Former U.S. President Jimmy Carter and his wife, Rosalynn, are traveling in West Africa Feb. 2-7, 2004, on behalf of The Carter Center. The purpose of their trip is two-fold: to call international attention to the need to eliminate the last 1 percent of Guinea worm disease remaining in the world and to launch the Development and Cooperation Initiative, a multiyear effort to help reduce poverty in Mali.
Members of the general public can accompany President Carter virtually as President Carter "blogs," or publishes regular journal entries from the field. Reports will be posted as they are received from President Carter, who will share his thoughts and feelings during his journey in West Africa.
Final Thoughts About Africa
In many ways, this fairly rapid visit to Togo, Ghana, and Mali has been typical of our excursions to Africa during the past two decades. We almost always make brief visits to a number of countries, have access to the highest officials, and have either problems to resolve, a new project to undertake, or an election to monitor. We also attempt to include some recreational activities that let us learn more about how the people live. It is especially enjoyable for me to ride through some remote areas and spend time with farmers or herdsmen.
All of us consider this trip to have been quite successful, although we realize that it will require another Guinea worm season to assess the apparently firm commitments made by the leaders in Ghana and Mali. One somewhat surprising lesson was that in the most persistent Guinea worm areas there has been an excessive dependence on some day acquiring a deep well. The simple and proven practice of filtering every drink was being ignored. Also, there has been some discontinuity in Mali and Ghana as the presidential administrations changed. It was very helpful on this trip to have the top officials of UNICEF and the World Health Organization join us.
It is disturbing to observe the adverse effect of some U.S. policies on the less-developed nations. Despite helpful contributions of USAID and military assistance in Mali, for instance, the grossly exorbitant cotton subsidies for mega-farms in America cost the country far more than all the combined assistance from rich nations. Malians produced more cotton last year than any other African country and it is their number one export, but they had to sell it with no profit in order to compete with the heavily subsidized U.S. crop. Also, there is a heavy-handed effort by Washington to force other countries to violate the basic premises of the newly established International Criminal Court. Our government threatens to withhold military assistance unless they will guarantee that U.S. citizens be immune to possible punishment for war crimes or other atrocities. Another interesting development has been the efforts from Washington to elevate the issue of terrorism, and American diplomatic officials are forced to participate in this over-emphasis. We were warned strenuously about the new terrorist dangers that had arisen when we planned our visit to Timbuktu and Mopti. I decided that we would take a chance, and when we met with representatives of a dozen donor agencies in Bamako, I asked if any of them had any evidence of increased violence in the area or terrorist threats. The unanimous response was laughter.
There are also problems with special targeting definitions that have unintended consequences. Despite an 8.5 percent HIV/AIDS rate and exciting promises from Washington, U.S. embassy personnel in Togo informed us that HIV/AIDS funds would be slashed this year from $1.5 million to $250,000. Paperwork requirements also plague the relationship between almost all donors and recipient countries. In our conversations with them, administrators of humanitarian assistance acknowledge that their requirements for the granting of aid are extremely complex and often contradictory, and the forms for requesting funds and subsequent reporting are daunting even for a highly advanced bureaucracy.
This presents a serious impediment to better education, health, or economic development. An apparently innocent restriction in the U.S. congress or a European parliament can block all expenditures for a well-meaning program. Throughout Africa, World Bank data indicate that needy countries are able to utilize only about 20 percent of funds that have been pledged or offered to them. Dedicated workers in the field are acutely aware of these restraints and deplore them.
Almost unknown tourist opportunities are often spectacular in their cultural or historical interests or in recreational enjoyment, but the poorest of countries have few resources or capabilities to advertise their sites or to organize efficient and understandable tours. Also, there is an intelligent and dedicated labor force available at relatively low cost for other business ventures - often where unprocessed raw materials are plentiful. There is no textile industry in Mali, Africa's major producer of cotton. As increasing wages have forced many manufacturing operations from New England to the South, then to Japan, Thailand, and now China, the next step may well be into Africa.
International election monitoring, such as we have done 47 times, is resulting in an increasing number of stable democratic governments. Africa is an exciting place, with highly diverse cultures, systems of government, and economic achievement. Dominated and exploited for centuries by colonial powers, the people now enjoy a degree of freedom, but often face extreme handicaps in attempting to compete in a global society where military, economic, and social power are held by rich nations where there is little concern or even awareness of their opportunities or their plight. This is the preeminent concern of The Carter Center. All of these factors exist in many African countries, and will be assessed and used in our new economic development project in Mali.
POSTED FEB. 9, 2004, 12 P.M., EST
February 5-8: Mali
Mali is one of the ten poorest nations in the world, with 91 percent of its citizens living on less than $2 per day. The illiteracy rate is 59 percent, and the infant mortality rate is 126 per thousand. The country is heavily indebted, and the government has been able to accept and utilize only 15 percent of available foreign aid.
The percent of HIV/AIDS infection is only 1.7 percent, second only to Senegal in Africa. These very low rates are primarily due to the severe condemnation of promiscuous husbands, who are often ostracized in strict Islamic communities if they are found to be infected.
The Carter Center began working in Mali many years ago with its agriculture and Guinea worm eradication programs; we launched our trachoma control effort here; we've monitored the last two presidential elections; and we have recently undertaken a Development and Cooperation Initiative (DACI), which will assist the government in long-range planning, improved bureaucratic efficiency, utilization of foreign economic assistance, and better overall cooperation among the government, donors, civil society, and the private sector.
The government has been overwhelmed trying to coordinate its assistance from wealthy countries. It has at least four ministries that deal with foreign assistance, further straining its already weak internal management capacity. Part of what the Center will do in Mali is to help organize the management of development assistance, working between the ministries and the donor community. One great advantage that we enjoy is based on the close personal friendship that I have formed in recent years with Mali's new president, Amadou Toumani Touré, commonly known as ATT. Prior to his election, he assisted us for seven years in promoting Guinea worm eradication in all the francophone countries.
Having become the leader of Mali following a military coup in 1991, Touré quickly organized democratic elections and turned power over to his elected successor, Alpha Oumar Konaré, in June 1992. ATT ran for president himself 10 years later and was overwhelmingly elected, being inaugurated in June 2002. This would be our third visit to the country.
We flew into the Malian capital of Bamako Thursday morning and were met by the foreign minister and prime minister, who is an independent economist appointed by the president. The Niger River runs through Bamako, located in the southwestern part of the country. The city is sprawled over a wide area and is obviously poverty stricken. There are few paved roads, one of which took us from the airport into town. Among the most interesting sights in Bamako are the enormous fruit bats that hang from the trees. They usually sleep during the day, and on previous visits we could see them swooping around at night and hear their sharp squeals.
After a review of DACI from Ed Cain, director of the Carter Center's Global Development Initiative, we had a political briefing at lunch with U.S. embassy personnel. We then drove to the president's palace, which is located on a hill overlooking the city. The building was constructed by the French during the days of colonialism and has beautiful gardens. We received a warm greeting from President Touré, who recalled several trips to The Carter Center in Atlanta for Guinea worm instruction and a personal visit with us in Plains, and then reviewed the optimum role we might play in the economic development of Mali.
He and I have exchanged a signed Memorandum of Understanding, which places our people within the president's own office to work as intimately as possible in carrying out the duties outlined above. He made no effort to minimize the lack of economic and social progress in the past and assured us that Mali's failures in utilizing foreign aid would be corrected as rapidly as possible. He will concentrate responsibilities in a single ministry, help to develop a comprehensive assessment of accomplishments and remaining needs, and implement an effective "freedom of information" law to ensure adequate transparency in expenditure of funds and to reduce corruption throughout the government.
He was distressed that Togo and most other countries have moved ahead of Mali in Guinea worm eradication, and pointed out accurately that he had worked much harder in this effort in some of them and perhaps had neglected his own nation. He is actually one of our best-trained experts and understands how to re-invigorate Mali's program in the few remaining northeastern communities.
After our meetings with the president and then the prime minister, we met with the array of donor organizations represented in Mali. I explained the role of The Carter Center, and they gave us a report on their assistance programs, along with a number of suggestions for improvement.
We attended a formal dinner with President Touré and a large assembly of other officials. Almost all such affairs are tiresome and boring, but this one was delightful. The orchestra, consisting of some ancient Malian instruments, played an impressive array of different music, the most popular being American jazz and blues. We had a good time interpreting the lyrics for President Touré and his wife. Some of the native singers presented long accolades about our accomplishments, our personal friendship, and extended welcome to us visitors. These were professionals who devote their lives to repeating the detailed history of Mali's mighty ancient kingdom and reciting many generations of genealogy, whose memory is passed down from father to son.
Touré said that one of his most valuable foreign aid contributions was from Fidel Castro, with 120 Cuban doctors spread throughout the poorest communities where most other medical doctors refrain from serving. In addition, dozens of Malian students go to Havana to receive a six-year course of study. All of them, he said, return to Mali to practice medicine and must pledge to serve for five years among the poor.
All our official duties having been completed, we departed Friday morning for Timbuktu and then Mopti and were met at each stop by dozens of government and military officials, a wide range of musicians and dancers, and hundreds of children holding up signs of welcome and thanks for our having ended the terrible scourge of Guinea worm in these areas. Both cities were located on the Niger River when founded in the 12th century, but the stream is now about 10 miles from Timbuktu as the Sahara desert has moved southward, and the sand has slowly taken over. When we visited the ancient mosque, consisting of nine concentric half-circles, we could see the top of the original entranceway now about a foot above floor level.
There is a dramatic change in architecture and foliage as one moves from one side of the town to the other. Most buildings in the town were made of mud and straw bricks with flat roofs; then from the Peace Monument, dedicated to tranquility with neighboring nations and a global effort to control trade in small arms, we looked northward to a scene of camels and domed desert huts, with woven fiber mats covering frameworks of limber limbs and tree branches. This, they said, is where the Sahara begins, though it all looked like desert to us. The difference is that they can grow a little millet and livestock in the area. Beyond this there were only sand dunes extending 500 miles to Algeria. One of the most interesting visits was to a working museum, where ancient manuscripts are being catalogued, scanned into digital images, and preserved in special preservative boxes. Most of the 20,000 inhabitants live in adobe houses, and there is a dormant atmosphere that emphasizes Timbuktu's ancient heritage.
Mopti is a vibrant and thriving community, about four times as large as Timbuktu and located at the junction of the Bonne and Niger rivers, mostly on three adjacent islands. The tourist guides say "don't look for special market areas; Mopti is a market." The entire area around the islands floods during the rainy season, so the approaching highways are elevated several meters above the rice fields that are exposed and used for grazing during the winter months. The rivers are filled with long slender boats that carry goods up and down the streams and accommodate fully employed fishermen and their nets.
We were honored and entertained by national and local political leaders, with surprisingly delicious meals of local fish, chicken, whole roasted lambs, and local fruits. There were also interminable dances, with drums and flutes.
Our last day was spent in a long trip eastward to the country of the Dogon people, who settled along a massive escarpment and have successfully resisted all efforts to change their culture or animist religion. We saw fields of onions and lettuce planted around remaining small ponds, with both men and women each carrying two calabash gourd containers of water out into the field and sprinkling water on the crops. Large fields of millet are grown during the rainy season, and the ubiquitous baobab trees have dry millet stalks and other provender arranged neatly in the branches about 20 feet off the ground, to be used for feeding livestock and thatching roofs. The high vertical face of the adjacent cliff is lined with ancient caves from previous tribal inhabitants, and stone and adobe granaries are lined up under the overhanging stone, far above the cultivated valley plain.
The village was small, protected by an adobe wall. We walked in narrow corridors between walls because the families each enclose their own area with an open space in the center for cooking, for their goats and sheep (and sometimes donkeys)...and where the many children play.
Their worshiped leader, called "the Ogon," lives in one of the cliff dwellings, but condescended to come down to greet us. He is not to be touched by another human, which may tend to dissipate some of his supernatural powers. Once again, we listened to drums and watched an array of brightly costumed dancers, some with hideous or comical masks, some on stilts, each group trying to outdo the others as they entertained and honored us. The people are desperately poor, but proud, hard working, intelligent, and have a great sense of humor. All their Guinea worm is gone forever, and they are eager for future development opportunities. A new highway has begun to increase tourism by reducing travel time from Mopti to just two hours.
Final stop: Home
POSTED FEB. 8, 2004, 1 P.M. EST
February 3-5 : Ghana
Greetings from Ghana. We departed en route to Accra Tuesday afternoon with a mixture of anticipation and trepidation. Ghana was the first country in which Rosalynn and I ever visited endemic villages, and we'll never forget seeing two-thirds of the total population incapacitated with the disease, many of them lying around under shade trees unable to walk. I described the scenes in my first message in this series. With our personal involvement and strong support from the national government, there were only 8,432 cases six years later, in 1994. There has been stagnation in Ghana's efforts since then, and in the last three years the number of cases reported has risen from 4,739 to 8,283.
All nations except Ghana have made significant and steady progress in recent years, resulting in a total reduction from 3.5 million to less than 35,000 (2003 provisional figures)-more than 99 percent. There are several excuses put forward for Ghana's poor performance: some ethnic conflict in the northeast, migrant farm workers that transmit the disease, and a lack of central control from the national government. The most disturbing event occurred last year when a serious outbreak of Guinea worm in the central section, around Lake Volta, was deliberately concealed. Solemn promises by the government to dig wells have not been honored. The Carter Center has marshaled a series of exceptional efforts to overcome these problems, but all have been fruitless. There is no doubt that our visit is timely, but we have received word that top officials are very concerned about our potential criticisms. Some intense observation, incisive analysis, and political diplomacy will be necessary.
After arriving in Accra, we received detailed briefings from our Carter Center staff and a political briefing and reception at the residence of U.S. Ambassador Mary Yates. On Wednesday morning, we flew to Tamale in the northern region. The director-general of the World Health Organization, Dr. LEE Jong-wook, and deputy executive director of UNICEF, Kul Gautam, came to Ghana and joined us and the Ghanaian minister of health for the trip.
Concerned because President John Agyekum Kufuor had not answered my letters about the Guinea worm problem or about plans for our trip, Ambassador Mary Yates arranged for me to communicate with the president through a distinguished mediary, Professor Yai. This friendly exchange helped to allay my concerns about the meeting scheduled for late afternoon.
At the endemic village, Dashei, we first visited the local water hole, which fills during the rainy season and serves as a source of all drinking water and, unfortunately, a breeding place for water fleas, which carry Guinea worm eggs. After a few more weeks, in March, this pond will dry up completely, and the people will have to travel 23 kilometers (about 14 miles) for water. We estimated that 3,000 people live in the community. After watching a demonstration of filtering water and the application of Abate (a larvicide that kills the intermediate host, a water flea, that carries eggs), we went into the village to meet with a large assembly of tribal chiefs, "Red Cross" women who work in our program, school children being taught about the disease, local and national government officials, and hundreds of other citizens.
Rows of small children and adults were lined up so that we could talk to them and examine their emerging Guinea worms. When questioned, even the youngest ones would show us scars on their arms and legs from infections during previous years. Forty percent of all cases are in children. In these "containment centers," those infected are given antibiotics, instructed on how to avoid worms in the future by filtering every drink of water, counted in our ongoing tabulation of cases, and permitted to return home.
We interrupted a class of children, six to eight years old, to ask them a few questions. All of them raised their hands eagerly when asked how many had had Guinea worms and indicated the scars on their little bodies. The smallest child, named Shadrach, reminded me of our grandson Hugo, who always has clean water to drink and will never be afflicted with three-foot-long worms developing in his body and then penetrating his skin to emerge over a period of several weeks through a painful sore that may cripple him for life. At least Shadrach and his friends now know that the use of a filter cloth can protect them completely, and we're determined to eliminate the worms permanently.
There was considerable consternation among all of us about the basic cause of their failure and a lot of embarrassment among officials when confronted with Ghana's poor performance, but obvious dedication to their duties. After a long series of speeches, I was anointed as an honorary king, clothed in a robe and hat, given a long hair whisk as a symbol of authority, and urged to dance around the arena accompanied by a chorus of drums. After this performance we went to a nearby club for a brief lunch, detailed visual assessments of Ghana's lack of progress, and another series of speeches.
It became increasingly obvious to me that a basic problem was that Ghana's officials, from field workers to the president, considered the drilling of deep borehole wells as the primary solution to the Guinea worm problem. The common theme was "a deep well will eradicate our Guinea worms." Although highly desirable and much needed in every village, this is not the way to eradicate the disease. Extremely expensive and time-consuming, with no assurance of finding potable water in many areas, the borehole dream had become a substitute for simple filtering of each drink and keeping people with emerging worms out of the ponds.
Most communities throughout the world have eradicated Guinea worm without drilling a well, and many people are still infected even when blessed with a good underground source of water. Just stopping by the local pond for one drink is all it takes. I explained this to them in very strong terms, had the ministers adopt the same sermon for our joint press conference, and we continued this explanation during our very pleasant visit with President Kufuor when we returned to Accra.
When all our meetings had been completed, we felt that a new day may have come to Ghana in its eradication effort. The president pledged full personal support to us and to the assembled news media, and there is little doubt that his ministers and key health workers will now join in a proper effort with a renewed sense of dedication.
After leaving the palace, we visited one of our favorite spots in Ghana: a shop where a skilled artist and wood carver makes full-sized caskets to match the primary life interest of the deceased. They are shaped and brilliantly painted like chickens, different vegetables, fish, airplanes, automobiles, carpenters' tools, serpents, Bibles, and sporting equipment. One of his newest was a jogging shoe, whose laced top opens to reveal the lined container to hold the cadaver. They require three weeks to build and are sold either just for burial, for about $500, or more permanent ones for display as art pieces, for about $2000. Maybe we'll buy one in the near future in which to bury the last Ghanaian Guinea worm.
Our next stop: Mali.
POSTED FEB. 5, 2004, 5 P.M. EST
Monday, Feb. 2, 2004: Togo
This marked the first full day of our West African journey, made possible by traveling in the "magic carpet" Gulfstream owned by our Trustee Dick Blum. In addition to him, Dr. John Hardman, our son Jeffrey, and Kathy Cade were on the plane. After a midnight refueling stop in Cape Verde, where we were met and briefed by the U.S. Ambassador, we arrived early this morning in Lome, Togo's capital city. We received a warm greeting from the Prime Minister, U.S. Ambassador Gregory Engle, our Carter Center colleagues, and school children bearing flowers. On our drive from the airport to the hotel, we noticed signs that the economy has deteriorated since our last visit ten years ago. In fact, annual per capita income has dropped from $600 to $293.
Having come here earlier to begin our Global 2000 agriculture and Guinea worm eradication programs, Rosalynn and I had returned four years later to monitor the 1993 presidential election, working side-by-side with NDI. Preparations were so obviously fraudulent that we were forced to condemn the process and, after hearing of threats against our safety, we had escaped hurriedly into nearby Benin. This current visit would be devoted almost exclusively to our Guinea worm program.
After a nap, we received a good briefing from Ernesto Ruiz-Tiben and Jim Ting, and were pleased at the good progress being made in Guinea worm eradication. There was a 58 percent reduction during the past year, down to 625 indigenous cases and 30 more that came in from Ghana. Most infection is concentrated in four states: Haho, Ogou, Keran, and Sotouboua. Over the last 12 months, Togo has established 15 new Guinea worm "care centers" and has conducted multiple, successful "Worm Weeks" - weeklong health care demonstrations - with about 40 U.S. Peace Corps volunteers participating.
Togo, which lies between Benin and Ghana and is slightly smaller than West Virginia, is the fifth most endemic country in the world, following Sudan, Ghana, Nigeria, and Mali. Although an encouraging decrease is being achieved, the challenge lies in continued diligence in surveillance, since some outbreaks are occurring in areas that were previously Guinea worm disease-free.
At lunch with the ambassador and his key staff, we learned that there are three priorities for U. S. policy in Togo: political democracy, economic development, and the control of HIV/AIDS. In all three cases, there is either no progress or retrogression. President Gnassingbe Eyadema has now been in office since 1967, and has been successful in modifying the laws to permit his unlimited reelection in the future. The AIDS/HIV program is also faltering, with about 8.5 percent of the population now infected. Embassy personnel reported that their AIDS funds have been slashed from $1.5 million in 2003 to $250,000 in 2004. So much for the grand promises in the State of the Union speech of a year ago!
In our meeting with President Eyadema, he and I did not resurrect the unpleasantness of our previous electoral visit, but concentrated on health issues. I congratulated him on the fine progress being made with Guinea worm, asked him to record a public service announcement about the disease, to expedite the drilling of wells in endemic villages with already available funds, and to extend the service of our national coordinator, Ignace Amegbo, for two years past his retirement eligibility. The president agreed with all these requests. He then asked me about AIDS/HIV, and I congratulated him on having mentioned the subject last month in his inaugural speech, and I outlined what has been done in some African countries that brought success.
A Togolese woman in a village strains her family's drinking water through a nylon filter to prevent them from contracting Guinea worm disease. In endemic countries like Togo, filtering all drinking water is a key element in eradicating Guinea worm disease.
In the evening, we had supper at the embassy residence with the key workers in our Togo health efforts, including Togo's ministers of health and water resources, and also the heads of of WHO (from Burundi), UNICEF (from Timbuktu, Mali), and the Peace Corps. With these good partners, we will intensify our common efforts to eradicate Guinea worm disease in this country.
We met Tuesday morning with Togo's Minister of Health Suzanne Aho, a small and quiet lady who was born in Saigon, lived a few years in Vietnam, was adopted by a soldier, moved to Madagascar and then to Benin. She married a Togolese and has three sons, who live in America, Britain, and France. She promised that she would visit a number of endemic villages later this month and expedite eradication of the disease. After meeting with her, the coordinator, and directors of WHO and UNICEF, we feel that bureaucratic differences have been resolved. We'll have to wait and see.
Our next stop will be Ghana, where we face by far our most serious challenge in West Africa. POSTED FEB. 3, 2004, 12:15 P.M. EST
Monday, Feb. 2, 2004: Pre-trip reflections
I remember the first time I saw Guinea worm disease. Rosalynn and I were shocked. We were in Denchira, a small rural village in Ghana. More than 200 Guinea worm victims had gathered to greet us. Almost everyone had Guinea worm, many lying on the ground unable to walk. Children couldn't go to school, and farmers couldn't harvest their crops. The entire community was crippled with this disease.
Most distressing was the sight of a Guinea worm emerging from a grapefruit-size abscess on the breast of a pregnant 15-year-old girl. She had been treated by a local custom of inserting a hot iron into the lesion caused by the emerging worm. (Later, she was found to have 11 other worms in her body!) It is shameful that this suffering is totally unnecessary.
Today, my wife, Rosalynn, and I begin our tour through West Africa on behalf of The Carter Center. Over the next five days, we will visit Togo, Ghana, and Mali to call international attention to the need to eliminate the last 1 percent of Guinea worm disease remaining in the world. In Mali, we also will talk with leaders about the Center's work there to assist with long-term development planning.
Joining us in Ghana will be the secretary-general of the World Health Organization, Director-General Dr. LEE Jong-wook, and UNICEF Deputy Executive Director Kul Gautam, our lead partners in the effort to eradicate Guinea worm. We will travel together to the town of Tamale, in northern Ghana, one of the most endemic regions remaining in the world.
The international coalition, which also includes the U.S. Peace Corps, has worked with 20 countries in Africa to reduce cases of the disease from 3.5 million in 1986 to fewer than 35,000 today. This is a remarkable success story that is on the verge of making history. Guinea worm can become the first parasitic disease ever to be eradicated, and the first disease to be eradicated without a vaccine.
We will meet with government leaders in each country to learn more about their challenges in combating the last remaining cases of the disease. Carter Center experts and other Guinea worm specialists have advised us for many years that the last few cases will be the hardest, requiring extra human and financial resources to overcome.
But it is essential that we escalate our efforts now, when we are so close to making this horrible and ancient disease - 2,000 to 3,000 years old - an affliction of the past and ending the needless suffering that weighs down Africa. We have the chance to stop Guinea worm now, and we must!
Guinea worm disease is contracted when people consume stagnant water, contaminated with microscopic water fleas carrying infective larvae. Inside a human's abdomen, the larvae mature and grow, some as long as three feet. After a year, the worm slowly emerges through a painful blister in the skin, usually on the lower limbs.
Relieving the suffering caused by Guinea worm is as easy as educating people about the disease and providing them with simple solutions to make their drinking water safe. Health is a human right and can be a foundation for peace. The end is in sight. Working together, we can stop Guinea worm now.
As I reflect on this return pilgrimage to Africa, I feel a sense of hope for the children, women, and men I will meet along the way and look forward to the experiences that await Rosalynn and me.
I will send my "blogs" (Web logs) from Africa, sharing with you my experiences from Togo, Ghana, and Mali via the Carter Center Web site during the coming days.
First stop: Togo