“Click, Clack” -­‐ Counting Canes Exploring causes of visual impairment in Ethiopia Sarah Noa Bozenhardt June 13th 2014 Patchwork Quilt Paper Studies in the Sciences SCIE-­‐300 Jane Slemon Bozenhardt 1 The rain begins to fall and mist covers Addis Ababa. As the summer turns into the wet months of the year, Aster Aseffa wraps her daughter Bethi into thick layers of cotton. Her soft voice fills the small room as she brings her child to sleep – a song harmonic and meaningful. Tunes transform into questions and thoughts when she begins to share her story: Aster is twenty-­‐three years old, a single mother, a student, and blind. When Aster moves through the city, she does so with distinct navigation. “Click, clack” – her cane feels along the pavement. Once in a while a finger, or two, reaches out to the side and feels along the walls that form the ever-­‐
present labyrinth of Ethiopia’s capital. But what’s hidden behind these lines of separation? There are kids playing, parents working, maids cooking. There is the smell of freshly baked Injera (the national food) mixed with red stains of the spice Berbere that burns and caresses your tongue at the same time. And somewhere there is a reason, an answer to Aster’s question: “Why?” The young mother lost her eyesight when she herself was only a child, still living in the rural South of Ethiopia: “My throat started to itch, it hurt to swallow.” When Aster speaks her voice doesn’t shiver, she is certain when she says: “It was the medicine. They gave me some herbs and then the light disappeared.” Eighteen years later Aster still doesn’t understand why her eyes can no longer sense her surroundings. It’s no different for her friends Wude, Kalikidan and Emebet. They all speak of the same uncertainty, an issue that in fact addresses an entire nation. Ethiopia is a home to an estimation of 75,000,000 citizens. The study “National Survey on Blindness, Low Vision and Trachoma in Ethiopia” from 2006 breaks this number into categories. An estimate of 1,200,456 people are blind, another 2,776,054 struggle low vision, and 9,034,931 children between the age of one and nine have Active Trachoma. (Berhane) This reveals that “the national prevalence of Bozenhardt 2 blindness is 1.6% […] and that low vision is 3.7%” (Berhane 1). Numbers might seem abstract on paper, but if you walk through the streets of Addis Ababa you hear them everyday: “Click, Clack.” Thus, the conversations with Aster Aseffa and the findings of the “National Survey on Blindness, Low Vision and Trachoma in Ethiopia” initiate an exploration that considers the main scientific causes of visual impairment in Ethiopia, leading to a thorough discussion of trachoma in relation to Aster’s loss of vision. If “approximately 80% of blindness in Ethiopia is […] avoidable; i.e. either preventable or curable” (Berhane 4), then this paper seeks to pick up Aster’s question: “Why?” The causes of blindness in Ethiopia can be broken into percentages and sections (see Fig.1). Figure 1, entitled Counting Canes, reveals a diagram referencing data from the “National Survey on Blindness, Low Vision and Trachoma in Ethiopia” that illustrates the main causes of blindness in the country graphically. Fig. 1 Causes of blindness in Ethiopia. Sarah Noa Bozenhardt. Counting Canes. Photography & digital imaging. Drawn from Berhane, Yemane. “National Survey on Blindness, Low Vision and Trachoma in Ethiopia.” Bozenhardt 3 Three factors stand out: Cataract, refractive error, and trachoma. Cataract is defined as “a cloudiness or opacity in the normally transparent crystalline lens of the eye” and “can cause a decrease in vision [that] may lead to eventual blindness” ("Cataracts). Refractive errors are “optical imperfections that prevent the eye from properly focusing light” (Heiting) and only recently has it been recognized that “a large number of people are blind in different parts of the world due to high refractive error” (Dandona 237). Last but not least, the bacterial eye disease trachoma is the “leading preventable cause of blindness worldwide” (Mayo Clinic Staff 1). Whereas the research prior to this paper delved into all these three causes of blindness, trachoma stood out as particularly important since it seems to relate to Aster Aseffa’s condition directly. Aster lost her eyesight as a child, and when referring back to the numbers introduced earlier, 9,034,931 children in Ethiopia between the age of one and nine have Active Trachoma. (Berhane) This number alone suggests likelihood that Aster may have been one of them. The following discussion of trachoma is motivated by the wish to find the wall that Aster’s fingers are searching for when she walks through the streets of Addis Ababa: “Click, Clack.” Trachoma is an eye disease that is “caused by the bacterium Chlamydia trachomatis” and “if left untreated, repeated trachoma infections can cause severe scarring of the inside of the eyelid and can cause the eyelashes to scratch the cornea” ("Hygiene-­‐related Diseases). The micro-­‐organism Chlamydia trachomatis “develops in the lining of the eyelid (conjunctiva), and is sometimes a respiratory or genital disease” (Mariotti 6). As the bacterium is spread through “personal contact with hands [...] or indirectly by flies seeking the secretions (discharges) from the eyes” (Mariotti 6) it is a highly contagious disease. Repeated infections during childhood result in the “eyelids [becoming] thick and [developing] scars” and “the Bozenhardt 4 eyelashes turning inwards and rubbing on the cornea” (Mariotti 6). Eventually the continuous scarring can cause visual loss and blindness. Images of eyes that were blinded by this process of trachoma reveal eyelids and eyelashes that turn inward to such a degree that they in fact hide the scarred eyeballs altogether. This description scientifically refers to Aster’s appearance, but it lacks the depiction of her beauty. However, the correlation between the two cannot be ignored, and thus further increases the likeliness of Aster’s condition as being related to trachoma. To continue the search, let’s look at some of the symptoms put in relation to the disease: Early stages of trachoma can be accompanied by “ear, nose, and throat complications” ("Trachoma). Sound familiar? A parallel may be drawn to Aster’s initial statement: “My throat started to itch, it hurt to swallow.” Along come symptoms such as “itching and irritation of the eyes and eyelids” as well as “discharge from the eyes containing mucus or pus” (Mayo Clinic Staff 1). As the inflammation increases overtime, vision is affected. The scratches in the cornea can be thought of as many little prisms that begin to break the light, so that imagery becomes blurred or refracted. When “corneal clouding” occurs the eyeball begins to look milky and this “cloud” affects the visual experience accordingly (see Fig. 2). (Mariotti 2) Figure 2, entitled Aster & Bethi, is a digital photograph that references these symptoms of the disease and seeks to represent the visual effect of trachoma in its early stages. The image was taken with a plastic bottle attached to the lens. A cut-­‐out whole in the bottle creates a “clear” space -­‐ the rest of the image is being distorted and clouded by the refraction of the light. Bozenhardt 5 Fig. 2 A visual reference to the experience of trachoma. Sarah Noa Bozenhardt. Aster & Bethi. Digital Photography. Additionally, the image was shot with a soft focus to emphasise the progressive lost of sight that occurs if trachoma triggers inflammation of the eye repetitively. Aster and her daughter Bethi are the subjects of the photograph. Their presence connects the scientific with the personal. The viewer of the image is invited to see what Aster must have experienced when she was a little child. Fig. 2 references symptoms, and symptoms are signals, so what happens next? Medically speaking trachoma is easily treatable: “In the early stages […], treatment with antibiotics alone may be enough to eliminate the infection” (Mayo Clinic Staff 4). If the disease has progressed further eyelid rotation surgery may be needed, during which an incision in the scarred lid is made to rotate the eyelashes away from the cornea. (Mayo Clinic Staff 6) Such surgical approaches can prevent Bozenhardt 6 further damage of the cornea and stop additional decrease in vision. However, when Aster says, “they gave me some herbs and then the light disappeared”, she points at the major issue accompanying trachoma and other causes of blindness in Ethiopia. Whether cataract, refractive error or trachoma, health care, sanitation and resources are needed to treat these preventable causes of visual impairment. The rain that is now heavily falling drowns the soft voice of Aster. Her words are lost and carried away in the thunder. Outside stands a green bucket, or “jerika” as Aster calls it, which collects the drops. Tomorrow the water will be used to wash Bethi. When the young mother sprinkles the cold liquid on her daughter’s face she does so with care and knowledge. Her fingers are clean when she wipes across Bethi’s eyes: This is where preventions starts. The “National Survey on Blindness, Low Vision and Trachoma in Ethiopia” includes household information in their research. References to “literacy, water source and sanitation” (Berhane 31) are drawn. Again, numbers can help to illustrate the causes of blindness in Ethiopia: “The majority (64.5%) of the household heads were illiterate. Only 9.6% had high school education or better” (Berhane 31). Another example is the issue of sanitation, which is clarified in the following: “The majority of households (84.6%) dispose their garbage in the open field; and 60.3% of the households had no latrine” (Berhane 31). Either reference reveals that Aster’s condition may have been medically caused by trachoma but originated earlier, and could have been prevented, not only with antibiotics or surgery, but also with education, awareness and hygiene. The SAFE strategy for preventing trachoma by the World Health Organization unites this perspective. The initiative has been “developed for controlling trachoma through the action of a combination of determinants including Surgery, Antibiotic treatment, Facial Bozenhardt 7 cleanliness and Environmental change” (Mariotti 5). To prevent trachoma the targeted communities should be informed and advised how to “improve general hygiene” and how to “build excreta disposal facilities and use them” (Mariotti 6). Thereafter, the transmission of trachoma through flies or contact between contaminated fingers and eyes could be hindered before the disease catches on -­‐ Aster learned it the hard way. The causes of blindness and low vision in Ethiopia are multiple. Some examples illustrated are cataract and refractive error. However, the eye disease trachoma stands out in the context of this paper, since parallels can be drawn between the medical appearance of the disease and Aster Aseffa. The exploration of trachoma -­‐ its origin, symptoms and effects – suggests likelihood that Aster was repetitively infected with the bacterium Chlamydia trachomatis when she was a young child. The lack of proper health care, education and hygiene may have resulted in the progression of the disease. As Aster gets older her eyes and eyelashes turn inwards, eventually scratching and scarring her cornea to such a degree that vision is lost. Today, Aster’s fingers may come across an unusual brick – an answer if you will. The rain continues to fall, Bethi’s breath is calm, and the streets of Addis remain framed by their labyrinth of walls. A young mother is on her way to school: “Click, Clack.” Bozenhardt 8 Works Cited Berhane, Yemane, Alemayehu Worku, and Abebe Bejiga. National Survey on Blindness, Low Vision and Trachoma in Ethiopia. Addis Ababa: Federal Ministry of Health in Ethiopia, 2006. Print. Berhane, Yemane. "Survey Report." Workshop on Evidence Based Interventions for Eye Health and Development in Ethiopia. Federal Ministry of Health of Ethiopia. Hilton Hotel, Addis Ababa. 18 Aug. 2006. Speech. Bozenhardt, Aster. Personal interview. Addis Ababa: 13 May 2014. "Cataracts." Free Online Medical Dictionary, Thesaurus and Encyclopedia, n.d. Web. 11 June 2014. <http://medical-­‐dictionary.thefreedictionary.com/Cataracts>. Dandona, Rakhi, and Lalit Dandona. "Refractive error blindness." Bulletin of the World Health Organization 79: 237 -­‐243. Print. Heiting, Gary. "Refractive Errors and Refraction: How the Eye Sees." All About Vision, May 2014. Web. 11 June 2014. <http://www.allaboutvision.com/eye-­‐
exam/refraction.html>. "Hygiene-­‐related Diseases." Centers for Disease Control and Prevention, 28 Dec. 2009. Web. 11 June 2014. <http://www.cdc.gov/healthywater/hygiene/disease/trachoa.html>. Mariotti, S.P., and A. Prüss. The SAFE strategy -­‐ Preventing trachoma. Geneva: World Health Organization, 2001. Print. Mayo Clinic Staff. "Diseases and Conditions -­‐ Trachoma." Mayo Foundation for Medical Education and Research, n.d. Web. 11 June 2014. <http://www.mayoclinic.org/disease-­‐conditions/trachoma/basics/definition/con-­‐
20025935?p=1>. "Trachoma." Wikipedia, n.d. Web. 11 June 2014. <http://en.wikipedia.org/wiki/Trachoma>.