implementation of the SAFE strategy improve or worsen gender equity?
Prepared by: Kilimanjaro Centre for Community Ophthalmology in collaboration with the British Columbia Centre for
Epidemiologic & International Ophthalmology
Summary
We will examine the global trachoma control programme, known as the Surgery, Antibiotics, Face-Washing and Environmental (SAFE)
strategy, from a gender perspective. In particular, we will explore the impact of health sector reform and public private partnerships on
implementation of trachoma control strategies from a gender perspective. We will measure the age/sex coverage of and re-infection
rate following ‘A’ (antibiotic) distribution in rural villages in three countries. In each of these settings, we will measure the cost and
social impact of establishing a community, regional, and national antibiotic distribution system. We will assess the gender-differential
impact of the implementation of surgical services. Finally, we will examine the implementation of prevention activities (face washing
and environmental changes) from the perspective of the burden of trachoma on men and women. The assessment will start in
Tanzania and be expanded to include two other countries (Vietnam and Egypt) where we have partnerships.
Background
Definitions
1) Trachoma
Trachoma is a form of chronic contagious conjunctivitis caused by Chlamydia trachomatis and characterized by recurrent re-infection. It
leads to scarring of conjunctival tissue, gradual shrinking of the upper lids, and inturned eyelashes (trichiasis), all of which are
aggravated by supra-infection. Young adults begin to manifest scars on the upper tarsal plate. With severe scarring and contraction,
trichiasis (in-turning of the eye lashes which rub on the globe) and entropion (inward turning of the eyelid margin) result.
Trachoma is predominantly found in rural communities where people live in overcrowded conditions and have limited access to water
and health care. Trachoma is the second or third leading cause of blindness worldwide. Globally, there are 150 million people
affected in 48 countries, 6 million of whom are blind.
Trachoma has been recognized as a serious public health problem in Tanzania, Egypt and Vietnam. In some endemic communities in
Tanzania, for example, over 30% of children have active disease and 5% of adults age 40 and over have trichiasis. Surveys in Egypt
have shown rates of active disease in children approaching 50%. Prevalence rates are considerably lower in Vietnam.
2) The SAFE Strategy
The World Health Organization has endorsed a multi-faceted strategy (SAFE) to combat trachoma, which consists of surgery (S) to
correct trichiasis, antibiotics (A) to treat active disease, and methods to interrupt transmission based on face washing (F) and
environmental improvements (E). Together, these strategies are known by the acronym of “SAFE”. Each component of the SAFE
strategy was incorporated based on limited research demonstrating some effectiveness against blinding trachoma.
In 1999, the International Trachoma Initiative (ITI) was established in order to address trachoma control. The Initiative, a public private
partnership with Pfizer Inc, endorsed the SAFE strategy and included free use of a Pfizer Inc donated Zithromax (Azithromycin), a
medicine patented by Pfizer, but far more expensive than alternate generic products such as tetracycline or its newer derivatives.
In 1999 the ITI programme identified Mali, Ghana, Morocco, Vietnam and Tanzania, as the first countries for its trachoma control
program. Later Sudan was added and in 2001 Nepal, Niger, and Ethiopia were included. In 2003 it is anticipated that Egypt will be
enrolled. In the authors experience, in some of these countries, most efforts and resources have been directed at antibiotic distribution
and monitoring, at the expense of other perhaps more long-term effective aspects of the SAFE strategy (particularly face washing and
environmental changes).
Rationale
Trachoma is predominantly a disease of women. Women have an estimated 4 fold increased risk of blindness from trachoma
compared to men. In order to effectively implement trachoma control, gender needs to be considered in all four components of the
SAFE strategy. Without knowing the role of gender in each component, health policy makers (both at the national level and increasingly
at the district level because of the resource intensive requirements of antibiotic distribution and monitoring) and trachoma programme
staff will not have the information necessary to make their plans and programmes gender-sensitive. Furthermore, without gender
specific information, countries adopting health sector reform and/or considering adoption of the ITI model (both often occurring
simultaneously) will not know whether health sector reform and this partnership improves or worsens the burden of trachoma induced
blindness on women.
Blindness as a global public health problem
Approximately two out of every three blind people in the world are women, most of who are older, and ninety per cent of who live in
poverty . This sex ratio holds true for most population-based blindness prevalence surveys from ‘Western industrialized’ and
economically poorer countries. This sex ratio also holds true, albeit for different reasons, for virtually all of the major preventable and
treatable blinding conditions in the world (cataract, trachoma, and glaucoma). The sex ratio only approaches one for age-adjusted rates
of untreatable conditions (i.e. age-related macular degeneration.
Biological differences explain very little of the increased prevalence among women. Instead, women of all ages (including children) are
exposed to causative factors, such as infectious diseases and malnutrition. More importantly, however, they utilize eye care services
much less than men
The World Health Organization (WHO) has recognized blindness as an important global health problem for both men and women,
unnecessarily afflicting approximately 50 million people. They estimate that this figure will increase to 75 million over the next 20 years
without increased prevention and treatment effort. Blindness is of significant interest to the WHO both because of its devastating impact
on peoples’ lives, especially those living in poverty, and because most blindness is preventable or curable, with some of the most cost-
effective programs available. For example cataract is routinely curable through surgery, and trachoma is preventable through clean
water and adequate sanitation.
The WHO is addressing global blindness through an international advocacy and training effort known as the Vision 2020 Initiative. Its
goal, as its name implies, is to eliminate treatable blindness by the year 2020. It also seeks to sensitize the general public, donors,
and service organizations to the increasing magnitude of blindness around the world. To date, however, Vision 2020 has not defined
gender specific needs or developed gender specific goals.
Important gender aspects of health sector reform and public private partnership for implementation of the SAFE strategy requiring
assessment
Surgery for trichiasis
In many poorer countries, including most countries of eastern Africa a significant number of adults have trichiasis that require
correction in order to avoid blindness. In addition, the growing number of older children and young adults with scarring of the upper lids
will add to the number of people needing surgery for trichiasis in the future.
To date, there is no gender specific data regarding trichiasis surgical programmes in place in Africa and Asia. Little is known on
surgical uptake among men or women. Based on data from cataract surgical programmes in poorer countries, if promotion of surgery
is not targeted to women, then women will remain under serviced compared to men. Information on current programme activities is
essential to developing gender specific interventions.
Researchers in Oman found that recurrent trichiasis following surgery is more common in women than men. Researchers have not
assessed recurrence of trichiasis by sex in other settings. It is not known whether this problem occurs elsewhere or whether it is due
to correctable factors such as the timing of the initial surgery, technique used, or due to re-infection.
In many trachoma endemic areas trichiasis surgery is offered free-of-charge to those needing surgery based on the assumption that
those requiring surgery are often the poorest and most marginalized in society. Even in settings (e.g., Tanzania) where health sector
reform has led to fees being charged for cataract and other eye surgery, trichiasis surgery remains free of charge.
Antibiotics
There is some evidence from Egypt that re-infection occurs more often in girls than boys following antibiotic distribution. However, there
is limited information on re-infection from other settings. Monitoring of antibiotic distribution has occurred to some extent in some
settings, but not according to sex. In some areas, (e.g., most programme areas in Vietnam and Rombo district in Tanzania) there is
targeted antibiotic distribution (in Vietnam: infected children and their family members; in Rombo: all children and women in selected
villages). However, the programme providers have not reported either the rationale for, or the effectiveness of these treatment
modalities.
In some countries antibiotic distribution programmes have been vertically organized, which can be a significant burden on the time of
health care staff. It is important to study whether the burden of delivery is more on female or male health care providers (and villagers
also involved in distribution) and if this burden (considerable travel away from the health centre) limits their ability to undertake other eye
care and health care responsibilities in the district.
With health sector reform in Tanzania, for example, a shift occurred in the responsibility of funding of antibiotic distribution. Although
the antibiotic was donated, the district health authorities have recently been asked to adopt the cost associated with distribution. It is
important to study whether the combination of health sector reform and public private partnership has shifted district health priorities to
antibiotic distribution at the expense of other programmes (e.g., cataract intervention programmes). In particular, what is the relative
effect on women versus men?
Face washing and environmental changes
Trachoma, once common throughout Europe and North America, has disappeared as a result of improved living standards.
Reductions in disease prevalence have been also been reported from developing countries (notably, Gambia and Malawi) without
antibiotic distribution and without increases in living standards. These reductions paralleled targeted improvements in sanitation,
water supply, education, and access to health care at the village level.
Women and girls bear an additional risk of infection and re-infection with Chlamydia trachomatis due to their domestic roles such as
fetching water, taking care of human and animal waste, and washing children’s faces. Improving access to water has multiple benefits
in improving hygiene and reducing the daily tasks borne by women and girls.
The F and E approaches to trachoma control have been shown to sustain impact on trachoma prevalence, and ultimately blindness vi-
v. To date, few researchers have investigated the impact of environmental and behavioural approaches to trachoma control,
specifically; few have developed strategies to modify the activities of women and girls; dealing with hygiene, water, and sanitation
efforts in communities and within households. In the author’s experience, the combination of health sector reform towards
establishing antibiotic distribution and the monitoring networks required of the public private partnership has lead to fewer resources
being dedicated to the environmental and behavioural approaches to trachoma control.
Needs
To study the impact of health sector reform on gender equity in trachoma control service.
To study interventions (the SAFE strategy) in terms of its impact (positive and negative) on existing gender inequities in blindness
prevention and treatment programs
To expand country specific capacity to design and conduct applied anthropologic and epidemiologic research in population and
public health and support collaborative relationships among “southern” research groups;
To advocate for gender equity in trachoma control programmes;
To facilitate relevant policy decisions related to gender equity at a national and international level.
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ii)World Health Organization. Global initiative for the elimination of avoidable blindness (WHO/PBL97.61) Geneva: WHO, 1997.
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Saharan village in absence of a disease control programme. Lancet. 1997; 349:1511-12.
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