Mali’s success against trachoma: a playbook for progress in insecure areas

An optimist by nature, Professor Lamine Traoré’s confidence that Mali would end trachoma never wavered.

That commitment remained intact as he led his nation’s trachoma program over the last 12 years through a series of coup d'états, armed rebellions, and growing insecurity across large swaths of the country.

As it turns out, even against these steep odds, Traoré’s confidence was well-founded. Earlier this year, the World Health Organization (WHO) announced that Mali was the first highly endemic country to eliminate trachoma.

“Yes, I am an optimist,” said Traoré. “But it is more than that. I was optimistic because our entire team and all of our partners, international and local, were motivated and galvanized.”

Mali’s remarkable success provides a playbook for other countries battling trachoma and should add a dose of hope to the plans of health leaders around the world working on similar challenges in highly unstable and insecure areas.

Mali is the only country in the world where the disease was highly endemic and has now been eliminated as a health concern. As recently as 1997, surveys found more than one quarter of children in Mali had active trachoma.

“The country went from 10 million people at risk to zero,” said Kelly Callahan, who has led The Carter Center’s global program against trachoma for the past nine years. “This is truly a tremendous achievement.”

Mali is just the latest and biggest win in the quickly accelerating global fight against trachoma, a neglected tropical disease caused by a bacterial eye infection that is easily transmitted from person to person through eye or nasal discharge. The late stage of the disease has visually impaired nearly 2 million people globally. The global prevalence of trachoma has decreased by an astounding 92% since 2002. The WHO has certified 18 countries – Benin, Cambodia, China, Gambia, Ghana, Iran, Iraq, Laos, Malawi, Mali, Mexico, Morocco, Myanmar, Nepal, Oman, Saudi Arabia, Togo, and Vanuatu – as having eliminated the disease as a public health problem. Noting this progress, a recent article in The Lancet posited that, “global elimination can still be achieved by 2030.”

Diving global progress are committed health ministries around the world supported by implementing partners including The Carter Center, Helen Keller Intl, and Sightsavers, and a coalition of funders including the Conrad N. Hilton Foundation, Lions Club International Foundation, and USAID. These partners and funders have supported national efforts to map trachoma – creating a powerful global data set that allows countries to identify hot spots and track progress – and supported programs around the world to distribute 1 billion doses of Zithromax donated by Pfizer to treat and prevent the disease. The organizations have also helped countries adopt the WHO’s SAFE strategy, a set of interventions proven to disrupt transmission, treat infection, and prevent blindness. The SAFE strategy consists of surgery to correct late-stage disease, antibiotics to help prevent and treat infection, facial cleanliness promotion, and environmental improvements, such as the provision of clean water.

The disease remains active in more than two dozen countries, often in remote areas or regions of instability and insecurity. This was the case in Mali.

Callahan said such insecurity is the largest hurdle to eliminating trachoma by 2030. But it is not an insurmountable hurdle, as Mali illustrates. In fact, health challenges can be a starting point that gets everyone to the table. “We can use health issues as a bridge to talk about peace,” she said.

Progress against trachoma is possible even in insecure areas, said Traoré: "You just must adapt to the context. You cannot forget that even the armed groups benefit from health programming."

Traoré’s team worked with local religious leaders, women leaders, civil society groups, and international leaders to negotiate access to thousands of villages. Each village head was provided with the details of each health worker, what their activities would include every time they visited – from surveying to surgery – when they would be visiting, and even what cars they would be driving. In some cases, ceasefires were negotiated to allow health workers into certain areas.

“Whenever possible, we rented local cars, we hired local people, and we brought local representatives with us when we went door to door for surveys, evaluations, or treatments,” said Traoré. “We benefited from their local knowledge and their contacts and that allowed us to avoid conflict and, in one case, averted a kidnapping.”

Health officials were constantly adapting and liaising through intermediaries with insurgents, said Sadi Moussa, The Carter Center’s senior country representative for Mali.

“Village chiefs know trachoma is an issue in their villages. They recognize it as a concern. So, you can reason and even negotiate with them,” said Moussa. “Sometimes they might say you need to bring an incentive, such as other medicines, malaria nets, or parts to repair a well in the village. This is about trust building and equipping communities, as much as possible, to own and lead programming.”

Mali’s success also demonstrates how health leaders can equip local leaders in remote or insecure areas to continue to fight the disease long after health workers have returned to their offices and facilities. Volunteers in every village across Mali were provided with charts and photographs to help them educate their neighbors about how to prevent trachoma and identify symptoms. They brought these educational materials to local gatherings, social events, and even to local churches and mosques. Local radio stations played public service announcements that reached far into insecure areas, reinforcing the messages of local volunteers about preventing and treating trachoma.

Investments in improving access to safe drinking water also helped drive down infections rates. Today, more than 80% of Mali’s population has access to drinking water, up from 49% in 2000.

The Carter Center’s Callahan explained that Mali’s trachoma programming required not only commitment from Mali’s ministry of health, but also from its ministry of water, ministry of finance, and ministry of education. “They all coordinated, built on each other’s strengths, and never wavered in their commitment,” said Callahan.

Finally, Mali also leveraged data and worked to ensure that lessons from even the most remote and challenging areas were shared across the program. Every month, representatives from each region of the country would speak about what was working and what wasn’t. And annual meetings brought evaluation teams together to present progress and share learnings.

“Our hope is that other neglected tropical disease programs can learn from Mali and reach their goal,” said Moussa. “Mali shows that we don’t have to wait for the crisis to be over to begin our public health efforts.”