Áù¾ÅÉ«ÌÃ

Sudanese Civil War

Áù¾ÅÉ«ÌÃ’s long-term commitment to peace and health in Sudan began in the late 1980s during the height of the Second Sudanese Civil War (1983-2005). In 1983, the Sudan People's Liberation Movement/Army (SPLM/A), the major southern rebel faction, took up arms against the central government. While power and wealth-sharing were at the core of the conflict, seemingly intractable disagreements over the proper role of religion in Sudan and independence for the south often defined the civil war. No solid statistics exist, but experts estimate that the war claimed between one and two million lives, mostly from illness induced by war and famine.

President Áù¾ÅÉ«ÌÃ's first direct mediation effort was between the Sudanese government and the SPLM/A in Nairobi, Kenya, in 1989. He remained in close contact with the leadership of the parties and other key players. In 1995, President Áù¾ÅÉ«Ìà secured a cease-fire from President Omar Al-Bashir and SPLM/A leader Dr. John Garang to allow for the treatment of Guinea worm and other diseases, including polio and river blindness. The "Guinea worm cease-fire" lasted almost six months.

In 2002, regional and international stakeholders, including the United States, made a significant effort to help the parties reach a peace agreement. In March of that year, President Áù¾ÅÉ«Ìà met with Al-Bashir in Khartoum and SPLM/A leaders in Rumbek in southern Sudan. Later that month, President Áù¾ÅÉ«Ìà hosted Garang at the Center in Atlanta for further talks.
These and other efforts eventually led to a Comprehensive Peace Agreement, signed in January 2005, between the government of Sudan and the SPLM/A. The Center supported the peace process by providing training to both sides and intervening in other ways to support the mediation effort led by the Intergovernmental Authority on Development.

Áù¾ÅÉ«Ìà Center Efforts in Sudan-Uganda (1999 – 2003)

During Sudan’s second civil war, the internal conflict between the government of Sudan and the SPLM/A was complicated by hostilities between the Sudanese and Ugandan governments, stemming in part from alleged links between the Ugandan government and the SPLM/A as well as between the Sudanese government and the Lord's Resistance Army (LRA). For many years, the LRA terrorized northern Uganda, attracting particular attention with its use of child soldiers.

In 1999, President Áù¾ÅÉ«Ìà and the Center negotiated the Nairobi Agreement between Sudan and Uganda, in which both sides committed to stop supporting forces acting against the other and agreed to reestablish full diplomatic relations, opening the door for improved regional relations.

Read the Nairobi Agreement, Dec. 8, 1999 »

Following the signing of the Nairobi Agreement, the Center assisted Sudan and Uganda with its implementation, convening a multitude of ministerial and security meetings between the two governments and other stakeholders.

War in Darfur and the “Two Areas” (2003 – Present)

The end of the Second Sudanese Civil War did not bring peace to Sudan. Conflict in the country’s western region of Darfur erupted in 2003 and quickly escalated. In 2011, as the war in Darfur continued, a second conflict broke out in South Kordofan and Blue Nile, two states in the southeastern part of Sudan. The war in the “Two Areas,” as the two states are known, pits the government against the Sudan People’s Liberation Movement/Army-North (SPLM/A-N), a movement largely composed of former SPLM/A fighters from border regions that remained part of Sudan following South Sudan’s secession. As of December 2019, an estimated 780,000 people had been displaced by the conflict in the Two Areas, while an estimated 2.7 million remain displaced by the fighting in Darfur.

Áù¾ÅÉ«Ìà convened meetings of government officials, opposition leaders, and civil society members to discuss possible paths to peace and also conducted various behind-the-scenes efforts to try to help bring an end to conflict.

Sudan-South Sudan Dialogue Initiative (2013 – 2015)

Since gaining independence in 2011, South Sudan has continued to experience tensions with Sudan, primarily over the oil pipeline between the two countries, oil revenues, contested territories along the disputed border, and the support of former armed groups operating in the rival country.

In 2013, Áù¾ÅÉ«Ìà launched a series of nongovernmental dialogues between prominent civil society leaders from Sudan and South Sudan in hopes of creating lasting peace and further normalizing relations between the two countries. The initiative created a forum for key individuals to voice their own opinions and devise their own solutions.

Sudanese Revolution (2018 – 2019)

In December 2018 rising food prices and eroding economic opportunity sparked popular protests across Sudan. Led largely by young people and women, the protests culminated in April 2019 with the ouster of President Al-Bashir after 30 years of rule. Eventually, civilian and military leaders negotiated both a political agreement and a constitutional charter, inaugurated a civilian prime minister and cabinet, and began reforms for a three-year transitional period toward democracy.

Áù¾ÅÉ«Ìà regularly meets with civilian government, military, and civil society leaders and is closely following the ongoing transition as it considers potential activities to help encourage a sustainable democratic transition and lasting peace.

Disease and conflict overlap in many of Sudan’s peripheral regions. Even in areas without active war or violent clashes, elements of conflict persist. There are underlying tribal tensions, a scarcity of resources such as water and land, and frequent population displacement. These factors significantly impede public health campaigns, including disease control, elimination, and eradication.

In 2017, Sudan’s Federal Ministry of Health asked the Center’s Conflict Resolution Program to support durable peace in areas where conflict hampers disease control. Since then, the Center has conducted research, convened stakeholders, and begun programming to simultaneously fight disease and wage peace in two distinct corners of Sudan.

One of those places is the Radom area in South Darfur, which has some of the highest rates of disease in Sudan and is therefore a target of Sudan’s Federal Ministry of Health for elimination of river blindness. Radom is one of the poorest, most remote, and inaccessible regions of Sudan.

In recent years, it has experienced a large demographic shift, with as many as 60,000 gold miners and 20,000 refugees from neighboring South Sudan and elsewhere entering the region. This shift, combined with scarce resources and existing local conflicts between farmers and nomads, puts the area at risk for widespread conflict. Áù¾ÅÉ«Ìà is working to develop and support a grassroots mechanism for conflict management, which has the potential to reduce conflict and make the area accessible to public health workers.

The Center also works in Blue Nile state, where a decade of conflict has prevented humanitarian access to territory under SPLM/A-N control. Áù¾ÅÉ«Ìà connects stakeholders in the Federal Ministry of Health to the Blue Nile Peace Council and SPLM/A-N. Through conflict prevention and mitigation efforts, the Center is trying to help create an enabling environment for public health campaigns.

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. Áù¾ÅÉ«Ìà observed national elections in 2010 and the January 2011 referendum on the self-determination of Southern Sudan that resulted from the agreement.

2010 National Elections

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, Áù¾ÅÉ«Ìà 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.

January 2011 Referendum

The referendum on the self-determination of South 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. Áù¾ÅÉ«Ìà undertook one of its largest election observation missions ever to support this critical vote.

Áù¾ÅÉ«Ìà 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. Áù¾ÅÉ«Ìà 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. Áù¾ÅÉ«Ìà 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 .

Transition Monitoring

Following the 2010 general elections and 2011 referendum, Áù¾ÅÉ«Ìà maintained a presence in both countries to observe each country's political environment and transition.

In Sudan, Áù¾ÅÉ«Ìà 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.

Supporting Nonpartisan Citizen Observers

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.

Current Status: Indigenous Transmission Stopped, 2002
Certification of Dracunculiasis Elimination: Pending

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 Áù¾ÅÉ«Ìà 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 about 54,890 reported in 2000.

In 2001, Áù¾ÅÉ«Ìà 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, documenting the interruption of indigenous transmission of Guinea worm disease in northern Sudan, currently the Republic of Sudan. (Note: While the Sudan Guinea Worm Eradication Program continued after 2002, its focus was on the southern region of the nation, which seceded from Sudan in 2011 and became the independent country of South Sudan. The is ongoing.)

In 2013, when three cases of Guinea worm were reported in the village of Kafia Kingi, near the Sudan-South Sudan border, Sudan's Ministry of Health immediately conducted active surveillance and interventions in Kafia-Kingi and four nearby villages. Although the program suspected that the cases were imported from South Sudan, village volunteers continued to conduct health education and house-to-house searches for cases twice a month, distribute cloth filters, and apply Abate, donated by BASF, to water sources monthly. Since then, no additional cases have been reported in Sudan.

For additional information and updates on the program activities below, read the latest issue of Eye of the Eagle.

Áù¾ÅÉ«Ìà began assisting Sudan's River Blindness (onchocerciasis) Program in 1995, formally establishing a presence in 1997 after the Center secured funding from the Lions Clubs International Foundation. Since then, the Center has worked with the government, other nongovernmental organizations, and the African Program for Onchocerciasis Control, under the umbrella of the National Onchocerciasis Task Force, to establish community-based treatment programs, which raise awareness in villages and enable the distribution of Mectizan® (ivermectin, donated by Merck & Co., Inc.).

Áù¾ÅÉ«Ìà has worked with the national program in three focus areas in Sudan: Abu Hamad (River Nile state), Radom (South Darfur state) and Galabat (Gedarif state). In December of that year, at the invitation of the government of Sudan, the Lions-Áù¾ÅÉ«Ìà Center Sightfirst Initiative expanded technical and financial assistance to support a new onchocerciasis elimination effort in the isolated desert focus of Abu Hamad, with a strategy based on increasing mass distribution of Mectizan from annual to every six months as a part of the country's staggered shift from control to elimination. The following year, Sudan began scaling up treatments to twice per year.

After a Áù¾ÅÉ«Ìà Center-supported impact assessment in Abu Hamad in 2011 concluded that transmission had been interrupted, the government formally announced success in the focus area, which entered a three-year post-treatment surveillance (PTS) period in May 2012. During this period, health education was provided at the community level, schools, and mosques to inform community members why biannual mass treatment was halted while surveillance of river blindness vectors continued. The communities were also sensitized about their responsibility to report any potential cases of onchocerciasis to ensure prompt diagnosis and treatment.

During the PTS period, there was no evidence of renewed transmission of the disease. The Sudan Federal Ministry of Health on Oct. 15, 2015, officially announced elimination of transmission of onchocerciasis from Abu Hamad. Abu Hamad is the first African focus to complete the WHO guidelines and demonstrate elimination of river blindness transmission.

The Galabat subfocus of Gedarif State is part of a cross-border focus with Ethiopia, known as the Galabat-Metema focus. Mass treatment in Galabat commenced in 2007 with annual treatment with ivermectin and increased to two treatment rounds a year in 2011. Interruption of transmission was coordinated with Ethiopia, and the entire cross-border focus was reclassified as “transmission interrupted” in 2018 after meeting the WHO verification guidelines. The last mass treatment with ivermectin was provided in 2017, and the focus began the PTS period in 2018. Assisted biannual treatments from 2011 varied due to population movements, with a low of 97,139 and a high of 133,626 (for a mean of 118,696). Áù¾ÅÉ«Ìà has also assisted treatments in Radom focus, but due to security concerns, the mapping of this focus has never been done, and the affected population is not known. Other known onchocerciasis foci are in Blue Nile state (Geisssan, Wad ElMahir, and Khory Bus). The potential for cross-border transmission of onchocerciasis is high, but again due to insecurity, mapping of these foci has never been completed. However, the recent political changes in Sudan give hope that security will improve so mapping of these foci can be done soon, the population affected can be known, and treatment can commence. The Federal Ministry of Health pays for the entire program, with Áù¾ÅÉ«Ìà supporting some assessment activities through a molecular lab equipped and trained in collaboration with program partners at the University of South Florida.

Since 1999, Áù¾ÅÉ«Ìà has assisted the full SAFE strategy in Sudan in collaboration with the government and funding partners. SAFE represents the World Health Organization-endorsed four-pronged strategy to eliminate blinding trachoma as a public health problem. SAFE stands for 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.

The Federal Ministry of Health (FMOH) of Sudan has been working toward trachoma control since 1962, when trachoma was incorporated into the National Program for the Prevention of Blindness.

Between 2006 and 2020, Áù¾ÅÉ«Ìà supported the majority of baseline prevalence surveys across the country. As of March 2023, only 11 localities remained to receive baseline surveys, all located in the Darfur region.

Between 2000 and 2023, Áù¾ÅÉ«Ìà supported 13,089 TT surgeries in Sudan to prevent immediate blindness. Áù¾ÅÉ«Ìà has also assisted in the distribution of over 9 million doses of Zithromax® (azithromycin, donated by Pfizer Inc) and tetracycline eye ointment for those ineligible for Zithromax, through mass drug administration campaigns to control the progress of the disease. During these campaigns, health education is provided to community members to demonstrate how to prevent and treat trachoma. Additionally, Áù¾ÅÉ«Ìà has worked with Sudan’s National Trachoma Control Program to develop school health education materials, while the National Centre for Curriculum and Education Research and Federal Ministry of Education revised and approved the trachoma curricula. Together, the FMOH, the Federal Ministry of Education, the National Trachoma Control Program, and Áù¾ÅÉ«Ìà produced teachers’ guidelines for basic and secondary schools on how to deliver information related to trachoma control. After years of implementing programmatic interventions, Áù¾ÅÉ«Ìà supported the FMOH to conduct impact surveys in multiple localities, with results showing significantly reduced trachoma.

In addition to work done at the local level, Áù¾ÅÉ«Ìà has been a leader in advocating for implementing trachoma programs in camps for refugees and internally displaced people, particularly Ethiopian and South Sudanese refugee camps in Gedarif and White Nile states, respectively. Over 200 individuals in South Sudanese refugee camps have received surgical services, and over 420,000 Ethiopian and South Sudanese refugees were treated with antibiotics in addition to receiving health education.

In 2022, the trachoma elimination target date was revised from 2020 to 2030. Insecurity and increasing inflation have made program implementation difficult and costly. In April 2023, a civil war broke out in Sudan, and the country remains inaccessible as a result. Despite these challenges, Áù¾ÅÉ«Ìà has pledged to continue supporting the national program in the fight against blinding trachoma.

Áù¾ÅÉ«Ìà works with the Sudan Federal Ministry of Health in the Public Health Training Initiative, a joint effort to improve the training of health professionals who work directly with women and children. The initiative focuses on improving the learning environment of adult students and midcareer professionals such as nurses and midwives.

Áù¾ÅÉ«Ìà 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 Áù¾ÅÉ«Ìà 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.