Eye of the Eagle

Volume 2, Number 2 THE CARTER CENTER July 2001 Sudan Treats More Onchocerciasis, Begins Trachoma Control In 2000

udan’s Onchocerciasis Control March 2, 2001. Sudan’s Onchocercia- the Year” (community directed dis- Program achieved considerable sis Control Program treated more than tributor) award to Ms. Elizabeth Sprogress against onchocerciasis 559,437 persons in 2000 compared to Henry, distributed more than 1,100 t- and trachoma during 2000. The 409,646 persons treated in 1999 shirts, posters sets, and illustrated flip- program reported this good news at (Figure 2). Almost 398,000 of the charts, and formed “Oncho Clubs” in the Fifth and Second Annual Program treatments in 2000 were in the Gov- seven schools in East Equatoria State. Reviews, respectively, of Carter ernment of Sudan (GOS) areas. Three members of the National Center-assisted River Blindness and Numbers from the Operation Lifeline Onchocerciasis Task Force from Trachoma Control Programs, which Sudan (OLS) areas (coordinated by Khartoum met with health authorities were held in Atlanta February 26- HealthNet International) are incom- from the Sudan Relief and Rehabilita- plete due to delayed reporting. Activi- tion Association and staff from the ties in parts of southern Sudan were Sudan People’s Liberation Movement What’s Inside impeded by increased insecurity and the withdrawal of several non-govern- continued on Page 2 More than 7 Million Treatments mental organizations Aided by Carter Center 2 (NGOs) in a dispute with FigureFigure 1 1 controlling authorities Focal Areas for Lions/Carter Center-Assisted Prevention of Blindness Programs 2000 Ethiopia Begins Treatment for there. The Ultimate Onchocerciasis 3 Treatment Goal for T Wadi Halfa Sudan is estimated to be Second Annual Review of 526,980 for the GOS Abu Hamad Carter Center-Assisted Trachoma O areas and 600,000 for the Control Programs 4 OLS areas. Treatments were conducted for the Trachoma knowledge, attitudes O T and practices in the South first time at Abu Hamad Gondar Zone of Ethiopia 5 and in the Al Baraka camp for displaced SAFE in the Amhara Region 6 persons in three new localities in Khartoum Lions International Receives North. O Raga Photo Album of Sudan TCP 7 The GOS program T Malakal held a successful On- Wau Sudan helps Yemen launch TCP 7 chocerciasis Day at Wau O O Tonj

in March 2000 that was O Tambura Yemen’s Trachoma Prevalence attended by the Federal O Yei O Juba Survey Model of Integration State Minister of Health. T Trachoma Control Program and Partnership 7 It presented a “CDD of O Onchocerciasis Control Program

W a g i n g P e a c e •w wF wi g. hc at ir nt eg r cD e i ns te ea rs .e o r• g B u i l d i n g H o p e 2 River Blindness

Sudan continued from Page 1 More Than 7 Million Treatments Aided by The Carter Center in 2000 in Nairobi in October 2000. Funding for the onchocerciasis activities is provided by the Lions-Carter Center total of 7,229,829 people were chaired by Dr. Frank Richards SightFirst Initiative and the African treated in Carter Center- (Technical Director, GRBP), were to Program for Onchocerciasis Control, and Aassisted Global 2000 river assess the status of each program and it is supported by two dozen other NGOs blindness programs (97 percent of the to determine impediments and (including Moslem Zakat Chamber, 2000 ATO). This represents an problems in program implementation. Sudanese Red Crescent/ICRC, and increase in treatments of 9 percent In attendance were GRBP country International Medical Corps). compared to 1999. Of the treatments representatives from Cameroon, Following KAP surveys and preva- in 2000, 7,015,575 (97 percent) were Ethiopia, Uganda, Nigeria, Sudan lence surveys conducted early in 2000, accomplished in partnership with the (Khartoum and Nairobi offices) and Sudan’s Trachoma Control Program Lions Clubs (LCIF) in Nigeria, Uganda, the Onchocerciasis Elimination began implementing all elements of the Cameroon, Sudan, and OEPA. Most Program for the Americas (OEPA). SAFE strategy in four villages around treatment activities in Africa were in Special guests included Professor Malakal in Upper Nile state in August collaboration with the African Program Mamoun Homeida, (Chairman, 2000. A total of 115 surgeries were done for Onchocerciasis Control (APOC). National Onchocerciasis Task Force, for trachomatous trichiasis and 12,671 A summary of treatment activities is Sudan), Ms. Irene Mueller (Program people were treated with Zithromax (78 provided in the treatment table (Table Manager, HealthNet International percent of the eligible population). In the 1, page 4). [HNI], Sudan, Mr. Peter Lynch town of Malakal average water supply was These gains were among the topics (Lions Clubs), Ms. Minnie Iwamoto increased from 11.5 to 47.4 liters per at The Carter Center’s fifth annual (Lymphatic Filariasis Program, Glaxo person as a result of a new water plant, review meeting for the Global 2000 SmithKline, Dr. Steve Blount (Direc- and pit latrines were increased to 47 River Blindness Program in Atlanta on tor of Global Health, CDC, Dr. percent of homes in 2000 (compared to February 26-28, 2001. The main Danny Haddad (Helen Keller World- 37 percent in 1999). Control measures purposes of the review, which was wide [HKW], Dr. Mary Alleman will be expanded in 2001 to at least 100,000 more people around Malakal, at Wadi Halfa and in Jongoli State, the latter Figure 2 with assistance of MEDAIR, Christian Mission Aid, and Adventist Development Sudan: Carter Center-Assisted Mectizan® Treatments as Part Relief Agency (ADRA). External support of the Total Treatments Provided, 1993-2000 for this program is provided by the Lions- Carter Center SightFirst Initiative, Pfizer 600,000 Inc., and the International Trachoma Other 500,000 Initiative. Prevalence surveys were Carter Center completed in March 2001 in camps for 400,000 displaced persons around Khartoum, and a national survey of nine states is planned 300,000 for later this year. The presentations for Sudan were 200,000 made by Professor Mamoun Homeida, 100,000 chairman of the National Task Forces for

Onchocerciasis and for Trachoma of the 0 Government of Sudan, Ms. Irene Mueller 1993 1994 1995 1996 1997 1998 1999 2000 of HealthNet International (river blind- ness), and Ms. Kelly Callahan of The Since 1997, GRBP activities in Sudan have been supported by Lions Clubs International Foundation Carter Center (trachoma).H W a g i n g P e a c e • F i g h t i n g D i s e a s e • B u i l d i n g H o p e 3 River Blindness

(Mectizan® Donation Program), and 2000 treatments, 619,719 were In OEPA, the strategy is to provide other observers. Each program made a achieved in collaboration with the two MectizanR treatment rounds per three hour presentation, with discus- LCIF in the West Province, while year in all endemic communities so as sions focused on treatment and 214,254 in the APOC supported to interrupt transmission of On- training activities, 2000 annual North Province project. chocerca volvulus, as well as stop treatment objectives (ATO’s), ulti- morbidity from river blindness. In mate treatment goals (UTG’s), Sudan order to reach this goal, all programs sustainability issues, Mectizan® (See article on cover page.) in the region will need to increase security, epidemiological assessment their treatment activities (Figure 4, activities, operations research, and OEPA page 8), especially in Venezuela, administrative issues. In the Americas, 367,619 people Ecuador, and Brazil, where semiannual A 2001 ATO of 8,016,909 for were treated with Mectizan in 2000, coverage is particularly low (41 GRBP-assisted countries was estab- 82 percent of their UTG and a 26 percent, 50 percent, and 56 percent lished at the conference, which percent increase compared to 1999. respectively).H includes projects for Ethiopia (see this page). The UTG (full coverage) of all GRBP assisted areas is 9,360,261 (Figure 3, page 4). Ethiopia Begins Treatment for

Nigeria Onchocerciasis GRBP, in collaboration with LCIF n March 2001 The Carter Center’s CDDs and health facility workers. and APOC, helped in treating Global 2000 River Blindness By the beginning of April 2001, 4,673,235 people with Mectizan in I Program assisted the ministry of treatment had started in all of the 2000. This was 88 percent of the health in launching the Ethiopia targeted woredas and by May, 203,884 Ultimate Treatment Goal (UTG), and Onchocerciasis Control Program in people had received treatment, 85 a 3 percent increase in treatments Kaffa and Sheka zones of the Southern percent of Ethiopia’s ATO! These compared to 1999. As the APOC Nations, Nationalities, and Peoples activities were undertaken by the assistance in GRBP programs in Region. The annual treatment Ministry of Health of Ethiopia in close Nigeria enters its fourth year in some objective for 2001 is to provide partnership with the Lions-Carter areas, the focus has been on MecitzanR treatment to 239,436 Center SightFirst Initiative and the sustainability and advocacy to mobilize people. The program also produced t- African Program for Onchocerciasis states and Local Government Areas shirts and posters that were delivered Control. (LGAs) to release funds budgeted for to zones for distribution to trachoma Congratulations to Ethiopia!H onchocerciasis activities.

Uganda The program in Uganda treated 903,429 people with Mectizan in 2000 in collaboration with LCIF and APOC. This was 97 percent of their UTG, and an increase in treatments of 10 percent compared to 1999.

Cameroon A total of 833,973 people were treated in Cameroon with GRBP assistance. This was 58 percent of the UTG, and a 23 percent increase in Barwick Rachel treatments compared to 1999. Of the A young woman’s height is measured and then Mectizan treatment is received in Kaffa zone, Ethiopia. w w w . c a r t e r c e n t e r . o r g 4 River Blindness

Onchoceriasis: 2000 Mectizan treatment figures for Global 2000 River Blindness Program (GRBP)-assisted areas in Nigeria, Cameroon, Uganda, and collaborative programs in Latin America and Sudan

Country/Tx TOTAL % ATO % ALL Category Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec GRBP TX NIGERIA *ATO(e ar p) 4,586,500 ATO(arv)= 7,712 TX(earp) 3,062 2,886 165,965 199,437 354,349 681,933 192,794 446,088 349,910 725,533 954,495 596,783 4,673,235 102% 65% TX(arv) 218 303 637 1,524 432 1,210 861 1,101 1,257 531 8,074 105% 57% UGANDA *ATO(e ar p) 931,568 ATO(arv)= 1,890 TX(earp) 12,539 817 776 156,414 97,087 150,257 189,757 80,853 134,964 41,985 18,344 19,636 903,429 97% 12% TX(arv) 490 162 339 134 221 544 0 1,890 100% 13% CAMEROON ATO(earp)=1,020,039 ATO(arv)= 2,611 TX(earp) 196,201 127,957 128,018 57,028 43,509 111,312 169,948 833,973 82% 12% TX(arv) 755 571 345 225 170 130 2,315 89% 16% OEPA* ATO(earp)= 411,044 ATO(arv)= 1,943 TX(earp) 188,238 101,024 31,171 47,186 367,619 89% 5% TX(arv) 1,053 343 222 148 1,766 91% 13% SUDAN ATO(earp)= 489,232 ATO(arv)= 593 TX(earp) 20,677 51,388 90,232 38,196 33,424 6,384 37,092 31,490 14,489 55,616 14,144 58,441 451,573 92% 6% TX(arv) Totals ATO(earp)= 7,438,383 ATO(arv)= 14,749 TX(earp) 36,278 55,091 445,211 394,047 681,061 966,531 547,661 615,459 574,043 915,922 986,983 891,994 7,229,829 97% 100% TX(arv) 0 0 1,271 793 1,554 2,434 777 1,569 1,474 1,775 1,257 679 14,045 95% 100% GRBP Cumulative totals= 28,406,539 ATO: Annual Treatment Objective, TX: Number Treated, earp: Eligible At Risk Population, arv: At Risk Villages (mass Mectizan treatment is provided) *OEPA figures reported quarterly Sudan figures only include GRBP-assisted treatments. A total persons treated in Sudan in 2000=559,437

Carter Center-assisted Programs: Mectizan Treatments 1996 - 2000, 2001 Annual Treatment Objective, and Ultimate Treatment Goal

10,000,000 9,360,261 9,000,000 8,016,909 7,229,829 8,000,000 6,655,929 7,000,000 5,626,767 6,000,000 5,090,511 5,000,000 3,828,180 4,000,000 3,000,000 2,000,000 1,000,000 0 1996 1997 1998 1999 2000 2001 UTG ATO

2/23/00 W a g i n g P e a c e • F i g h t i n g D i s e a s e • B u i l d i n g H o p e 5 Trachoma

medical care, they do not perceive the Trachoma knowledge, attitudes cost of tetracycline ointment to be a and practices in the South Gondar barrier. However, both villagers and health care workers reported that Zone of Ethiopia ophthalmic tetracycline is often not available in health centers or pharma- cies in villages and towns. Instead, n October 2000, The Carter with health workers, teachers and traditional medications, such as ICenter began a partnership with development agents suggest that these herbal remedies, kohl and butter are Ethiopia’s Amhara Regional individuals also need training on often used to treat active trachoma. Health Bureau to help control blind- trachoma control. n Access to trichiasis surgery ing trachoma in four districts of the n Facial cleanliness Women with trichiasis know that South Gondar Zone. The four dis- Most children in the study villages their condition can be treated surgi- tricts, Simada, Dera, Estie and had very dirty faces, with visible ocular cally, but report that they do not have Ebinate, are comprised of 157 sub- and/or nasal discharge, and/or at least access to those services. District and districts with a total population of five flies near the eyes. Children did zonal health centers do not have over one million inhabitants. not appear to be bothered by flies and surgeons or equipment to offer In February 2001, a qualitative did not shoo them away. trichiasis surgery. Trichiasis surgery is knowledge, attitudes and practices n Access to water available in regional hospitals, but this (KAP) study was completed including Access to water is not perceived to is not considered a viable option for focus group discussions with men, be a problem in any of the study many patients interviewed. As a women, and school children in all four villages. Water sources include hand result, trichiasis patients use tradi- districts. In addition, health workers, pumps, wells, rivers, and unprotected tional forceps to epilate their eye- schoolteachers and village chairper- springs. One respondent said that lashes and temporarily relieve their sons were interviewed, and environ- access to water is not a problem, but pain. mental risk factors for trachoma were that communities do not understand n Health education channels assessed. Dr. Tewodros Assefa, re- the appropriate uses of water. Villagers in the South Gondar gional team leader for prevention of n Latrine use Zone receive health education focus- blindness, directed the study teams. Latrines are not commonly used in ing on family planning and HIV/AIDS The Carter Center provided technical the communities visited. In some from village health volunteers. These and financial support, which was made communities, clean, uncovered latrines group discussions are held in possible by the Lions-Carter Center were found at the school, or in the churches, schools, village meetings SightFirst Initiative. Key findings of teacher’s house or chairman’s com- and other social gatherings. Outreach the study are summarized below: pound Community members reported health workers discuss children’s n Importance of eye disease that they are not accustomed to using health during monthly visits. Some Eye diseases, including trachoma, latrines, which are not part of their schools have used theater to dissemi- are perceived to be important health culture. Adults reported that they nate information to the entire com- problems, along with malaria and walk far from their compounds to munity. Access to radios was reported pneumonia. defecate in the bush. Children def- to be mainly limited to men. Women n Knowledge of trachoma ecate close to home. Direct observa- said they listen to music on the radio, Study participants are quite aware tion showed that there were human but do not understand the content of of what active, inflammatory trachoma excreta within 100 meters of the the messages transmitted.H is and have some knowledge of its compounds visited. transmission and prevention. Trichi- n Treatment of active trachoma asis is also well known but is consid- Study participants know that ered to be a different disease. In tetracycline ointment is used to treat addition, many persons hold tradi- active trachoma and can be purchased tional beliefs about both active from health posts. Although most trachoma and trichiasis. Discussions community members receive free w w w . c a r t e r c e n t e r . o r g 6 Trachoma Second Annual Review of Carter Center- Trachoma References Assisted Trachoma Control Programs Bowman RJ. Sillah A. Van Dehn C. Goode VM. Muquit M. mproving trachoma control efforts Vietnam and Tanzania who coordinate Johnson GJ. Milligan P. Rowley J. and strengthening the “F” and “E” TCP activities for the International Faal H. Bailey RL.” Operational Icomponents of the control strategy Trachoma Initiative (ITI) in those comparison of single-dose were targeted as specific recommenda- countries. Representatives of Lions azithromycin and topical tetracy- tions at the second annual program International, the Hilton Foundation, cline for trachoma.” Investigative review for Carter Center-assisted World Vision International, Pfizer Inc, Ophthalmology & Visual Science. trachoma control programs. The the International Trachoma Initiative, 41(13):4074-9, 2000 Dec. national program coordinators from Helen Keller Worldwide, the Centers Sudan, Yemen and Ghana represented for Disease Control and Prevention, Dobson R. “New fly trap may their programs at the meeting, held at and Emory University also attended. reduce prevalence of blindness The Carter Center in Atlanta March 1- Special sessions on health educa- from trachoma.” Bulletin of the 2, 2001. Regional program coordina- tion and disease surveillance generated World Health Organization. tors or other representatives from lively debate and illuminated interest- 78(10):1282, 2000. Ethiopia, Mali, Niger, Nigeria, and ing aspects of each program. Reports Ghana also presented. Nigeria was from the participants were very posi- Guzey M. Aslan G. Ozardali I. represented by The Carter Center’s tive, in keeping with the enthusiasm Basar E. Satici A. Karadede S. country director, Dr. Emmanuel Miri. with which the program coordinators “Three-day course of oral The Operation Lifeline Sudan/South rose to the challenge to make progress azithromycin vs topical oxytetracy- program, which is part of Sudan’s in 2000. At the conclusion of the cline/polymyxin in treatment of national TCP, was represented by Ms. meeting, the challenge was renewed to active endemic trachoma.” Kelly Callahan and Dr. Jeremiah make greater progress in 2001. All Japanese Journal of Ophthalmology. Ngondi, The Carter Center/Nairobi indications are that the programs and 44(4):387-91, 2000 Jul-Aug. resident technical advisor and TCP their partners are prepared to do just manager, respectively. Also participat- that.H Markel H. “The eyes have it: ing were the medical officers from trachoma, the perception of disease, the United States Public Health Service, and the American SAFE in the Amhara Region Jewish immigration experience, ast October, during the long drive from Ebinate to Bahir Dar after 1897-1924”. Bulletin of the History Lcompleting the qualitative knowledge, attitudes and practices (KAP) of Medicine. 74(3):525-60, 2000 study in the South Gondar Zone of Ethiopia (see article, page 5), Dr. Fall. Tewodros Assefa, Regional Prevention of Blindness Team Leader, Amhara Regional Health Bureau, and Ms. Misrak Makonnen of The Carter Center Wedner SH. Ross DA. Balira R. and their team, took on the challenge of translating SAFE into Amharic, Kaji L. Foster A. “Prevalence of the language of the Amhara Region, which includes South Gondar. Their eye diseases in primary school new acronym to describe the strategies for controlling trachoma is children in a rural area of Tanza- “Mamene.” Taken whole, mamene means believe, but the three letters nia.” British Journal of Ophthalmol- that spell mamene stand for: ogy. 84(11):1291-7, 2000 Nov. Ma – Maskorete, meaning surgery Me – Medehanit, meaning medication (including antibiotics) Ne – Netsehena, meaning cleanliness (both facial and environmental) Dr. Tewodros proposed this Amharic acronym to national and regional prevention of blindness workers at the Prevention of Blindness Workshop in February 2001, and it received enthusiastic approval.H W a g i n g P e a c e • F i g h t i n g D i s e a s e • B u i l d i n g H o p e 7 Trachoma Lions International Receives Photo Yemen’s Trachoma Album of Sudan TCP Prevalence Survey Begins r. James Zingeser, Carter Center D nder the leadership of Dr. senior epidemi- ologist, attended the USaleh A. Al-Shabba, general January 11, 2001, director, Prevention of Blind- SightFirst Advisory ness, and Dr. Abdul Hakeem Al- committee meeting in Oak Kohlani, general director, National Brook, Illinois. There, he Center for Epidemiology and Disease presented Lions Interna- Surveillance, in the Republic of Yemen’s tional with an album of his Ministry of Public Health, Yemen’s photographs documenting Trachoma Control Program began a the very successful launch national integrated trachoma preva- of Sudan’s national lence survey in February 2001. Dr. Al- Trachoma Control Kohlani designed this population-based, Programme in Malakal last two stage cluster survey to: August. Lions Interna- Lions Clubs 1. collect epidemiological data to tional President Dr. Jean Dr. Zingeser presents album to President Behar at Lions assess personal and environmental risk Behar graciously accepted Headquarters in Oakbrook, IL. factors for getting trachoma, including the album on behalf of the access to, and use of, latrines and water, Lions, thanking President 2. do ophthalmic and physical Carter and reaffirming Lions photographs document the treatment of examinations, and International’s commitment to the more than 12,000 men, women and 3. collect laboratory samples to Lions-Carter Center SightFirst Initiative, children in the Malakal area with test for evidence of systemic illness. which provided the funding to launch Zithromax, donated by Pfizer, Inc.H The survey, which will eventually the Sudan and Ethiopia programs. The cover all 20 governorates, began in four governorates with technical and financial support from The Carter Sudan helps choma prevalence survey. Dr. Malik Center and the World Health Organiza- also assisted Dr. Abdul Hakeem Al- tion. The initial four governorates Yemen launch Kohlani in designing the prevalence represent the four regions of Yemen, survey. On April 22, a team from one each from the coastal, middle TCP Yemen’s Trachoma Control Program, highland, highland and desert areas. In led by Dr. Saleh Al-Shabba, general addition to randomly sampled villages, r. Malik Ali Abdel Gadir, director, Prevention of Blindness, the ministry teams will visit schools to deputy director of Sudan’s D arrived in Khartoum to observe and collect disease and risk data from national Trachoma Control work with the Sudanese Trachoma school children.H Program, flew to Sana’a, Yemen on Control Program in Khartoum and November 15, 2000 to assist the Malakal. The Carter Center financed Yemen Trachoma Control Program. and coordinated the travel of Dr. Over the following two weeks, Dr. Malik and the Yemeni team.The Malik helped train ophthalmologists Carter Center’s assistance to Yemen is and epidemiologists in trachoma made possible by funding from the control and survey techniques in Conrad N. Hilton Foundation.H preparation for their national tra-

w w w . c a r t e r c e n t e r . o r g 8 Global Health News

Meetings Ethiopia PBL Workshop participants included prevention of blindness team leaders Workshop from the national and regional levels, Gates Foundation From February 12-16, Ethiopia’s regional health bureau staff from all of Federal Ministry of Health hosted a Ethiopia’s regions, as well as two Supports Conference National Workshop on the Prevention Lions: Mr. Ramendra Harjivan Shah on Eradicability of and Control of Blindness in Ethiopia and Dr. Tebebe Berhan (District at the Addis Ababa Hilton Hotel. The SightFirst Chairman for Ethiopia). Onchocerciasis workshop was organized in collabora- NGO participants included the hosts The Bill & Melinda Gates Foun- tion with the World Health Organiza- as well as World Vision, Help Age, dation has asked The Carter Center to tion, Lions Clubs International, Menchen fur Menchen, World Vision convene a conference of experts to re- Christoffel-Blindenmission (CBM), International and Mr. Teshome Gebre, assess the potential eradicability of ORBIS International, and the Interna- Ms. Misrak Makonnen and Dr. James onchocerciasis and to develop an tional Trachoma Initiative (ITI). Zingeser from The Carter Center. agenda for demonstration efforts and further research to facilitate eradica- tion or improved control of the disease. The conference will take place in January 2002 at The Carter Center, Atlanta, Georgia, USA. Donor Representatives Visit Ghana and Niger Hilton Foundation vice president Ms. Dyanne Hayes and Mr. Gil and Mrs. Sukey Garcetti, of the Roth Family Foundation, made a supervi- sory visit to Ghana, Niger and Burkina Faso with representatives of World Misrak Makonnen Participants in Knowledge, Attitudes, and Practices (KAP) study in Ebinate Woreda, Vision International, Helen Keller South Gondar Zone (see article on page 5). Worldwide and The Carter Center in January 2001. Ms. Hayes’ messages of encouragement, support and solidarity Onchocerciasis in the Americas: Percent of delivered on behalf of the Hilton UTG(2) reached in 2000, by country Foundation were enthusiastically well Ultimate Treatment received by host ministries of health Goal (2)* and partner organizations. C o lo m b ia 99% 2,202

Mexico 91% 317,648

Guatemala 74% 320,000

Brazil 56% 13,588

Ecuador 50% 38,642

Venezuela 41% 167,760 Disclaimer: Inclusion of information in Región 73% 859,840

Eye of the Eagle does not constitute 0% 20% 40% 60% 80% 100% 120% “publication” of that information. *Ultimate Treatment Goal (2) = UTG multiplied by two W a g i n g P e a c e • F i g h t i n g D i s e a s e • B u i l d i n g H o p e w w w . c a r t e r c e n t e r . o r g