Sudan
Located immediately south of Egypt, Sudan is the African continent's largest country, comparable in size to the United States east of the Mississippi River, and is home to 42 million people of many races, religions, and cultures. The Sudanese, though, have been caught in a myriad of effects, including famine and disease, from civil war that raged for all but 10 years since Sudan's independence in 1956. Since 1983, more than 2 million people have died, and 4 million have been forced from their homes.
On Jan. 9, 2005, the government of Sudan and the Sudan People's Liberation Movement/Army signed a historic peace agreement in Nairobi, Kenya, bringing an end to Africa's longest-running civil war.
The Carter Center has been deeply committed for nearly two decades to alleviating suffering in Sudan and finding ways to bring lasting peace. The Center's first project in Sudan, the Sasakawa-Global 2000 agricultural project, began in 1986, helping farmers to greatly improve crop yields. From that first activity, the Center has continually expanded its efforts to help the long-suffering people of Sudan through four programs that are active in the country today.
The Center's Conflict Resolution Program has helped find ways to end Sudan's civil war, working with President Carter to directly negotiate between the parties and working to help focus local, regional, and international opinion on peace, not war. Among the program's achievements was the negotiation of the 1995 "Guinea worm cease-fire," which gave international health workers -- including the Center's Guinea Worm Eradication Program -- an unprecedented period of almost six months of relative peace, allowing health workers to enter areas of Sudan previously inaccessible due to fighting. More recently, President Carter brokered the 1999 Nairobi Agreement between the governments of Sudan and Uganda, in which the governments pledged to stop supporting rebels acting against each other's governments.
The Guinea Worm Eradication Program, the flagship public health program of The Carter Center, has helped reduce the worldwide incidence of Guinea worm disease by 99 percent since it started in 1986. Guinea worm disease will be the first parasitic disease to be eradicated and the first disease to be eradicated without using vaccines. Because Sudan harbors the majority of the remaining cases of Guinea worm, it is a crucial site for eradication efforts.
The success of the Guinea Worm Eradication Program also has been a vehicle for development and has broadly promoted Sudanese public health and welfare, while fostering the introduction of two additional health programs, river blindness and trachoma, to the region. However, the vitality of these public health initiatives depends on peace, because the hazards of the civil conflict hinder their full implementation. Thus, the Carter Center's Conflict Resolution Program, Guinea Worm Eradication Program, River Blindness Program, and Trachoma Control Program work together to produce a better life in Sudan by waging peace, fighting disease, and building hope.
Current status: Endemic
Indigenous cases reported in 2009 (provisional): 2,753
Since 1995, The Carter Center has worked to reduce the cases of Guinea worm disease in Sudan through its Guinea Worm Eradication Program. Harboring almost three-quarters of the world's remaining cases in 2009, Sudan has become the last frontier on the difficult path to eradicating this debilitating parasitic disease. However, despite the severe conditions the Sudanese people experienced as a result of the civil war, both the northern and southern regions have made great progress overall in reducing their number of cases. Since 2003, no indigenous cases have been reported in the northern regions of Sudan. The incidence of Guinea worm disease has been reduced in Sudan from 118,578 cases in 1996 to a provisional total of 2,753 cases reported in 2009 - a 98 percent decrease.
Smallpox, the first disease to be eradicated in human history, was eliminated from Sudan during the 10-year cease-fire (1973-1983). Some experts believe that without this window of peace in Sudan, smallpox would not have been eliminated from the country in 1977 or globally in 1980.
Smallpox's eradication led experts to believe other diseases are eradicable, and in 1980, Guinea worm disease became the second disease in history to be targeted for eradication. The Carter Center's leadership of the Guinea worm effort began in 1986, following the inauguration of the International Drinking Water Supply and Sanitation Decade and a commitment by the Centers for Disease Control and Prevention to target Guinea worm disease.
The "Guinea worm cease-fire," brokered by President Carter in 1995, lasted for almost six months, suspending fighting to treat Guinea worm and other diseases, like river blindness, and to immunize children. The cease-fire is one of many examples of how The Carter Center is actively and neutrally involved in the areas of peace and health in Sudan despite many challenges. Read the article: Historic Cease-fire Enables Health Workers To Attack Guinea Worm and Other Diseases in Sudan >The war made the southern areas uninviting, or worse, inaccessible, to foreign aid workers, such as those with the Guinea Worm Eradication Program, who endanger their lives by working in the war zone to initiate treatments. Since the comprehensive peace agreement was signed in 2005, there has been relative stability in the area; however, the possibility of future confict is still very real.
Guinea worm disease, also known as dracunculiasis, is a parasitic disease that has affected people since biblical times. Guinea worm is contracted when humans drink water contaminated with the infected larvae of microscopic water-flea-like organisms called copepods. Once ingested, the larvae mature, during which time patients show no symptoms of infection.
By the time a threadlike, whitish Guinea worm burns a hole from inside, breaks through the skin, and forms a sore on the person carrying it, it has lived in the body for about a year. Traditionally, the infected person wraps the Guinea worm around a small stick and extracts it by rolling the 2- to 3-foot worm on it, a slow and painful process that takes many weeks.
The emerging Guinea worm often causes fever, nausea, secondary infection, and burning pain, earning the parasite one of its nicknames, "the fiery serpent."
The burning pain leads people to cool their wound in water, and when the female worm touches water, she releases hundreds of thousands of larvae, beginning the cycle again. Because Guinea worm is transmitted through contaminated water, it usually affects the poorest of the poor in remote villages, and the economic effects are devastating. The debilitating pain of those months compromises productivity, preventing many from working, attending school, caring for children, and harvesting crops.
No medicine can prevent or kill the adult Guinea worms, although the nontoxic ABATE® larvicide, donated by BASF Corporation, kills the waterborne larvae. Used in many endemic countries, ABATE application has been a crucial element in the fight against the disease. While more endemic villages are benefiting from regular water treatments in Southern Sudan, transportation of ABATE in the area is difficult and expensive, and the four-month rainy season renders makeshift roads impassable, creating such vast swamps that proper application is nearly impossible.
Although the program has been severely handicapped by war and the nature of the terrain, village-based volunteers remain dedicated to preventing their neighbors from suffering. These "Guinea worm warriors" will need the continued support and political will of Sudan's leaders and external partners to fully eradicate Guinea worm from Sudan.
Read about the Carter Center's "Guinea worm warriors."
In 2001, the Center's Guinea Worm Eradication Program and partners such as Health and Development International, the Hydro Polymers of Norsk Hydro, and Norwegian Church Aid spearheaded the Sudan Pipe Filter Project. In only a few months, the project manufactured for distribution more than 9.3 million Guinea worm pipe filters – hard plastic straws equipped with nylon cloth for straining microscopic water fleas out of drinking water – to every man, woman, and child at risk for the disease in Sudan. In conjunction with the pipe filter distribution, a targeted health education campaign was launched, including flip charts, radio public service announcements, and community demonstrations.
Read Pipe Filters Renew Hope (PDF, The Carter Center News, January - July 2001, Page 5).
Even the most basic medical supplies are hard to come by in rural Southern Sudan. In 2003, the Humanitarian Action Campaign, an initiative of the Norwegian Medical Students Association, chose to support the Center's Guinea worm program in Sudan by raising funds to purchase 7,000 much-needed medical bags filled with gauze, antiseptics, scissors, and pain relievers. The students also purchased 3,000 replenishment medical kit supplies.
Each year The Carter Center continues to support more previously inaccessible communities. Improved reporting, surveillance, and Guinea worm filter cloth and pipe filter distribution, in conjunction with many other interventions, have enabled the Sudanese people to reduce incidences of Guinea worm disease. During 2006, the program began surveillance activities in previously inaccessible areas. The data collected from these newly reached areas revealed a clear picture of the prevalence of Guinea worm in Southern Sudan. As predicted, with a gain in access due to the negotiated peace settlement, Guinea worm cases have risen as surveillance and cases searches reveal the extent of this painful disease. Guinea worm eradication must continue to be a priority in postwar Sudan.
Read the article: Sudan's War and Eradication of Dracunculiasis (published in The Lancet, March 2003).
Remarkably, because Guinea worm has no cure, the impending eradication would be achieved largely through health education, which helps curb the disease by preventing its transmission. By providing education on the biological causes of the disease, the Guinea Worm Eradication Program helps people understand how to manage and prevent it, with the extra benefit of reinforcing sound health practices and building a sense of hope that people in endemic communities really are able to improve their own lives. The program has witnessed that when people are given the proper tools and health education, there is a dramatic drop in cases. It remains vital that Sudan continue to expand its social mobilization while aggressively intensifying health education. Effectiveness of case containment must also be improved by making surveillance active and complete, with the goal of case detection and containment within 24 hours of the worm's emergence. This basis of public health education, built by efforts against Guinea worm, has made it possible for the Center's fight against disease in Sudan to extend into other illnesses, such as river blindness and trachoma.
With efforts such as the pipe filter project, increased health education, and the possibility for sustained peace, cases of Guinea worm disease continue to dwindle and indicate that Guinea worm disease eradication is truly on the horizon.
The Carter Center is currently fighting Guinea worm disease in the following Sudanese states: Jonglei, Upper Nile, Central Equatoria, East Equatoria, North Bahr Al Gazal, West Bahr Al Gazal, Lakes, and Warab.
Until Guinea worm disease is eradicated in Sudan, all countries bordering this nation will be at risk, especially Uganda, Kenya, and Ethiopia. Therefore it is imperative to monitor and report the importation/exportation of Guinea worm cases from Sudan to its neighbors. The international Guinea worm coalition believes at least four years after the peace settlement will be required to eradicate the disease. Sudan must continue the momentum.
Globally, the Center has seen the number of cases of the disease drop more than 99 percent, from 3.5 million to 4,619 cases as reported in 2008. 2009 case totals, estimated at 3,000, will be confirmed in 2010. The number of cases of Guinea worm disease continues to dwindle, and, with efforts like these, eradication is truly on the horizon. Yet, without a sustained peace in Sudan, the battle for Guinea worm eradication hangs in the balance.
Read the press release: Carter Center Releases Action Plan for Guinea Worm Eradication, Targets Ghana, Nigeria, and Sudan.
Click here to learn more about the Carter Center's Guinea Worm Eradication Program
Updated February 2010
An estimated 5 million people are at risk of river blindness (onchocerciasis) in the whole of Sudan. The highest incidence of blinding onchocerciasis occurs in Southern Sudan, which includes the area affected by civil war. After the 1995 "Guinea worm cease-fire" paved the way for treatments to reach Sudan's conflict areas, The Carter Center River Blindness Program in partnership with local Lions Clubs started working with afflicted communities to subdue the threat of river blindness in the country by distributing the drug Mectizan®, donated by Merck & Co., Inc.
Mectizan is the only drug that treats river blindness without major side effects. Mectizan kills microfilariae in a single, yearly oral dose, thereby eliminating the risk of blindness in the treated individuals.
The Carter Center's River Blindness Program assists in the delivery of Mectizan to control river blindness in Sudan with support from the Lions Clubs International Foundation. The Center works with the government of Sudan, other nongovernmental organizations, and the African Programme for Onchocerciasis Control. Together, under the umbrella organization of the National Onchocerciasis Task Force, they establish community-based treatment programs, which raise awareness in villages and enable the distribution of Mectizan.
Like each of the Center's other health programs in Sudan, the River Blindness Program is not without obstacles. Transportation of Mectizan is difficult or even impossible to some of the areas made remote by fighting and poor road conditions, and project workers' lives are often in danger.
Since launching the program in 1996, The Carter Center has helped to provide more than 3 million Mectizan treatments in Sudan. The first Sudan River Blindness Program review was held July 2008, through the support of Lions Clubs International/SightFirst. Also in 2008, more than 242,300 treatments were delivered in northern Sudan.
Community involvement and the work of community members have made all the difference; people work as community-directed distributors in their own villages, fighting the disease at home.
The Carter Center has taken the lead in establishing trachoma control and Guinea worm eradication programs throughout South Sudan.
Learn more about the Carter Center's River Blindness Program >
Updated September 2009
The Carter Center has supported the trachoma control program in Sudan in collaboration with the Federal Ministry of Health since 1999. Support from the Conrad N. Hilton Foundation, the Lions Clubs International Foundation and Pfizer Inc., have enabled trachoma prevalence mapping and implementation of SAFE strategy interventions. After the signing of the Comprehensive Peace Agreement in 2005, The Carter Center extended its support to the newly formed Government of Southern Sudan to administer trachoma control in two southern states—Jonglei and Eastern Equatoria—where the trachoma burden is among the worst in the world.
The Carter Center supports trachoma control in six African countries in partnership with trachoma-endemic communities, ministries of health, the Lions Clubs International Foundation, Pfizer Inc., and the Conrad N. Hilton Foundation.
The leading cause of preventable blindness in the world, trachoma is an excruciating bacterial disease endemic to the poorest countries of the world. Over time and through repeated infections, trachoma leads to the permanent scarring of the inner eyelid, deforming the lid and causing the lashes to turn inward and press painfully against the sensitive eye. Although not typically a fatal disease, severe trachoma is disabling, debilitating, and eventually leads to blindness.
The World Health Organizations recommends the implementation of the SAFE strategy for trachoma control: Surgery to correct scarring from advanced trachoma, Antibiotics to treat early trachoma infections, Facial cleanliness to prevent disease transmission, and Environmental changes to improve hygiene and sanitation.
The Center's first efforts in Sudan, supported by the Conrad N. Hilton Foundation, were to conduct baseline surveys of trachoma prevalence. The surveys disproved the commonly held belief that only northern regions of the nation were affected by trachoma. While the Center currently supports the Federal Ministry of Health of Sudan to conduct additional trachoma prevalence mapping throughout the entire northern states, it also has called attention to the devastating impact of this disease in Southern Sudan.
In 2008, a Carter Center-led survey found the trachoma prevalence of Ayod County, Southern Sudan to be one of the most severe ever documented. Many children there are nearly blind due to the advanced form of trachoma—trichiasis—which in other places is seen only in older adults who have had repeated trachoma infections over many years. Fortunately, with help from The Carter Center, the number of children and adults with this debilitating condition are being reduced.
Read the Press Release: Sept. 24, 2008 - A Clearer Picture of Trachoma in Southern Sudan: Bacterial Eye Disease Devastates Ayod County.
The Carter Center supports SAFE strategy interventions in both areas of Sudan. Surgical delivery and surgeon training are facilitated in coordination with the ministries of health. Surgical outreach services and campaigns are organized in both Northern and Southern Sudan.
The Carter Center also facilitates the mass distribution of antibiotics in districts were clinical signs of trachoma exceed 10 percent in children. Zithromax® (azithromycin), donated by Pfizer Inc., and tetracycline eye ointment, purchased by The Carter Center, are provided to adults and children older than six months of age. Infants and self-reporting pregnant women are provided tetracycline eye ointment.
The Carter Center continues to promote ongoing health education through community health worker training, radio programming and school-based health activities. Household latrine construction has begun in the Southern States.
In Sudan, the program has supported a cumulative total of 4,583 trichiasis surgeries, has trained 78 trichiasis surgeons, and distributed 1,412,031 doses of azithromycin and 10,823 doses of tetracycline eye ointment. In addition, almost 2,000 people have been trained in health education and 77 schools participate in ongoing trachoma control activities.
In Government of Southern Sudan areas, the Center has supported a cumulative total of 4,473 surgeries, has trained 76 trichiasis surgeons, and facilitated the distribution of 1,499,302 doses of azithromycin and 217,571 doses of tetracycline eye ointment. A total of 3,441 villages currently benefit from on-going health education and a cumulative total of 20,326 new persons have been trained in health education.
Working with our partners in Sudan, The Carter Center is building hope by helping trachoma-endemic communities access the tools and knowledge they need to fight this debilitating disease.
Read the Article: Effect of Three Years of SAFE (Surgery, Antibiotics, Facial Cleanliness, and Environmental Change) Strategy for Trachoma Control in Southern Sudan.
Read the Article: Risk Factors for Trachomatous Trichiasis in Children: Cross-Sectional Household Surveys in Southern Sudan (PDF).
Read the Article: What Will Happen If We Do Nothing To Control Trachoma: Health Expectancies for Blinding Trachoma in Southern Sudan (PDF).
Learn more about the Carter Center's Trachoma Control Program >
Updated September 2009
The Carter Center's work in Sudan began in 1986 with the Sasakawa-Global 2000 agricultural assistance program, teaching more than 1 million African farming families new farming techniques to double, triple, or quadruple their yields of maize and other grains. Led by Nobel Peace Prize winner Dr. Norman Borlaug, the program is a joint venture between The Carter Center and the Sasakawa Africa Association. The program provides farmers with credit for fertilizers and enhanced seeds to grow test plots. These test plots often yield 200 to 400 percent more crops, and farmers go on to teach other farmers, creating a ripple effect to stimulate self-sufficiency.
Improving crop yields solves only part of the problem: Farmers must store and then sell their crops, and transportation can be costly and inefficient. The program identifies post-harvesting methods and local markets for these surpluses to decrease importing grains. The five-year project in Sudan was completed in 1992.
Learn more about the Carter Center's Agriculture Program >
After more than 20 years of violent civil strife that displaced millions of Sudanese and resulted in the death of nearly 2 million people, Sudan is in need of lasting peace and stability. The Comprehensive Peace Agreement (CPA) signed in Naivasha, Kenya, is the country's best hope for a transition from a state of conflict to development, democracy, and peace. While the CPA holds promise as a potential conduit for peace throughout Sudan, there remain the daunting problems of addressing the crisis in Darfur and marginalization in other areas of the country.
Through its provisions calling for democratic elections throughout Sudan, the CPA holds the key to a more transparent, representative political structure for all Sudanese. During former U.S. President Jimmy Carter's trip to Sudan with the Elders in October 2007, both President Omar al-Bashir and First Vice President Salva Kiir asked The Carter Center to observe the electoral process in Sudan.
Following the commencement of long-term election observation activities in Sudan in February 2008 at the invitation of the Government of Sudan and the Government of Southern Sudan, The Carter Center deployed 12 long-term observers based in five of Sudan's regions to assess the electoral process. The long-term observers come from eight countries: Cameroon, Canada, India, the Netherlands, Norway, the United Kingdom, the United States, and Zimbabwe. For the voter registration period, scheduled to last from Nov. 1- Dec. 7, 2009, the long-term observers are being joined by an additional 20 medium-term observers to assess voter registration throughout Sudan, at both static and mobile registration centres. The Carter Center mission will observe physical registration activities; the initial publication of voter registry lists; the submission of complaints and objections to the lists; and the final publication of the voter registry. Field offices in Khartoum and Juba will continue to support and manage this observation mission.
The Center will continue to build strong relationships in preparation for expanding the international observation mission prior to national elections expected in 2009. The Center is committed to participating in this process as a neutral, nonpartisan actor promoting a transparent, credible, and peaceful electoral process. By supporting the adoption of international standards for democratic elections, The Carter Center hopes to encourage Sudan to hold well-managed, transparent elections throughout the country.
Read election reports >
The Carter Center's Conflict Resolution Program has worked for more than a decade to mediate conflict in Sudan and to improve the climate for a just and lasting peace agreement to end the longest ongoing conflict in Africa.
The reasons for the conflict have been highly complicated, including ethnic and regional power struggles, religious differences, disputes over oil production and revenues, and issues of governance, leaving most Southerners feeling deeply marginalized and many in other regions feeling similarly unrepresented. These problems were compounded by a record of broken agreements and military government, leaving Sudan deeply divided and the Sudanese people mistrustful and profoundly scarred by the trauma of war.
For many years, the most visible conflict was between the Sudan People's Liberation Movement/Army, the major Southern rebel faction, and the National Islamic Front government of President Omar al Bashir. While power and wealth-sharing were at the core of the conflict, seemingly intractable disagreements over the proper role of religion in Sudan and the right to self-determination for the South often defined the war.
President Carter's first direct mediation effort in Sudan was between the government and the SPLM/A in Nairobi in 1989. He has remained in close personal contact with the leadership of the parties and other key players and has sought to narrow differences and promote peace at various times. In 1995, he was able to secure a cease-fire from Sudan President Bashir and then SPLM/A leader Dr. John Garang to allow for the treatment of Guinea worm and other diseases, to pilot the effort against river blindness, and to provide an opportunity for children to be immunized against polio and other illnesses. This cease-fire lasted almost six months, the longest such humanitarian cease-fire ever achieved.
Read the article: Historic Cease-fire Enables Health Workers To Attack Guinea Worm and Other Diseases in Sudan.
In 2002, however, regional and international parties - including the United States - made a significant effort to assist the parties toward developing a peace agreement. In March of that year, President Carter visited Khartoum in the North and Rumbek in southern Sudan, meeting with President Bashir and SPLM/A leaders. Later that month, President Carter hosted Dr. Garang at the Center in Atlanta for further talks.
These regional and international efforts made significant progress, including agreement for a nationwide cessation of hostilities and apparent breakthrough agreements on religion and self-determination. This progress then led to a Comprehensive Peace Agreement signed January 2005 by the government of Sudan and the SPLM/A in Naivasha, Kenya. CRP supported the Naivasha negotiation process by providing prenegotiation training to both the government of Sudan and the SPLM/A and intervening in other ways to support the Intergovernmental Authority on Development-led mediation effort.
Even as peace was being achieved between the government of Sudan and the SPLM/A, conflict in the western region of Darfur escalated, attracting international attention. The Carter Center continues its engagement on this situation and the implementation of the Comprehensive Peace Agreement as the African Union moves forward in their efforts to facilitate a peace process.
The internal conflict between the government of Sudan and the SPLM/A was complicated by hostilities between the Sudanese government and the Ugandan government, including the role of the Lord's Resistance Army. The Lord's Resistance Army is a quasi-spiritual Ugandan rebel group that has had bases in Southern Sudan and has been fighting the government of Uganda for almost 20 years. The LRA has kept northern Uganda in a state of almost continuous insecurity and has attracted particular attention due to its use of child soldiers, kidnapped from their homes in northern Uganda and forced to fight, often against their relatives and neighbors.
In 1999, President Carter and the Conflict Resolution Program negotiated the Nairobi Agreement between Sudan and Uganda, in which both sides committed to stop supporting forces against each other's government and agreed to eventually re-establish full diplomatic relations between them, opening the door for improved regional peacemaking. Following the signing of the Nairobi Agreement, the Conflict Resolution Program engaged intensively to ensure its implementation, convening a multitude of ministerial and security meetings between the two governments and other interested parties and making strenuous efforts to initiate dialogue between the LRA and the government of Uganda. Full diplomatic relations have since been restored between the two countries, and Uganda became a key regional partner in pushing for a peaceful resolution to Sudan's civil war, but efforts to end the civil war in northern Uganda through dialogue have yet to succeed.
Read the Nairobi Agreement, Dec. 8, 1999.
Learn more about the Carter Center's Conflict Resolution Program >
Election Reports
March 18, 2010: Carter Center Welcomes Sudan's Elections Campaign, Urges Steps to Ensure Open and Inclusive Process
Dec. 17, 2009: Carter Center Commends Broad Participation in Sudan's Registration, Urges Additional Steps to Ensure Genuine Elections
Nov. 30, 2009: Carter Center Welcomes Peaceful Voter Registration in Sudan; Urges Further Steps to Improve Registration Process
Nov. 2, 2009: Carter Center Concerned About Sudan's Voter Registration Process and Obstacles to Observer Accreditation
Aug. 20, 2009: Carter Center Announces Agreement With the Government of Sudan, the National Elections Commission and the Government of Southern Sudan on Election Observation
Aug. 19, 2009: Status of the Electoral Process in Sudan – Concerns Remain Over Electoral Delays and Peace Agreement Implementation (PDF)
May 7, 2009: Carter Center Welcomes Sudan's Electoral Calendar but Urges Additional Steps to Ensure Genuine and Viable Elections
Updated March 2010
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