The gift of sight

JEREMY WATSON
Scotsman.com

PROUD to be part of Sightsavers International's battle against preventable blindness, Scotland on Sunday travelled with them to Tanzania to witness at first hand the ravages of a disease affecting up to half of the population in remote villages - yet it can be cured for £5. We discovered just how easy, and cheap, it can be to transform lives.

THE river bed is baking. The short 'rainy' season is long over and there have been months of drying under the hot Tanzanian sun. Low cliffs carved by centuries of gradual erosion trap the heat, and the glare from the round, smooth stones underfoot is dazzling. The temperature pushes towards 37¡C and just the act of walking into this furnace sets the sweat trickling down your back.

Then you see them, out in the centre of the bed, descending into what appears to be a hole in the ground. From the lip, all becomes clear. One woman stooping, plastic bowl in hand, is scooping water out of a makeshift well, dug by the men of the village. It takes her 15 minutes to fill a pail with a browny, brackish concoction before giving way. The exercise is repeated by the other two women and they are ready to leave. In unison, they place small pads on their heads, then the pails on top of the pads.

In the straight-backed, graceful manner of African women, they turn and file past, beginning their 15-minute walk back through the parched fields and on to their village, precious cargo safely on board. It's a routine these women perform every day amid, to the Western eye, an extraordinarily beautiful landscape of blood-red soil, angular thorn trees and low, rocky hills. And the routine has a purpose: to provide water their families need for drinking - despite its saltiness - for cooking and for washing their own and their children's faces.

JEREMY WATSON IN TANZANIA

Living in the arid Tanzanian highlands, where the average annual rainfall is less than 10mm, comes with a price. Flies are abundant and land with insistent regularity on children's faces. But with water in such short supply, daily washing is not a priority. The bacteria left by the flies gets rubbed into eyes. Repeated over time, a conjunctivitis-like condition called trachoma sets in. In the worst-affected areas, up to 50% of the population - mainly children and women - can be affected.

If caught early, it can be treated with a simple course of antibiotic ointment, costing just 50p. If allowed to develop, the eyelids turn in on themselves, the eyelashes stick to the cornea and the victim is gradually blinded. It's distressing and painful but, ultimately, preventable.

This is what prompts the daily journey to the well for the women of Mkulula village. But, in reality, they have it relatively easy. In some remoter villages, such as Chamndidi, women - in a human convoy sometimes hundreds strong - leave at 4am for a two-hour walk to a well. After filling up, they have a two-hour trek back, water balanced precariously on their heads.

There is no other option, as village executive officer Aaron Mwendelanga explains: "Trachoma is very serious for us because it means that people are not able to work in the fields and earn money for the village. The village depends on everyone working to improve the economy.

"But the lack of water is a very, very big problem. To get water here means a walk of seven kilometres to the well. The women do it and they walk 14 kilometres a day, every day. Each home uses four buckets a day. They can only carry one bucket, which is why so many women have to go. But if we want to keep trachoma at bay then this is what we have to do."

Tanzania is a former British colony - it was named Tanganyika before merging with Zanzibar in 1964 - that gained its independence in 1961. Today, it is one of the largest, most populous and most politically stable countries in east Africa. More than five million people - around the size of Scotland's population - cram into Dar es Salaam, the commercial capital on the Indian Ocean coast, but most of the rest live in scattered mud-brick villages typical of the country. Tanzania's health service is well developed along Western lines and largely free but, as in many of its neighbours, the sheer scale of the health problems and the complexity of reaching remote rural communities are often overwhelming.

With Aids rampant and debilitating tropical diseases such as malaria endemic, treatment of some conditions falls way down the list of priorities. It is left to charities such as Sightsavers International, which has recently established a fund-raising operation in Scotland, to help fill the gap.

Trachoma may not be life-threatening but it can have a devastating effect on villages where average income is usually less than one US dollar per day. Around 80 million people suffer from trachoma worldwide and it is the second most common cause of avoidable blindness after cataracts. Almost six million people have blindness caused by trachoma and many millions more are at risk. In Tanzania, where the disease is common in rural areas with inadequate supplies of fresh water and problems with basic sanitation, trachoma causes 20% of all cases of blindness. It is semi-desert areas such as Iringa, more than 400 miles inland, that suffer most.

To get to Iringa, you have to leave Dar es Salaam and its hideous traffic jams behind. The road arrows inland, first through fertile mango groves and past brilliantly flowering purple jacarandas, that most flamboyant of African trees. At the entrance to Mikumi National Park, a classic flat African savannah, travellers are warned not to leave their vehicles because of dangerous wild animals. Giraffes, wildebeest, baboons, zebras and elephants graze unconcerned just a few yards off the roadside.

Beyond the park, the road rises into boulder-strewn hills where mud-brick villages perch on isolated promontories. Then it snakes into the mountains and the brilliantly coloured forest wilderness of the Kitonga Pass.

Up on an escarpment is Iringa, the regional capital, with its frenzied market where villagers congregate daily to sell their wares. Beyond the airport, asphalt roads are replaced by dusty red highways. Just over an hour later you are in villages where all the standard certainties of modern Western life, including electricity, running water and toilets, are luxuries enjoyed by a very few.

Here, life involves growing enough crops in the fertile, if water-starved, soil - groundnuts, maize, millet, cassava - in the five months of the rainy season to last the whole year. Any surplus can be sold off. But also central to village life are the herds of bony cattle, with their distinctive fatty 'fins' rising from their backs, and goats.

To Westerners, it appears a harsh, subsistence lifestyle amid an unforgiving environment. By rights, these should be deeply unhappy people, incredibly poor and underprivileged by Western standards. Yet once initial suspicions are overcome, like most African villages they are warm, hospitable places, with friendly adults and insatiably curious, giggling children.

Everywhere, however, there is a fine film of red dust, blown by the capricious winds that sweep these hot, arid plains, coating hands, arms, legs, faces and clothes. With water so scarce, people can go for days, even weeks, without washing. Flies attracted by the animal herds and the plentiful supplies of dung - both human and animal - spread a bacteria, chlamydia trachomatis, from person to person, depositing it on unwashed faces. When the bacteria-laden dirt is rubbed into eyes, the cycle of trachoma infection begins. When this sets in, there is a discharge from the infected eye. That, in turn, attracts more flies to feed. More flies then spread more disease to the humans around them.

Trachoma is most prevalent in young children but the adult village women, normally in closer proximity to their offspring, suffer more than men. In these communities, women are three times more likely than men to be blinded by the disease.

Without intervention, families remain trapped within a cycle of poverty, as the disease and its long-term effects are passed from one generation to the next. But there are innumerable circumstances, including water shortages, lack of money and cultural taboos, that have proved to be often insurmountable barriers to improvement.

In some villages, flies are so common children lose the will to shoo them away. In others, they are such a big part of the natural world that they are treated almost with respect.

Dr Peter Mihale, the eye-care co-ordinator for the Iringa region, explains: "Flies are a natural part of life so chasing flies away is like chasing away your blessings. So the villagers choose to leave the flies there; that's part of the problem.

"We have to get the message across that you need to wash your face. You will get the disease in around six weeks if you don't wash your face. It is only cleanliness that will help in the long term."

Although progress is slow, there have been falls in infection rates even in the driest areas. The strategy, which Sightsavers International is part of, was devised by the World Health Organisation (WHO) and is split into four prongs of attack. Called SAFE - Surgery, Antibiotics, Face washing and Environmental change - it involves treatment of existing cases, with a long-term goal of prevention. New wells are part of the strategy, as are communal latrines to deny the flies their breeding grounds. But, as always, money is short.

Despite this, there has been gradual progress. In some of the more accessible areas, trachoma rates have dived from around 80% to less than 10%. In remoter communities, however, half the children are still infected, while the other half remain at constant risk.

About an hour out of Mkulula, along deeply rutted roads that twist past unworldly giant baobab trees, the red-dust track peters out. Along the narrow path is Marekani village, where 50% of the inhabitants have various stages of trachoma because of the potent combination of poverty and unsanitary conditions.

The houses are made of mud, with wooden supports. Inside one, the possessions of Zebedaro Marroda, an elderly man who earlier that day underwent surgery for trichiasis - which develops from trachoma - are laid out: a blanket for sleeping, a stone bowl for grinding maize and a few cooking utensils.

Children in dirt-covered, ragged clothes run around excitedly in a village that, despite its health-care problems, still has all the genuine charm of a rural African community on a warm, sunny afternoon when most of the day's work has been done. The women and their children are long back from the two-hour daily journey to the well.

It's here we meet Ibrahim Abdul, the front-line worker in the battle against trachoma. He has volunteered to be a community health worker in the area, a position that attracts no pay, just status and the use of a precious bicycle to get him from village to village.

Abdul's first role is to identify villagers with the disease and refer them to the nearest health centre where they will undergo screening, treatment with ointment or surgery if required. He also has to promote the SAFE strategy.

"I try to educate the villagers on what they should do," he says. "We tell them to wash their hands and faces and keep their houses clean; to avoid touching someone who is infected and to wash their hands before going anywhere near their eyes. But it is very difficult because of the lack of water. The number of cases is coming down slowly but not fast enough."

Abdul and an army of others like him perform a vital role in thousands of remote villages. The system works and progress is being made. But recently he has had to perform his duties without his trusty bike, broken beyond repair after hitting a rut too many times. For the sake of £30 - the price of a new bicycle - his job has become much harder.

When the village children are diagnosed with trachoma, treatment is simple. An inexpensive tube of antibiotic ointment, tetracycline, if applied over a six-week period, effectively cures the disease. But diagnosis is perhaps the easiest part in communities that rely on older children to look after their valuable livestock, moving them daily to new grazing.

"There are many children with the active disease," says Dr Mihale. "But they keep moving with the cattle so it is difficult to keep up with them. You can give the treatment one day and tomorrow they are gone. We do not know whether they have improved or not. They are also spreading it and exposure becomes repeated."

Even if the children all stayed in one place, there is not always enough ointment to go around. "We have budgets and we cannot always afford what we want. But this is where money from organisations like Sightsavers can really help us out."

Surgeons capable of carrying out the delicate surgery - at a cost of just £5 - for the villagers with trichiasis are also in short supply. It is often a struggle to keep up with demand. When trichiasis is reversed, however, the benefits are immediate.

In Mkulula, Yona Masambwa has been waiting to meet us. A 60-year-old farmer, he has undergone a trichiasis operation on his right eye before but now his left eye is damaged. Dr Julieth Tesha, an eye surgeon, pulls his lids apart to reveal the lashes sticking to the cornea.

Masambwa says: "I still have a duty to help my family but it is very difficult when the eyelashes are rubbing because it is very painful. There is a sandy, gritty feeling all the time and I have lost my vision."

Malita Mbwilo had also just been picked up by routine screening after suffering trichiasis for almost six years. She cannot cook, clean or perform any of her daily chores, making her a burden on her family. Although she went to the health centre some time ago, she left without treatment because the clinic was too busy. She didn't want to cause any trouble and simply returned home to suffer.

Both Masambwa and Mbwilo are given lifts to the nearest health centre - a barely equipped building, itself without running water for two months - where Dr Tesha will perform the surgery that day. Outside, they join a silent queue of six sheltering from the fierce midday sun on the front porch. Inside, a nurse is placing a clean sheet over a simple bench to prepare for Masambwa's operation.

Dr Tesha guides him on to the bench and numbs his left eye with anaesthetic. Operating next to the window to gain the maximum daylight, she expertly makes an incision along the length of the damaged eyelid's underside. She then carefully lifts the side of the lid fringed with the eyelashes outward and back into the correct position. The two sides are then stitched back together again.

The operation cannot undo the damage already done to the cornea, which makes the eye vulnerable to infection. But it can stop further injury, restore sight and halt the distressing pain.

The procedure is completed in just over 20 minutes. Masambwa rests, patch over his eye, before returning home with a health worker. Tomorrow, when the patch is taken off, he should be able to see again and regain some of his former active life.

In seven days, one of the team of doctors will make the long journey to his village to remove the stitches. It will probably be David Ulandah, a personable young doctor who has accompanied us on our trip, proudly sporting his official T-shirt with its "wash your face daily" logo. He gave up general surgery for eye surgery when he realised how great the need was for someone with his expertise.

"It is a very tiring job because you have to travel to remote villages every day but it is very satisfying," he says. "When you operate on someone and they see their children for the first time in years, then it is a great privilege."

Back towards Iringa that evening, as the sun begins to cast long shadows over the plain, a group of women are in a state of excitement, grouped around a tap through which water is running.

We stop to take photographs but, despite the usual warmth of the welcome, there is a slight tension. This tap only runs at highly restricted times of the year and they are afraid it may be switched off at any moment and the precious chance will be gone.

A few hundred yards down the road, Ester Sanzagal, 60, approves of the younger women taking the opportunity to wash their children. She developed trichiasis in both eyes and endured the pain and the indignity of not being able to look after her three grandchildren properly, before she was finally diagnosed and operated on.

"My vision was very blurred and I could only look after the house and the children with difficulty," she says. "Before the operation, I couldn't see them at all. Now I can see their faces again and I am free from the pain.

"I take care to wash them now. When I was their age, trachoma was just part of life. It still is for many but I have learned that does not need to be the case."

HOW TO HELP
TRACHOMA can be cured using a 50p tube of antibiotic ointment. The most severe form, blinding trichiasis, can be reversed by an operation costing £5. There are three ways you can help by taking part in Scotland on Sunday’s Christmas appeal.

Today, or during the next few weeks as the appeal continues, you can use the coupon below donate.

Next Sunday, December 2, we will announce our ‘ Bring 50p to Work’ day, in which organisations will be asked to encourage employees to contribute so that antibiotic ointment and other services provided by Sightsavers can be purchased. The event will take place on Friday, December 14.

Finally, on December 9, Scotland on Sunday will launch an online auction (www.scotlandonsunday.com) offering a range of exciting lots readers can bid for. It’s a great chance to get an unusual Christmas present.