(Audio by Odette Yousef; production by Eric Durban)

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(Photos by Odette Yousef)

Hygiene… and access to water

This woman travels 5 hours each day to get water, and says that after cooking, there isn't enough left for facewashing.

Facewashing is part of the multi-pronged strategy recommended by the World Health Organization, and is a focus of the trachoma control program in Ethiopia. Children, especially, are the targets of this campaign, because they tend to get dirty faces more frequently than adults.  Musca sorbens, the swarming flies found in northwest Ethiopia, feed off of discharge from the nose and eyes. In so doing, they often transmit the trachoma-causing microorganism from infected people to others.  Keeping one’s face clean can greatly reduce the risk of being infected.  In many parts of Amhara, the cleanliness of students’ faces has become a part of their daily evaluations, and children are taught to wash their faces thoroughly and regularly.

INTERACTIVE FEATURE

Children at the Wuchale Primary School in Amhara, Ethiopia demonstrate the facewashing exercises they are taught in class.

(Video by Odette Yousef; production by Eric Durban)

Early morning, a line of plastic, yellow jerrycans at a water pump, waiting to be filled.

But even something as simple as regular facewashing can be a challenge.  In rural Ethiopia, less than a quarter of the population has access to safe water — one of the lowest rates in the world.  In Amhara, getting water to drink and use for the day’s cooking is a deliberate and often time-consuming daily activity, which may involve as many as 6 hours of walking to a nearby public pump, waiting in line to fill jugs, then hauling them onto one’s back for a weary trek home.

INTERACTIVE FEATURE:

Women and children gather water at a pumping station early one morning.

(Video by Odette Yousef; production by Eric Durban)

The World Bank, the African Development Bank, and UNICEF are among the many groups that are trying to improve access to safe water in Ethiopia.  In the meantime, Paul Emerson, director of the Carter Center’s Trachoma Control Program, says villagers can at least benefit from lessons about how to use water efficiently:

“What we are promoting are things like ‘leaky tins,’ which are quite often gourds or plastic jerry cans, with a small hole stuck in the bottom of it plugged with a straw or a stick. Pull out the stick and you get a fine jet of water no more than an eighth of an inch across. You can use that little stream of water to wash your hands and wash your face. You can use one liter of water for about 20 kids, or 20 people, or 4 people in a household can wash their faces 5 times each with a liter of water.”

Sanitation and Latrines

Another long-term solution to trachoma is to reduce the population of flies that spread it.  In Amhara, the tactic is to eliminate their preferred breeding ground: human feces in the open field.  In 2006, only 8% of rural Ethiopia had access to improved sanitation facilities, according to the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.  The Carter Center estimates that more than 700,000 household pit latrines were built with its assistance in Amhara between 2002 and 2008. Latrines also have the added benefit of keeping children from getting common diarrheal diseases.

A typical household latrine in Amhara.

“Just the fact that you create in a village maybe 100 latrines, maybe that cost $1 each, and we taught them how to do this, that improves the quality of life of everybody in the village, as well as getting rid of trachoma.” - Fmr. President and Carter Center founder Jimmy Carter

Health Extension Workers show rural households how to construct, maintain, and use the latrines.  The pits are usually covered with a cement slab, and families often build a small structure around it of branches and a straw roof.

…through Children

“Now the importance of this message is that it’s the kids themselves who are empowered to protect themselves, they don’t have to wait for a benefactor to come along and do it for them.” - Paul Emerson, director of The Carter Center Trachoma Control Program

Where trachoma is highly endemic, children are often the most heavily infected group. They pass it on to the adults in their households, putting elders at risk of blindness.

Children serve as trachoma’s reservoir of infection, and it is often from them that adults get the disease.  But children are also one key to stopping trachoma’s spread.  The Ethiopian government and the Carter Center have created a curriculum that promotes facial cleanliness and awareness of trachoma in schools. Every morning, teachers inspect students’ faces for cleanliness. Those that are unclean are shown in the mirror, and then made to wash up.

Paul Emerson, director of the Carter Center’s Trachoma Control Program, says children are required to bring the lessons home, and to become effective educators in their own households:

“The kids will go home, and as part of the school health package one of the homework assignments is to find out if there’s anyone in their family or neighborhood with trichiasis, and to go and interview them. And then to report that back to the class, and to advise that person, how trichiasis is caused and that there is a free surgery available that can reverse the condition.”

One challenge of the endeavor has been to tie the relatively benign condition of sore eyes that children experience when they get trachoma, to the debilitating, blinding phase that can set in many years later, after repeated infections.  Some schools try to make that connection through games that underscore the value of eyesight, such as “pin the tail on the donkey.”

In Amhara, nearly two-thirds of the children are estimated to have active cases of trachoma.

Emerson says the curriculum also helps debunk a notion that is common in many places where trachoma is hyperendemic: that blindness from trachoma is an inevitable part of aging.

INTERACTIVE:

Narration by Fmr. President and Founder of The Carter Center, Jimmy Carter; and Dr. Paul Emerson, director of The Carter Center Trachoma Control Program.

Countering the Urban Rumor Mill

“One rumor is enough to destroy something really built and well-established, even. Because people start doubting and asking.” - Teshome Gebre, Country Representative for Ethiopia, The Carter Center

Although trachoma mainly affects rural areas, The Carter Center and the Ethiopian Ministry of Health expend time and resources educating dwellers of urban and peri-urban areas.  In the two months leading up to Maltra Week, targeted radio ads promoted the campaign, and a touring bus traveled into towns to host education and entertainment film nights.

Paul Emerson, director of the Carter Center Trachoma Control Program, says the target of these urban campaigns is young men, in their twenties.

“If there’s ever going to be a source of rumor or false information about the false campaigns, it always originates in this group of people. and they’re very well-connected, they have cell phones, they have relatives in the rural areas, and if they have a positive experience here, which they clearly are, then you get a very positive message going out, instead of the risk of a negative rumor coming out.”

Emerson says in the past, the program has had to counter rumors that their distribution of Zithromax, a drug that treats trachoma, was really a stealth family planning campaign engineered by the Ethiopian government.

“Maybe the most important of all, just to show people who have been hopeless in the face of trachoma for 10,000 years that something can be done about it, and that the people who are suffering from it themselves can help themselves, by getting rid of flies, by washing their face and so forth. This is very important.”  - Fmr. President and founder of The Carter Center, Jimmy Carter

• 75% of blindness globally is preventable or curable.
• The leading cause of preventable blindness is trachoma.
• Ethiopia is the country most affected by trachoma.

More than 80 million people are thought to have active Chlamydia trachomatis,  a disease found in areas of poor hygiene and sanitation.   Not to be confused with River Blindness, trachoma is bacterial, and is spread through direct or indirect contact with the infectious agent.  Repeated exposure over several years can ultimately cause blindness.

Once thought to be present in most countries in the world, trachoma is now concentrated in the most poverty-stricken regions of Africa, Asia, Central and South America, Australia and the Middle East.  The World Health Organization’s Alliance for the Global Elimination of Blinding Trachoma has committed to stamping it out by the year 2020.

What happens…

This man is in the final, blinding stage of trachoma, called trichiasis, where the eyelashes turn inward, scratching the cornea. To relieve the pain, he uses a technique common in Ethiopia: he epilates. Using tweezers, he has plucked out every single eyelash.

Trachoma affects the lining of the eyelid, causing it to form granule-like bumps, and to appear red and irritated.  Repeated infections over the years cause the underside of the eyelid to scar. The scar tissue pulls the eyelid inward, so that the eyelashes scratch against the cornea, a condition known as trichiasis.  The constant rubbing against the globe of the eye is painful, and causes sensitivity to light and particulate matter, like dust and smoke.  Within just 18 months, it can begin to cause irreversible visual impairment.  If not surgically corrected, it causes blindness.

How you get it…

The disease spreads when people live in close quarters, sharing bedsheets or washcloths with an infected person.  In some of the most affected areas of the world, including Ethiopia, the main vector of the disease is Musca sorbens, an eye-seeking fly that feeds off of ocular discharge of an infected person. When it later lands near another person’s eye, it spreads the disease.  Musca sorbens breeds outdoors in human stool, and is often found where people do not have access to latrines, toilets, or other sanitary waste facilities.

Children serve as a pool of infection for the microorganism, presumably because they tend to have dirtier faces that attract flies.  For reasons not entirely known, their infections rarely progress to trichiasis or blindness.  However, they do put adults in their household at risk.  Parents and grandparents are often infected through close contact with children in the household, putting them at risk for visual impairment.

The S.A.F.E. Strategy…

Students learn the S.A.F.E. strategy for trachoma prevention and treatment in schools.

The World Health Organization endorses a four-pronged approach to trachoma control, known as the S.A.F.E. strategy.

S - Surgery to correct inverted eyelids, which occur in the most advanced stage of trachoma.
A - Antibiotics, namely azythromicin, to treat trachoma infection.
F - Facial cleanliness, particularly important for children, to clear off infectious ocular and nasal discharge that attracts eye-seeking flies, and which they spread to other people.
E - Environmental improvements, such as the building of latrines and access to water.  Latrines help to reduce the population of flies that spread trachoma, and access to water promotes cleanliness.

In Ethiopia’s most trachoma-ridden region, the northwestern state of Amhara, the full S.A.F.E. strategy was first applied to selected areas in 2001.  Today, the full strategy covers nearly every district in that area.

“…the first day of the survey showed an extremely serious condition in Mitchell County, and one which demanded immediate and drastic action on the part of the local authorities.” - Dr. John McMullen, Report of Trachoma Clinic Conducted at Pelham, Mitchell County, Ga., November 14, 1921-April 1, 1922

INTERACTIVE FEATURE

Narration by Alan Kraut, Professor of History at American University in Washington, D.C.

Trachoma in Georgia: A “Serious Condition”

An eye doctor in Thomasville, Georgia, wrote to the State Health Department in 1921, concerned that several patients from Mitchell County in southwest Georgia presented with what appeared to be trachoma. Prior to that, a few cases of trachoma had been found in north Georgia, where the U.S. Public Health Service had surveyed 25 counties in 1913, and found seven cases. In response to the south Georgia’s letter, the State Health Department applied to federal officials for help. The U.S. Public Health Service sent Dr. John McMullen, a surgeon and epidemiologist, to investigate. (1)

McMullen arrived in September in Camilla, the county seat. The visit was noted by the weekly paper of nearby Pelham. It tied the investigation to the town of Hopeful, to the west:

“Dr. John McMullen, who is connected with the U.S. Public Health Services [sic] with headquarters in Kentucky, is in Camilla to conduct an investigation of a suspicious eye disease which has been reported from the Twelfth District… It seems that several people from the Hopeful neighborhood have recently been treated by a specialist for an unusual affection [sic] of the eyes showing some of the indications of the disease know [sic] as trachoma, a very serious and dangerous eye disease. ” (2)

Dr. John McMullen published this report after his investigation into a trachoma outbreak in southwest Georgia in 1921.

McMullen deemed the situation to be “an extremely serious condition” (3) and recommended the immediate opening of a clinic. County officials procured the use of a facility in Pelham that had previously been a private hospital, but had failed. It was opened in November of 1921, with 25 beds, and, according to McMullen’s report, patients “overran the hospital,” keeping the staff busy “practically all of the time.” (4)

“Aside from the public-health aspect of this question, many of the cases admitted to the hospital presented that pathetic appearance which is so commonly seen in the trachoma clinics and which appeals to the humanitarian side and stimulates the workers to the highest possible effort to retain the flickering light all but lost as a result of this mutilating disease.” (5)

The clinic, intended from the start to be only temporary, was open for four-and-a-half months, and McMullen reported that 200 cases of trachoma were cured. (6)

The building that once served as the temporary Pelham Trachoma Hospital on Curry St. has since been turned into a house.

The following year, Pelham reopened the trachoma clinic to handle some additional cases that were found. It’s not clear when that closed. (7)

A Second Outbreak

A larger outbreak in the same part of Georgia was reported just a few years later.  The cases began cropping up around 1930, and Georgia’s Health Department created a field unit to keep track of the disease, and handle existing cases.  They lobbied Georgia’s General Assembly for the money to do that:

“As an aid in securing the additional funds, the county health officer brought a number of children to the State Capitol who were suffering from the effects of trachoma and had them circulate through the vicinity so that the members of the Assembly could see the debilitating consequences of the menace.” (8)

It worked — the state funded the unit.  The outbreak extended beyond just Mitchell County, into neighboring Decatur County of Southwest Georgia.  Health officials found more than 3,000 cases of trachoma, and the unit operated for two years. (9)

SOURCES:

1. Abercrombie, Thomas Franklin. History of Public Health in Georgia, 1733-1950. Atlanta, Ga.: n.p. 1953.

2. “Trachoma, an Affection [sic] Reported in Hopeful Section.” The Pelham Journal 23 Sept. 1921: 1.

3. McMullen, John. “Report of Trachoma Clinic Conducted at Pelham, Mitchell County, Ga., November 14, 1921-April 1, 1922.” Public Health Reports (1896-1970) Vol. 37, No. 35 (Sep. 1, 1922): 2089-2094

4. Ibid.

5. Ibid.

6. Ibid.

7.   Annual Report of the Surgeon General of the Public Health Service of the United States. Washington: Government Printing Office. 1923: 74.

8.  Abercrombie: 82.

9. Ibid.

• Ethiopia has the highest proportion of people at risk of getting trachoma (85% of its population, about 65 million people)
• Ethiopia has the greatest number of people in the final, blinding stage of trachoma (more than 1 million)
• Ethiopia has the greatest number of people who have gone blind from trachoma (138,000)

Map by Golbez, under a Creative Commons Attribution 3.0 License.

The Carter Center has launched trachoma control programs in Ghana, Mali, Niger, Sudan and Nigeria, but its most challenging location is Ethiopia.  The Ethiopia program began in 2001, in partnership with the federal Ministry of Health and the Lions Clubs of Ethiopia.  It has focused its efforts on the country’s most affected region: the northwestern state of Amhara.  Two thirds of its work there has been funded by money raised by the Lions Clubs of Ethiopia, through the Lions Clubs International Foundation.  The antibiotic it has distributed, Zithromax, has all been donated by Pfizer.  The Center aims to effectively control trachoma in the region by 2012.

Amhara: Ground Zero

• Amhara accounts for roughly 20% of Ethiopia’s population.
• Amhara carries 45% of the country’s trachoma burden.

More than 85% of Amhara’s 17 million people live in rural areas, situated in the mountainous highlands.  They are overwhelmingly subsistence farmers, growing teff, a grain that is used to make injera, a spongy, flat bread typically served with Ethiopian meals.

The Amhara region of Ethiopia

In Ethiopia, Amhara has the highest rate of active trachoma in children aged 1-9 (62%), and the highest rate of adults who have reached the final, blinding stage of trachoma (5.2%).  The prevalence is attributed mainly to the area’s poverty, poor access to water, and poor sanitation.  Families live in small huts, crowding a small space in which it’s easy for disease to spread from children to the parents. And in some areas of the rural mountains, mothers or children have to walk hours to get water, and then lug it back home.  After cooking, drinking, and feeding the animals, there often isn’t enough left to wash hands, or children’s faces.  This contributes to the spread of trachoma.

The other major contributing factor in Amhara is the presence of swarming flies, Musca sorbens, that thrive in places of poor sanitation.  The flies like to breed in outdoor human stool, and they feed off of discharge around the eyes and nose. As they feed, they transmit the microorganism that infects they eyes with trachoma, from one person to the next.  Sanitation facilities have historically been lacking in Amhara — another effect of the region’s poverty.  Since 2003, however, hundreds of thousands of household latrines have been built with the help of The Carter Center and other development groups.  The country’s Health Extension Program has also incorporated latrine-building into the educational mission of its rural health workers.