Now in Sight: Success Against an Infection That Blinds
Posted July 16, 2018 6:35 p.m. EDT
GETA, Nepal — Fifteen years ago, Shiva Lal Rana walked 20 miles to Geta Eye Hospital to ask doctors to pluck out all his eyelashes.
Trachoma, a bacterial infection, had swollen and inverted his eyelids. With every blink, his lashes raked his corneas.
“The scratching hurt my eyes so much I could barely go out in the sun to plow,” he said. “I was always rubbing them.”
Worse, he feared the fate that others with the infection had suffered. The tiny scratches could accumulate and ultimately blind him.
Instead, doctors performed what was then a new operation: They sliced open his eyelids, rolled them back and sutured them with the lashes facing outward again. And they gave him antibiotics to clear up the infection.
“My vision is much better now,” said Rana, a tiny, lively man who guessed he was about 65. “I can recognize people. I can work.”
His personal triumph parallels his nation’s. In May, the World Health Organization declared that Nepal had eliminated trachoma as a public health problem, making it the sixth country to do so. In June, Ghana became the seventh.
Quietly, in the shadow of fights against better-known diseases like Ebola, AIDS and malaria, the 20-year battle against trachoma is chalking up impressive victories.
Those successes, experts say, show the wisdom of advocating and enforcing basic public health practices, rather than waiting for a miracle cure or a new vaccine.
They are also a testament to the unheralded but steady generosity of Americans. Much of the progress was made through donations by a U.S. drug company, U.S. foundations and American taxpayers.
Trachoma is the world’s leading infectious cause of blindness. (Cataracts blind more people but are not infectious.) About 190 million people in 41 countries are at risk, the WHO estimates.
About 1.2 million people are already completely blind because of it, and about twice that many have lost some eyesight. About 7 million have eyelids that are torquing inward and need the 20-minute operation Rana had, and about 21 million have infected lids that can still be cured without surgery.
A global campaign to wipe out trachoma was launched 20 years ago. Since then, Cambodia, Laos, Mexico, Morocco and Oman have officially eliminated the infection as a public health problem, along with Ghana and Nepal.
In addition, China, Gambia, Iran, Iraq and Myanmar claim to have succeeded but have not sought WHO. certification. Most wealthy nations eliminated the disease earlier, but trachoma was a worldwide scourge until well into the last century. Early photographs from Ellis Island show health inspectors using buttonhooks to flip over immigrants’ eyelids, looking for the telltale white pustules. Trachoma was common in Appalachia into the 1930s and found on some Indian reservations until the 1970s.
“Elimination as a public health problem” is different from complete eradication of the bacteria, which experts see as impossible. The phrase means that less than 5 percent of a country’s children have any symptoms, and fewer than 1 in 1,000 adults have vision loss from scarred eyeballs.
Nepal still gets new cases of trachoma each year from next-door India; many Nepalis go back and forth as seasonal laborers.
The bacterium, Chlamydia trachomatis, can be transmitted from person to person by, for example, sharing a towel. But in rural areas, it is more commonly transmitted by flies that crawl over children’s faces to eat the discharge from runny eyes and noses, and then flit back to human feces to lay their eggs.
Victims are first infected as toddlers, but permanent eye damage takes decades and usually sets in after age 30. To break that chain, the WHO recommends a four-pronged strategy: surgery for advanced cases; annual antibiotic doses for everyone in hard-hit areas; teaching mothers to wash their children’s faces frequently; and use of pit latrines, which reduce fly populations.
— American Generosity
Although the campaign against trachoma has some British and Australian support, much of it is paid for and run by Americans.
Looking at a chart of countries hard hit by the infection, Paul Emerson, director of the International Trachoma Initiative in Atlanta, rattled off about a dozen nations in Africa that were nearing success.
They easily outnumbered the few he said “still had issues” or “were hard nuts to crack.”
Despite the Trump administration’s hostility to foreign aid, Emerson said he was not hearing of any threats to cut U.S. funding of the initiative.
“I don’t know if it’s because we’re so small that we’re overlooked, because we’re not controversial, or because we’re doing such a good job,” he said. “I’d like to think it’s the latter.”
In any case, he said, “The U.S. government portion is quite small potatoes. We really operate on a shoestring.”
The WHO’s trachoma strategy was initially developed from research supported by a New York-based charity, the Edna McConnell Clark Foundation, created by the heirs to the Avon cosmetics fortune.
In 1998, the foundation joined Pfizer, the drug company, to start the International Trachoma Initiative. Pfizer’s oral antibiotic Zithromax was much easier and faster to use than the messy tetracycline ointment previously prescribed to treat trachoma.
In 2006, the George W. Bush administration budgeted $15 million for the U.S. Agency for International Development to attack several neglected tropical diseases, trachoma included. Since then, about $85 million has been spent on trachoma, a USAID representative said.
That has had an unexpected, even revolutionary, benefit. In villages where thousands of Zithromax doses were distributed, doctors noticed that fewer children died.
That led to a major study published in April showing that giving antibiotics prophylactically to infants in very poor countries could work like a vaccine, preventing up to 25 percent of early deaths. The WHO is considering whether to recommend routinely giving antibiotics to newborns in poor countries.
The Bush administration’s interest in neglected diseases, Emerson explained, was driven by the Global Health Council, an advocacy group with ties to the pharma industry.
Companies like Merck and Pfizer were willing to donate billions of dollars’ worth of medicine to the fights against neglected diseases, as long as they could take tax deductions and be assured that the campaigns would last long enough to justify the cost of building new factories.
It was a major commitment. The 700 million doses that Pfizer has donated to treat trachoma since 2002 are more than the company has sold during that time, a spokeswoman said. The company recently agreed to keep donating the antibiotic until at least 2025.
Part of the USAID money pays for surgery, but most goes to the dull but crucial task of assembling epidemiological data. Trachoma cases are spread over vast areas but — unlike Ebola, for example — never trigger the explosive outbreaks that cause panic and provoke big donations.
That means testing thousands of rural people; mapping which villages have the worst problems; distributing drugs; starting the public education programs; and then repeating the process annually to confirm that it is working. In different countries, groups like the Carter Center and Helen Keller International help deliver these services.
“It’s important for American taxpayers to know that this is having a real impact,” said Dharmpal Prasad Raman, chief Nepal adviser for RTI/Envision, a group that contracts with USAID to run the trachoma program here.
“When a mother cooking inside on a wood stove has vision problems, it’s very dangerous for her and her children.”
— A Country of the Blind
Nepal achieved success against trachoma relatively quickly, despite serious political turmoil. Before its campaign began in 2002, the country had survived a Maoist insurrection and what was reported to be a murder-suicide within the royal family that ultimately ended the monarchy.
But Nepal was fertile ground, because it already had a serious vision crisis — and an entity devoted to fighting it.
In 1981, a health survey found that nearly 1 percent of all Nepalis were blind. Cataracts were the biggest cause, and scientists suspected that sun damage in the thin mountain air and smoke from indoor cooking were partly to blame.
Trachoma was the second leading cause — and it was most common here on the hot, flat plain where Nepal abuts India. In some villages, 60 percent of children were infected, said Ramesh C. Bhatta, an ophthalmological officer at Geta Eye Hospital.
On many Nepalese temples, the Buddha’s eyes are painted on all four sides. The eyelids usually have an unusual downward bulge, and some have theorized that the tradition reflects the swollen lids that were once the norm here.
Since 1978, the country has had a nonprofit devoted to fighting blindness. Nepal Netra Jyoti Sangh, which means National Society for Comprehensive Eye Care, was founded by a prominent ophthalmic surgeon with royal connections.
It now has 18 eye hospitals, 80 clinics, 3,000 paid staff and 10,000 volunteers, and delivers nearly all eye care in Nepal, from eyeglasses to retinal surgery, partly through an arrangement with the health ministry and partly by accepting paying patients.
It runs the hospital here in Geta, where the equipment is modern, the tile walls and marble floors are clean, and the price of every procedure is painted on an outside wall in bright blue and white. Cataract surgery, for example, is $32 per eye, or $41.60 for same-day service.
Thousands of paying patients come from India, said the hospital’s director, Dr. Suresh Raj Pant.
Nepal also had another early advantage: a network of over 50,000 “female community health volunteers.”
The corps of FCHVs was started by the country’s first female health minister in 1994, far earlier than many other countries, from Peru to Ethiopia, created similar programs.
Their original goal was to promote birth control, but the women proved so effective and popular that they are now trained for many health tasks, like giving out vitamin A and polio vaccine, testing newborns for pneumonia and malnutrition — and diagnosing trachoma.
“When the FCHVs talk, people listen,” said Raman of RTI/Envision. “These women are powerful.” — No Destructive Rumors
Nepal has also been lucky in that its people quickly adopted the WHO program. In many poor countries, rumors, opposition from traditional healers and the power of habit can destroy such efforts.
For example, in Tanzania, about 20 percent of all patients needing eyelid surgery refuse it because of a persistent rumor that recovery takes six months. In reality, the bandages come off after 24 hours, and patients can usually farm or work a few days later.
“But Nepalis perceive antibiotics to be good,” said Achut Babu Ojha, a program manager with RTI/Envision. “They also clear up scabies, sore throats and ear infections, so people easily accepted Zithromax.”
In Kaluwapur, a farming village a few miles north of Geta, Bilando Rana, 63, who is not related to Shiva Lal Rana, had her eyelids re-inverted five years ago at one of the “eye camps” the hospital set up in a local schoolhouse.
“For about three months, I couldn’t work in the fields or cook food for the children because of the pain,” she said. “I knew it was something our healer couldn’t fix.”
Instead of fighting traditional healers, Raman said, the program has offered them training in recognizing the signs of trachoma in the hopes that they will refer people to the camps or clinics.
Nepalis have even accepted outhouses, a significant accomplishment because rural people often have difficulty breaking their most personal habits.
Twenty years ago, Raman said, he worked for a charity that built 50 houses, all with latrines, for flood victims. A year later, he said, 47 of the latrines were being used to store firewood or shelter goats.
Bilando Rana said her family dug an outhouse eight years ago after local officials encouraged everyone in her village to do so.
Encouragement includes both carrots and sticks, Raman said. Local leaders can earn fancy certificates declaring their villages “open-defecation-free.” But they may also be threatened with the loss of services like road repair if latrines are not built.
The campaign also focused on schoolchildren.
“Experience has shown that, if children shame each other, if they say, ‘My house has a latrine and yours doesn’t,’ that will make their parents do it,” Raman said.
Asked if it was hard for her to stop using the fields at night, as she previously had, Bilando Rana shrugged and said of the latrine: “It’s comfortable enough.”
“Also,” she added, “it was a long way to walk, and I’m getting old.”