Looking Back on the Quest to Eliminate Trachoma

There are some patients you never forget — not because they are famous, but because of the story they have to tell and the everlasting impression it makes on you. 

In 1997, I was traveling through Africa as a young medical student and volunteer, teaching eye care staff at local clinics how to maintain microsurgical instruments and make some standard medical supplies themselves. I ended up joining the outreach project of an eye clinic I was visiting in the Jimma Zone of Ethiopia. One day while I was at the clinic, an older woman walked in. She explained to us that she had been blind for several years, but now, every morning when she woke up, she had to put margarine under her eyelid because, otherwise, she experienced unbearable pain every time she blinked.

I recall my brain working overtime in that moment but drawing a complete blank. This wasn't a common complaint I had experienced in clinics or something I had learned from my professors — it was something else. We examined the woman's eye. Her eyelid had completely turned in on itself, and her eyelashes were scratching her eyeball. The resulting damage and infections of the cornea and eyeball had caused her to go completely blind, but the agonizing pain caused by the scratching eyelashes remained. 

At that point, as a medical student trained in Europe, I was still clueless about what could have caused an infection with damage so painful that the patient had to resort to margarine for relief. The ophthalmologist running the clinic said nonchalantly, "Trichiasis due to trachoma. This is the end stage — nothing we can do anymore."

When the ophthalmologist saw my raised eyebrow and querulous expression, he explained that the cause was a bacterial infection of the inside of the upper eyelid that creates little blisters, which then heal into small scars. With repeated infections, the number of scars created becomes so great that they make the eyelid turn in on itself and cause the eyelashes to scratch the cornea — a condition known as trichiasis — ultimately resulting in blindness. In its early stages, the condition is easy to treat, but once the patient is blind, nothing can be done. 

Trachoma — the most common infectious cause of blindness globally — is estimated to affect more than 2.5 million people, according to a recent report from the World Health Organization. Women, particularly in low-income countries, are more susceptible to infection than men; this may be because, as primary caregivers in home settings, they have greater contact with children. The burden of trachoma is particularly high in Ethiopia and its Southern Nations, Nationalities, and Peoples' Region (SNNPR) districts.

Because of what I saw in that clinic, as well as several similar experiences, my career took a different path. Instead of pursuing my dream of becoming an ophthalmologist, I decided to focus on public health ophthalmology, starting as regional coordinator for Africa for Trachoma and River Blindness for Helen Keller International. In that role, I worked to implement WHO's SAFE strategy for eliminating trachoma: Surgery to correct trichiasis, Antibiotics to treat infection, and Facial cleanliness and Environmental improvements to limit transmission of infection.

Through that work, I learned that some of the most effective interventions for fighting the disease, while relatively straightforward, yield tremendous impact. Actions such as improving hygiene practices so that children's faces are kept clean, thus reducing the disease-spreading discharge from their eyes, or administering cost-effective antibiotics at the first sign of infection, can make all the difference in preventing the loss of sight. Other proven interventions, such as improving access to surgery for trichiasis and to safe water for face-washing, are more complex to implement, underscoring the need for continued investment.

When I served as director of the International Trachoma Initiative, we launched the Trachoma Atlas to help our teams and others map the spread of the disease and determine how best to target prevention efforts. It was daunting to see the number of districts in which trachoma was endemic (or suspected to be) at the time. But working together as a community, it has been nothing less than astonishing to track the changes in prevalence on the maps over time and see the impact we have made. Indeed, collaborations across the global eye health sector have led to an astounding 91 percent reduction in the number of people at risk of trachoma around the world since 2002.

Orbis International has been working in Ethiopia for more than twenty years. In fact, our Addis Ababa office was our first program office outside the United States and represented a major step toward building a sustainable legacy of quality eye care at the community level — a goal that continues to drive our work every day. Our efforts in SNNPR to date have resulted in the elimination of trachoma in six districts, with another six districts showing significant decreases. And last year, we were able to increase our support to ensure that all districts in SNNPR are covered by the SAFE strategy.

For more than two decades, the elimination of trachoma has been a major part of my life. I look back to where we were when I started on this journey and where we are today, and know that while there's still much more to be done, stories like the one told by the trachoma-affected Ethiopian woman who used margarine to treat her pain will soon be relegated to the medical history books.

Danny Haddad, MD, is chief of programs at Orbis International, a global nonprofit that has been transforming lives through the prevention and treatment of avoidable blindness for nearly four decades. With a network of partners, Orbis mentors, trains, and inspires  local eye care teams — from health workers in rural clinics to eye surgeons in urban centers — to work together to save and restore vision, ensuring that no one has to face a life of avoidable blindness.

(Photo credit: Martin Kharumwa/Orbis International)

Comments

[Munir Ahmed]

Wow! Excellent story telling depicting the sufferings, learning from a woman feeling and becoming a public health Ophthalmologist dedicated to his two decades of professionalism in Trachoma elimination in Africa. I find this article thrilling and inspiring for those works in public health and Ophthalmology in particular. As we live in a country without Trachoma so I find his story explaining About Trachoma and the strategy used which is wonderful. This has been a very simple and reader friendly article and for me , Danny has also show cased his best achievement in his lifetime I would imagine. Congratulations Danny!

[stefanie meredith]

On reading this I realise i should have written a post about my journey with onchocerciasis - thank you Danny, it has made me revisit my own path and interest in NTDs and the progress made.

[Ciku]

What a significant role you have played Danny in the fight against Trachoma! Congratilations. Keep it up till Trachoma is down to zero.