where we work
The Carter Center has worked with the people of South Sudan since 1986, when that area was still part of Sudan. Since South Sudan's independence in 2011, the Center has continued to assist the newly established nation in resolving conflict, negotiating and preserving peace, and eliminating devastating neglected diseases.
After more than 20 years of civil strife that displaced millions of Sudanese and resulted in the deaths of nearly 2 million people, the Comprehensive Peace Agreement brought hope for a transition from a state of conflict to development, democracy, and peace. Calling for democratic elections throughout Sudan, the agreement offered a more transparent, representative political structure for all Sudanese. The Carter Center observed national elections in 2010 and the January 2011 referendum on the self-determination of Southern Sudan that resulted from the agreement.
The April 2010 elections in Sudan were mandated by the 2005 Comprehensive Peace Agreement. The Center launched its observation of these elections in February 2008 with the deployment of 12 long-term observers to assess the electoral process. An additional 20 medium-term observers were deployed to observe both static and mobile centers during the voter registration period, and in early April 2010, they were joined by 70 short-term observers to witness the balloting, counting, and tabulation processes for the national elections.
Although the election process was generally peaceful, Carter Center observers found it fell far short of Sudan's domestic and international obligations in many respects. Intimidation and violence in some areas of Sudan undercut inclusiveness; civic education was insufficient; the inaccuracy of the final voter registry prevented full participation in the process; insufficient materials were provided to many polling stations; the environment in Darfur did not support the holding of democratic elections; and vote tabulation throughout the country lacked important safeguards for accuracy and transparency.
The referendum on the self-determination of Southern Sudan was described in the 2005 Comprehensive Peace Agreement as the final benchmark of the agreement, which ended more than 20 years of civil conflict. The Carter Center undertook one of its largest election observation missions ever to help support this critical vote.
The Carter Center launched its mission to observe the referendum in August 2010, and in September deployed 16 long-term observers, followed in November by an additional 56 medium-term observers to assess the political environment surrounding voter registration. In addition to the long-term observers already on the ground, 30 observers traveled throughout Sudan to visit registration sites in the North and South, and 26 observers were deployed to the eight out-of-country registration locations. The Carter Center deployed more than 50 short-term observers to assess voting, counting, and tabulation for the referendum held Jan. 9-15, 2011.
The observation mission congratulated the people of Sudan for successfully conducting the historic referendum, which was marked by an overwhelming turnout during a peaceful and orderly seven-day voting period. The Carter Center found that the process was broadly consistent with international standards for democratic elections and represented the genuine will of the electorate. Despite many obstacles and challenges with administration of the referendum, almost all registered Southern Sudanese were able to exercise their right to .
Following the 2010 general elections and 2011 referendum, The Carter Center maintained a presence in both countries to observe each country's political environment and transition.
In Sudan, Carter Center experts tracked developments from Khartoum related to democratic processes, including discussions around anticipated popular consultations in Blue Nile and South Kordofan, remaining outcomes of the peace agreement, and a possible constitutional review process. The Center released public statements commenting on the popular consultations on , , and .
In South Sudan, the Center maintained its presence after the referendum to observe, analyze, and comment on the drafting of a transitional constitution as well as critical pieces of legislation that would become the backbone of the world's newest democracy: the political parties act and national elections act. The Center released a public statement on , on the draft transitional constitution, encouraging an inclusive process and consideration of key international standards, particularly that the principles of separation of powers be upheld. On , and , the Center released public statements offering analysis and recommendations for the Elections Act and Political Parties Act that reflected international standards and best practices.
The transparency and legitimacy of elections are greatly strengthened when national observer groups play a substantial role in providing accurate and impartial assessments of the electoral process. Around the April 2010 general elections, the Center supported six civil society organizations as they recruited, trained, and deployed 5,625 citizen observers. Partner organizations released regular public reports during the election period commenting on the elections and offering recommendations to improve the process. Partners noted that in some locations, there were inadequate materials, including ballots, and that identification procedures weren't always followed properly. They also pointed out problems with procedures for assisted voting that compromised the secrecy of the ballot, and reported intimidation and harassment of voters and observers.
For the 2011 referendum, the Center supported five organizations that recruited, trained, and deployed over 3,000 observers across all of Sudan's 25 states as well as Kenya, Uganda, and Ethiopia. The Center's support included technical and financial assistance to conduct a survey to gauge the integrity of the voter registration process, which, in combination with data gathered by observers during the registration process, allowed partner organizations to draw conclusions about the integrity of the voters list.
Since South Sudan gained independence from Sudan in 2011, internal conflicts have continued to plague the new nation.
Between 2010 and 2012, conflicts killed more than 4,500 people and displaced 20,000, and 1,800 children went missing. Then in 2013, President Salva Kiir accused former Vice President Riek Machar of mounting a coup, leading to the South Sudan Civil War. Tension between Kiir and Machar, in turn, sparked violence in Juba and elsewhere between government forces, often associated with Kiir's Dinka tribe, and members of Machar's Nuer tribe. The Sudan People's Liberation Movement-In Opposition (SPLA-IO), composed almost exclusively of ethnic Nuer, quickly formed around Machar, and significant clashes between SPLA and SPLA-IO erupted in late 2013, throughout 2014, and into 2015. The violence left an estimated 20,000 dead and displaced an estimated 2.1 million, many of whom fled to Ethiopia, Kenya, and Uganda or returned to Sudan. As of August 2015, food and physical insecurity within the country remained high, particularly in the predominantly Nuer-populated northeastern region where most fighting has occurred, and thousands are temporarily sheltered in United Nations compounds for their safety. In June, the U.N. released a report detailing atrocities, including rape and castration, committed by both government and SPLA-IO forces.
Mediation efforts undertaken by the Inter-governmental Authority on Development (IGAD) produced a series of frequently violated cease-fire agreements. However, in mid-August 2015 an IGAD-drafted peace proposal, which would create a 30-month interim period of shared governance between the SPLA and SPLA-IO pending new elections, was signed in Addis Ababa, Ethiopia, by the government, the SPLA-IO, and other parties.
The Carter Center regularly meets with South Sudanese actors and pays close attention the ongoing conflict, and is studying potential programming based on the evolution of the fighting and peace negotiations.
Since South Sudan's independence, South Sudan and Sudan have continued to experience tensions, primarily over the oil pipeline between the two countries, oil revenue, the disputed borderline, contested territories along the border, especially Abyei, and support to armed groups operating in the rival country.
The Carter Center's Conflict Resolution Program has been involved in attempting to resolve these disputes through support to the Sudan-South Sudan Dialogue Group, which is composed of prominent civil society figures and aims at creating a peaceful dialogue between the two countries in order to further normalize relations.
The contested area of Abyei, to which both Sudan and South Sudan lay claim, lies at the heart of current frictions. In March 2011, the Sudanese Armed Forces invaded Abyei, displacing over 110,000 Ngok Dinka residents of the area. Three months later, the Sudanese forces withdrew under an arrangement that saw the deployment of United Nations peacekeeping forces to the area. In October 2013, the Ngok Dinka held a unilateral referendum, not backed by Juba, Khartoum, or international actors, in which they overwhelmingly voted to join South Sudan. The vote, however, changed little on the ground, and the territory remains a no man's land.
In February 2012, Sudan and South Sudan signed a Non-Aggression Pact, in which each agreed not to interfere in the internal affairs of the other. However, in April, following skirmishes along the border, South Sudan seized the oil-producing area of Heglig. Soon after, the U.N. Security Council passed Resolution 2046 calling for an immediate cease-fire, the withdrawal of forces, and negotiations, and SPLA forces withdrew. As tensions eased, in September 2012 the two governments signed a series of Cooperation Agreements on economic and oil matters, borders, nationality, and security.
In 2013, in partnership with the Future Studies Centre in Khartoum and the Ebony Centre for Strategic Studies in Juba, The Carter Center launched a series of non-governmental dialogues between prominent leaders from Sudan and South Sudan in hopes of strengthening peace and creating a lasting understanding between the two countries. The initiative created a forum for key individuals to come up with ideas on what needs to be done in practical terms and in an achievable way. The initiative is co-chaired by Gen. Lazaro Sumbeiywo, chief mediator of the 2005 Sudan Comprehensive Peace Agreement, and Ambassador David Kapya, special adviser to the former president of Tanzania, Benjamin Mkapa. At present, the Dialogue Group primarily works to encourage at high levels the implementation of the 2012 Cooperation Agreements and other similar bilateral agreements between Sudan and South Sudan.
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With its vast distances, difficult terrain, and entrenched poverty, South Sudan is a challenging environment for resolving health issues. Nevertheless, The Carter Center is committed to improving conditions there.
Current status: Endemic
Indigenous human cases reported in 2023: 2*
Animal infections reported in 2023: 1*
Current Guinea worm case reports >
South Sudan is close to stopping transmission. It provisionally reported two cases in 2023 after reporting five cases in 2022. Residual challenges include sporadic insecurity, population displacements, and extreme mobility of cattle herders.
After South Sudan went more than a year and a half with no reported cases, the country’s health minister announced during a March 2018 news conference at The Carter Center that it had interrupted transmission of the disease. However, cases were subsequently discovered in newly pacified areas, and the country remains endemic.
When the Sudan Guinea Worm Eradication Program was initiated in 1995, civil war impeded access to many Guinea worm-endemic areas, especially communities in the south. The same year, President Carter brokered the "Guinea worm cease-fire," at the time considered the longest humanitarian cease-fire in history. Conflict was suspended for six months, allowing health workers to distribute medicine and preventative health measures including cloth water filters, ivermectin for river blindness, childhood immunizations, and vitamin A. During the cease-fire, the Guinea worm program was able to access more than 2,000 Guinea worm-endemic villages and distribute more than 200,000 cloth filters. The program continued to build on this initial success even as conflict resumed, distributing an additional 600,000 cloth filters over the next four years. Cases consequently declined from 118,578 reported in 1996 to 54,890 reported in 2000.
In 2001, The Carter Center and its partners, including Health Development International, Hydro Polymers of Norsk Hydro, Johnson & Johnson, and Norwegian Church Aid, spearheaded the Sudan Pipe Filter Project. In only a few months, the project worked to produce, assemble, and distribute more than 9 million pipe filters, one for each at-risk person in Sudan. These portable, straw-like plastic pipes equipped with nylon filters would help ensure that drinking water was free of tiny water fleas (copepods) carrying Guinea worm larvae. Additionally, a targeted health education campaign was launched, including flip charts, radio public service announcements, and community demonstrations. The last indigenous case was reported in 2002, thus interrupting indigenous transmission of Guinea worm disease in northern Sudan, currently the Republic of Sudan.
In 2005, the Comprehensive Peace Agreement interrupted Sudan's civil war and set a timetable for southern Sudan to declare its independence, thus bringing relative stability to the nation. The national program was able to begin surveillance activities in previously inaccessible areas in southern Sudan, and the number of Guinea worm cases reported in this region increased from 5,565 in 2005 to 20,582 in 2006 as improved surveillance revealed the extent of the disease in the south.
The people of southern Sudan voted overwhelmingly for secession from Sudan in January 2011. The newly independent Republic of South Sudan was officially established on July 9, 2011.
The South Sudan Guinea Worm Eradication Program reported 70 cases in 2014 compared to 113 cases for the same period in 2013, a reduction of 38 percent. This was a remarkable success in light of political and ethnic hostilities that broke out in December 2013 and spilled over into early 2014. Even given circumstances of unrest and an isolated outbreak (accounting for the majority of South Sudan's 2014 cases), the program continued to function at a high level by reducing and containing cases.
In 2015, South Sudan reported only five cases, a reduction of 94 percent from the previous year, and an overall reduction of more than 99.9 percent since 2006.
In 2023, South Sudan provisionally reported two human cases and one animal infection.
*All figures for humans and animals are provisional until officially confirmed, typically in March each year.
Since 2000, The Carter Center has assisted the Trachoma Control Program in South Sudan through prevalence mapping and the implementation of SAFE strategy interventions. SAFE represents the World Health Organization-endorsed four-pronged strategy to eliminate blinding trachoma as a public health problem: Surgery, Antibiotics, Facial cleanliness, and Environmental improvement. Trachomatous trichiasis (TT), the advanced stage of the disease, turns eyelashes inward, causing corneal abrasions and pain with each blink. A 20-minute surgical procedure turns eyelashes back outward, easing the pain and halting further damage to the cornea, reducing the threat of blindness. Antibiotics treat trachoma infection. Facial cleanliness is promoted through the provision of health education messages to communities. Environmental improvement is achieved by promoting the construction of household latrines to reduce the population of flies that may carry the disease from person to person.
Baseline prevalence surveys conducted in South Sudan between 2001 and 2023 showed that South Sudan is highly endemic for trachoma. South Sudan had some of the highest known trachoma prevalence levels in the world, with one baseline survey conducted in one county showing over 50% trachomatous inflammation-follicular (TF, an indication of the disease) in children ages 1 to 9 years, and 4% trachomatous trichiasis (TT) in adults 15 years and above. These far exceed WHO thresholds for trachoma elimination as a public health problem. Additionally, a TT surgical camp conducted in May 2023 in one county found a significant number of children as young as 5 years old suffering from the late-stage effects of the disease and needing surgical services to prevent blindness. TT is typically found in those 30 years and older and normally is almost unheard of in children. This data highlights the force of infection and severity of the disease in parts of South Sudan.
The Carter Center supports the SAFE strategy in South Sudan, including TT surgery for the advanced stage of the disease, and mass distribution of antibiotics in counties where clinical signs of trachoma are observed in 5% or more of children ages 1 to 9 years. Zithromax® (azithromycin, donated by Pfizer Inc) and tetracycline eye ointment, purchased by The Carter Center, are provided to all people living in endemic counties where The Carter Center works.
Since 2000, The Carter Center has assisted the national program with over 12,120 TT surgeries and the distribution of more than 4.7 million doses of azithromycin. Beginning in 2022, The Carter Center expanded its TT surgical outreach program to include the provision of cataract surgeries by partnering with the Himalayan Cataract Project, which resulted in over 1,100 patients receiving cataract surgery in a one-year period. The Carter Center has also supported the promotion of health education in over 3,200 villages and the construction of more than 600 household latrines.
Additionally, The Carter Center has been working to provide trachoma prevention services to South Sudanese internally displaced people (IDP) and refugees. In August 2019, a round of Zithromax was administered in two United Nations camps in Juba. A total of 25,035 IDPs from known hyperendemic areas were treated with antibiotics across both camps. Between 2019 and 2022 in White Nile state, Sudan, The Carter Center worked with the Sudan Ministry of Health to provide trachoma services to South Sudanese refugees through the provision of TT surgery and three rounds of mass drug administration to over 120,000 people.
South Sudan has set 2030 as its goal to eliminate trachoma as a public health problem. Much is needed to achieve this ambitious goal. First, more investment in eye care services and eye care professionals is required. This includes training and supporting more TT surgeons so that they can conduct sight-saving surgeries in their communities. Second, the full SAFE strategy must be implemented in all known endemic counties. Given how severe the burden of trachoma is in South Sudan, this will require partners and donors to invest in at least five to 10 years of programmatic support. Lack of road infrastructure, instances of insecurity, the remoteness of villages, and the need to import most food, consumables and medical supplies mean the cost of conducting programmatic interventions is higher in South Sudan than in other countries. Despite these challenges, The Carter Center has pledged to continue assisting the national program in the fight against blinding trachoma.
The Carter Center worked in Sudan from 1986 to 1992 to teach small-scale farm families superior farming techniques to increase grain crop yields. Led by the late Nobel Peace Prize laureate Dr. Norman Borlaug, the program was a joint venture between The Carter Center and the Sasakawa Africa Association. The program provided farmers with credit for fertilizers and enhanced seeds to grow test plots, often yielding 200 to 400 percent more crops. Participating farmers went on to teach others, creating a ripple effect to stimulate self-sufficiency. One notable success was for the period from 1985-1986 to 1991-1992, when wheat production increased by over 950 percent compared to the base year 1984-1985 and met country demand in 1991-1992.
Additionally, the program identified less costly, more efficient harvesting methods and local markets for these surpluses. The five-year project in Sudan was completed in 1992.
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