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Reflecting on the past and looking forward towards elimination

In this video Allen Foster reflects on his experiences treating trachoma in the 70s and 80s and looks forward to the global elimination of trachoma.
[Daksha Patel] So Allen, for over the five weeks, we have covered everything from what is trachoma and where to map and how big is the problem, and then how to implement this SAFE strategy. And finally, in this final week, we’ve looked at what does it mean to do a validation process and complete the dossier for WHO? But ultimately, it is about the patient with trachoma. So you’ve been involved with trachoma for many decades. What would you say has been your experience as a clinician? [Allen Foster] I can remember, Daksha, when I, as a young doctor, first went out to Tanzania, to work in Tanzania.
And I’d trained in England and, of course, I’d read about trachoma and may have even written essays about them for exams. But I’d never actually seen a patient with trachoma. And arriving at the hospital where I ended up working for the next 10 years, my interest really was about cataracts, because one wants to operate on cataracts and help people see again after cataract surgery. But I was just amazed by the number of patients that came with trichiasis and really bad trichiasis, entropion as it’s called, with both upper eyelids turned in, and also with blindness from the corneal scarring.
So that was really my first exposure to trachoma was to see these patients come in who were blind, who thought that they might get cataract surgery, but actually they were blind from trichiasis and from trachoma. And so one of the things I had to do was to learn to do trichiasis surgery. I had never done one in my training. And, fortunately, there was a senior ophthalmologist who was working at another hospital, and he occasionally came to visit. And so he taught me how to do my first trichiasis operations. And I also remember reading an article in the British Journal of Ophthalmology written by John Sandford Smith in 1975, describing how to do trichiasis surgery. So that’s how it started.
And I have to say, at that time, it was mainly about patients with trichiasis and entropion and then, of course, I started teaching nurses how to do the surgery, because there were so many to do. But we didn’t actually see a lot of patients with active disease. And the reason is they were in mainly children, and they were not coming to the clinics as such with that problem. Although I do remember one kind of youngish woman coming, who had very severe active trachoma with pannus, so the vessels were growing into the cornea in both eyes and really beginning to obscure her vision.
And I remember I actually decided to treat her with systemic antibiotics instead of just with topical tetracycline ointment, because that’s what we had in those days. It was the tetracycline ointment. And using the systemic tetracycline and seeing the pannus actually regress and disappear. So that was my initial experience as a clinician. It was patients who were blind with trichiasis and trying to help them save whatever vision they had left and at least make them comfortable. Subsequently, the antibiotic eye ointment was replaced by the tablet azithromycin, a one-time dose. And then, of course, that was revolutionary in terms of reducing disease prevalence and reducing transmission. [Daksha] So, Allen, it appears that success for eliminating trachoma is possible.
What would that mean for global health? [Allen] Let me go back to the kind of origins of where I started it. I remember going to an area which was called Kongwa, which was very near to where I worked and was a district. And when you went there, you were just amazed or overcome by the problem of the disease. So you would have women 40, 50, 60 totally blind, being led around by young children– blind from trichiasis and trachoma. And then you would have the younger mums, the kind of 20-year-olds, lashes beginning to turn in, finding it difficult to see with the pain, not able to look after their children, get the water, and things like that.
And then if you go to the schools, children rubbing their eyes, discharge, not being able to focus, not being able to kind of pay attention and read and get the education that they need. That was Kongwa in the 1970s, into the early 1980s, as a whole district. If you go to Kongwa today, it is totally different. So you don’t find women with trichiasis and entropion. The grandmothers can help the mothers, and the mothers can see and look after their families. They can do work and have employment or money coming in from the farming that they do. The children going to school haven’t got watery, sticky eyes anymore. They can concentrate and so on.
So the disease trachoma 30 or 40 years ago affected the whole community and its health and, not only its health, but its kind of economy and its development. It was something that just pressed it down. It was everywhere and kept the society, kept the community, down. Today that disease has disappeared, and the community is lifted up. Generally, the health is better, and the economic development of the villages are much, much better as well. So that’s what’s happened with trachoma in that one district, but it’s now happening in more than 1,000 districts around the world.
And in some places it’s already totally happened and eliminated and even some countries have totally done it, countries like Morocco and Oman have eliminated trachoma all together. In other districts, some districts are done, but some other districts still have to be done within the country. In other places, it’s happening, but it’s earlier on. And in other places, they’re only still just beginning to get going with the programme to eliminate trachoma. But it will happen in the next five years and so those 1,000 districts around the world which have been suppressed will be lifted up. And instead of having poor health, their health will be better. And instead of having suppressed economy, their economy will be better.
The women will be able to farm. The children will be able to go to school. There will be work opportunities, education opportunities, because trachoma has been eliminated. So that’s the impact it has. It must not just be seen as an interesting eye disease. It’s far more than that. And I think in looking at that vision of success for the future, we have to acknowledge the many players that have made it possible. And particularly recently, the donation programme from Pfizer of Zithromax has made a tremendous difference to treating the infection, interrupting transmission, that means the whole natural history of eliminating the disease can be shortened because of Zithromax.
To ITI, International Trachoma Initiative, who have looked after that programme and given a focus to elimination and to all the other NGOs who have been involved as well in developing the safe programmes in countries and supporting them. Of course, to the World Health Organization, because they provided the leadership for trachoma control around the world. And with them, not forgetting the governments, because the governments have given the resources, particularly those governments that have invested in water and sanitation and in health, because that’s the way to actually get rid of trachoma and therefore to lift up the people within those countries and to give economic development.
But the fight is not over, although the end is in sight, although we can see that trachoma will be eliminated in our lifetimes, there are still battles to be won in some parts of the world. [Daksha] Thank you, Allen, for sharing your personal experience with trachoma and the journey that you’ve followed for the last 40 years and how sharing that vision of success that we are likely to have if we eliminate trachoma. So I’d also like to thank all the participants who have done this course on eliminating trachoma, and we hope that you are able to implement all the things that you’ve learned on this course. So thank you.

Public health can be defined as “efforts to protect, promote and restore the people’s health”. It is a combination of sciences, skills and beliefs directed to the maintenance and improvement of the health of all the people through collective or social actions.

Trachoma is an old public health problem. In the modern world, we have a solution. Public health interventions are clearly defined through the SAFE strategy. Global partnerships, national commitment, cross-sectoral collaboration and donated antibiotics provide the ideal framework to achieve elimination.

Success, however begins and is achieved almost exclusively at the grass-root level, in trachoma-endemic districts.

It requires the dedication and commitment of individual health workers, the expertise of TT surgeons and partnerships with communities to maximise trust and acceptance of interventions such as antibiotics. Each individual involved in trachoma and the delivery of SAFE strategy makes an essential contribution towards achieving a shared goal of eliminating trachoma from the world.

If you are based in a trachoma endemic region, we would appreciate your feedback in the Comments on how this course has provided practical guidance for you and your team.

Thank you for taking this course!

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Eliminating Trachoma

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