Ethiopia Didn't Meet its Trachoma Goal by 2020. Now What?

“We are left-over citizens of this country,” a sentiment shared among interviewees who voyage kilometers for hours on foot. For those living in southern rural regions of Ethiopia, experiencing excruciating eye pain, resorting to plucking out eyelashes as a means of temporary relief, traveling for kilometers often on foot, and even being sent home with nothing but eyedrops is not the exception of what treatment for trachoma looks like but the norm.

A nun with an eye infection in the village at Lalibela, Ethiopia, famous for its rock-hewn churches. Trachoma is the commonest infectious cause of blindness world-wide especially in marginalized communities and is prevalent in Ethiopia. (Credit: Sushil Dawka)

Eye infections are the leading cause of preventable visual impairment and blindness in many sub-Saharan countries, but Ethiopia single-handedly carries half of the global burden of the disease. With individuals in rural areas of the country facing a burden 25% higher than their urban counterparts, it is no surprise that many rural residents of the country feel that their health is disregarded.

Since the WHO declared it a public health issue, Ethiopia has made major progress with antibiotic distribution and prevention campaigns. While these efforts have been impactful, they were still not enough to meet the WHO goal of eliminating trachoma as a public health problem by 2020, and instead, Ethiopia has looked to 2030 as the target year. During this time, Ethiopia’s next steps should not just be treating short-term fixes but serious investment in long-term infrastructure and progress tracking systems.

Trachoma falls under the class of neglected tropical diseases, but in Ethiopia, the title reflects a lot more than that. It is not only a neglected disease but a disease of neglect, specifically of neglected infrastructure and communities. As of 2022, about 22% of people in Ethiopia practice open defecation, while 23% have access to basic drinking water. The high prevalence of the disease in rural Ethiopia is an indicator of its poverty since it arises from unclean environments and water and poor sanitation, which rural areas are more likely to give rise to.

Researchers looking at rural communities in the Amhara region found implemented interventions that addressed safe drinking water, sanitation, and good hygiene habits. They noted that while theirs were better funded than typical trachoma programs, they did not see a significant reduction in trachoma among the trial and control groups. However, these findings should not render WASH efforts ineffective; instead, they point to an even greater need to support such interventions fundamentally. University of California San Francisco ophthalmologist Jeremey Keegan declares the current issue is insufficient investment in water, sanitation, and hygiene (WASH) infrastructure. Individuals whose water sources were public pipes had far higher rates of good trachoma prevention practices, as opposed to those who used spring water, a study in rural Lemo found, likely due to the significantly higher risk for contamination that a spring presents. The research shows that a clear need for investment in accessible, clean water, from a lack of safe wells, latrines, and cleaning stations is hindering the effectiveness of intervention efforts to eliminate trachoma.

Mass distribution of antibiotics for trachoma in Ethiopia (Credit: Community Eye Health Journa)

Antibiotic administration remains one of the fastest ways to reduce trachoma prevalence, but relying on antibiotics alone is not sustainable. Overuse could lead to resistance to the antibiotic, and without addressing reinfection, the disease will only continue to resurface. Fortunately, despite slow progress, researchers from Denmark highlighted the potential for an effective trachoma vaccine that would ensure future generations are protected from trachoma but call for additional funding. Additionally, effective monitoring and evaluation for progress in trachoma elimination could be a major issue in Ethiopia’s efforts so far, as a survey of key stakeholders revealed a common low belief in the possibility of trachoma elimination in Ethiopia due to suspected weak methods to measure progress and adjust strategies accordingly. Improved data collection will be essential in guiding future interventions and in gaining support from stakeholders.

Ethiopia’s failure to eliminate trachoma as a public-health problem by 2020 should be a call to redirect action towards balancing short-term antibiotic distribution with long-term investment in WASH-focused infrastructure as well as vaccine development and strengthened progress tracking. Humanitarian aid organizations like Habitat for Humanity, which has worked to improve housing, sanitation, and access to clean water in the Woreda region of Ethiopia, provide venues for those of us who aren’t major stakeholders to enable such efforts from home financially. However, no individual financial contribution will be enough. Through government initiative and commitment alongside international support, Ethiopia must focus on infrastructure reform, vaccine development, and strong progress tracking so that in 2030 and beyond, no Ethiopian suffers the pain of this entirely preventable disease.