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Indigenous health

Trachoma in Australia

Hugh R Taylor
Med J Aust 2001; 175 (7): 371-372.

Indigenous Health

Trachoma in Australia

Hugh R Taylor

Australia is the only developed country in the world where blinding trachoma still exists

MJA 2001; 175: 371-372


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?  


References

  1. National Trachoma and Eye Health Program. Sydney: Royal Australian College of Ophthalmologists, 1980.
  2. Taylor HR. Eye health in Aboriginal and Torres Strait Islander communities. Report of a review commissioned by the Commonwealth Minister for Health and Family Services, the Hon Dr Michael Wooldridge. Canberra: Commonwealth of Australia, 1997.
  3. Dawson C, Schachter J. Can blinding trachoma be eliminated worldwide? Arch Ophthalmol 1999; 117: 974.
  4. Taylor HR. Towards the global elimination of trachoma. Nat Med 1999; 5: 492-493.
  5. World Health Organization. Future approaches to trachoma control. Report of a global scientific meeting; 1996 June 17-20, Geneva, Switzerland. Geneva: WHO, 1996. (WHO Publication 96.56.)
  6. Taylor HR, Prendergast RA, Dawson CR, et al. An animal model of cicatrizing trachoma. Invest Ophthalmol Vis Sci 1981; 21: 422-433.
  7. Taylor HR, Maclean IW, Brunham RC, et al. Chlamydial heat shock proteins and trachoma. Infect Immun 1990; 58: 3061-3063.
  8. Taylor HR, Millan-Velasco F, Sommer A. The ecology of trachoma: an epidemiological study of trachoma in Southern Mexico. Bull World Health Organ 1985; 63: 559-567.
  9. Taylor HR, West SK, Mmbaga BBO, et al. Hygiene factors and increased risk of trachoma in Central Tanzania. Arch Ophthalmol 1989; 107: 1821-1825.
  10. Water: a report on the provision of water and sanitation in remote Aboriginal and Torres Strait Islander communities. Canberra: AGPS, 1994.
  11. Jones R. The housing needs of indigenous Australians, 1991. Research Monograph No. 8. Canberra: Centre for Aboriginal Economic Policy Research, Australian National University, 1994: 149-151.

This is an edited version of a talk presented on the ABC Radio National program Ockham's Razor, 1 July 2001.


Authors' details

Centre for Eye Research Australia, East Melbourne, VIC.
Hugh R Taylor, AC, MD, FRACO, Professor of Ophthalmology.

Reprints: Professor H R Taylor, Centre for Eye Research Australia, Locked Bag 8, East Melbourne, VIC 8002.
h.taylorATunimelb.edu.au


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