Curing trachoma eyes & disease prevention in trachoma ‘endemic Ethiopia’: Ethics & fairness need to be guiding principles

20 Feb

By Keffyalew Gebremedhin – The Ethiopia Observatory (TEO)

–I–

TRACKING TRACHOMA MUST BE PRIORITY TASK IN DEFENSE OF ETHIOPIAN CHILDREN

The World Health Organization’s (WHO) target date of 2020 for the global elimination of trachoma “as a public health problem” is fast approaching. Accordingly, the campaign has thus come to be known in all parts of the world in its short form: GET 2020 – i.e., Global Elimination of Trachoma by 2020.

Treatment of the disease and its prevention have been standardized, in what WHO calls SAFE Strategy, where “S” stands for surgery and “A” for mass distribution of antibiotics; “F” for face wash; and finally the “E” denotes cleaning the environment, especially ending or preventing open defecation on the ground.

With the gains of public health in mind as well as the political dividends, since the last decade Ethiopia has joined the campaign in dribs and drabs. Certainly, its response to WHO’s call for action against this blinding disease is positive. It also coincides with the national and international efforts targeting the other seven neglected tropical diseases (NTDs) in Ethiopia, i.e., onchocerciasis (river blindness), schistosomiasis (bilharzia), soil-transmitted helminths (STH), lymphatic filariasis (elephantiasis), dracunculiasis (Guinea-worm disease), leishmaniasis (parasite infection) and podoconiosis (lymph vessels’ disease).

Trachoma is poor developing nations’ problem, mostly of Africans. Much in the same manner, WHO affirms endemicity of the disease in Ethiopia. This is also consistent with the findings of Ethiopia’s Ministry of Health that claims, of the country’s 817 districts, 603 or 74.0 percent, are trachoma districts.

Moreover, the Ethiopian Journal of Health Development in 2007 reported that the highest prevalence of active trachoma is found in: Amhara (62.6%), Oromia (41.3%), SNNP (33.2%), Tigray (26.5%), Somali (22.6%) and Gambella (19.1%).

Without meaning to secondguess the minister of health, nonetheless, on the eve of Ethiopia’s launch of its 18-month long trachoma elimination campaign, Ato Kesete Birhan Admasu on February 12, 2015 chose to put the endemicity rate at 30 percent of other Sub-Saharan African countries, as partly does the Trachoma Atlas, below.

Credit: Trachoma Atlas

Credit: Trachoma Atlas

–II–

On aid and local resources

Irrespective of trachoma prevalence rate in Ethiopia and, thinking of the current campaign against the backdrop of nation’s capacity to put resources at the disposal of health professionals, the extravagance of today’s Ethiopia’s leaders has been the most incomprehensible.

Their pretensions have recently forced a poor country Ethiopia to earmark ETB 500 million ($25.0 million) for festivities, i.e., ETB 100 million ($5.0 million) for TPLF’s 40th anniversary; ETB 400 ($20.0 million) for the dances and feasts of Nations and Nationalities and Flag Days and ideological training of students. It should not escape attention that, donor-aid dependent Ethiopia to fight all the NTDs, including trachoma, could now manage to allocate ETB 10 million ($500,000) – although we are not clear if this is even its money – for training anti-trachoma workers, according to the minister of health.

It goes thus, Minister of Health Kesete Birhan Admasu is quoted by Turkish news outlet Anadolu Agency some days ago stating, “We are expanding health science colleges and increasing the number of health professionals to 3,000 annually from a previous 1,200”.

As to trachoma tracking, i.e., treatment and data collection are concerned, we have bee made aware that the trachoma mapping around the world would be finalized in March 2015. The question is what is the success rate so far in Ethiopia in this major and a must struggle against trachoma?
–III–

Assessing progress

While limited progress has been registered in some areas of Ethiopia, governance problems and the environmental factors remain the country’s Achilles heel. These problems manifest themselves in the iniquitous distribution of disease elimination and prevention services on one hand and the difficulty of raising the standards of basic hygiene on the other, both aspects of which we would raise in brief here.

The governance side of the problem is what underlies the data collection efforts and distribution of the available limited treatments. Ethiopians have been aware of for a long time and incensed by systematic prioritization of a single region or regions. This has benefited a region or  a few regions via political support for eyesight care or better health services and modern technologies, mostly with the help of foreign institutes and non-governmental organizations, some hyphenated Ethiopians coordinating from abroad with senior TPLF officials.

Surely, not that the TPLF cares about Tigray region, especially when its words are compared to the mistreatments it also inflicts on Tigreans. But, it is always the case that unlawful dispossessions and illegal transfer of resources and opportunities of other Ethiopians to TPLF Tigreans has resulted in empowerment of the elites of the minority ethnic group over others. It is no accident, therefore, that, for instance, 53 percent of Tigrean mothers give birth in hospitals, by the admission of the media the TPLF controls. Compare this improved state of childbirth in Tigray with the national average, which is about ten percent for the rest of Ethiopia.

This blog had already questioned the logic of that with earnestness in a March 2014 article. Universities in Tigray benefit more than other Ethiopian higher institutions of learning. They receive funds in substantial numbers in the middle of the fiscal year; best scholarships flock in their direction. although their performances have hardly proved better than the older higher institutions of learning, such as Addis Abeba and Jimma Universities, as could be seen in my review of performances of Ethiopian universities in 2014 and 2013.

This simply means that, as in everything else in Ethiopia, nonetheless, there are huge benefits, services and resources moving in Tigray’s direction, including health services, although, even when over there the beneficiaries could be a small group, the rest differentiated by quintiles.

A similar complaint about preferential regional treatments was made during testimony at the US Congress in April 2013, when Obang Metho accused the TPLF regime of practicing discrimnatory governance in Ethiopia. In that connection, in his example, he compared Tigray Vs Gambella,to point out:

“[I]n their own region of Tigray, there are five hospitals and four universities whereas in a region like Gambella, there are no universities and only one hospital without running water.”

Nearly in the same tone, this charge by Obang Metho has also been corroborated by the WHO. It wrote in the 2012-2015 Country Cooperation Strategy (CCS):

“Coverage and access of health services in pastoralist areas as well as the Developing Regional States (Gambella, Benishangul-Gumuz, Afar and Somali) is very low, making the population vulnerable to various health problems.”

What does this mean? Implementation of the national strategies has been unequal and preferential, even when the Ethiopian Health Policy and Practice document professes the importance of expanding universal health coverage (UHC) by strengthening the primary health care (PHC) as “A plausible approach to address” the task of addressing the nation’s health “challenges and the widening gap of inequality.”

Amplifying that and touching upon a broader problem, WHO further notes in the same document:

“Large disparities exist in service coverage among regions, with immunization coverage as low as 44% in Afar (compared to the national average of 86%) and 59% of zones in the country achieving more than 80% coverage, due to geographic access, security, human resource capacity, health infrastructure (including availability of functional cold chain systems) and lifestyle, among other factors. The last imported case of wild poliovirus was in April 2008. Although acute flaccid paralysis (AFP) surveillance has remained certification level standard at national level since 2004, there are gaps in some bordering regions and zones with threat of undetected importation and circulation of wild poliovirus.”

On the environmental side, poverty-induced bad human habits persist, such as continuation of open defecation. This has been contributing to the harms trachoma has been causing to millions of unsuspecting Ethiopians, especially children. Data show in the 2014 UNICEF Factsheet on Ethiopia indicates that while progress in this area has been equitable across all regional states, least benefiting from improvements in sanitation is the population in the poorest quintile.

In the circumstances, 38.1 million Ethiopians in 2014 practiced open defecation. This in turn has come back with its adverse consequences for trachoma eradication in the country, in several instances creating conditions for re-infection and thus necessitating increases in frequency of repeat treatments; this is also seen as being contributory to some of the other so-called neglected tropical diseases (NTDs).

WHO warns nations that trachoma is transmitted through contact with eye and nose discharge of infected people, particularly young children passing the disease to others. Also spreading it are flies, which have been in contact with the eyes and nose of infected people.

Then there is the problem of water shortage in general in many parts of Ethiopia, especially rural Ethiopia, much less to speak about the luxury of clean water supply. If we speak of urban areas, it is not much different. As a matter of fact, GRID-Arendal, the United Nation’s Environmental Program’s (UNEP) collaborator on environmental issues in March 2010 posted information that it is only five per cent of the solid waste that is collected and recycled in Addis Ababa. The rest is piled on open ground, river banks or streams and near bridges, where it is washed into the rivers. With new investments, the new fabric manufacturing plants and horticulture have worsened this further with wastes flowing into the surrounding rivers of Addis Abeba.

Further, Arendal expressed concerns about food poisoning in the city due to 60 percent of the city’s food supplies coming from ‘urban farmers’, who irrigate their crops using the wastewater. This is said to account for many of the illnesses and outbreaks of infectious diseases in the city, afflicting residents, especially children.

WHO has been trying to spread awareness that the environmental risk factors influencing the transmission of trachoma include: poor hygiene; crowded households; water shortage; and inadequate latrines and sanitation facilities.

As we get closer to winding down of WHO’s 2020 global trachoma elimination target assessments, there would be some laggards. I pray that Ethiopia is not one of them. Success in GET 2020 would be measured, among others, by the reduction in the prevalence of avoidable visual impairment by 25 percent by 2019 from the baseline of 2010 data, according to WHO. Add to this, how many professional eye care specialists a given country would have by then, for instance, Ethiopia per a million of its population.
 

–IV–

Here is the frightening Ethiopia trachoma picture and the twisted road ahead

    * Nine million Ethiopian children under nine years of age are reported to have active trachoma.

* Trachoma is the second leading cause of blindness in Ethiopia. Light For The World reports that 1.28 million blind persons live in the country; every second case of blindness is due to cataract and could be easily addressed by surgery. It is established that 1.3 million adults are in need of lid surgery.

Trachoma affected 9-yr old girl (Credit: Sodere)

Trachoma affected 9-yr old girl (Credit: Sodere)

** Ethiopia, according to the International Council of Ophthalmology (ICO), has 103 ophthalmologists – thinly bred professionals even on global scale. In Ethiopia, at the moment one ophthalmologist must serve a million people. This underlines the troubling dilemma of a developing country whose needs cannot be met with these few pairs of hands providing the majority of the nation’s 94 million citizens with the much-needed services let alone to reduce, much less to eliminate trachoma.

* On the governance side, case of conflicting story has been flying around since 2013 about trachoma mapping, when mapping of Tigray and Somali regions’ was first completed, according to Light For The World. Already by then, Tigray had been assisted by a consortium of European development professionals in the field for 15 years under the umbrella of Light For The World. In 2015, we still read about “mapping the mountainous region”, as do different groups and companies canvassing the country to do the same, it seems without any coordination.

* The International Coalition for Trachoma Control (ICTC) in September 2014 observed, as had done the BBC on January 26, 2014: “Ethiopia has the highest burden of trachoma in the world. In 2012, the Oromia region contained the largest unmapped area of the country for suspected disease burden and was the least supported in terms of NGO partner engagement for trachoma elimination initiatives. More than 200 districts in Ethiopia are now working to eliminate trachoma through partnership of the Federal Ministry of Health, Regional Health Bureaus and many international and local development partners.”

* WHO gently points out to what is lacking: “Limited access to timely and adequate information on some of the most important diseases has affected the design and implementation of effective intervention strategies. Mapping of selected diseases and strengthening of capacity for early detection of outbreaks, reporting and timely response will continue to be important issues to be addressed.”

* In spite of this untenable situation, implementation of the national health strategies have been unequal and preferential, even when the Ethiopian Health Policy and Practice advocates the importance of expanding universal health coverage (UHC) by strengthening the primary health care (PHC), as “A plausible approach to address” the task of addressing the nation’s health “challenges and the widening gap of inequality.”

* Thanks to the massive support of philanthropists’ and donations to the health sector, according to the World Bank, within the decade between 2005-2013, “small health posts or clinics nearly quadrupled from 4,211 to 14,416, the number of health centers increased from 519 to 3,245, and the number of public hospitals grew from 79 to 127″. Without questioning how many of them have been staffed by qualified professionals, medicines, equipment and running water? The Bank simply brushes this question and states “providing quality services remains a major challenge” in Ethiopia.

–V–

‘Surgeons act as Ethiopia’s final defense against blindness’

A VOA story on trachoma has very much amazed us by the fact that while its content is localized, the story by Kim Lewis portrays trachoma treatment in Tigray it is reporting about as if the efforts were national, if only one looks to the title. Of the limited scope of in Surgeons act as Ethiopia’s final defense against blindness, nonetheless Light for The World, a European confederation of national development NGOs from several countries, states:

“Having been engaged in Trachoma work in Ethiopia for the last 15 years, it is a logical step for LIGHT FOR THE WORLD to scale up its work and invest substantially in the efforts to eliminate blinding trachoma in Tigray and Somali region, two provinces where comprehensive eye health has also been supported for a long time … LIGHT FOR THE WORLD is an implementing NGO for trachoma mapping in the Tigray and Somali Regions of Ethiopia. In Tigray, the mapping was conducted by the Tigray Regional Health Bureau in collaboration with LIGHT FOR THE WORLD who provided technical support and took responsibility for the training of the survey teams and the provision of initial funding for the training and conducting the survey.”

Mapping trachoma in Ethiopia (Credit: Ministry of Health and SCI)

Mapping trachoma in Ethiopia (Credit: Ministry of Health and SCI)

After reading the above-mentioned story originating from the VOA, we decided to investigate how well the national trachoma elimination efforts have been distributed in Ethiopia. As we read from Light For The World, above, trachoma mapping has already been done for Tigray and Somali regions. At the same time, in August 2013 an agreement was initialed between Ethiopia and SCI to undertake mapping in Tigray, Amhara, Oromiya, SNNPR, and in focal areas in the regions of Afar, Somali, Gambella, and Benishangul-Gumuz, the areas shown in the map, colored blue.

At the same time, there is a different reporting from June 24, 2013 by Sightsavers about Ethiopia completing trachoma mapping in two regions: Tigray and Oromia. The mapping is done by a consortium of the International Trachoma Initiative (ITI), NGOs and academic institutions, led by Sightsavers and funded by the UK government. ITI, Light for the World, ORBIS and The Fred Hollows Foundation have been supporting Ethiopia’s Ministry of Health to conduct household surveys, collecting the data on smartphones.

Of this same undertaking, The Guardian on its January 11, 2013 issue reported:

“Teams of surveyors are mapping the spread of trachoma, which can cause blindness, in rural Ethiopia. Cases are often found in remote areas with little access to healthcare. It has taken more than 12 years to identify what is estimated to be half of the world’s trachoma-endemic districts. Funded by the UK government, a consortium led by Sightsavers hopes to survey the remaining endemic districts in less than three years.”

Trachoma campaign in Tigray now boasts of huge reduction of this blinding disease visible already by 2015. Light For The World says, in another article by Kim Lewis of VOA, it has been in Tigray for 15 years; it has carried out mapping in Tigray and Somali regions to collect and analyze data that will help them treat the 4.5 million people who live in places where trachoma is endemic.

The burden of disease on the rest of the country is bigger than Tigray, the help the other regions receive unmatched. Moreover, for instance, why isn’t the trachoma activity in the other regions very well coordinated, especially with one professional body, such as one or a consortium of NGOs operating as in Tigray, instead of the haphazard manner we have witnessed in trachoma mapping?

Many donors, individuals and states are happy to help and organizations to work in Ethiopia, which we should appreciate. This still needs governmental plan and institutions to guide them and coordinate their activities. In August 2013, in Ethiopia-SCI project document an organization wanting to help in fighting trachoma implied that the regime must benefit from the “political momentum and donor advocacy [that] is building behind large-scale control of many neglected tropical diseases (NTDs) in the country” – since Ethiopia with its huge population and eight transmissible diseases is a WHO target country – even if it is latecomer to fighting these diseases.

Whatever is the official response, the inescapable question staring on our country at the moment and for the foreseeable future is where is Ethiopia headed with its ethnic-based policies, political attitudes and provincial mentality?

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