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Trachoma is a disease that has been with us from antiquity. It is
discussed in ancient Egyptian texts written on papyrus and in even
earlier writings from ancient China.
Chronic infection with the trachoma organism, Chlamydia
trachomatis, can lead to blindness. The disease came to
prominence in Europe during the Napoleonic wars, when tens of
thousands of British and French troops returned with trachoma after
fighting in Egypt. It spread rapidly through the armies of Europe,
where the troops lived in crowded and insanitary barracks.
Most of all, trachoma was a disease of the urban slums. In Europe, as
people left their relatively healthy rural homes they were crowded
into the workhouses and tenements created by the Industrial
Revolution. Personal and community hygiene fell to an all-time low
and the prevalence of trachoma surged.
Trachoma was rampant throughout Europe and North America in the 19th
century. In addition to tuberculosis and typhus, trachoma was one of
the diseases that would-be immigrants to the United States were
examined for — if found to have trachoma, they were sent all the way
back to Europe.
The early European settlers of Australia brought trachoma with them.
Whether the Australian Indigenous people had trachoma before
colonisation is unclear, but it seems unlikely, as small groups of
nomadic hunter-gatherers can maintain good hygiene.
However, with the poor housing conditions of the early settlers, and
with the heat, dirt and flies of Australia, trachoma (or "sandy
blight" as it was often called) became widespread and well known. It
even left its stamp on certain place names (eg, Sandy Blight Junction
in the Western Desert and the Ophthalmia Ranges in the Western
Australian Pilbara).
However, by the beginning of the 20th century, hygiene and living
conditions in our larger cities had started to improve. In 1901, one of
my predecessors at the Eye and Ear Hospital in Melbourne stated he
could no longer find cases of active trachoma from Melbourne to teach
his students. Instead he had to find people who lived in the Goulburn or
LaTrobe valleys in Victoria. But, even in rural Australia, trachoma
was disappearing, and by the late 1930s sandy blight had essentially
disappeared as most Australians moved into proper housing with
separate beds, running water and adequate sewerage and rubbish
removal.
The same happened in other developed countries. In England, the
trachoma schools and clinics closed before World War II, and the last
trachoma hospitals in the United States closed just after the war. In
the 1950s, trachoma also disappeared in Italy and the Soviet
Union.
Despite the disappearance of trachoma from most of the Australian
population, it has remained prevalent among certain groups of
Indigenous Australians. The late Father Frank Flynn, an
Australian-born and London-trained ophthalmologist turned
Catholic priest, worked as an Army chaplain in Darwin in 1941. He was
the first to recognise the frequent occurrence of trachoma among
Indigenous people in the Northern Territory, and their welfare
became his life's work.
After World War II, Ida Mann, an English ophthalmologist who had
worked with Frank Flynn in London before the war, moved to Perth. She
subsequently conducted extraordinary trips throughout the
outback, examining and treating Indigenous people with
trachoma.
In the 1960s, Fred Hollows took up his position as Professor of
Ophthalmology at the University of New South Wales and became aware of
the importance of trachoma in Australia. First working with the
Gurindji people at Wave Hill in the Northern Territory and then with
the people around Bourke in far western New South Wales, he cajoled the
Federal Government and the Royal Australian College of
Ophthalmologists into establishing the National Trachoma and Eye
Health Program (the "Trachoma Program").
From 1976 to 1978, the Trachoma Program teams visited every
Indigenous community in Australia (including some groups in large
urban centres), examining over 62 000 Indigenous people and nearly 40
000 others (consisting of whites, Asians, etc, in rural and remote
areas). It gave a clear picture of the number of people affected with
trachoma and its distribution. They also treated nearly 40 000 people
for trachoma and set up clear guidelines and recommendations as to
what needed to be done to eliminate trachoma.1
In 1996, I was asked by the Federal Minister for Health to prepare a
report on Indigenous eye health.2 It was very satisfying to go
back to places like Bourke and Broome and find that trachoma had
essentially disappeared over the previous 20 years. Clearly,
progress was being made — at least in the towns and larger
communities.
In other areas, although the amount of trachoma had decreased and
fewer children were affected, their elders still had scarred eyelids
and blindness from the inturned eyelashes caused by trachoma.
However, I was devastated to find that in some other communities, such
as Jigalong in the Western Desert, and Amata and Fregon in the Musgrave
Ranges, the rates of trachoma in children had not changed one jot over
the 20-year period.
At a meeting of the World Health Organization (WHO) in Geneva a few
years ago, we added up the number of countries where blinding trachoma
still occurred. We counted 54 — Australia is the only developed
country on that list. WHO has launched a special program for the Global
Elimination of blinding Trachoma by the year 2020 ("GET
2020").3-5 Its aim is to eliminate
trachoma from the poorest areas of Africa and Asia over the next 20
years. My colleagues from other countries turn to me and ask, "How can
you possibly still have trachoma in your country?".
Fred Hollows once said that trachoma was a disease of the crèche, the
preschool childcare group. Studies I subsequently did, both in the
laboratory6,7 and in the
field,8,9 identified and confirmed
the importance of repeated episodes of reinfection by C.
trachomatis. Each episode of infection gives more inflammation
that leads to more scarring and a greater likelihood of eventual
blindness.
Endemic trachoma persists in areas where living standards are
inadequate, with poor personal and community hygiene that permit the
frequent spreading of infected eye secretions from one child to
another. To stop trachoma, one needs to stop the transmission by
improving living conditions. After all, this is what happened in
mainstream Australia 100 years ago.
Nowadays, Australians in both urban and rural areas expect to have the
basic facilities that are needed for healthy living, such as a house,
electricity, clean running water and sewerage, a made road and a
rubbish collection facility. We expect them as a right — just recall
the outrage in Sydney when the water supply was contaminated in 1998!
Nevertheless, the Aboriginal and Torres Strait Islander Commission
(ATSIC) has reported that half of the Indigenous people in the
Northern Territory do not have adequate housing,10 and one in six
communities do not even have potable water. ATSIC estimated that in
1991 there was a $2 billion deficit in funding for basic
infrastructure and housing in Indigenous communities. These are
services provided by local and state governments to everyone else in
Australia.
To eliminate trachoma in Australia we need to upgrade the basic
services and housing of Indigenous communities in the outback to the
same minimal standard that every other Australian enjoys. This is
fundamental and can only occur if the Australian community accepts
the need and insists that the problem be rectified. We must direct and
empower federal, state and local governments to provide the basic
community infrastructure and health hardware. This would be a good
example of "practical reconciliation" espoused by the Coalition
Government.
Using research findings of the past decade or so, we have worked with
WHO to devise the so-called "SAFE strategy" to eliminate
trachoma.5 The SAFE strategy has four
components: "S" for surgery (to correct inturned eyelashes); "A" for
antibiotics (to eliminate chlamydial infection); "F" for facial
cleanliness (to reduce the spread of infection from one child to
another); and "E" for environmental improvement (to upgrade
community hygiene and living conditions).
Some of the recommendations contained in the review of eye health in
Aboriginal and Torres Strait Islander communities2 related to
trachoma, and the Federal
Government accepted the recommendations that included the
implementation of the SAFE strategy in all communities where
trachoma still exists. In 1997, when he accepted the report, the
Federal Minister for Health, Dr Wooldridge, promised to "do whatever
it takes". The Prime Minister also supported this work, and on a visit
to Nhulunbuy in 1998 announced the provision of azithromycin to treat
trachoma in Indigenous communities.
However, since then, disappointingly little has happened. In most
places, little has changed, even though the problem has been clearly
identified, strategies have been carefully laid out, verbal support
has been given by leaders and there has been a lot of discussion with
bureaucrats.
In areas with severe trachoma, one in five of the older people have
inturned lashes, and about half of these are either blind already or
will eventually go blind. It is a tragedy to see their children or their
grandchildren suffering from trachoma infection, because you know
that they are on the same escalator and will certainly suffer the same
fate if things do not improve.
We can stop this if we as a community care. Trachoma is entirely
preventable. Although it disappeared from white Australia 100 years
ago, it could take another century to disappear from Indigenous
Australia if we do not do something about it. We can not wait that long.
All Australians have the right to sight. The time to act is now. Do we
have the will?
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