International Coalition for Trachoma Control

Australia is home to the oldest continuous living culture in the world. Australia’s Indigenous population are two distinct cultural groups, Aboriginal and Torres Strait Islander peoples, and there is great diversity within the 250+ nations/language groups spread across the continent.

Aboriginal and Torres Strait Islander people have been involved in Australia’s journey to eliminate trachoma since the 1970s when the National Trachoma and Eye Health Program (NTEHP) was undertaken. It was led by ophthalmologist, Fred Hollows, and teams travelled across the country screening and treating more than 100,000 people from 465 communities over the course of two years. 

Key to the NTEHP’s success was the involvement of Aboriginal people in roles related to community and cultural engagement. People such as Jilipia Jones, Gordon Briscoe, Trevor Buzzacott, Rose Murray and Reg Murray provided a range of knowledge, skills and cultural expertise to the team during community visits. They often travelled ahead to speak with communities and explain the program and the reason for the visits. This demonstrated the key principle of Aboriginal voice and involvement in these programs.

The 1970s also marked another important moment in Australia’s Indigenous health journey, the start of the Aboriginal community-controlled health movement. The National Aboriginal Community Controlled Health Organisation (NACCHO) was established in 1974 and is a living embodiment of the aspirations of Aboriginal communities and their struggle for self-determination. NACCHO is the national peak body representing 143 Aboriginal community-controlled health organisations across the country on Aboriginal health and wellbeing issues.

NACCHO and its member services have and continue to play an imperative role in the sustainable elimination of trachoma in Australia.

The prevalence of trachoma had fallen since the 1970s, but in 2009 the rate in children aged 5 – 9 years in outback communities was still 14%. By 2019 is it had reduced to 4.5%[1]. Trachoma is still found in remote communities in Central Australia, although the number of at-risk communities has reduced from 205 (2008) to 53 (2019). The total population in these endemic areas is approximately 50,000.

There has not been just one single approach to reduce trachoma. Rather many people, communities and organisations have worked hard together to implement the SAFE strategy.  Screening and mass drug administration (MDA) is usually undertaken by public health nurses and Aboriginal Health Workers and trichiasis is detected and handled by the existing health services.

Working with Aboriginal and Torres Strait Islander people and communities to create health promotion resources to promote facial cleanliness

In 2010, the ‘Clean Faces, Strong Eyes’ trachoma health promotion suite of resources were developed by Indigenous Eye Health at The University of Melbourne in partnership with the Ngumbin Reference Group, an advisory group of Indigenous community members from the Katherine West Region in the Northern Territory and the Centre for Disease Control Northern Territory.

The Ngumbin Reference Group provided a wealth of knowledge and cultural expertise in the development of these resources. Having the group involved as partners in this process was imperative to the success and adoption of these resources in remote Indigenous communities.

The resources feature a health promotion mascot called ‘Milpa the Trachoma Goanna’. ‘Milpa’ is the Walpiri word for ‘eyes’. The campaigns key message is ‘Clean Faces, Strong Eyes’, which highlights the importance of facial cleanliness in the prevention of trachoma. The character of Milpa has a recognition rate of over 80% in Central Australian Indigenous communities and has been a key driver in the reduction of trachoma prevalence rates. All these resources are available for communities to adapt and use in their own language, imagery, and messaging. The translation of resources into Aboriginal languages has been key. These resources are provided at no cost and are funded by the Australian Government as part of their ongoing commitment to eliminate trachoma in Australia.

Building capacity in Aboriginal and Torres Strait Islander communities to take ownership of trachoma elimination

The Environmental Health Trachoma Project (#endingtrachoma) aims to reduce the incidence of trachoma and skin infections in ‘trachoma at-risk’ Aboriginal communities in remote Western Australia. The project works with the regional Public Health Units and the Aboriginal Environmental Health workforce, who are located within Aboriginal communities, to develop sustainable and realistic trachoma prevention strategies within a broader environmental health context. The key has been to work with local Aboriginal communities to identify their priorities to reduce trachoma and other hygiene related illnesses.

The #EndingTrachoma project has highlighted the importance of the environmental improvement’s component of the WHO’s SAFE strategy to eliminate trachoma. A key success of the project is strengthening the capacity of the local Aboriginal environmental health workforce.

Improving the prompt repair and maintenance of washing facilities in houses is the most significant element to fix in terms of Environmental Improvements in the Australian context.

Impact of COVID-19 on elimination efforts

One of the ‘Clean Faces, Strong Eyes Milpa’s Six Steps to Stop Germs’ resources

The strength of the Aboriginal community-controlled health sector was proven during the current pandemic when they united to protect Indigenous communities against the spread of COVID-19. The pandemic also emphasised the importance of good hygiene in preventing illness and many community leaders and organisations were involved in strong local communications, often translated into Aboriginal languages.

Trachoma health promotion messages also were broadened to include other hygiene actions to also address other hygiene-related illnesses including otitis media, rheumatic heart fever, scabies, tooth and gum disease, gastrointestinal disease, respiratory disease and COVID-19.

A broader hygiene focus allows for greater collaboration with other organisations and health promotion programs. This unified and consistent messaging gives a more manageable approach to health promotion for healthservices that have many competing priorities. It also provides opportunities to embed the key trachoma prevention message about facial cleanliness in existing programs. Read more about the development of ‘Milpa’s Six Steps to Stop Germs’ here.

During COVID-19, the resources were adapted to include the new action ‘cough into your elbow’. These new resources include a community service announcement video developed with Indigenous Community TV and featured Milpa the Trachoma Goanna.

Challenges

We know from experience that trachoma disappeared from most parts of Australia when living conditions improved. This included reducing overcrowding, improving housing and access to health hardware. We still have further work to achieve this in remote communities.

Multisectoral collaboration continues to be a challenge in the elimination of trachoma as a public health problem. Bringing together sectors, such as health, education, and housing – to improve communication and partnerships is an ongoing area of focus.

Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030 provides a blueprint to strengthen these partnerships and its implementation will play an important role to achieve and sustain trachoma elimination in Australia.

Conclusions

In Australia, many partners have worked hard to secure and maintain ongoing funding from the Australia Government to progress the elimination of trachoma as a public health problem.

The focus remains on implementation of the WHO SAFE strategy; however, increased ownership and leadership by Aboriginal and Torres Strait Islander people and communities needs to be fostered for sustainable elimination.

An important part of that process is supporting the creation and ongoing development of the Aboriginal and Torres Strait Islander workforce. This needs to happen at all levels of elimination efforts, but particularly on the ground in the communities where trachoma is present.

This blog was written by Nick Wilson, Emma Stanford and Professor Hugh Taylor at the University of Melbourne

References

[1] Australian Trachoma Surveillance Report 2019. Kirby Institute, UNSW Sydney, Sydney NSW 2052