Move over Chutes & Ladders: Schisto & Ladders has educational value plus worms

The game "Schisto & Ladders" is introduced to students in an elementary school in a part of Nigeria where the neglected tropical disease schistosomiasis, spread by parasitic worms, affects many residents. This version of the classic "Chutes & Ladders" games aims to teach children how to avoid getting infected — and details of the treatment for those who catch it. Daniel Amao hide caption

Chutes & Ladders has been a beloved board game in the U.S. since the 1940s — adapted from an ancient Indian game that aimed to teach moral lessons.

Kids in Nigeria are now playing a version called "Schisto & Ladders." It too aims to teach — about how to prevent a disease called schistosomiasis. It's a parasitic

infection caused by a worm that infects humans via skin contact with infested waters.

An unlucky player might land on a square that says "playing in a river" That puts you at risk for this tropical disease — and sends your game token down a worm instead of a chute.

Nigerian researcher and educator Cynthia Umunnakwe is one of the developers of the game — it's part of an arsenal of creative approaches to warding off the illness. Known locally at "Atosi Aja" or Bloody Urine , the disease not only causes blood in the urine but has other short-term symptoms such as fever and rash. If untreated, it can cause major organ and neurological damage, infertility and even bladder cancer. In Nigeria, it is associated with higher rates of bladder cancer in young people.

Known as a Neglected Tropical Disease because of the lack of funding to fight it, schistosomiasis is a serious challenge for impoverished communities. There are over 200 million cases across sub-Saharan Africa. School age children are at the greatest risk of infection because they like to play in the water and their immune systems aren't fully developed.

Though effective medication exists, the issue is persistent in areas with a lack of easy access to testing, treatment and clean water so people don't rely on local bodies of water for drinking and bathing. Awareness of its transmission is also an issue. Touching infested water, even just a splash, can risk infection, as microscopic larvae swimming along the surface are able to wriggle through skin.

Uh oh, a worm!

The game, created in 2014 by a team led by Professor of Parasitology Uwem Ekpo of Akwa Ibom State University, follows the classic pattern: Roll a dice to advance up a winding path to the top of the colorful board. A player could land on a square that sends them up a ladder or sliding down a Schisto worm (which takes the place of the traditional chute). An example of a positive square is "eat before taking medicine" – the right thing to do for someone who's infected and sends the player up a ladder to move ahead in the game.

Another square with negative consequences says "Blood in Urine" but the neighboring square offers the player a path to redemption: "visit the health center" with a drawing of a smiling health worker.

"Children go up the ladder when they encounter a good behavior [in the game] that would prevent schistosomiasis," Cynthia Umunnakwe says. These include "Take praziquantel at school" and "Cutting vegetation around a river" – removing invasive plants that offer ideal conditions for proliferation of the intermediate snail hosts, which carry the parasite.

The game also highlights key steps of transmission.

The "Fetching water from a stream" square showed a child stooped at the river's edge. A schistosome worm stretched from this square down the board to the complication of the illness, depicted in another square reading "Swollen belly"; while "Defecating near a river," brings the player's piece far down the board, landing on a square reading "Spreading infection." These represent two chances to interrupt the parasite's life cycle: Avoiding infection of humans at the larval stage via water contact and discouraging propagation of the parasite into river water via human waste, where eggs in waste can then reinfect snails.

Playing the game

On a visit to a schoolhouse in Apojola village in July 2025, Cynthia Umunnakwe taught young children to play "Schisto & Ladders" — part of a Ministry of Health program that also provided urine testing and treatment for those affected.

And it's not just a game. In this part of Ogun State, a third of residents screened at a urine testing clinic were found to have active schistosomiasis infection. The disease is common in these rural fishing villages where residents rely on freshwater for daily living. Tthe Oyan River is used for the essential daily tasks of washing clothes, fishing and cleaning and preparing cassava root, the main crop. The shallow river's edge is also a playground for schoolchildren, who splash around for fun — and also are told by their parents to check fish traps.

"Hi everyone, I am Dr. Cynthia from Nigeria." she says with a smile – she holds a Ph.D in parasitology – and offers a wave. She supervises the pushing of tables and benches into clusters in the classroom, and then the game begins.

Umunnakwe also brought in live snails — familiar to the youngsters who play in the river — so they could recognize the host for the parasite that infects humans, leading to this illness. They were collected by her colleague, Dr. Olubukola Adelakun. a veterinary public health researcher and post-doctoral scholar at Federal University of Agriculture in Abeokuta who researches the habitat of these snails. She had waded waist-deep in the river water the day before, clad in waterproof waders to protect from infection. She had scrubbed their shells clean for easy identification, as there are many similar freshwater snails in the area, though none of them had the characteristic shell shapes of the parasite-carrying snails.

The day's activities included medical help as well. In a neighboring schoolhouse, Ministry of Health staff offered all children the oral drug praziquantel, which can both prevent and treat the disease. They got free snacks for participating, since eating before treatment can help ease stomach pain that often occurs if the drug is taken on an empty stomach.

The team's doctor administered treatment doses according to height, with a standardized measuring tape against the wall to help determine the dose.

In previous years, Cynthia Umunnakwe had conducted research demonstrating the game's impact, published in International Health . In a six-month study involving 275 students across six schools in rural Ogun State — schools where praziquantel had previously been rejected because of false rumors that it caused fainting and even death — not a single child in the study group had heard of the drug before playing the game. The game was played in each school for the duration of the trial, and the team surveyed children before and after the trial, conducted focus group discussions with students, parents, and caregivers. By the end of the trial, more than two-thirds of the students knew what the drug was and understood it was safe, and 65% put their names down, with parental permission, to receive treatment.

"So we are hoping that by playing this game that the schoolchildren will actually translate the knowledge acquired into changing their behaviors," Umunnakwe said,

"Hey, wò ó, mo wà lókè!" said a boy who won the game by reaching the final "Schisto-free child" square: "Hey look, I'm on top!"

William McCarthy is a medical student at McGovern Medical School and a researcher and writer committed to global child health problem-solving. His research includes environmental health and global health diagnostics innovation. Currently, he studies schistosomiasis with the Prakash Lab at Stanford Bioengineering, where he works on community-led approaches to infectious disease control. He's CEO and co-founder of the student-led nonprofit group Health In Your Hands Diagnostics.