, along
the Mekong River Delta. Schistosoma japonicum infection occurs in
China, Indonesia and the Philippines [6]. The ecology of schistosomiasis includes tropical lotic (lakes
and reservoirs) and lentic environments (rivers). Controlling
schistosomiasis is especially daunting, primarily because the parasites
are thoroughly integrated into the ecosystems in which they occur.
A notable exception is Japan, where Schistosoma japonicum was
eradicated from all of its islands by 1976, based largely on ecological
However, most underdeveloped countries do not have the political
stability, infrastructure, or the financial resources to implement such
massive control measures; additionally, civil unrest and warfare
have also taken their toll. Thus, schistosomiasis will remain a health
problem for some time to come. Despite major advances in control
and substantial decreases in morbidity and mortality, schistosomiasis
continues to spread to new geographic areas. Furthermore, there are
reports of resistance to praziquantel, the mainstay of medical treatment
Schistosomiasis has been extensively studied in Puerto Rico [1,813]. In 1906, fecal samples from 600 Puerto Ricans were examined
without finding any schistosome eggs. Three years later over 2,600
persons had been examined without discovering any schistosome eggs
J Community Med Health Educ
ISSN: 2161-0711 JCMHE, an open access journal
in their feces. However, in 1914, a large scale irrigation system for
sugar cane was constructed in the south. The prevalence of infection
in children from Guayama, a town in the irrigated zone, rose from 0
to 25% soon after irrigation began [4]. Between 1904 and 1959 240,605
single fecal tests were conducted of which 10% were positive for
schistosomiasis [14]. Likewise, in 1945 the US Army Medical Corps
discovered that nearly 10% of 19,139 Selective Service recruits aged 1838 were infected [1].
This study describes the pamphlet Bilharzia published by the
Division of Community Education as part of its series Books for the
People. A brief overview of the division that developed and distributed
it as well as its place in the social milieu in which the publication
appeared are examined.
The division of community education
In 1948 Puerto Rican poet, journalist and politician Luis Muñoz
Marín became the first elected governor. From the beginning of his
administration that lasted until 1965 Muñoz Marín worked toward
improving living conditions throughout the island, especially among
the rural peasantry.
The Commonwealth of Puerto Rico, established in 1952, redefined
the political relationship between the United States and the island.
A new ambiguous political status-autonomy without sovereignty,
self-government without self-determination- set-out to create a new
social, political, and cultural identity. Muñoz Marín, was committed
to promoting a Puerto Rican cultural identity centered around the
idealization of traditional rural life, while simultaneously attempting to
*Corresponding author: Cristóbal S Berry-Cabán, Womack Army Medical
Center, Fort Bragg, North Carolina, USA, Tel: 910-907-8844, 813-451-3004;
E-mail: [email protected], [email protected]
Received September 04, 2013; Accepted November 26, 2013; Published
November 28, 2013
Citation: Berry-Cabán CS (2013) Schistosomiasis Control in Puerto RicoThe Division of Community Education. J Community Med Health Educ 3: 251.
Copyright: © 2013 Berry-Cabán CS. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Volume 3 • Issue 7 • 1000251
Citation: Berry-Cabán CS (2013) Schistosomiasis Control in Puerto Rico-The Division of Community Education. J Community Med Health Educ 3:
251. doi:10.4172/2161-0711.1000251
Page 2 of 4
create a new democratic citizenry, both of which would bolster the new
government’s legitimacy.
Among the governor’s first projects was the formation of the
Division of Community Education (División de Educación de la
Comunidad). DIVEDCO, as it was commonly known operated for over
40 years and its impact on the health of Puerto Ricans is well recognized
[15]. DIVEDCO brought together rising authors, artists, composers,
and filmmakers to produce pamphlets, films, and posters that educated
the people about health, public safety, democracy, literacy, and civic
participation issues [15,16].
Muñoz Marín’s idea of using literature, art, and film, was inspired
by the Federal Art Project the visual arts arm of the Works Progress
Administration, the largest of the New Deal agencies established by
President Franklin D. Roosevelt. Three individuals who had been
involved with Roosevelt’s New Deal also played key roles in the
development of DIVEDCO: Edwin Rosskam served as its first director,
and the husband and wife team of Jack and Irene Delano were in charge
of the film and graphics departments [16-18].
Figure 1: Bilharzia, 1961.
Print materials played a predominant role in the promotion of
health education at DIVEDCO and encompassed both pamphlets
and posters. These tools provided health and community educators
with much needed information on diseases and conveyed important
preventive health messages motivating people to take actions to
improve their health.
Over a period spanning nearly 40 years DIVEDCO produced
and distributed, free of charge, some forty educational pamphlets on
various subjects. Copiously illustrated by DIVEDCO’s leading artists,
this series of pamphlets called Libros Para el Pueblo (Books for the
People) were written in simple language, and contained stories, poems,
essays, and other short texts with clear, direct messages that could be
understood by audiences of all ages and educational levels. Most books
contained a brief introduction that explained the nature and purpose
of the readings, and pointed out the lessons that they aimed to teach.
Some also included brief quizzes at the end that were meant to help
readers synthesize the information contained in the book. Thousands
of copies of each pamphlet were distributed throughout the island
by DIVEDCO field workers, who also stressed the importance of the
books and encouraging rural communities to discuss the texts among
themselves and apply its principles.
Books for the people
Bilharzia. Bilharzia published in 1961 and reprinted in 1968 was
edited by René Marqués; written by Benji Donniger and Fred Ward;
and illustrated by Carlos Rivera, Antonio Maldonado, Isabel Bernal
among others [19]. In 24 brief pages the writers outline the history,
occurrence, reservoir, susceptibility and treatment and control
measures of schistosomiasis. The cover is striking (Figure 1). It features
a skull and is printed in bright red with a simple one-word title
Bilharzia. This booklet’s dramatic cover illustration, by Carlos Osorio,
embodied DIVEDCO’s belief in the power of art to communicate
important messages to audiences that were largely made up of semiliterate peasant families.
All species of schistosomes use freshwater snails as intermediate
hosts that are essential to the completion of their life cycle. The
infection is generally acquired by agricultural work, domestic chores
or recreational activities such as swimming or bathing in fresh water
contaminated with the parasites.
The face page of Bilharzias shows the “Cycle of Death” (Figure 2).
J Community Med Health Educ
ISSN: 2161-0711 JCMHE, an open access journal
Figure 2: The Cycle of Death; Front page, Bilharzia, 1961.
An infected man is pictured defecating in a river thus eliminating eggs
with his feces or urine. Under optimal conditions the eggs hatch and
release miracidia that swim and penetrate specific snail intermediate
hosts (in this case Australorbis glabratus). The cercariæ leave the snail
and penetrate skin and finally another person is infected. The stages
in the snail include two generations of sporocysts and the production
of cercariae. Upon release from the snail, the infective cercariae
swim, penetrate the skin of the human host, and shed their forked
tail, becoming schistosomulae. The schistosomulae migrate through
several tissues and stages to their residence in the veins. Adult worms
in humans reside in the mesenteric venules in various locations that
at times seem to be specific for each species: for instance, Schistosoma
japonicum is more frequently found in the superior mesenteric veins
draining the small intestine, and Schistosoma mansoni occurs more
often in the superior mesenteric veins draining the large intestine.
Volume 3 • Issue 7 • 1000251
Citation: Berry-Cabán CS (2013) Schistosomiasis Control in Puerto Rico-The Division of Community Education. J Community Med Health Educ 3:
251. doi:10.4172/2161-0711.1000251
Page 3 of 4
However, both species can occupy either location, and they are capable
of moving between sites, so it is not possible to state unequivocally that
one species only occurs in one location. Schistosoma haematobium
most often occurs in the venous plexus of bladder, but it can also be
found in the rectal venules. When people with the disease urinate or
defecate in fresh water, these eggs are passed and the cycle begins again.
Each stage of this cycle is further amplified in the pamphlet.
It begins with “What is Bilharzia.” After a very brief history of
schistosomiasis, it presents a fictitious account of an 8 year old boy,
who while being examined at the Fajardo District Hospital is found
infected with thousands of eggs. This leads the reader to a chapter
on how one contracts schistosomiasis. Each chapter presents a small
vignette, “It’s Monday. Mother and daughter have clothing to wash.
The stream is fresh and there is place where one can wash and talk to
the neighbors.”
Symptoms and treatment are described. When the adult flukes
begin laying eggs (about 4 to 8 weeks later, vague discomfort (malaise),
fatigue, fever, and abdominal pain, may develop. The pamphlet
describes how in an advanced stage schistosomiasis may include:
abdominal pain, enlarged liver, blood in the stool or blood in the urine,
and problems passing urine and of course urticaria.
If schistosomiasis is ascertained early on the pamphlet suggests,
there are more opportunities for treatment. Until recently (i.e., early
1960s), it states, tartar emetic, a poisonous crystalline compound
was used as an expectorant for the treatment of schistosomiasis.
In recommended the antimony compound Faudin, also known as
Stibophen, an intramuscular injection. Anyone under treatment
should have their stool examined regularly recognizing that it may take
up to two years to become disease free.
“What is the Government Doing?” In this chapter the
government’s efforts are examined. The lead agency being the Puerto
Rican Department of Health. “Death to the Australorbis,” describes
the government’s efforts to eliminate the snail from the island’s rivers.
Other efforts included access to potable water and sanitary education
is reviewed.
Lastly the book ends with a chapter on “What can you do,” that
describes simple efforts such as boiling water, what to do if you don’t
have a latrine and an exhortation to “read this book and other materials
and discuss it with members of your community”.
Bilharzia was part of a concerted program to control the disease.
Launched in 1953, the program used limited chemotherapy and snail
control by environmental, biological and chemical means. At the same
time, extensive programs of water supply, health education and free
latrine distribution were implemented across the island (Figure 3).
Schistosomiasis is one of the tropical diseases targeted for control
by the Special Program for Research and Training in Tropical Diseases
of the United Nations Development Program, the World Bank and
the World Health Organization (WHO). As early as 1950 the WHO
emphasized the dangers of developing irrigation schemes in regions
infected with schistosomiasis [20]. The 65th World Health Assembly
has set a goal of treating annually at least 75% of school-age children
infected with schistosomes [8].
Puerto Rico has made great strides in ameliorating schistosomiasis.
In a review article, George Hillyer shows the efforts taken since 1904
toward identifying, documenting and abating schistosomiasis [9]. By
1976 the proportion of children reacting positively to the skin test
J Community Med Health Educ
ISSN: 2161-0711 JCMHE, an open access journal
Figure 3: Warning sign seen in Puerto Rico in 1954. Sign reads: Do not bathe
here. There is Bilharzia. Source: CDC.
decreased from 24% in 1963 to 5%. During the 1980’s very few cases
were reported [9] and in 1994 the Puerto Rico Department of Health
established a commission to evaluate the status of schistosomiasis
throughout the island. A 2012 schistosomiasis risk assessment noted
that in Puerto Rico “low rates of infection have been reported from
all parts of the island. Risk of infection is also present on the islands of
Vieques and Culebra, both located off the eastern coast of Puerto Rico
Bilharzia was one of the many pamphlets produced by the
DIVEDCO’s writers and artists. Created to educate as many people
as possible, the pamphlets were striking and attractive, but they also
captured the public’s attention. These pamphlets were often printed in
editions of about 5,000 copies. Other health issues covered included
The White Plague about tuberculosis, Science against Superstition,
Blood and nutrition [15].
More than a government agency, DIVEDCO was a social
experiment aimed at educating the masses. Many of the Libros Para
el Pueblo was published as companion pieces for the DIVEDCO’s
films, and in a similar manner, many of the films were inspired by
the stories and essays in the booklets. Indeed, Bilharzia was released
as a companion text to the 1960 film Sucedió en piedras blancas (It
Happened in Piedras Blancas). Directed by Benji Doniger, it is the story
of a young Puerto Rican government doctor who is assigned to fight
schistosomiasis in a rural district and informs Puerto Ricans about the
dangers posed by this common disease.
While there is no way to determine the impact of Bilharzia and
other public health pamphlets in the series produced by DIVECO, in
short, however, the carefully planned distribution of pamphlets, posters,
and films among Puerto Rico’s rural peasantry was a key component of
a 40-year public health and education campaign, through which the
island’s government was able to foster not only community heath,
development and self-reliance, but also a sense of national pride that
was forever crystallized in the bountiful cultural production of the
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Citation: Berry-Cabán CS (2013) Schistosomiasis Control in Puerto Rico-The Division of Community Education. J Community Med Health Educ 3:
251. doi:10.4172/2161-0711.1000251
Page 4 of 4
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Citation: Berry-Cabán CS (2013) Schistosomiasis Control in Puerto Rico-The Division
of Community Education. J Community Med Health Educ 3: 251. doi:10.4172/21610711.1000251
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