Curing trachoma means eliminating poverty

Prime Minister Kevin Rudd has announced an allocation of $58 million to eradicate the eye disease trachoma from Indigenous populations.

Not before time. And it remains to be seen if this budget is not only enough to find all the cases of the disease in distant parts of this vast country and carry out treatment, but also to eliminate its major cause: extreme community, family and individual poverty. This requires considerable restructuring of the country’s economic landscape.

Australia is the only developed country with a substantial number of cases of this preventable condition which causes blindness. It is found in hot, dusty climates where there are swarms of flies, and has always been associated with profound material poverty. It was eliminated from Australia’s non-Indigenous population by the 1930s.

The US-based Carter Centre reports that trachoma, “the leading cause of preventable blindness worldwide”, is caused by infection with Chlamydia trachomatis bacteria, and is both treatable and preventable. It affects the poorest of the poor - “people marginalized and neglected in developing countries who are already struggling to survive” in Ethiopia, Ghana, Mali, Niger, Nigeria, and Sudan. Average life expectancy in these countries is 40 to 50 years, in Australia 80 years.

“Trachoma has blinded seven million people worldwide and an additional 500 million are living at risk. Compounding the misery of lost eyesight is trachoma's devastating economic and social impact on communities already on the edge of survival ... In the countries where The Carter Center fights trachoma, the average annual income is between US$100 and US$370” [my italics]. In contrast Australia’s average annual income is close to US$50,000.

In the 1920s young doctor Raphael Cilento (later to become Queensland Director-General of Health) was calling for clean water, sewerage systems and better living conditions to prevent hookworm, tuberculosis and trachoma among Aborigines.

In 1939 Australian Indigenous activist Margaret Tucker found “vile” housing and sanitary conditions at a New South Wales Aboriginal station, with health conditions “including rampant trachoma”. On housing, hygiene conditions and sewage disposal in remote communities, Ross Bailie wrote “Easy access to an adequate supply of water for washing is also critical to preventing a range of … infections, including … trachoma”.

Thus trachoma doubles as an individual severe sickness and also as a symptom of the material conditions that cause it. Medical programs and skills of a high order are essential to treat the disease and so are the radical community developments needed to obviate the extreme poverty that causes it. This could well cost much more than the $58 million of the current Australian government allocation.

It is more than 30 years since eye disease guru Fred Hollows’ treatment program was inaugurated with the kind of enthusiasm and energy the inimitable eye specialist could muster.

In his autobiography he describes a tour of outback communities as part of a medical exploration team, and wondered if they would find trachoma at Bourke, less than 800km from Sydney. He rang the ophthalmologist who paid periodic visits to that area and was told he would not find trachoma there.

“We'd arranged to do the eye examinations at the Bourke show-grounds … it was very hot and there were dust storms and willywillys making everything very difficult. The first kid arrived, a five-year-old and I decided I'd examine him for trachoma … there they were - those tiny accumulations of white blood cells, less than a millimetre in diameter, the trachoma follicles”. He thought “here's one that hasn't been picked up”, but the next five children he examined also had trachoma follicles.

“I was very annoyed for humanitarian and professional reasons. There was really no excuse for the complete non-detection of trachoma and I knew it meant that the Aborigines had to be living in sub-standard conditions”.

Hollows believed in the value of the right kind of publicity. “There is a very good record of the trachoma work on film and in print. Shaun McIlwraith, the medical correspondent for the Sydney Morning Herald travelled with us at various times, and his reports and feature articles helped to advertise the program and build the widespread public support we enjoyed.”

The publicity associated with Hollows’ visits to camps through South Australia, New South Wales, Queensland and the Northern Territory in 1974 “highlighted the need for a national attack on the trachoma problem”.

This was 35 years ago.

However, one of Hollows’ colleagues at that time, Hugh Taylor, now Professor of Indigenous Eye Health in Melbourne University's School of Population Health, told Dani Cooper of the ABC in December 2007 trachoma remained entrenched among outback Indigenous Australian communities. Following a five-week survey of the Katherine region in the Northern Territory he said the continuing high rate of trachoma in outback Indigenous communities was “a disgrace”, with up to half the children in some communities infected.

Taylor said Australia is the only developed country still to have this preventable disease and the nation was on track to be the last country in the world where the infection is endemic.

The advanced stage of trachoma is trichiasis and women are three times more likely to contract it than men. The condition not only causes severe pain it also makes it extremely uncomfortable for women to cook over smoky fires, collect water in bright sun, or farm in dusty fields. Thus women incapacitated with trichiasis become a burden on their families and communities where resources are scarce.

Professor Taylor’s survey of the Katherine region found one in 12 adults had in-turned eyelashes as a result of inflammatory trachoma as a child. These in-turned lashes rub the eye and cause blindness. “I expect one in six of the children are on the same escalator to trachoma as these older people”, Taylor said.

“The Aboriginal community is a non-written culture visually based so to have something that takes away their vision, particularly for elders, is devastating.” The infection, mainly spread through poor living conditions, affects communities found mainly in inland and remote Western Australian, South Australia and the Northern Territory. In coastal communities trachoma is less common because children's faces are kept cleaner by playing in water.

Up to now, “a lack of government commitment and targeted resources on the ground” have been the main impediments to eliminating the disease among Indigenous Australians, Taylor said.

Compared with Australia’s failure to eradicate trachoma Morocco had done so in 10 years.

In 2007 ABC Television reviewed the situation, introduced by Leigh Sales: “If you're old enough, you might remember the National Trachoma and Eye Health Program run in the outback in the 1970s by the legendary Professor Fred Hollows, who went on to become Australian of the Year. That program was meant to eliminate trachoma, the major cause of blindness among Indigenous Australians. But despite the enormous attention the work generated at the time, it faded after only a few years and now 30 years on, trachoma is still endemic among Aboriginal communities. Australia stands isolated as the only developed country in the world where trachoma is still a major public health problem.”

Reporter Murray McLaughlin reported on Minyerri, an Aboriginal community in the Northern Territory 200km southeast of Katherine where the 250-strong community was being screened for trachoma.

McLaughlin: “The National Trachoma and Eye Health Program ran for only three years in the late 1970s and screened more than 60,000 Indigenous Australians. It was directed by the late Professor Fred Hollows, who had always maintained his rage about the widespread and needless blindness caused by trachoma”.

McLaughlin said the screening team was finding more than 20 per cent of Aboriginal children up to 14 years had obvious signs of trachoma.

Katrina Roper of the Centre for Disease Control reported there had not been many full-scale studies of the level of scarring and trichiasis in older people. The condition was “a reflection on their poverty, their lack of access to water, lack of basic hygiene capabilities within some communities, due to distance, remoteness, infrastructure. It is disturbing that it is still a problem.”

The screening program was also supporting research by Cambridge University which was trialling a kit, like a pregnancy test, which instantly reveals the presence of trachoma. At present, the only certain test for trachoma is by DNA analysis, which can take weeks in a distant laboratory.

Professor Taylor has served on a World Health Organisation committee which reviews global progress on the elimination of trachoma. He reports his international peers say to him “Hugh, how can this still be a problem in Australia, a rich affluent country, a donor nation? How can there still be trachoma in the Aboriginal communities?”

He added “It's shocking to me to go back to some communities and find that nothing has changed in the last 25 or 30 years since we first worked in those communities”.

In his autobiography Fred Hollows said very few young people were actually blinded by trachoma, but some had undergone enucleation, removal of an eye.

When British atomic bomb tests were taking place in Western deserts some Indigenous communities were exposed to a plume, or cloud, of radiation fall-out. Blind man Yumi was a member of one such community. The question Hollows asked was: “did the exposure to radiation contribute to his blindness? An Aboriginal kid was blinded by trachoma and the same kid was exposed, at a particularly vulnerable age in respect of his immunological system, to radiation. How many such subjects were there? Babies and adults aplenty, scandalously. But how many young people, infected with trachoma, moving into the age zone when the immune system will contain or repel the disease, but not quite there? Very few. Of course, the authorities argued that the two things were unrelated. The South Australian authorities claimed that Yumi Lester's blindness was caused by measles - but that was their explanation for almost all Aboriginal eye disease. They were the people who told me to expect a 1 per cent trachoma incidence among Aboriginal kids whereas I found 80 per cent.”

Hollows found a good deal of follicular trachoma in Nepal for much the same reasons as in Aboriginal Australia - poor living conditions, inadequate water for washing, overcrowding. Seven women to every man were in this condition because of poor hygiene in the crèche. “The women were spending a lot of time among pus and other secretions, passing the chylamidial infection around.”

He reported trachoma in England was initially called “Egyptian ophthalmia” because it was thought that it had been introduced into Britain by seamen returning from the Battle of the Nile. It was these cases that led to the establishment of the first eye hospital at Moorfields in London.

“Whether that account of the origin of the disease in England is true or not, it was certainly the case that trachoma was widespread among the poor in Egypt. We were taken on a tour of some villages about 30 kilometres from Alexandria by a professor of ophthalmology. I took my magnifiers and torch and I was shocked to see many five-year-old children with advanced conjunctival scarring. Many of them were certainly on the road to trachomatous blindness. The people were subsistence farmers living in the most appalling conditions - no clean running water to the houses and the water they washed in was downstream from where people and animals urinated and defecate.”

For millennia poor conditions have produced poor health.