February 19, 2007
From The Carter Center, Rosalynn and I were joined by Dr. John and Laura Hardman, John and Becky Moores, and Dr. Don and Ernestine Hopkins.
GHANA: In our Guinea worm eradication effort, Ghana has been our worst disappointment. We found 179,556 cases in 1989, and the government mounted a major effort. In 2001, there were only 4,739 cases in the country, and Ghana was providing campaign leadership among Africa's Anglophone nations. Tragically, there were still 4,132 cases reported in 2006, and the incidence of the disease was rising. We made a special effort to visit Ghana in 2004 to encourage containment of detected cases and the use of filter cloths, Abate, and education, but the government's almost exclusive emphasis seemed still to be on one important but long-term facet of control: providing water systems to villages. We were shocked to learn that in January 2007 there were 1001 new cases, almost double the number a year ago.
I first met with Ghanaian Kofi Annan, who just completed his fine service as United Nations Secretary General, and he agreed to help us with the Guinea worm problem. We spent the following day (February 7) in briefings among our own team, officials in the Ministry of Health, and with representatives from WHO, UNICEF, Japan, EU, UK, and Peace Corps. Then we met with President Kufuor and, hopefully, convinced him to involve all of his cabinet members, to get maximum publicity, and to emphasize the need for educating villagers, using filter cloths and Abate in all the water holes. I gave him charts showing the progress in all other nations and the high incidence of Guinea worm in the Northern Region of Ghana. We also pointed out that carriers with tanks are still hauling water from some infected ponds to the villages. One problem with Guinea worm is that it takes 12 months for the worms to emerge after the larvae are imbibed, so an outbreak just reveals what happened a year earlier.
The next day we flew north to Tamale, and drove to the village of Tingoli, where Guinea worm has been eliminated and good progress is being made on trachoma. There were about 125 latrines built in the village of 2,500, and no flies were evident. We then went to Savelugu, where about 700 new cases of Guinea worm were found in January. Apparently, a turbine pump had failed a year ago and water carriers sold contaminated water in the nearby towns. We visited the hospital area where dozens of little children, some screaming in pain, were being treated by attendants who attempted to expedite the emergence of the worms and applied sterile bandages. One woman, 57 years old, had worms coming from her breast, genitals, and both feet. It was her first worms since she was 15 years old. It was a horrifying scene of unnecessary suffering.
Back in Accra, we had a packed press conference, and Director General of the Ministry of Health Agyeman Badu Akosa and I gave the media a frank report on Ghana's failure to control Guinea worm. Later, I convened a meeting of partners and health experts, and we all agreed to mount a special effort to apply more Abate, increase containment of people with worms emerging, enhance education, distribute more filters, and strengthen patrol of water holes to prevent contamination and the hauling of infested water to villages. We induced Professor Akosa to become Ghana's "Guinea worm czar," and then I called President Kufuor, who agreed to accept our recommendations.
SUDAN: The next morning we flew to Garoua, Cameroon, in a chartered Fokker 28 for refueling and discussions with government leaders and news media. In Khartoum, we first met with Health Minister Dr. Tabita Botors Shokai, who reported no indigenous cases of Guinea worm and just two imported cases in the northern states. We have always had excellent cooperation from the Khartoum government in both agriculture (wheat) and health (Guinea worm, trachoma, and onchocerciasis) programs. We are testing double Mectizan treatment in two areas (Abu Hamed and Sundus), which has proven to be effective in South and Central America to eliminate the disease permanently. There seems to be close cooperation in the health ministries of North and South Sudan. International Lions President Jimmy Ross joined us to observe our sight programs, for which Lions SightFirst has provided a total of more than $26 million, even in Sudan, which just organized its first Lions club.
Saturday morning we flew south to Juba, the capital of Southern Sudan, where we have a greatly expanded effort (now 150 workers) to eradicate Guinea worm in communities just made accessible by the Comprehensive Peace Agreement (CPA) between the North and South. In 2006 there were 20,237 cases found in 3,362 endemic villages in South Sudan, and we now have 13,637 trained village volunteers working under about 1,000 supervisors and field officers. Our resident technical advisor Steven Becknell reports almost universal enthusiasm among both villagers and our staff in combating the disease. We also have a modest trachoma program in the south.
The CPA has resulted in a fragile ceasefire. Its terms are very complex, but call for a division of oil revenues, the determination of a boundary between the north and south, separate elections prior to 2009, and then a referendum in the south in 2011 to determine whether Sudan will be united or become two nations. High hopes for implementation of the CPA have dissipated as world attention has shifted to the tragedy in Darfur. Arguments about N/S boundaries seem to center on whether the 1905 British delineation should prevail or those of 1956, when Sudan achieved independence.
After joining Mrs. Garang for a visit to the burial site of John Garang, we met with President Salva Kiir, who flew in from Yei for our meeting. He was concerned about delays in implementing the CPA, especially the Abyei protocol and the delineation of the boundary line between north and south. There is much oil revenue involved, and an additional referendum will be conducted in the Abyei region to determine whether the people prefer to be in the south or north. This issue could precipitate another general conflict. Acting as vice-president of Sudan, Kiir seems to be personally compatible with President Omar al-Bashir.
Back in Khartoum, Rosalynn, John Hardman, and I met with President Bashir and his top advisors. I have known him for almost 20 years, even before he became president in 1989, and The Carter Center has had excellent results with his ministries in the fields of agriculture and health. In general, it was obvious that there is a negative relationship between Sudan and the US, and Washington has little influence in Khartoum, either of a positive or negative nature. With almost 13 percent annual economic growth rate and support from Arab nations, China, Russia, and other countries, Sudan is almost impervious to pressure from the Western world. However, Bashir referred frequently to the United Nations (UN) and the African Union (AU), and to the CPA with South Sudan and the Darfur Peace Agreement negotiated last May, which Sudan accepted and some rebel groups rejected. He agreed that a political, not military, solution is the only option and expressed full confidence in Jan Eliasson (UN) and Salim Salim (AU) as negotiators to address the conflict in Darfur.
There are sealed indictments from the Prosecutor of the International Criminal Court (ICC) against a group of Sudanese officers and some of the Arab and African Darfurians for "war crimes" and "crimes against humanity," and I reminded the president that the ICC investigations are continuing. Predictably, he denied any atrocities having been conducted under his command, and said that all official allegations were being investigated. The ICC is an independent agency, and its threat is a powerful factor if backed by the international community.
Bashir said that financial aid was going to Darfur, under the peace agreement, amounting to $300 million for each of the two years and then $200 million for a third year. 185 UN technical military advisors were authorized in November to serve in a hybrid force, but he knew of only about 50 who have been assigned to Darfur for duty. With about 10,000 combat troops from African nations deployed in the region, non-combatant troops can be assigned from other countries, with the number to be determined by the AU commanding officer. He claimed that this arrangement had been worked out by his government, the UN, and the AU. His stated goal is to incorporate about 20,000 of the Arab and African militia into Sudan's regular army within the next six months.
He said that there are a number of UN agencies plus about 200 Non-Governmental Organizations (NGOs) providing services in Darfur, and claimed that any harassment of them was perpetrated by uncontrollable rebel groups and local officials who were eager to seize vehicles and supplies from any vulnerable source. He denied having received any reports of such abuse being committed by his own troops. However, I had confirmed reports that last month (January), aid workers in both Nyala and Guereida were arrested, beaten, and some of the women were raped by uniformed Sudanese. Other relief agencies and human rights representatives are prohibited from obtaining timely visas and are often harassed. If these key international observers and providers of services are forced out of Darfur, then it is inevitable that human suffering will escalate. The UN, other official agencies, and governments of NGOs must express strong, public, and formal complaints to protect these dedicated people.
The borders of Chad and Central African Republic have been repeatedly penetrated by janjaweed troops from Sudan, who have ravaged villages and terrorized the inhabitants.
Constant bickering in international forums is sapping away united support in implementing peace agreements already concluded. Arguments continue about whether atrocities in Darfur are "war crimes," "crimes against humanity," or "genocide," although all of them are extremely serious under international law. Also, the continuing altercation about the exact make-up of forces in Darfur is probably fruitless. The Sudanese government has enough international backing to honor the negotiated decision that all combatant troops and the force commanders will come from African nations. The UN should implement the agreements already negotiated, fill the non-Africans positions, and provide full support for all the military forces to be deployed.
UN negotiator Jan Eliasson and AU negotiator Salim Salim must be given unimpeded opportunities to investigate all facets of the crisis in Darfur, and their forthcoming recommendations should be implemented with international pressure on all the substantive rebel groups and the government of Sudan. They should also insure proper access and support for UN and NGO humanitarian agencies. The work of the ICC is also a crucial factor in deterring further crimes against innocent people in Darfur and in bringing perpetrators to justice.
Full implementation of the peace agreement between North and South Sudan must also be assured, and the stalled work of designated commissions should be resumed. The delineation of Abyei is the key point of contention, and must be resolved. The US played a key role in the past, and should combine its efforts with those of the UN and AU. It might be helpful to bring General Lazaro Sumbeiywo back from Kenya to help resolve the especially difficult negotiating points. His abilities are proven and he has the respect of both sides.
ETHIOPIA: In Addis, we first had a briefing from minister of Health Dr. Tedros and our CC staff, and learned that there have been no Guinea worm cases since July 2006 and just one earlier last year. Ethiopia has the world's highest incidence of blindness, and we work with Lions and others on Onchocerciasis (River Blindness) and Trachoma. We treated 2,600,000 people for Onchocerciasis last year and are greatly expanding our trachoma program to cover the entire Amhara district, where about 40 percent of Ethiopia's cases are found. So far, our program has resulted in 64,000 eye surgeries, 303,400 new latrines, 2,925,000 treatments with Zithromax in 2006, and teachers report that 62 percent of the children come to school with clean faces.
Our most ambitious health program is to work with the government of Ethiopia (GOE) in providing two long-lasting impregnated nets to every household in malaria endemic areas, which will cover about 50 million people. The GOE is furnishing 17 million nets and we the other three million, and The Carter Center will be responsible for their distribution (between now and July) and for monitoring their use and the results for seven years. Our total cost will be $47 million, for which we are now seeking funds.
Our primary reason for coming to Ethiopia is to assess the public health training initiative and to encourage other African nations to adopt facets of it that are pertinent to their own countries. Health and/or education ministers from Nigeria, Ghana, Benin, Mali, Kenya, North and South Sudan, Uganda and Tanzania attended a 3-day conference for this purpose. Using funds from donors, we have furnished about $8.7 million, permitting our Ethiopian partners to reach ambitious goals of training texts (modules) for 65 diseases and health challenges, 101 lecture booklets, 538 regional workshops, training of more than 700 faculty, 7,135 students graduated from seven regional universities (most of them new), and training of 17,400 health extension workers. Our budget of $5 million for the next two years will bring the total number of health workers to 30,000 (an extension worker for every 2,500 people), plus 5,000 health officers with training equivalent to registered nurses or physician assistants.
In my meeting with Prime Minister Meles Zinawe, we discussed our health and education projects and the situation in Somalia and Sudan. He expects the recognized federal government in Somalia to participate in a series of discussions with moderate Islamic leaders and representatives of the war lords and other factions. He looks forward to the replacement of Ethiopian troops with forces recruited from other members of the AU. His opinions re Darfur and N/S Sudan were compatible with those I expressed above. He reported progress being made in healing the political wounds of the 2005 elections and preparations for the upcoming local elections, to be held late this year.
The next day we flew southwest to Jima and inspected our programs concerning river blindness and the installation of bed nets to control malaria in the village of Afeta. A large number of the villagers were blind and others were suffering from various stages of the disease. We are providing treatment with Merck's Mectizan to all people in communities within which 40 percent or more of the people are infected. Although adult worms remain in their bodies, annual doses control "leopard spots" on the skin and prevent blindness and terrible itching (they scratch themselves with stones and pieces of wood).
After a press conference, I met with Mali's former president Konari, who is now head of the AU Commission. He is very eager to see the role of the AU increase in the numerous crises throughout the continent, including the Western Sahara, Somaliland, Somalia, N/S Sudan, Darfur, Chad, Central African Republic, and the Ethiopia-Eritrea border dispute.
While I was meeting with Konari, Rosalynn and the other women in our party went to the presidential compound for a coffee ceremony with the First Lady, Azeb Mesfin, who is leading a mental health effort. Ethiopia is a great coffee growing country, and Azeb roasted green beans on a charcoal fire, crushed them with a mortar and pestle, made the coffee and served it. They had a great time while there exploring the recently renovated old, beautiful building that was formerly used by the communist dictator Mengistu Haile Mariam. They were reminded that Mengistu suffocated Emperor Haile Selassie, his predecessor, with a pillow and he was buried under this building.
NIGERIA : With fueling stops in Juba and Douala, we finally arrived in Abuja and went to meet with President Obasanjo. We discussed the parliamentary and presidential elections to be held in April, and the president informed us that he intends to return to his farm and build Africa's first presidential library. Our inspection team reported recently that the upcoming election will probably be no more honest than the last two.
We reviewed our success with Guinea worm (656,000 cases to 48). We suggested that his government furnish 9 million long-lasting impregnated nets to cover the Lymphatic Filariasis (LF) areas that we are assisting, which will also be effective in controlling malaria. He agreed to do this, provided The Carter Center will manage their distribution. Concerning the troubles in Sudan, he suggests that all nations give full support to the UN-AU teams.
We spent our final day in Africa in Nasarawa state, where all Guinea worm has been eradicated but many people suffer from LF and Schistosomiasis. Welcomed by huge crowds, we made our way to the local river, where many children were swimming and women were washing clothes. Any contact with the water exposed their skin to the Schisto disease, which results in adult worms living in the blood stream and producing eggs that seek escape from the body through urine and feces – also penetrating the liver and other organs. These parasites not only cause intense scarring of the internal organs but starve the children by competing for any nutrients that are available. We gave doses of praziquantel to a number of the children and then visited victims of both diseases. LF is commonly known as elephantiasis, a grotesque growth of genitals, legs and arms. One man's scrotum was the size of a basketball. It is transmitted by the same mosquitoes as malaria, and we have been distributing treated bed nets in the region.
After a press conference, I spoke at National Day ceremonies at the U.S. embassy before we departed for the airport for Frankfurt, New York, and home.