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Installing toilets to reduce blindness

A person checked for trachoma. Sightsavers
Lack of access to clean toilets or an adequate water supply, living in close proximity to animals, and poor public health awareness have helped put 2.3 million people in northern Nigeria’s Borno State at risk of contracting trachoma, a bacterial infection causing blindness.

But practising simple good hygiene and stopping open defecation can significantly reduce the chances of contracting the disease, says NGO Helen Keller International (HKI).

Two-thirds of Borno’s 15 districts are trachoma-endemic, according to an HKI survey, with half of those infected, primary-school-age children. The state also has Nigeria's highest river blindness prevalence levels.

“Poor sanitation, lack of personal hygiene and acute water shortages are major causes of this disturbing health problem,” HKI’s project manager in Borno State, Peter Aimankhu, told IRIN.

Trachoma is a chronic contagious disease marked by inflammation of the eye-membrane, eyelids and the cornea of the eye; the formation of scar tissue leads to impaired vision and blindness, making trachoma the world’s leading cause of preventable blindness. It is spread through eye-to-eye infection through people or through flies.

The illness, infecting 41 million people worldwide, is characterized by the World Health Organization as one of the world’s forgotten diseases.

Why Borno?

Northern Borno State, on the Niger, Chad and Cameroon borders, is particularly prone to trachoma because it is dominated by cattle-rearers, many of whom whom keep their animals in their homes, and use their dried manure as fertilizer or to plaster their mud houses, attracting flies, according to HKI.

Poverty and poor hygiene practices, whereby villagers defecate in the bush near their homes, rather than using latrines, helps the disease to spread, said Sarah Wakirwa, an ophthalmic nurse involved in an HKI trachoma prevention project.

"Most of the people are poor and the cost of digging pit latrines is far beyond their reach. Some have no option but to defecate in the bush even if they will want to have a toilet," HKI project manager Aimankhu said. The bulk of Borno State’s population lives on less than a dollar a day.

Northern Borno is arid and villagers must trek long distances to source water for domestic use, so many prioritize water use for drinking and cooking and only use it to wash every few days.

Not a priority

Between 2002 and 2007 HKI went from village to village to spread public health messages; helped people treat trachoma with a simple antibiotic (tetracycline) eye ointment; performed surgery on 781 people with advanced cases - called trachiasis - where the eyelashes turn inwards, scratching the cornea and causing blindness. The organization focused on 344 of the most at-risk villages in 10 of the 15 affected government areas in the state.

But the government has done very little to tackle the disease since, say villagers.

Because it is non-fatal and causes progressive rather than sudden damage, the disease is often not taken seriously by health practitioners or governments, says HKI.

According to a Borno State Ministry of Health official, who asked to go unnamed, “the government does not prioritize health in its budgeting, and trachoma is not one of its health priorities.”

However, it can ruin lives if contracted. “My life has not been the same since I lost my sight to trachoma six years ago,” Maiduguri resident Lado Bukar, told IRIN. “It started with reddening of my eyes followed by itching which I mistook for mild infection that could be treated with eye drops.”

“The ailment progressed for five years and I began to lose my vision. I lost my job as a private security guard and now live on begging.”


HKI staff also constructed ventilated pit latrines for primary schools in 10 villages in the worst-hit area of Bama near the Cameroon border, and trained teachers to detect the signs of trachoma early in their pupils.

Trachoma rates in these schools declined, says HKI. The programme has been a success when teachers are included to encourage pupils to wash their hands and faces and avoid defecating in the bush.

“But it is a different thing when they return home because compliance then depends on parents’ disposition to personal hygiene,” HKI’s ophthalmic nurse Sarah Wakirwa, told IRIN. And despite public health campaigns, most villagers still keep their cattle in their homes and coat their houses in manure said Aimankhu.

The government health officer told IRIN: “It all boils down to environmental and personal hygiene. The government can only tell the people what they should do to avoid preventable diseases, including trachoma, but cannot force compliance. That is a personal issue.”

With insufficient funding to treat the five remaining government areas, HKI’s Wakirwa worries the 12,000 treated people risk being re-infected by those in the five as-yet untreated government areas. A prevalence survey has to be carried out to assess the impact the project has had on the communities covered, Aimankhu said.

HKI is optimistic it will find the funding to complete the treatment, but even when money does become available, it will have to rebuild its medical teams as the existing ones have been disbanded by Borno State health management who appointed the staff to clinics and hospitals across the state.

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