Ethiopia has the highest proportion of people at risk of getting trachoma (85% of its population, about 65 million people), according to a report by The Carter Center. Ethiopia has also the greatest number of people in the final, blinding stage of trachoma (more than 1 million). It has the greatest number of people who have gone blind from trachoma (138,000).

The predeterminants of trachoma are poverty, which manifests as poor access to sanitation, poor access to hygiene, high density living conditions, and a general poor health. All of those go together, then trachoma gets laid on top of it. It used to be the slums of London, now it’s the rural areas of populous countries, like Ethiopia. – Dr. Paul Emerson, director of The Carter Center Trachoma Control Program

The Carter Center has launched trachoma control programs in Ghana, Mali, Niger, Sudan and Nigeria, but its most challenging location is Ethiopia. The Ethiopia program began in 2001, in partnership with the federal Ministry of Health and the Lions Clubs of Ethiopia. It has focused its efforts on the country’s most affected region: the northwestern state of Amhara. Two thirds of its work there has been funded by money raised by the Lions Clubs of Ethiopia, through the Lions Clubs International Foundation. The antibiotic it has distributed, Zithromax, has all been donated by Pfizer. The Center aims to effectively control trachoma in the region by 2012.

Trachoma affects the lining of the eyelid, causing it to form granule-like bumps, and to appear red and irritated.  Repeated infections over the years cause the underside of the eyelid to scar. The scar tissue pulls the eyelid inward, so that the eyelashes scratch against the cornea, a condition known as trichiasis.  The constant rubbing against the globe of the eye is painful, and causes sensitivity to light and particulate matter, like dust and smoke.  Within just 18 months, it can begin to cause irreversible visual impairment.  If not surgically corrected, it causes blindness.

Amhara region: Ground Zero

Amhara region, which accounts for roughly 20% of Ethiopia’s population, carries 45% of the country’s trachoma burden.

More than 85% of Amhara’s 17 million people live in rural areas, situated in the mountainous highlands. They are overwhelmingly subsistence farmers, growing teff, a grain that is used to make injera, a spongy, flat bread typically served with Ethiopian meals.

In Ethiopia, Amhara region has the highest rate of active trachoma in children aged 1-9 (62%), and the highest rate of adults who have reached the final, blinding stage of trachoma (5.2%). The prevalence is attributed mainly to the area’s poverty, poor access to water, and poor sanitation. Families live in small huts, crowding a small space in which it’s easy for disease to spread from children to the parents. And in some areas of the rural mountains, mothers or children have to walk hours to get water, and then lug it back home. After cooking, drinking, and feeding the animals, there often isn’t enough left to wash hands, or children’s faces. This contributes to the spread of trachoma.

The other major contributing factor in Amhara is the presence of swarming flies, Musca sorbens, that thrive in places of poor sanitation. The flies like to breed in outdoor human stool, and they feed off of discharge around the eyes and nose. As they feed, they transmit the microorganism that infects they eyes with trachoma, from one person to the next. Sanitation facilities have historically been lacking in Amhara — another effect of the region’s poverty. Since 2003, however, hundreds of thousands of household latrines have been built with the help of The Carter Center and other development groups.

The World Health Organization endorses a four-pronged approach to trachoma control, known as the S.A.F.E. strategy.

S – Surgery to correct inverted eyelids, which occur in the most advanced stage of trachoma.
A – Antibiotics, namely azythromicin, to treat trachoma infection.
F – Facial cleanliness, particularly important for children, to clear off infectious ocular and nasal discharge that attracts eye-seeking flies, and which they spread to other people.
E – Environmental improvements, such as the building of latrines and access to water. Latrines help to reduce the population of flies that spread trachoma, and access to water promotes cleanliness.