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June 9, 2011

In rural China, Stanford researchers look for persuasive fix to fight intestinal worms

Stanford's Scott Rozelle is leading the Rural Education Action Project's efforts to show the Chinese government the best way to treat intestinal worm infections – an affliction that could weaken the country's boom and hurt its role in the global economy.

By Adam Gorlick


Linxiu Zhang, REAP's co-director, left, talks with Li Qunyan, center, who lives in a rural village of about 2,000 people in Guizhou Province. Her 5-year-old son, right, was diagnosed with intestinal worms during a survey conducted by REAP researchers last year. (Photo: Adam Gorlick / Stanford News Service)


GUIZHOU PROVINCE, CHINA – The village markets in this province's southwest corner are a cramped hodgepodge of human need. Here, a vendor sells underwear and shoes. A few feet away, pots and pans are for sale – their polished silver gleaming even on a cloudy day. Vegetables, chickens, bundles of dried tobacco and water buffalo all command a price.

Even the local dentist sets up shop at a bazaar that springs to life once every five days in a village of about 2,000 people. A steady stream of customers take a seat behind his sidewalk table to have their rotted and broken teeth fixed.

With his back turned to a puddle of blood pooled on the street between the makeshift dental clinic and a butcher's stall, the village's deputy Communist Party secretary has this to say about his community and its residents:

"They should all be healthy," Cai Ronxue insists after dropping his finished cigarette to the ground. "We care about sanitation. We pay attention to that."

Researchers with Stanford's Rural Education Action Project (REAP) have been paying attention, too. And they've reached a far different conclusion about the health and welfare of this rural area.

Fighting worms

In a survey conducted last year of about 1,700 children in Guizhou and bordering Sichuan provinces, REAP found that about 35 percent of them had intestinal worms – parasites that thrive when poor sanitation, undercooked meat and livestock mingle. The rates of worms were higher in Guizhou, reaching to 80 percent in some places.

Led by Stanford economist Scott Rozelle, the REAP researchers have come here to visit with the families who participated in the survey and talk to the doctors and government officials they're urging to fight the high rates of worm infestation. A team of about 20, the group consists of economists, doctors and political scientists from Stanford and other American universities as well as Chinese academics.

REAP's findings spurred the government to earmark about $10 million to do something about worms in rural China. A few years ago, officials spent some money on improving sanitation, educating parents and giving children medicine. But they did all those things at the same time and didn't measure the results, making it impossible to tell what – if any – method worked and how effective it was. Rozelle's team also found high rates of worm re-infection, meaning whatever was done in the past had no lasting impact.

"What you really need to do is have the government give these kids medicine, medicine and more medicine for the next 10 or 20 years until they're old enough to move to the city," Rozelle says. "They'll get better, and the social return is that they'll be able to work harder when they grow up and integrate into a society a generation from now."

De-worming pills cost less than a piece of candy – about 15 cents for a single tablet that could make a big difference if taken just twice a year. But in order to convince the government to make that investment, Rozelle needs data. So REAP plans to conduct a set of experiments designed to demonstrate the best and most cost-effective way to deal with the problem.

Although intestinal worms aren't usually a deadly affliction, they sap enough nutrients and vitamins to stunt growth, drain energy and sometimes lead to severe malnutrition. That makes it harder for children to do well in school and grow up strong, creating a disadvantage that Rozelle and other economists fear will keep them from competing in a red-hot economy that each year lures millions from the poor countryside to more competitive and lucrative jobs in the cities.

With the youngest generations left behind in the boom, the worry is that a growing class of frustrated and disenfranchised young adults will lead to a backlash of violence and instability that jeopardizes this country's place in the global economy.

An ongoing risk

Along the dirt and paved paths leading away from this village's narrow and crowded market, views open over stunning scenery of rice fields stretched below humpbacked limestone mountains. Houses of brick and concrete overlook the countryside. Villagers' toilets are almost always outside, consisting of little more than an opening over a large pit. There's no running water for hand washing, making it easy for contaminated feces to spread.

"There's lots of room for an ongoing risk of infection," says Dr. Scott Smith, an expert on intestinal worms at Stanford's School of Medicine. Smith spent a few hours talking to villagers and examining toilets outside a few homes and in the local school.

"I think this is just an accepted standard and it doesn't strike anybody as unusual," he says. "They don't feel that they need to do anything differently."

Lack of awareness

Li Qunyan lives here with her six children. Her husband works in a city about 200 miles away and comes home a few times a year during Chinese festivals. Her only son, who is 5, is one of the kids diagnosed with worms in the REAP study. But after giving the boy a de-worming pill, she never really thought about the problem again. And she didn't worry – or even wonder – whether her five other children had worms.

"That's pretty typical," said Matt Boswell, a project manager for REAP. "People have a completely different context for thinking about worms. They don't see it as a problem, and they don't even understand why we're here asking them about it."

The village doctor, who only has a middle school education and some additional health care training, says he's sold a few dozen de-worming tablets in the past month. But he, too, is unfazed by the parasites.

He hesitates a bit while thinking about what the village's most common ailment is.

"Colds," he finally says.

A cheap problem to fix

"The problem we have is how to make de-worming a sustainable part of the public health system," said Linxiu Zhang, REAP's co-director and deputy director for the Center for Chinese Agriculture Policy at the Chinese Academy of Sciences. "It's a cheap problem to fix, but there's no public awareness of the issue. Our purpose is to test the best ways of delivering the message to the government and the school and how we can raise parents' awareness."

Days before the REAP team came to this area, de-worming pills were given to children who participated in last year's study. Wei Jun seemed grateful that his daughter received one. But how much he valued the medication – and whether he'd buy any for his family – is unclear.

Asked if he knew how much the pill cost, he said no.



Scott Rozelle, Stanford Rural Education Action Project: (650) 724-6402,

Dan Stober, Stanford News Service: (650) 721-6965,

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