Cost-Effective Interventions Beyond Health Systems
The preceding examples show that health interventions can succeed in situations of dire poverty and even during violent conflict. In addition, a look at the history of the unprecedented gains in human health in the 20th century reveals that improvements in health are not dependent upon economic development. As noted in chapter 1, technical progress—embodied in scientific knowledge, cost-effectiveness analyses, and managerial expertise—can define and deliver cost-effective interventions in almost any setting. Nonetheless, as the battle against trachoma in Morocco illustrates, the potential synergies between health interventions and improvements in general social conditions are significant (DCP2, chapters 50 and 67).
"The incidence of Hib meningitis in Chile has fallen by 91 percent and that of pneumonia and other forms of Hib disease by 80 percent."
Trachoma is a disease of poverty. It is a highly contagious bacterial infection, and repeated infections lead to corneal scarring and eventually blindness, usually at the age of 40 to 50. The disease is spread by direct contact with eye and nose secretions from affected individuals, by contact with contaminated towels and clothing, and by flies. Disease transmission is rapid and intense in conditions of overcrowding, poor hygiene, and poverty.
" trachoma has disappeared from Europe and North America, but it continues to afflict the developing world."
With economic development and improved hygiene, trachoma has disappeared from Europe and North America, but it continues to afflict the developing world, particularly the millions of people living in hot, dry regions where access to clean water, sanitation, and health care is limited. Children are its first victims. In endemic areas, prevalence rates in children age two to five years reach 90 percent. The disease also disproportionately affects women, who because of their close contact with children are infected two or three time more frequently than men. The heaviest burden of blindness from trachoma affects the populations of Sub-Saharan Africa. Trachoma is linked to poverty as both a symptom and a cause, because trachoma-related blindness strikes people in their economically most productive years.
Initially, Morocco handled trachoma as though it were primarily a medical problem. In the 1970s and 1980s, schoolchildren in the most affected provinces were treated with tetracycline eye ointment twice a year, but this did nothing to improve the standard of living among the rural poor. Thus, while trachoma virtually disappeared from developing urban areas, it pervaded poorer, rural areas. In the early 1990s, a national survey found that more than 5 percent of Morocco's population exhibited signs of trachoma and that virtually all the cases were concentrated in five poor, rural provinces.
"In the early 1990s, more than 5 percent of Morocco's population exhibited signs of trachoma"
In 1991, Morocco set up the National Blindness Control Program. This expansive partnership included the five government divisions responsible for health, education, employment, equipment, and water; international organizations; bilateral and multilateral agencies; and local nongovernmental organizations (NGOs). Between 1997 and 1999, the government incorporated the so-called SAFE (surgery, antibiotics, face washing, environmental change) community strategy into the National Blindness Control Program. This strategy worked as follows:
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Surgery: a simple, quick, inexpensive procedure to save patients' vision with a success rate of 80 percent. In Morocco, mobile surgical units staffed by doctors and specialized nurses performed the surgery.
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Antibiotics: one-dose azithromycin to treat active infections and reduce the community pool of infections. The government developed multiple strategies for distributing the donated drug based on the recognition that trachoma is a community disease and that reinfection is likely to occur if only isolated cases are treated.
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Face washing: regular face washing can break the cycle of reinfection and prevent bacteria from spreading. Information, education, and communication campaigns have proven effective in changing people's behavior.
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Environmental change: improved living conditions and community hygiene are essential for reducing the spread of trachoma. The government oversaw the construction of latrines in 32 villages and the provision of potable water in 74 villages. Some 350 local village associations also undertook to build latrines, drill wells, and store animal dung safely so that it could be used for fertilizer without spreading flies. Access to potable water increased from 13 percent of all rural communities in 1992 to 60 percent in 2000. With the acknowledgment that reducing poverty and improving literacy among women is central to the fight against trachoma, the government undertook interventions to improve literacy among women and implemented economic programs to increase women's incomes.
" improved living conditions and community hygiene are essential for reducing the spread of trachoma."
The adoption of SAFE was driven by Morocco's recognition that, as the head of the National Blindness Control Program observed, "Trachoma at the level of these regions is not strictly a medical problem; it is essentially the reflection of a socioeconomic problem The real enemies are the disfavored rural communities, illiteracy, family overcrowding, lack of water, the accumulation of animal wastes, and the proliferation of domestic flies. In sum, the enemy to combat is not chlamydia but poverty" (quoted in Levine and others 2004, p. 86).
"Morocco has achieved a 75 percent drop in the prevalence of trachoma since 1999 and its complete elimination from some provinces"
With a health program that intentionally moves beyond the health system to include and encourage broader aspects of economic development, Morocco has achieved a 75 percent drop in the prevalence of trachoma since 1999 and its complete elimination from some provinces—the most rapid progress against trachoma in a single country ever recorded.
