Since 2002, huge strides have been made towards the global elimination of trachoma as a public health problem. The World Health Organization Weekly Epidemiological Record, published on 24 July 2020, reported that the number of people at risk of trachoma has declined from 1.5 billion in 2002 to 136.9 million in 2020 – a 91% reduction. However, as the global burden of trachoma shrinks, it is becoming increasingly clear that new and tailored approaches are needed to reach many of the most marginalized communities, including indigenous populations, who have limited access to health services as a result of distinct social and cultural practices as well as economic and political policies.
To mark the International Day of the World’s Indigenous Peoples we provide a snapshot of work to reach indigenous populations with trachoma interventions in two regions: the World Health Organization (WHO) Region of the Americas and the WHO Africa Region.
WHO Region of the Americas
The WHO Region of the Americas spans the North and South America continents hosting a rich diversity of ethnicities and cultures, including an estimated 45 million indigenous peoples from 826 indigenous communities in addition to Afro-descendants and Roma communities. Neglected tropical diseases (NTDs), including trachoma, are known to be a public health problem among many of the 34 million people living in the Amazon rainforest – the world’s largest tropical rainforest, which also encompasses 2,467 indigenous territories occupying almost one quarter of the region’s land. The diversity of social, cultural, and government practices as well as the difficulty in accessing communities within the Amazon region presents several logistical challenges.
To expand the benefits of health programs efficiently, the Pan-American Health Organization (PAHO) recommends an integrated approach that delivers essential health services for a range of NTDs and eye health issues as well as cross-sectoral preventive measures, such as improved access to education, safe housing and water, sanitation and hygiene. This integrated package aims to improve the uptake of several interventions and helps to sustain gains made and build sustainable, resilient and accessible health systems for indigenous populations.
For example, in Colombia, the Ministry of Health is distributing treatment for soil-transmitted helminths alongside trachoma interventions. To ensure population coverage of interventions and access to interventions, the Ministry of Health is working with neighbouring countries, through PAHO, to identify travel routes of nomadic indigenous populations, as well as hiring health workers from local or nearby districts who are more familiar with local cultures and languages.
Indigenous health in the WHO Region of the Americas in being targeted through the regions Policy on Ethnicity and Health, which was unanimously adopted by PAHO Member States at the 29th Pan American Sanitary Conference in September 2017. The policy commits Member States to working with communities to develop inclusive, collaborative solutions to address health gaps, including the provision of interventions for NTDs, to advance progress toward universal health coverage.
WHO Africa Region
In the south-eastern corner of South Sudan bordering Ethiopia, Kenya, and Uganda, live the Toposa people, an agricultural-pastoral people whose traditional way of life involves significant migration to ensure the health of their livestock. During the dry season, some goats and sheep are kept close to the village while the cattle and remaining animals go to “cattle camps”, locations where grazing and water is always available. There are no specific land ownership rights in these grazing lands and herds are not always in the same areas at the same time of the year.
In 2015, trachoma mapping in three counties where the Toposa lived showed active trachoma between 30 to 47% in children one to nine years. However, access to trachoma interventions is complicated by limited access to water and sanitation, few healthcare centers and seasonal migration patterns to cattle camps that result in portions of the population being away from the village for half the year.
In 2016, the South Sudan Ministry of Health, with support of The Carter Center, expanded village-based mass drug administration (MDA) strategies to include reaching out to cattle camps. Expanding the MDA required several adaptions to usual programming including:
1) Determining the number of cattle camps and where they are located each year.
This is critical to the success of programs as rainfall and other weather patterns can significantly impact where and when interventions should be targeted. For example, in 2018, over 10,000 people received treatment across 35 cattle camps. However, in 2019, higher rain fall meant that 9,500 people received treatments across 25 camps which were located close to the village. As cattle camp teams often travel to cattle camps by foot, which can take from two hours to two days, understanding how many and where the camps are located is essential to prepare teams for the work being undertaken.
2) Community engagement
Working collaboratively with communities underpins the success of all NTD programs. However, this is particularly important in the case of indigenous and nomadic communities, whose beliefs might impact the uptake of interventions. Identifying community leaders to act as community mobilizers can be critical to share information with cattle camp residents and ensure the effectiveness of health campaigns.
3) Data collection
It is important for programs to disaggregate data to document the number of people treated in camps compared to the villages. Reaching cattle camps can add costs and time to a program; therefore having data that shows the number of additional people reached through an adapted approach can be an important advocacy tool locally, nationally and at the donor level.
In 2011, the Lobaye and the Sangha-mbaéré regions of the Central African Republic, home to the Bayaka people, were estimated to have a prevalence of 28.0% and 32.3% of active trachoma. The Bayaka are a nomadic ethnic group that travel frequently to hunt and gather materials, as well as other cultural practices, such as conducting funerals, which presents several challenges to provide trachoma interventions.
In 2017, the Ministry of Health began implementing mass drug administration in Lobaye and the Sangha-mbaéré. Recognizing the distinct social practices and history of marginalization of indigenous communities within the broader national population, the Ministry of Health used three specific approaches: 1) Limiting the marginalization of the community by educating other communities living in the same region; 2) Encouraging social cohesion by promoting equity in social and health activities; and 3) Using local human resources to improve community engagement with the program.
The Ministry of Health worked closely with the Bayaka communities, connecting with them at their camps, employing people who speak the local language and are known and trusted by the community, and ensuring sufficient time was allocated to engage the community. This allowed the Ministry of Health to identify travel routes and plan interventions effectively, ensuring that the community would be present at the time of mass drug administration campaigns.
Reaching 2030 targets
Indigenous and nomadic populations differ significantly around the world, however many share common challenges related to their human rights and access to public services, including health, education and basic infrastructure, such as clean water and sanitation. The United Nations Declaration on the Rights of Indigenous Peoples emphatically states ‘Indigenous peoples have the right, without discrimination, to the improvement of their economic and social conditions, including, inter alia, in the areas of education, employment, vocational training and retraining, housing, sanitation, health and social security’.
To achieve this as well as NTD targets in the draft World Health Organization 2021-2030 NTD road map and the 2030 Sustainable Development Goals, health systems must be strengthened with an explicit focus on tailored strategies to improve indigenous health. The realization of these fundamental human rights will make countries better prepared to tackle current and future health challenges, and will have cross-cutting social, cultural and economic benefits that will benefit future generations for years to come and ensure no one is left behind.
This blog was developed by ICTC, drawing on contributions from Angelia Sanders, The Carter Center, Martha Saboya, PAHO, and Dr Georges Yaya, Ministry of Health, Central African Republic