by Jimmy Carter
8 | WOMEN AND THE CARTER CENTER
The Carter Center has confronted the issue of sexual discrimination and abuse of women through our work with families in remote communities in more than seventy developing nations, and we have seen how religious beliefs and violence have impacted their lives in patriarchal societies. Of even greater significance is what we have learned about the vital role that liberated women can play in correcting the most serious problems that plague their relatives and neighbors. Almost everywhere, we find that women are relegated to secondary positions of influence and authority within a community but almost always do most of the work and prove to be the key participants in any successful project. Whenever men are plagued with poverty, disease, or persecution, the women are suffering more. When there is a shortage of food or limited access to education, the men and boys have first priority. When there are few opportunities for jobs or desirable positions in any facet of life, they are rarely filled by women. When a civil conflict erupts, women are the primary victims of bombs and missiles, the displaced adults in charge of children, and the victims of rape. Beyond all this are the special biases that come from the distortion of religious beliefs and the imposition of discriminatory tribal customs that lead to honor killings, genital cutting, or child marriage.
Waging peace, fighting disease, and building hope are the major themes of The Carter Center, and one of our basic principles is not to duplicate what others are doing or to compete with them. If the U.S. government, World Health Organization, World Bank, or any university or nongovernmental organization is adequately addressing a problem, we don’t get involved. We try to fill vacuums in the world, both in the projects we undertake and the regions in which we serve. Over the years we have mediated peace agreements, increased production of food grains in Africa, enhanced freedom and democracy by monitoring troubled elections, and defended human rights.
Somewhat to our surprise, we have been asked increasingly to concentrate our financial and personal resources in reducing the ravages of neglected tropical diseases, concentrating on trachoma, lymphatic filariasis (elephantiasis), onchocerciasis (river blindness), schistosomiasis, and dracunculiasis (Guinea worm). Under the direction of Dr. Don Hopkins, director of all our health programs, we also target malaria, since the same mosquito is the vector for filariasis. Although no longer found in developed countries, these diseases still afflict hundreds of millions of people in Africa and some regions in Latin America and Asia.
Early on we received criticism from well-meaning liberal friends that by saving lives in Africa we were contributing to the population explosion in the region and would be better engaged in improving education and agricultural production. I brought these suggestions to our health director at the time, Dr. William Foege, who was the former director of the Centers for Disease Control and had played the key role in eradicating smallpox. He produced official data to show me that the best way to reduce a high birthrate is for parents to be convinced that their children will live. There is a direct relation between reducing the infant mortality rate and a subsequent decrease in population growth. The logical explanation is that parents in poor regions depend on a certain number of surviving offspring to provide support in their older years; when child survival is doubtful, they produce the maximum number of children. It is also clear that a family’s health is dependent on the knowledge of the mother about the advantages of good sanitation, proper diet, and other factors that can prevent or control prevalent diseases. Our primary health programs have been built on these premises for more than three decades.
Carter Center personnel or domestic trainees go into the most remote villages in the jungle or desert to teach people about their disease and what they can do to prevent it or ease the suffering. In doing this work, we have to become intimately involved in the daily lives of the people. If medicines, filter cloths, pesticides, or protective nets are required, we work with national health ministers, but we still retain control of the delivery system and let the local people do the work themselves. We give them full credit for success. Our focus on the most worthy projects is helped by the International Task Force for Disease Eradication (ITFDE), which is located at our Center and is the only organization of its kind. With participants from leading health organizations, the ITFDE regularly assesses all human illnesses to determine which might be targeted for elimination in a particular region or for global eradication.
Our most highly publicized struggle has been with dracunculiasis, or Guinea worm, and we are approaching our goal of having this be the second disease in history that is totally eradicated. This has been a massive effort lasting more than twenty-five years and involving direct intervention by our staff or trainees in more than 26,000 isolated villages in twenty countries. This long struggle has given us an unprecedented insight into the special role of women in some of the most destitute families on earth.
Guinea worm disease is caused by drinking contaminated water from a pond that fills during the rainy season and then becomes stagnant and slowly dries up during the rest of the year. Microscopic Guinea worm larvae in the water are consumed by tiny water fleas, which then are swallowed by people drinking the water. Inside a human’s abdomen, the parasite larvae mate. Over about a year, the female matures and grows into a worm two to three feet long and begins emerging through the skin. The exit point is usually through the feet or legs but can be at any other part of the body.
A large sore develops around the emerging worm and is very painful, sometimes destroying muscle tissue so the aftereffect in a joint is similar to polio. There is almost unbearable pain for about thirty days, and the victim is incapacitated, unable to go to school or work in the field. There is no medical cure available, and the cause of the disease is usually unknown to villagers; many believe it must be a divine curse, derived from drinking goat’s blood, the confluence of stars, or some other source. The only treatment for thousands of years has been performed by local religious leaders (or witch doctors), who wrap the emerging worm around a stick or other object about the size of a pencil and exert enough pressure to expedite the process by a few days. Care must be taken to pull out the entire worm, as any part remaining in the body will rot and become infected.
I first saw Guinea worm in a small village in Ghana, where about 350 of the 500 residents had worms coming out of their bodies. The villagers were assembled in an open space under large trees, except for about two dozen whose affliction was too great for them to walk or leave their hut. I noticed a lovely young woman on the edge of the crowd, holding a baby in her right arm, and after the ceremonies I went over to ask her the name of her child. But there was no baby; instead she was holding her right breast, which was almost a foot long and had a worm emerging from the nipple. Later I learned that a total of twelve worms emerged from different places in her body.
We had a wealthy man with us, and he paid for a well to be dug and a pump installed, so within a few weeks the pond was abandoned as a water source for the people. They have never had another case of Guinea worm in their village.
Like most other diseases in developing nations, Guinea worm especially affects the female members of a family. The first person expected to assist a sufferer is the mother or a girl child who must then be kept out of school. If people have learned the source of the disease, they naturally blame the women, who are almost invariably the ones who bring the water from the pond, often carrying five-gallon containers on their heads. To retrieve the water they walk into the pond, and if worms are emerging from their bodies thousands of eggs may be released to perpetuate the cycle. Fortunately it is also the women who assume responsibility for protecting their family and their village. For instance, more than 95 percent of our last remaining cases have been in South Sudan, where we are now concentrating our efforts. These final cases are very difficult to detect early and to control, and we have to expend an extraordinary effort to isolate people who contract the disease but also to monitor closely all the hundreds of villages whe
re another case might reappear. Although in South Sudan there were 520 cases in 2012 and only 113 in 2013, we have retained about 120 people on our fulltime payroll to perform these duties, most of them native to the area. They are assisted by more than ten thousand unpaid volunteers, all of them trained women who are trusted by other villagers.
Since the beginning of this effort in 1990, 131 women have served as our technical advisors, most of them holding a master’s degree in public health. They have served in Sudan, South Sudan, Togo, Benin, Uganda, Ghana, Chad, Niger, Ethiopia, Nigeria, and other endemic countries. At our Carter Center headquarters in Atlanta, women have led our effort to gain publicity for the program and to secure funding to cover its costs. All these women have interacted with each other and gained a special insight into the massive challenges and how to overcome them. Among the six thousand women who conducted the extensive survey to detect new cases in Ghana, one leader expressed the feeling of many of her fellow workers, most of them previously excluded from leading such efforts: “It’s about time they involved us. We’re the only ones who know how things work anyway.”
The final stages of eliminating Guinea worm disease from Nigeria were headed by the country’s former president General Yakubu Gowon. When excluded from a decision about how to treat a village pond in Nigeria, a group of women with newfound self-confidence confronted him and stopped the process because approval had been obtained only from the male village leaders. Gowon quickly corrected his mistake.
In the beginning one of our biggest obstacles was to educate people in all the small and isolated communities about this ancient blight and how to eliminate it. Without television or radio service and when communities five miles apart speak different languages and only a few men are just partially literate, we had to devise a completely new form of communication. We finally resorted to cartoons: simple drawings of women dipping water from a pond and drinking it. Those who were shown using a filter were all right, but the others had worms coming out of their body. Women wrote original plays and songs to explain the process and printed the colored cartoons onto cloth, which was used to make dresses and shirts for other members of their family. I was proud when they gave me one of the shirts on a visit with them.
Some of the people had never seen a picture or photograph before, and this would occasionally cause problems. One group of Peace Corps volunteers in a remote area of Niger made some of the drawings, showing the women standing in the knee-deep pond. When the villagers first saw the cartoon, a chorus of voices cried, “I’d rather have Guinea worm than no feet!”
Of all the “neglected” diseases on which The Carter Center has focused its efforts to control or eradicate, blinding trachoma is the only one twice as common in women as in men. It also is the only one of these diseases that I knew when I was a child. We depended on horses and mules to pull our plows and vehicles and raised cattle, sheep, hogs, goats, geese, ducks, and chickens to provide food for our family and surplus meat, eggs, and milk to sell for additional income. Our barn lot was usually ankle deep in manure and rainwater, and most of what my sisters and I swept from our yard with brush brooms was droppings from the free-roaming fowl. We were always surrounded by swarms of houseflies, even inside our home, despite screens on our doors and windows, and they were especially attracted to children’s eyes as they sought moisture and sustenance. Flies carry filth that causes infection, and I was almost constantly afflicted with sore eyes that my mother would treat to prevent development into the more serious trachoma. Some of our neighbors were not so fortunate. The advanced stage causes the upper eyelids to turn inward, slashing the cornea with every blink and causing blindness. I was reminded of this in more recent years when we visited the villages and homes of Dinka and Masai families in Kenya, Sudan, and other African countries. From a distance the children appear to be wearing eyeglasses; nearby, it is seen to be a ring of flies encircling their eyeballs, searching for moisture.
Except for cataracts, trachoma is the most prevalent cause of blindness, still afflicting tens of millions of the world’s poorest people. The Carter Center combats trachoma in almost a dozen countries in Africa, having begun this effort in Ghana in 1998. There is a comprehensive treatment program recommended by the World Health Organization that uses the acronym SAFE: surgery, antibiotics, face washing, and environment. We have eliminated blinding trachoma in several countries, and our major challenge is now in Ethiopia, where we have concentrated our efforts for many years. In 2000 the Pfizer pharmaceutical company agreed to my request for a free supply of azithromycin (Zithromax), which is the best antibiotic for treating trachoma. In November 2013 we administered our one-hundred-millionth dose. We have taught several thousand health workers, mostly women, to perform eyelid surgeries, a simple process with adequate training, and provided them with the necessary sterile instruments. They now perform about 40 percent of these operations in the world. We also marshaled schoolteachers and parents in the endemic areas to encourage children to wash their face, which they had never thought of doing before.
In correcting the problem in a community, women are the agents for change in health education, responsible for cleanliness in the home, taking care of laundry, and educating their children in hygienic behavior. In treating trachoma and other diseases on a broad scale, the Ministry of Health in Ethiopia has learned that women enjoy a greater level of trust from heads of households and better access to neighbors’ homes than men. We have been able to train 6,500 health extension workers in the Amhara region, and all are women. They lead teams that now distribute up to 20 million doses of Zithromax each year to treat infected eyes. In recent months the ministry has implemented a new all-volunteer corps of female health workers, called the 1 to 5 Health Development Army because they select one-fifth of the families and train them to minister to four others. Early in 2013 we mobilized over twenty thousand of these volunteers and saw the population coverage with Zithromax increase to almost 93 percent. Our health experts attribute this success to the Health Development Army having a personal and close relationship with their neighbors and therefore noticing if specific individuals are missing treatments.
Our specialists in trachoma observed that one new volunteer to become an “eye surgeon” had a scar on her eyelids. She explained that her advanced trachoma infection had been corrected by surgery performed by one of her trained neighbors. Her life was changed; instead of having a disabling condition leading to misery, poverty, and total blindness, she became an active health promoter for her community. She was proud yet tearful when she told her full story.
Having dealt with surgery, antibiotics, and face washing, (S-A-F), this left the problem of the environment (E): the ubiquitous flies that breed and feed on a constant supply of human and animal excrement and carry infection from one person to another. Surprisingly, it was a “women’s liberation movement” that gave us a major breakthrough in solving this problem. I remembered that we had had an outdoor privy behind our house (the only one on the farm) and that we had covered our home site with strong doses of powdered or liquid DDT, a poison that controlled flies, mosquitoes, and other insects. This was a key factor in ridding ourselves of both trachoma and malaria. (It was later learned that DDT was also eliminating butterflies and many birds, especially those species like hawks and other raptors that consumed bodies within which the long-lasting pesticide had accumulated, so the outdoor use of DDT is now prohibited throughout the world.) We knew that in Ethiopia and other regions in Africa many men simply step behind a bush to defecate and are often seen urinating alongside roads and highways, but we learned that it was absolutely taboo for a woman to be seen relieving herself. The most convenient recourse for themselves and their daughters was to find a concealed place in or around the family home. Working with local people, we taught them how to build latrines as a means to improve the environment by reducing the population of flies. It is a very simple design that consists of a hole in the ground, some way to prevent the hole from caving in while a pe
rson stands or squats over it, and an enclosure of brush or cloth for privacy. If the family provides the labor, the financial cost is only about a dollar. We were hoping for a few thousand latrines to be built during the first year, but the word spread from village to village as Ethiopian housewives adopted this as a practical move toward liberation, and the total number of latrines built that year was 86,500! By the end of 2012 we had seen 2.9 million latrines built as more wives and mothers demanded this beneficial addition to their freedom and health. I am proud of my growing reputation as the world’s most preeminent sponsor of latrines.
This somewhat humorous account illustrates that despite their inferior social status, these women were strong and even dominant, deeply involved in all aspects of improving health care, and extremely effective in solving their own problems, with associated benefits to their entire community.
In fact, though formerly excluded from positions of leadership or responsibility, dedicated and competent women have been the key to our success in every health project. We responded to a request from the prime minister of Ethiopia in 1992 to train health workers for the general population of about 82 million. He stipulated that they would not be permitted to leave Ethiopia in the process, as he was concerned that they would not return after graduation. We developed a curriculum for each of the diseases and health problems they faced (about seventy) and used local university campuses for classes. The final result after ten years was 7,000 graduates who have the capability of a physician’s assistant or registered nurse, plus 27,000 with training equivalent to a licensed practical nurse. This was enough to provide a female health worker for every 2,400 citizens, deployed as evenly as possible throughout the country.