Africa Trip Report: March 2002

By Jimmy Carter

Rosalynn and I and Carter Center staff flew from Atlanta via Frankfurt and Cairo, and at the latter stop received a briefing on Egypt's perspective of the Sudan situation. Egypt has been working in concert with Libya, and their primary goal has been a united Sudan. This pleases Khartoum and contradicts the Sudan People's Liberation Movement's (SPLM) position of retaining the right to independence for the south if their other primary goals are not realized. President Mubarak is now in Washington to discuss this issue and the Middle East.

Dr. Ghaza Salahuddin Atabani (Ghazi) met me at the Khartoum airport. He is special advisor to the president, in charge of the peace effort, and possibly the most influential person in the government on this issue. He has a reputation as a hard-liner and a tough negotiator, and I know him well. In March 1995 it was Ghazi with whom I negotiated and finally concluded a ceasefire agreement that lasted six months and permitted us to launch our Guinea worm and river blindness projects throughout Sudan. He is now designated to work with U.S. special envoy Jack Danforth in the American peace effort.

The next morning I met briefly with President Al-Bashir, and we were joined by former Sudanese president Nimeiri, one of the very few Arab leaders who endorsed the Camp David Accords and the Israel-Egypt peace treaty. He has returned to Khartoum after more than 10 years as an exile in Egypt.

We then convened the 7th annual Guinea worm eradication meeting to a full house of representatives from endemic countries. A highlight of the conference was President Al Bashir's unveiling of three postage stamps, all commemorating the eradication of Guinea worm. There were reports from Don Hopkins of The Carter Center and representatives of WHO, Sudan, and UNICEF. I was presented an honorary degree by Juba University, and then Bashir and I spoke about our common commitment to complete the eradication of Guinea worm.

Since launching our effort in 1986, we've reduced cases by 98.5% (from 3.5 million to 65,000), with 80% of the remaining ones in Southern Sudan. The disease has been eradicated in seven countries, with four others now having less than 100 cases. Although Nigeria has only 1% left and Ghana 2%, these two countries contain 70% of cases remaining outside Sudan. We all know that it will take three or four years of peace before total success is possible in the 2,500 or so inaccessible Sudanese villages in the war zone. We also have good programs in Sudan dealing with river blindness and trachoma, but with the same handicap in the combat area.

I met with President Bashir and then Ghazi and found them committed to the Danforth initiative, knowing that it is the only American effort and that the European and African peace efforts will be severely dampened if the United States withdraws. They
claimed to be quite concerned about the strafing attack carried out by their own air force on civilians in Bieh, which they said was against the policy of the government. They hoped that a letter sent to Danforth adopting all four of his proposals would be adequate for the United States to resume its involvement.

Carter Center Director of Conflict Resolution Programs Dr. Ben Hoffman and I had a good meeting with EU Ambassador Xavier Marchal, who seems determined to do everything possible to support the peace process. Dr. John Hardman, executive director of The Carter Center, met with the ambassadors from Great Britain and the Netherlands. Despite some differences in attitude, there is a general consensus that the U.S. initiative is the only driving force around which others can marshal, and that the IGAD process has to be the focus.

We flew about 2-1/2 hours to Rumbek, in Southwest Sudan, regional headquarters of the revolutionary forces. We were met by a large crowd led by SPLM deputy chairman Salva Kiir and SRRA (health organization) Executive Director Elijah Malok. After leaving our plane, we watched while they slaughtered a tethered bull, and we jumped over the dying and still bleeding animal to bring good fortune to the observers and us.

Rosalynn and I then met privately with Kiir, who is the key negotiator for the southerners, and seemed to speak with confidence and authority. We first discussed radio broadcasts to publicize the use of pipe filters against Guinea worm, and the prospects seem dismal. What the southerners want is a transmitting station of their own, but Kiir claimed that the government would bomb any such installation of the SPLM. I questioned Kiir about current peace processes in Sudan and the SPLM's willingness to accept a nationwide ceasefire during prospective peace talks.

He favored the four American proposals but declared that Khartoum would never accept them. I told him that an acceptance had been sent to Washington yesterday, and he responded that they wouldn't be honored. When I asked him what they would do if we presume compliance with U.S. proposals, he said that IGAD would be the proper forum.

Kiir emphasized that SPLM's basic claim was the right of self-determination - including the ultimate option of independence for the south if two other options were not negotiated satisfactorily. The first would be a unified nation with completely equal rights for all people, fair sharing of wealth, religious freedom, and autonomous elections in the south. He doubted that the Government of Sudan (GOS) would ever accept this. The second option would apply during an interim period between four (SPLM preference) and 10 (GOS) years, with a confederation of two separate political entities.

Each would have its own government and elected officials, and they would work out more permanent relationships at the negotiating table. If neither of these options proved to be acceptable, then a referendum would be held with complete independence as a final option. They believe that, minus this option, their bargaining leverage is severely limited. He emphasized that full participation and support of the United States and other international players will be necessary if there is to be any hope for a successful peace process.

Later, Malok, Kiir, and I spoke to an assembly of SPLM leaders who were to participate in a negotiating training course led by Dr. Hoffman. (He already had conducted such a course in Khartoum). I outlined the general principles for peace summarized above, urged everyone to encourage the use of already distributed pipe filters to eradicate Guinea worm, and then got approval from Malok for more of our people to receive passes to enter the south to combat Guinea worm and river blindness.

After leaving Rumbek, 10 of us crammed into a King Air, and we flew three hours to Nairobi, where we took a DC-9 chartered by the Bill and Melinda Gates Foundation, stopped in Malawi for refueling, and proceeded to Johannesburg for the next leg of our trip focusing on HIV/AIDS in Africa. Deputy Chief of Mission John Blaney met us and gave me a briefing on the situation in South Africa.

Next morning we went birding with Ken Newman, who has written and illustrated the preeminent bird book for southern Africa, and John Ledger, president of the international Endangered Wildlife Trust. We observed 21 species, including a pair of beautiful black eagles that were nesting on a high cliff alongside a waterfall in the Witwatersrand National Botanical Garden. We watched as they awoke, preened, warmed in the morning sun, and then soaring high, took off on their daily hunting expedition. Each year the female lays two eggs, four days apart - called Cain and Abel by ornithologists. If both hatch, the older bird always attacks and kills its junior.

After Bill Gates Jr. (father of Microsoft CEO Bill Gates III) and his wife Mimi arrived with Gates Foundation staff members, we concentrated on the HIV/AIDS issue, as did, it seemed, everyone with whom we met in the U.S. embassy staff and the government. There is a raging battle in South Africa, brought about by President Mbeki's claim that anti-retroviral treatments are unproven and likely to be toxic. This even includes the well-proven nevirapine, which can protect babies of HIV mothers from the infection.

This is being used against national policy in some provinces and could reduce by half the 60,000 annual AIDS deaths in infants. Our expert on the trip was Dr. Helene Gayle, who recently left the Centers for Disease Control to head the Foundation's global crusade against HIV/AIDS.

Accompanied by Nelson Mandela, we visited a clinic in Soweto where this mother-to-child treatment is offered. Nelson, Bill, and I held little babies during most of the brief ceremony while their HIV-positive mothers sat on the front row. There is the need for an aggressive response to the devastating impact of AIDS in South Africa, which has grown in the last 12 years from less than 1% to now more than 20% of all adults, with an estimated 1,800 new HIV-infected people each day and inevitable deaths of 7 million already infected people in the next eight years. Other political parties are attacking the ANC's relatively quiescent attitude toward AIDS.

Although the big debate has been about anti-retroviral treatment, there is an almost undetectable government-sponsored prevention program in the country. In some countries there are billboards every few hundred yards emphasizing the seriousness of the AIDS epidemic, a call to use condoms and refrain from casual sex, and a personal endorsement of the anti-AIDS program by the president. We never saw even one such billboard in South Africa. There is a private group called LoveLife that has some small ones in Soweto, but their most provocative message is "Talk about sex."

After first declining to see us, Mbeki changed his mind at the last minute, and Friday morning we flew to Capetown to visit with him and his minister of health. I outlined our concern about the lack of progress on AIDS in South Africa, pointed out that we didn't want to be embroiled in the HIV vs. AIDS controversy or the claim that anti-retroviral medicine was toxic. What we wanted was to offer our services (Gates Foundation and Carter Center) to remove the stigma from the president by emphasizing positive aspects of a comprehensive prevention program, based on South Africa's own efforts and supplemented by best practices from very poor countries that have known success.

We also offered to organize a "pledging" conference so that approved programs could be financed. One example might be a nationwide advertising program contributed by the business community. When I added that I hadn't seen a single billboard that mentioned AIDS or condoms, they responded that a contract had just been signed with an advertising firm to do this.

Their overall response was to defend the system they have, which, so far as we can tell, is minimal. Most of what is being done in the country is by private and local groups, often over the opposition of the central government.

Then we took off for Namibia, Angola, and Abuja. At each stop, The U.S. ambassadors briefed us about the political situation and HIV/AIDS. Namibia has a 23% infection rate, and Angola 8%, mostly because of the war and relative immobility of the population. Angola is breathing a sigh of relief with the recent death of revolutionary leader Jonas Savimbi, and their rapidly increasing oil production bodes well for the future if the aftermath of the 41-year war can be accommodated. Luanda airport was full of airplanes of all kinds, since most of the roads have been destroyed. After a long day on the plane, we arrived in Abuja, where I called Dennis Weaver in Plains, and he reported everything going well with our inn/antique mall.

Saturday morning in Abuja, Nigeria, breakfast was with President Obasanjo, the Gates entourage, and a large assembly of cabinet officers and other health specialists. With limited funds (only $14 million), the president is taking a public leadership role in dealing with 3.6 million people infected with HIV, and struggling to hold the level to its present 5.8% of the population.

We then went to the ghetto area of Mabushi, where there are 5,000 "commercial sex workers." A group of young prostitutes explained their circumstances, abuse, and their leadership role in the use of condoms (some clients offer five times as much for "naked sex"). We had a fine forum with leaders from all over Nigeria on all aspects of their struggle to control AIDS. They have a serious problem, but Obasanjo is leading the effort - a startling contrast to what we had seen in South Africa.

I informed President Obasanjo that Nigerian customs was delaying delivery of 100,000 filters and nine vehicles to be used in our Guinea worm eradicating program. He immediately called the responsible officials, and we presume that this problem will be resolved permanently.

Sunday morning we had a rousing Baptist service in the presidential chapel, with a strong input by Obasanjo, great music, and good preaching, televised nationwide. I was surprised to learn the day before that I was giving a sermon on HIV/AIDS, and I tried to explain how Jesus would address the problem of illicit sex and suffering. I used as texts His attitude toward Mary Magdalene, the Samaritan woman at the well (with five lovers), and the woman caught in adultery and sentenced to be stoned to death. All showed His love and forgiveness, and Matthew 25's "Unto the least of these" put a responsibility on all of us.

We made a late decision to spend some time in Bangui, Central African Republic (CAR), and were met at the airport by Prime Minister Ziguele. We just had time for a quick visit to the only AIDS clinic in the country, and it was heartrending. On that particular day there were 267 "patients," all of whom had AIDS, many of them mothers standing in long lines, holding emaciated babies, to welcome us.

Their only treatment is a morsel of food each day, and when they are no longer ambulatory they are moved to the nearby hospital to die. Ninety percent of the hospital beds are filled with these patients. The country has no detectable program to prevent the further spread of HIV infections, and the U.S. ambassador was distressed that CAR had no idea how to prepare a request to meet the March 15 deadline for funding from the Global Fund for AIDS, TB, and Malaria.

In Nairobi, we had a briefing from Ambassador Johnnie Carson and AIDS experts from CDC, and next morning we met with General Lazarus Sumbeiywo, the chief IGAD negotiator for peace in Sudan.

Later, we and the Gates delegation met with President Daniel Moi and his key cabinet ministers. Moi was knowledgeable about HIV/AIDS, and Kenya has adopted a prevention program that has arrested the incidence and slightly reduced it at the 13% level.

We then went to Kibera, known as the largest slum area in Africa, and conducted a public discussion on HIV/AIDS. There was vivid testimony from AIDS victims, commercial sex workers, AIDS orphans, students, workers and officials in the nation's AIDS programs, and representatives of the news media and employers. Afterward, Bill Gates and I had a luncheon with newspaper editors, radio owners, and others to encourage them to promulgate accurate information about the AIDS epidemic and what can be done about it.

Our final event was a visit to Kenyatta Hospital, where research is being done on an AIDS vaccine. This effort is based on a cadre of Kenyan prostitutes who were found to be immune to HIV infection. A synthesized duplication of their antibodies is now being implanted in a group of about 120 "clean" volunteers, and their blood cells have shown the presence of the same antibodies. There will be a second phase of testing among about 1,500 people, then a final one of the vaccine itself, among 10 times as many
"high risk" people, including truck drivers and prostitutes. The Gates Foundation is pro-viding $126 million for this research, in Kenya and four other places.

We were overwhelmed during the trip with the personal tragedies and the statistics. Two million people have died during the 19 years of the Sudanese war, while 2.3 million Africans died last year from AIDS. In Nairobi, Kenya, 20% of citizens are HIV-positive, and in the nation of Botswana the prevalence is 35%. There is a desperate need for expert advice and funding, with other nations looking to the United States to set the standard for contributions directly or through the Global Fund. So far, the pledges have been very disappointing. One obvious fact is that this effort is so highly personal and closely observed that the chances for waste or corruption are minimal.

Instead of going home, we spent the night in Washington, to present the the Jimmy and Rosalynn Carter Award for Humanitarian Contributions to the Health of Humankind from The National Foundation for Infectious Diseases to Bill and Melinda Gates. Before the banquet, we gave them a verbal trip report. They are well informed about all aspects of their foundation's work, including infectious diseases and vaccinations. Narrowly focused and efficient, their annual contributions in this field exceed the total budget of the World Health Organization!