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AUSTRALIA shares a dubious distinction with the Gambia , Burkina Faso and Ethiopia as one of the world's trachoma hotspots. It is the only OECD country that has failed to eradicate trachoma, where it is found almost exclusively among aborigines. In Australia , prevalence is difficult to establish, due to a dearth of consistent epidemiological studies, but health surveys indicate that eye problems are among the most commonly reported conditions among aborigines. Prevalence varies between communities, ranging from 14% to 55% among paediatric patients. Best estimates are that 20,000 and 30,000 aboriginal children suffer from trachoma, according to Hugh Taylor MD, managing director of the Centre for Eye Research in Melbourne . "The scattered nature of the aboriginal population is part of the problem, but the whites are widely scattered across the country, too, and they get treated pretty well. But the bigger problem is that the Australian government has particular problems relating to aboriginal issues and particularly health issues," he notes. Trachoma is not the only eye problem. Aborigines are also 10 times more likely to go blind than the rest of the population, with most blindness due to corneal scarring from trachoma or cataract. It has been estimated that only 200 to 250 cataract operations are performed each year for indigenous people - one-tenth of the estimated operations required. Ophthalmologists also fear an epidemic of diabetic retinopathy in years to come. "Aborigines have about 10 times as much diabetes as occurs in white Australia . There is a serious problem already with diabetic retinopathy. Glaucoma and AMD are not a problem, because most aborigines have a life expectancy of 50 years, 20 years less than the rest of the population," said Dr. Taylor. There are reasons for this. Aborigines are at higher risk for some eye conditions, such as trachoma, and may have limited opportunities for diagnosis, management and treatment. Difficulties in accessing facilities and services can be due to poverty, lack of appropriate services and lack of transport. Indigenous culture is fundamentally different from Westernised Australia. The excellent health service developed for the rest of the population is often inappropriate. Aborigines are a highly mobile population, often moving between widely separated communities for work, which makes delivering services more difficult. The Australian Federal Government has, in the past, made concerted efforts to tackle the problem, but they were not sustained, an essential requirement with a disease like trachoma. While antibiotics are a highly effective treatment for early stage trachoma, this approach requires disciplined compliance. The risk of repeat infection is great if the underlying causes, like poor sanitation and health behaviours, are not tackled. It requires regular screening combined with a regional approach, in response to community mobility, for treatment to be effective. This was underlined by one study that evaluated the effectiveness of the SAFE programme, developed by the World Health Organisation, for the eradication of trachoma. SAFE stands for Surgery for trichiasis, community Antibiotic programmes, Facial cleanliness, and Environmental health improvements.The programme took place in Central Australia from 1998-2000. It aimed to treat current infections and alleviate their underlying causes, such as overcrowding, inadequate face washing and poor sanitation. It failed to achieve a sustained improvement in trachomatous infection. The study's authors concluded: "Single-community programmes will not achieve elimination of trachoma in the near future. Longterm eradication requires widespread changes, throughout the region, to conditions that allow transmission of trachoma. This requires not only community motivation, but also sustained political will and support." The authors pointed to mobility as a problem, with the attendant risk of people carrying infection into the community, or cured people picking up a new infection in another community. "There are no widespread systematic face washing programmes going on, though there are occasional health promotion plugs for this. But this is only one health behaviour among many that needs attention. Environmental health improvements, especially housing is a huge issue, being addressed in patches, with limited success in co-ordinating health, education, employment, and economic development with the housing developments. In general, poor housing and overcrowding is the norm in many remote communities," Dan Ewald MD, consultant ophthalmologist and author of the SAFE study, told EuroTimes. Dr. Ewald doesn't believe that housing alone will solve the problem, believing instead that a wider programme to offer social improvements, health education, house maintenance and even the provision of hygiene consumables like soap, brooms and toilet paper is required. "You can't expect people to have a high priority for health behaviours if there is a high degree of social chaos and dysfunction and other over-riding priorities. International readers need to appreciate that the colonisation history in Australia is very recent. There are Aboriginal people living in Central Australia who remember the first white contact with their people. They have been subject to many different racist and disempowering policies since then." In his report to the Federal Government five year's ago, Dr. Taylor emphasised the scale of the problem. "Despite the hard work and commitment of a number of individuals and organisations over the last ten to twenty years, the standards of Aboriginal eye health in some areas of our country remain appalling, and this seems inexcusable. Having said that, I believe there is good reason for optimism as there are a number of examples of the effective delivery of quality eye care." Hugh Taylor AC, MD Dan Ewald, BMed, MPH&TM, M.App.Epid Mark Loane MD Flying ophthalmologists hold out hope for Australia 's aborigines Delivering eye care to Australia 's aborigines is a tough task: the population is very small, it's scattered across a vast continent and many aborigines live in the most remote and inaccessible regions of Australia . One innovative project uses flying ophthalmologists, carrying the latest equipment, to serve them. The Cape York eye health programme regularly flies in a team of ophthalmologists to one of the most remote regions of Northern Australia . It serves 14,000 people in 14 communities in an area the size of Southern England . The programme was set up by Dr. Mark Loane, a consultant ophthalmologist with a practice in Brisbane . The structure is simple, but robust and effective, and treats primarily refractive error, diabetic retinopathy and cataract. One major problem with treatment for aborigines throughout the continent is identifying pathologies; another is the extent of refractive problems. Dr. Loane's programme tackles both issues at once. An optometrist flies around the Cape York region, three times a year, delivering glasses and identifying pathologies. Local and flying doctors based in the region also feed in pathologies into the programme. Once a year the optometrist is accompanied by an ophthalmologist, who comes equipped with a Haag Streit slit lamp, a green diode laser and a YAG laser for diabetic retinopathy treatment and capsulotomy. Diagnoses and treatment are performed at the same time. "All our equipment has to be portable, because we can't afford to equip every community with a slit lamp microscope and laser. It has to be lightweight because we're flying around in light aircraft, and you'll fly into a mountain if you carry too much. So we've installed a Haag Streit table in every community, and we just carry the slit lamp around with us. You have to have this equipment because if you don't treat patients straight away, you can't be sure people will turn up for the next visit," said Dr. Loane. The visiting ophthalmologist also assesses patients for cataract surgery, and performs all measurements. This data forms part of a surgery list. Once a year, Dr. Loane, another ophthalmologist, a scrub nurse and an anaesthetist set up an operations centre in Weipa, the Cape 's largest and most central town. "We perform five or six days of surgery, each doing 20-25 cataracts a day. They include some of the most difficult cataract I've come across. Some of the lenses are traumatised, sometimes the cataracts are very dense," said Dr. Loane. "We have the best equipment, we use state-of-the-art phaco and folding lenses. It works out cheaper to use the best equipment; you get less follow up and PCO. Ophthalmologists are also an obsessive bunch, so you have to give them the best equipment. There is nothing more frustrating than coming into areas and finding you haven't the capacity to do your finest work."
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