Beyond the White House

Simon & Schuster

Trachoma

Trachoma is the leading cause of preventable blindness in the world, but it is still known as one of the "neglected" diseases. It is caused by infection and can be treated, but 7 million people have been stricken blind by trachoma. An additional 500 million, usually the poorest and most forgotten in communities that are already struggling for survival, are at risk. In African countries, these are often areas where lymphatic filariasis, Guinea worm, schistosomiasis, and onchocerciasis are also endemic.

I knew about cases of trachoma as a boy, and I often had conjunctivitis, or sore eyes. As is the case now in our targeted areas of Africa, flies were everywhere, breeding in the excrement from both animals and humans. Our barn lot was nearby, and chickens, ducks, and geese ran freely in the yard. Screened doors and windows helped, but we also had to put a piece of gauze on top of any open pot or pitcher to keep the fl ies out of our milk or food. Fortunately, my mother was a nurse and a stickler for cleanliness, and our family had the only outdoor privy in the community. Trachoma was considered a threat to America in those early years, so doctors at Ellis Island used buttonhooks to examine the undersides of immigrants' eyelids and shipped those with trachoma back to their home countries.

Trachoma is caused by fi lthy and infected eyes, beginning as conjunctivitis and ultimately causing the upper eyelids to turn inward. Every blink drags the eyelashes across the corneas, causing pain like a thorn in the eye and then permanent blindness. The disease can be transmitted by contact with an infected person, by hands, a towel, or a garment, or carried by flies that have come in contact with discharge from infected eyes. Transmission is enhanced by an intimate relationship between mother and child or within a family or close-knit community.

Rosalynn and I had noticed during our visits to Masai and Dinka villages that, when seen from a distance, children appeared to be wearing eyeglasses, but when we approached them it was clear that rings of flies were sucking moisture from their eyes. The children rarely brushed the flies away and had never been taught to wash their faces.

In 1997, at the request of the Conrad N. Hilton Foundation, The Carter Center decided to make a major effort to help control trachoma in Ghana, Mali, Niger, and Nigeria, countries where the average annual income ranges from $100 to $370. We knew that trachoma only deepened the despair and poverty in these communities.

We began learning about the disease and raising funds to support the new program. Having been a district governor of Lions Clubs International during the mid-1960s, I knew that protecting eyesight was the organization's major benevolent project. I went to their Chicago headquarters to relay our plans, and they pledged a total of $16 million for five years, permitting an expansion of our program to Ethiopia and Sudan. The Hilton Foundation promised $13.6 million for a total of ten years.

The first cases of trachoma that we saw were in Mali, where Rosalynn, our Carter Center team, and I were joined by Jim Ervin, president of Lions Clubs International, and leaders of Lions Clubs in the country. Through an interpreter, we talked to a blind grandmother who said she was thirty years old. She was holding in her arms a little boy, about the same age as Amy's son, our youngest grandchild. Someone said, "The fl ies cluster shoulder to shoulder around an infected eye." With proper treatment, the grandson would never be blind.

Along with other organizations involved in the International Trachoma Initiative, we use the acronym SAFE as a guide to treatment: S = surgery, A = antibiotic, F = face cleaning, and E = environment.

Before surgery, victims carry crude tweezers, with which they pluck out all their eyelashes, but the hairs grow back even sharper. We are able to train nurses or physician's assistants to perform the simple surgery, a fi fteen- minute procedure, to restore the eyelids to their normal position. On surgery day, hundreds of people desperate for relief stream into eyelid surgery camps run by the government and paid for by The Carter Center. We prefer a month of training, which costs six hundred dollars per worker, plus eight hundred dollars for two surgical instrument kits each. The materials for each operation cost about ten dollars.

In September 2000, Jim Ervin went with me to the headquarters of Pfizer Inc, the world's largest pharmaceutical company, where we met with corporate leaders and I spoke to several hundred of their assembled employees about trachoma. I described the SAFE program and emphasized that their antibiotic Zithromax had proven to be most effective against the infection. I described how Merck had been contributing free Mectizan for the treatment of onchocerciasis, and their CEO, William Steere, offered to provide Zithromax whenever we could set up an effective system in a country for its use. Subsequently, Pfizer has expanded this commitment so that it now includes more than 135 million treatments. This is an invaluable contribution in fifteen of the fifty-five countries where trachoma is endemic.

Children can be taught by parents, teachers, or health workers to keep their faces clean, and the plethora of flies can be reduced by maintaining a sanitary environment using methods that are taken for granted in the developed world.

We combat trachoma in six countries, but our most intense effort is in the Amhara region of central Ethiopia, the most severely affected place in the nation. Our survey revealed that up to 80 percent of children there had early stages of the disease. Approximately 1.25 percent of all Ethiopians are blind, the highest incidence in the world, and more than 80 percent have some form of trachoma. Because mothers look after the children and children are the most heavily infected, women are three times more likely to develop the late stage of the disease. Usually the main workers in the house, women incapacitated with trachoma become a special burden. While their children may care for older blind women, younger women are frequently divorced by their husbands and sent back to their parents. In some communities in Ethiopia and Sudan, as many as 20 percent of women over fifteen years old are going blind and risk these social and economic punishments for their illness.

Dr. Paul Emerson joined The Carter Center as director for the Trachoma Control Program in November 2004. He had devoted nearly a decade to operational research and program evaluation in support of the global effort to control the disease, and under his leadership we quickly extended programs begun by Dr. Jim Zingeser to encourage face washing. Our latest reports from teachers and others show that more than 60 percent of the children are proudly demonstrating clean faces each morning.

The next stage of our program proved the most interesting and earned me a new reputation in Ethiopia. We learned that it was taboo for women to relieve themselves where they could be seen. They had to either defecate and urinate within their living compounds or restrain themselves until dark. One woman told Dr. Emerson, "I am a prisoner of daylight!" We decided to distribute simple plans for the construction of latrines: just dig a hole in the ground; fix the top with boards, stones, or concrete so it wouldn't cave in; and enclose it for privacy with brush, clay, or cloth. A latrine could be constructed for a cost of less than a dollar.

As latrines were being built and cleanliness became more important, many communities did not have access to enough soap, and they revived the lost craft of soap making. This provided not only an affordable method of sanitation but also a new product that women could sell to generate income.

We set an ambitious goal in Amhara district of ten thousand latrines during the first year, but we underestimated the power of women who saw them as a form of liberation. Family by family and village by village, latrine building was adopted as a major project, and 306,000 latrines were built within three years! We encouraged families to hang a gourd filled with water at each entrance, with a tiny hole at the bottom plugged with a stick. When we visited the area in 2005, people were especially proud to show us how they could now wash their faces and hands after using the privy. I became known as the Father of Latrines.

Malaria

There is an apparent anomaly in the current statistics from the World Health Organization on annual deaths from diseases in the developing world, which seem to underestimate the ravages of malaria. In order of deadliness, (1) respiratory diseases come fi rst at 4 million deaths per year, followed by (2) HIV/AIDS, 3 million, (3) malaria, 1 to 5 million, (4) diarrhea, 2.2 million, and (5) tuberculosis, 2 million. But the organization also states, "Malaria kills more than three thousand children each day in sub- Saharan Africa," which amounts to 1.1 million annually just for this age group and geographic area. In Ethiopia, we know that annual deaths from HIV/AIDS are 130,000, while 270,000 die from malaria. This devastating disease causes a lifetime of suffering from chills, diarrhea, pain, and high fevers, with its fatalities concentrated among pregnant women and children in their first five years of life.

Malaria was prevalent in southwestern Georgia when I was growing up during the Great Depression, and it was not until 1946 that the Communicable Disease Center (CDC) was established, primarily to eliminate this disease. A year later, a vast effort was begun to screen houses and to spray outdoor wet places with DDT, and by 1950 only two thousand cases were reported. Malaria was considered eradicated from the United States by 1951. (The CDC subsequently became known as Centers for Disease Control and Prevention.) Meanwhile, the insecticide DDT has been banned from outdoor use in most nations since its devastating effect on wildlife became known.

Along with HIV/AIDS and tuberculosis, malaria qualifies as one of the "big three" diseases for which nations can qualify for financial grants from the Global Fund, a public-private partnership based in Switzerland. Nations that receive grants must quickly demonstrate that the money is being used wisely and effectively. In 2006, Ethiopian Prime Minister Meles Zenawi decided to make an all-out effort to reduce the threat of malaria throughout his nation, and we accepted his challenge to join in a partnership with the government ministries.

The plan was to utilize one of the most remarkable technological innovations of recent years -- bed nets made of fi bers that are impregnated before weaving with a pesticide whose lethal effect on mosquitoes would last for about seven years. Instead of merely being repelled by the nets, the insects would be killed on contact. There were 50 million people living in the endemic areas of Ethiopia, which meant that 20 million nets would be needed to provide an average of 2 per household. It would be a massive project to identify the communities to be included, acquire the nets, distribute them, and then ensure their proper installation, use, and care. The government would acquire 17 million nets using a portion of its Global Fund grant, its own resources, and support from other donors. We agreed to provide the remaining 3 million, be responsible for distributing bed nets in the areas where we already were controlling onchocerciasis and trachoma, and monitor the results for the seven-year period. As an added measure in certain areas, DDT would be used to spray interior walls of homes while being strictly prohibited from outdoor applications.

We located fourteen regional storage areas and began buying the bed nets before launching our six- month distribution effort in January 2007. It is hard to imagine the volume of 3 million nets. One enormous pile was named "Carter's Mountain." The total cost of our Center's portion of the malaria program in Ethiopia will be $46 million, an amount that we are attempting to raise from private contributors. This is the largest project in a single country that we have ever undertaken.

Advantages for our Center include a thorough knowledge of the malaria-endemic areas, derived from our battles against Guinea worm, trachoma, and onchocerciasis, along with a large cadre of trained native health workers who can now combine their efforts against several diseases simultaneously. As previously mentioned, the most direct ancillary benefit will be against lymphatic filariasis, since mosquitoes also spread this disease.

Task Force for Disease Eradication

The International Task Force for Disease Eradication (ITFDE) was formed at The Carter Center in 1988 to evaluate disease control and prevention and the potential for eradicating infectious diseases. Composed of scientists and notable international health organizations from around the world, the task force fi rst met from 1988 to 1992, concluding that six diseases -- dracunculiasis, poliomyelitis, mumps, rubella, lymphatic filariasis, and cysticercosis -- could be eradicated. Some of these targets proved to be unrealistic, even if theoretically feasible. Guinea worm and polio eradication were already under way, but this ITFDE report has led to a new effort to eliminate lymphatic filariasis.

In June 2001, we were able to secure support from the Bill & Melinda Gates Foundation and resumed the effort to review progress in disease eradication and to make recommendations regarding opportunities for eradication or better control of certain diseases. Two diseases (Guinea worm and polio) have been designated by the World Health Organization for worldwide eradication, and five others (leprosy, lymphatic filariasis, river blindness, trachoma, and schistosomiasis) for elimination or dramatic reduction in specific regions. Not coincidentally, our Center's health programs address five of these seven diseases (all except polio and leprosy). In 2006, the ITFDE encouraged the Dominican Republic and Haiti to cooperate in eliminating malaria and lymphatic filariasis from the island of Hispaniola, and in 2007 it continued to monitor the potential for eliminating onchocerciasis in selected areas of Africa.

The task force also analyzes major diseases that become vulnerable to control thanks to new scientific knowledge or technological innovation. One notable example is the long-term impregnated bed nets for combating mosquito-borne malaria and lymphatic filariasis.

Agriculture

Shortly after we left the White House, Rosalynn and I had a visit from Ryoichi Sasakawa, one of the most remarkable men we have known.

Our first encounter with him was when his staff members called and requested permission to visit us at our home in Plains, along with Reverend Wayne Smith, founder of the Friendship Force. When the elderly Japanese man first entered our home, he expressed amazement that we lived in "such a humble dwelling." His second utterance was "I understand that you need money to build a presidential library, and I want to make an initial contribution of $500,000."

This was obviously a favorable introduction, and we soon learned more about Mr. Sasakawa's background. He had been a famous fighter pilot in World War II, and at the war's end was imprisoned by General MacArthur for three years for alleged corruption and subversive activities involving Japan's military operations in the Orient. During this time of incarceration he devised an ingenious scheme for rejuvenating Japan's devastated industrial capability. When finally freed (without having been put on trial), Sasakawa developed a legal and official gambling syndicate. Since there were no lotteries, horse racing, or dog racing events, he built a network of lakes throughout Japan and designed standard speedboats on which bets could be placed.

The organization was first named the Japan Shipbuilding Industry Foundation, and several Japanese cabinet members, including the minister of transportation and finance, were designated to serve as directors. Gambling profits amounted to hundreds of millions of dollars, and practical control of these funds remained in Mr. Sasakawa's hands. When we first met him, he had established several benevolent organizations around the world, one of which was the United States-Japan Foundation, which he endowed with $50 million. Sasakawa also made large contributions to UN agencies and expressed an interest in forming a partnership with The Carter Center to meet some benevolent needs in the developing world.

After several years of exploratory discussions, we decided to convene a meeting in Geneva with Sasakawa, the scientist Norman Borlaug, and me presiding. Our purpose was to find ways to increase the production of food grains in Africa, beginning with four nations as test cases. We selected Sudan, Ghana, Tanzania, and Zimbabwe so that we could employ the different seasons north and south of the equator. Sasakawa's foundation would provide the funding, I would represent The Carter Center in negotiating contracts with leaders of selected nations, and Borlaug would implement some of the agricultural techniques that had made him famous and earned him the Nobel Peace Prize in 1970 as the father of the Green Revolution in India and Pakistan.We decided that our project would be called Global 2000 (later changed to Sasakawa-Global 2000).

Along with our health programs, work with farm families in their fields gave us an unprecedented insight into their cultural practices. After our Global 2000 agriculture program had been implemented for a few years, we traveled to a few of the nations to honor the most outstanding farmers. One such visit was to a rural village in Zimbabwe about 125 miles from the capital city, Harare. I dressed that morning in the hotel as though I would be going to our own farm near Plains.

When we finally arrived at the site, we found several hundred villagers assembled in the village square, with young men and women already costumed and dancing. We were guided to two large trees, where a small man, proudly dressed in a wrinkled suit and tie, was standing under one of the trees and holding a plaque designating him as the outstanding farmer of the year. After exchanging ceremonial honors with the village chief and other dignitaries, we were invited to the farmer's home for lunch, served by his wife and daughters. When we finished eating, I suggested that we proceed to some of his fields to observe his agricultural management techniques. The vehemence of his objections was surprising, with an emphasis on the need to go through his animal pen, the heat of the midday sun, the likelihood of getting my clothes dirty, and the distance to the growing crops.

Pointing out that I was a farmer myself, accustomed to livestock manure and dressed in my work clothes, I finally prevailed, and our small entourage moved toward his cultivated fi elds, with his wife walking behind us with Rosalynn. On the way, the farmer and I exchanged comments about his cattle, and he was quite knowledgeable about this phase of his enterprise. Since our G2000 programs were restricted to food grains, I was eager to reach his field of maize (corn), whose quality had earned his honors. We could all see that it was an outstanding crop, approaching any yield that I might realize on our farm in Georgia.

Mostly as a courtesy, I asked a series of questions: "How wide do you space your rows?" "What variety of maize did you choose?" "When did you apply the fertilizer, and what formula was used?" "Did you have any problem with insects?"

It quickly became obvious that our host knew nothing about the crop. Finally, he just turned to his wife, who provided all the answers. She was obviously the only farmer in the family, and she and the children had made all the decisions and done all the work, while her husband took care of the cattle -- and the money when the crop was sold.

Copyright © 2007 by Jimmy Carter

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