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Lutte contre le trachome en Afrique subsaharienne

Anne-Marie Moulin
Jeanne Orfila
Doulaye Sacko
et al.

Part One. Synopsis and recommendations. English Version


Texte intégral

1A certain resignation has long characterized the management of diseases leading to blindness in the poorest countries, where chronic diseases tended to appear as an inescapable fate. It was compensated by the hope that history was going in the direction of decrease in this ancient affliction. Among these diseases, trachoma, poorly recognized by the population but well known by doctors, seemed like a relic from the past, destined to disappear spontaneously. Today, the review confirms that such a wait-and-see attitude is no longer valid. It recommends a forceful campaign policy, in order to achieve in one generation what could require several.

2The economic consequences of trachoma are certainly difficult to quantify in monetary terms with the desired precision, but it affects very many populations. Furthermore, the ageing of the African population will increase the number of blind people, putting an additional burden on the community. Adults over forty years of age, afflicted by blindness, represent a sector of the working population prematurely deprived of their independence. Becoming blind late in life, they are not adapted to the handicap; nor have they learnt trades compatible with their disability.

3Fighting poverty, the mother of all problems, is on the agenda. An indirect means of fighting it is to tackle it through diseases, which like blindness of infectious origin, are at the same time cause and consequence of impoverishment. Modern economists have discovered, or rediscovered, that poverty is not only defined by the amount of money available, but by the habitat, living conditions, marginalization and despair. Combating blindness, by tackling all these factors, will attack the roots of poverty more surely than any rise in the GNP and will put into practice, in a visionary way, what the WHO had formulated in 1949 as a "right to health" in all senses of the term.

4Trachoma control is not mechanically restricted to reproducing a strategy impelled from above. Deciding is not only choosing between several possibilities, but also inventing original solutions. Having in mind the abandoning of several attempts at eradication of diseases, which revolved around a presumed radical single means, specialists have preferred a more complex strategy; a mixture of repetition and innovation, involving both State and population, combining medical and technical measures with social and environmental measures. The SAFE strategy is interesting because it broadly integrates the technical and the social, politics and the community. With the difficulty of keeping a balance between the two, it is always tempting to favor the wide distribution of antibiotics and surgery, apparently easier to implement through a single government decision.

5The Alliance for eliminating blinding trachoma has proposed such a strategy, without however fixing the precise terms of its composition, which leaves governments the freedom to adjust the terms of a policy. On their side, the specialists have endeavored to counterbalance the components with a policy that seems reasonable. In short, it is a "SAFE" bet that the war on trachoma in sub-Saharan Africa will be won. Thus, the future of trachoma in every respect is a crucial experience in the history of international public health.

6Thus, the strategy for eliminating blinding trachoma does not act through one single exclusive measure. Specialists have not wanted to decide between the medico-surgical approach of a technical nature and the ecological and political approach. Epidemiology, resulting from a long tradition of research, has allowed us to determine the components of the infection fairly well. Even if it is not always easy, it is logical to act simultaneously on access to water, daily behavior, education at school, environmental improvement, etc. However, these approaches, geometrically compatible in the overall project, must be deployed in the long term following very different speeds.

7Antibiotic therapy once appeared as a short-term miracle solution, but we now know its risks and limits.

8Less spectacular than that for cataracts, trachoma surgery prevents a large percentage of blindness.

9In the longer term, improving access to water is likely to bring about a transformation in private and public hygiene. Changes in behavior only give a result very gradually, and their beneficial effects then become rooted in habits. The trachoma control campaign should have an effect on many other diseases related to water, especially diarrhea in childhood, respiratory infections and intestinal parasitosis.

10Finally, environmental sanitation, always late to arrive in water systems, can relay and increase the effects and continue the decline of the infection, apart from any antibiotic therapy.

11The establishment of all these measures, aimed at the wellbeing of society, should change the living conditions that have allowed the infection to survive at a low level. Thus, the proposed strategy counts on the positive convergence of several factors. This is a silent revolution, which only in some respects is a repetition of what has occurred in the rest of the world.

12A fight against an ancient, rather forgotten disease may thus be transformed into a spearhead campaign to relieve the sufferings of the population and increase their daily welfare. The result of the program depends on the ability of governments to improve the living conditions of the population, and on the latter's ability to make their demands heard and realized. If it succeeds, the war on trachoma symbolizes a new type of action, closer to the questions and answers of the local communities, so often referred to in public health policies, and so often absent from implementation and evaluation in the field.

13In many respects, the review goes further than the sole question of trachoma. It touches two major problems of West Africa and the modern world.

14The first problem is improving the operation of existing health services.

15These organizations are now being evaluated critically. Since the creation of modern hospitals, the universal establishment of primary health care units, and privatization-competition between centers, there have been many formulas and systems over the last three decades. There is currently a crisis of confidence, partly linked to the inadequacy of wages and hard times, which has made the relationship between health workers and sick people difficult and frustrating. The behavior of health workers regarding the population, the population's unfulfilled expectations, are also in question. Today, the time has come for a revitalization of the existing organizations, and a more precise assessment of human resources. In this age of technical progress, these determining factors very often restrict any improvement. There is no miracle cure in this field; what is needed is an effort to concretely think how to accomplish the projected tasks.

16The program against blindness may be the opportunity for a profound transformation of the relationship between patients and health workers. The search for trachomatous follicles on the inside of the eyelid can be explained to the patient. The prevention of blindness confers on health workers an obvious respect, especially if it is combined with effective treatment. Screening for and treating trachoma are not only technical actions. Checking the condition of the eyes should be a sign of involvement with the community, not just the simple assertion of power or unshared knowledge.

17The second question that the review touches on is the decentralization recommended by international organizations, and which answers the population's desire for democracy. The community is responsible for screening for eye infections and the distribution of antibiotics. These illustrate the new reforms. Nevertheless, the State is responsible for implementing the best overall plan and ensuring that it works, using skills as well as possible, choosing the regions for intervention, progressively analyzing experience in all its aspects, positive and negative, and modifying the strategy in line with the disease.

18How can we keep the two links of the chain firmly together, local initiative and state involvement? The trachoma review is an opportunity for thinking about a balance between current decentralization and the policy-making State. The State has the most information and can negotiate with international partners, especially the NGOs so that they work with maximum efficiency without their independence being uncontrolled and costly.

19Through its contribution to thought about the best use of human resources within the health systems, the balance between State and communities and between States and NGOs, the trachoma review is decidedly modern. The near future will tell us if the course of history agrees with what the specialists have projected, based on knowledge that is always changing.

20The expert group review not only concerns effects implemented in time, it also concerns those implemented in space. The plan attacks each area, paying attention to the diversity of countries, which the writers of the synopsis could not adequately take into account. The "pockets of trachoma" are examined through all their aspects: climatic, demographic, economic conditions, etc. While progressing from one area to the next, the program will encounter obstacles, or favorable factors, that will be instructive. The third dimension of the review is geographic. The program is expanded to include other West African countries, not only Mali, and then beyond to the whole African continent, where the countries could benefit from the diversity of Malian experiences and the drive of the model. Improving health by prevention of certain forms of blindness and conjunctivitis in childhood will thus be a contribution both symbolic and practical to the development of countries where trachoma is still rife.

21The review provides an old and yet changing message, soon to be confronted by biological, political and social realities, themselves also changing in Mali and elsewhere. It is not like a bottle with a message thrown into the sea, but a robust creation with a life of its own. Far from considering that they have accomplished their mission, its authors hope to follow the effects and wait for the results of the only test that counts, namely time.

© IRD Éditions, 2006

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