Saturday I tagged along as researchers David Rollinson (Natural History Museum) and Steffi Knopp (Swiss Tropical and Public Health Institute) drove the island to visit 23 of the 45 schools that will be included in the elimination program. Each school will be placed in one of the three arms of the study: treatment only, treatment and behavior change, or treatment and snail control.
In a nutshell this is what I did all day:
Photos of toilets. Lots of them.
An example of a school in Pemba.
There was a point to this, though. In addition to identifying the schools to be involved and the number of enrolled kids, we looked at water and latrine availability on each campus.
It was also a chance to note which schools seemed to be in better shape than others, and which ones were situated near freshwater water sources that could serve as snail habitats.
The species of worm that affects those in Zanzibar is primarily S. haematobium, which causes urogenital symptoms like bloody urine. So instead of sampling stool, in Zanzibar urine is tested for eggs. A large difficulty in the task of eliminating schisto here is that small children playing in freshwater bodies tend to pee in the water, spreading eggs. 
That behavior is common worldwide and will be difficult to change, but another challenge is that while many people here know about kichocho, they believe it’s a disease that only affects boys and don’t think to check the urine of little girls.
Because of the nature of transmission, through urine, it was heartening to find that almost all of the schools we visited had available latrines for the children. Their condition, however, was a different story. Some schools had newer latrines, while others had old, crumbling buildings with barely functioning doors.
Newly constructed latrines at another school.
An older latrine at a school.
Additionally, many of the schools had newer tanks for water and basins attached with taps for hand washing. Those that lacked the new plastic tanks had older cement tanks or at least piped water to a single tap.
We were surprised by the amount of new construction going on and the efforts that seemed to be made toward supplying schools with fresh water and toilet facilities. Pemba, which has a higher prevalence than Unguja, seems to have made large strides in the improvement of sanitation, which could have beneficial effects on the spread of several diseases, not just schisto.
Driving around the island also revealed that numerous villages had water tanks and a tap available to the community, and some even had latrines that could be seen from the road.
While we were glad to see the available toilets and water in most of the schools, we also noted that many classrooms were without desks and some schools looked rather rundown. When we met children or adults at the schools there was a mixture of those aware of kichocho and those unaware of the disease or its prevalence in the area. Some went as far as to say they knew water sources where kids were getting infected, while others looked at me as if I’d grown wings when I asked them if they knew about the disease.
Shaali Ame, head of the PHL lab, has been involved in mass drug administration efforts for schisto and other diseases in Zanzibar for years. He says that they have not encountered too much resistance from locals when giving treatment, but part of that is due to the school-based nature of the national plan and collaboration with the Ministry of Education. “Life is a little bit easier,” he said. “The students are organized and teachers are cooperative.”
For the community-wide treatment, previous awareness and knowledge of the disease can go a long way. If no one knows that blood in the urine is a bad thing, then they won’t seek help. Hopefully repeated treatments and community involvement through ZEST will bring a new awareness of kichocho to residents, parents especially. “After seeing the success [of the drug] they will see this is a real medicine,” he said.
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