A historic cease-fire negotiated by former President Jimmy Carter has enabled health workers to reach remote regions of Sudan to treat Guinea worm and other diseases. The agreement marks the longest cease-fire ever negotiated to fight disease and implement preventive health programs.

The disputing parties in Sudan's 12-year-old civil war took a bold step this spring by agreeing to a two-month cease-fire. President Carter and Sudan's military leader, Lt. Gen. Omar Hassan al-Bashir, announced the cease-fire in late March, with the Sudanese People's Liberation Movement/Army (SPLM/A) and the South Sudan Independence Movement/Army (SSIM/A) signing on a few days later. The announcement came during a trip to Africa by President Carter and former First Lady Rosalynn Carter to assess progress toward Guinea worm eradication. In late May, the government, the SPLM/A, and the SSIM/A extended the cease-fire for another two months.

"The primary purpose of the cease-fire is to permit the leaders and citizens of Sudan, working with others, to carry out a major effort to eradicate Guinea worm disease, prevent river blindness, and immunize children against polio and other diseases," President Carter said.

More than 1 million people, mostly civilians, have died as a result of fighting or famine and disease caused by the war, which has pitted the northern-based Islamic government against southern Sudanese rebels. Because of the cease-fire, health workers are able to distribute cloth filters used to prevent Guinea worm disease; deliver the drug Mecti-zanr to treat river blindness; vaccinate children against polio, measles, and other diseases; and distribute Vitamin A, an essential nutrient for children.

The Center's Global 2000 program is leading the effort to eradicate Guinea worm disease by the December 1995 target date. Guinea worm affects people in India, Pakistan, Yemen, and 16 African nations. The total number of cases worldwide has dropped almost 95 percent since 1986.

The Center has many partners in this effort: the Centers for Disease Control and Prevention; the U.S. Agency for International Development; UNICEF; the U.N. Development Program (UNDP); the World Health Organization; the Japan International Cooperation Agency; and the governments of the United Arab Emirates, Saudi Arabia, Norway, and the Netherlands, among others. In addition, DuPont Co., Precision Fabrics Group, and American Home Products have donated cloth filters, larvicide, and educational materials.

Of all endemic countries, Sudan has the highest number of Guinea worm cases remaining. In 1994, Sudan had more than 53,000 cases out of 163,000 reported in the world. Ninety percent of Sudan's cases were in the south.

The same region has some of the most severe cases of river blindness in Africa. Spread through the bites of black flies, river blindness causes persistent itching, rashes, and depigmentation of the skin. Ultimately, it can cause blindness. Eighteen million people in Africa, Latin America, and the Middle East are infected. Of those, 400,000 are permanently blind.

Guinea worm disease is also devastating. People become infected by drinking water con-taminated with microscopic larvae. A year later, mature, thread-like worms up to a yard long work their way out through painful blisters on the skin. Emergence of the worm and resulting infections can cause permanent scarring and crippling similar to polio.

More than half of a village population may be unable to farm or attend school for weeks or months. No cure exists. But Guinea worm is preventable by:

• straining drinking water through a cloth;
• treating drinking water with the nontoxic chemical Abate; or
• finding other ways to provide safe drinking water sources, such as drilling borehole wells. These techniques are now being used in Sudan.

"The southern warring parties have both said they can get rid of Guinea worm if the logistics and supply lines are provided," said Donald Hopkins, M.D., senior health consultant for Global 2000. "The cease-fire has clearly provided these requirements."

After the cease-fire began, the Sudanese government, UNICEF, and UNDP provided planes and trucks to deliver health supplies and educational materials. (Photo: Frank Richards)

After the cease-fire began, the Sudanese government, UNICEF, and UNDP provided planes and trucks to deliver health supplies and educational materials. Health teams have made substantial progress. By mid-July, they already had:

• visited 2,253 Guinea worm villages;
• distributed 115,425 cloth filters to households;
• vaccinated 34,481 children for polio and 40,000 children for measles;
• given Vitamin A supplements to 35,000 children;
• treated 9,031 children with oral rehydration therapy for diarrhea; and
• delivered 200,000 Mectizanr tablets, donated by the American pharmaceutical firm Merck & Co. Inc., for distribution in the field to treat river blindness.

Merck and The Carter Center have worked together since 1988 to facilitate drug distribution through the Mectizan Donation Program. The program is administered by The Task Force for Child Survival and Development, an independent partner of the Center. A committee of experts oversees distribution of the drug, which, when given once a year, prevents river blindness.

"Since the beginning of the cease-fire, the government of Sudan, U.N. agencies, and the NGO communities in Khartoum and Nairobi have made significant progress in public health promotion," said Health Policy Fellow William Foege, M.D., chair of the Mectizan Expert Committee. "This is proving to be a circular process. The success of the public health initiatives has strengthened the cease-fire."

The Carters will return to Sudan in July to assess progress on the health initiatives and explore the possibility of advancing the peace process.

The Carter Center's Role in Sudan

It was no accident hat President Carter was able to broker a cease-fire in Sudan. The Carter Center has a long history of involvement with the Sudanese people, including helping them to increase wheat production 500 percent in five years.

"Since 1989, when the Center convened peace negotiations between the government of Sudan and SPLM/A leaders, we have continued to work in agriculture and disease prevention and to explore avenues for peace," said John Hardman, M.D., executive director of the Center. "After the cease-fire was negotiated in March, the Center established offices in Khartoum and Nairobi to facilitate new health initiatives."

The mission in Sudan exemplifies how people and resources can come together to resolve conflict, promote human rights, and fight disease, poverty, and hunger worldwide.

"The Carter Center has been successful when other efforts have failed largely because we recognize that many problems are interrelated," said Marion Creekmore, director of programs. "In addition to trying to stop fighting where it occurs, we believe that helping people attain adequate shelter, medicine, food, basic human rights, and representative government must all be part of the package to ensure long-term, sustainable peace."

President Carter negotiated the cease-fire during a trip to Africa to assess progress on Guinea worm eradication in Sudan, Nigeria, Ghana, and Kenya. As part of the agreement, the Carters' son, Chip, spent two weeks in Sudan with a Center team to help coordinate health initiatives.

"War is the main impediment to making Guinea worm the second major disease after smallpox to be globally eradicated," President Carter said. "With a continued cease-fire, I believe that health goals can be met, and progress can be made in bringing a resolution to this devastating conflict."