Hosted by Dr. Hunter Cherwek, with guests Dr. Danny Haddad and Dr. Alemayehu Sisay.
Dr. Hunter Cherwek: It’s fair to say that 2020 did not turn out the way any of us expected.
I’m Dr. Hunter Cherwek, Vice President of Clinical Services at Orbis International. You might know Orbis from our Flying Eye Hospital, which is a teaching hospital on board an MD-10 aircraft. It’s pretty incredible.
I was supposed to be traveling with the Flying Eye Hospital this year, bringing training programs to local eye health teams around the world. Instead, like many of you, I’m working from home here in Virginia. But it's tough to complain. My team and my family are healthy and I am grateful for all that we are doing now with Orbis.
Really, though, I’d much prefer to be on the Flying Eye Hospital. Because for me, the fight against global blindness isn’t just a job – it’s a calling. I knew very early on in my career – while I was still in med school – what I wanted to do. There aren’t many professions where a 10- or 20-minute cataract procedure can change not only an individual's life, but a family. You don't need an intensive care unit, you don't need blood transfusions; we can do cataract surgery almost anywhere and that can change someone’s life forever.
So, in 2005, the day I finished my ophthalmology residency, I joined the Flying Eye Hospital team and I never looked back. It’s been a heartbreaking decision to ground the Flying Eye Hospital when COVID hit. But just because things haven’t gone as planned this year, doesn’t mean that our fight against global blindness has come to a halt. From here in Virginia, I’m working with my colleagues around the world to innovate, adapt and create new solutions and ways to move forward.
And that’s what Sightlines is about. I’ll be your host for this series looking at how Orbis is responding to COVID and tackling the overwhelming challenge of global blindness. Together we’ll explore how the pandemic is adding new challenges to this fight and how the spirit of innovation that led our founders to put a hospital on board a plane is helping us overcome those challenges.
There are some things we can’t do right now, but right now we’re focused on what we can do and what we're doing very well. Before we get going, let’s take a look at why global blindness matters so much and what’s being done about it.
Here’s the problem. Hundreds of millions of people around the world are blind or visually impaired. And most don’t have to be. An astonishing 75% of these cases could be treated – or even altogether prevented. I’m constantly thinking about how much good could be done in the world by restoring the eyesight to these millions of people. What it would mean for the people’s individual lives, for local economies, for education, healthcare, and the cycle of poverty.
And the thing is, we can bring the gift of sight to millions of people. The remedies, very often, are quite straightforward. A pair of glasses, a 10-minute cataract surgery, an annual dose of antibiotics to prevent an infectious, blinding disease called trachoma. These things alone could restore sight or prevent blindness for millions of children and millions of adults. The challenge is to get this sight-saving care to people who currently don’t have access in places like Bangladesh, Peru, Vietnam, Ethiopia, Bolivia, India, Guyana, and beyond. Right now, that’s a bigger challenge than ever.
Orbis’s mission is to work with a network of partners around the world to mentor, train and inspire local teams to fight blindness in their communities. Training is at the very heart of what we do – because it takes a skilled worker to do eye exams, perform cataract surgeries, and get that sight-saving care to the people who need it.
But in-person training projects aren’t possible right now. So, what can we do?
A lot.
First, we’re taking steps to support our partner hospitals around the world. That means helping them implement safety measures so that emergency eye care – for conditions that must be treated immediately – can still be delivered as safely as possible.
Second, we’re looking at how programs can be reshaped and optimized for the current situation. In India, for instance, Orbis has a long-running program called REACH that provides basic eye screenings and glasses to children in schools. With schools closed, however, the usual REACH activities can’t happen. So instead, REACH teams have been redeployed to help treat emergency eye cases in hospitals.
And what about the Orbis Flying Eye Hospital? Well, it was supposed to be in Zambia, Cameroon, Mongolia, and India this year. And nothing can replace the hands-on training that would have happened on board. But while the plane is grounded, we’ve moved the training projects online. Our team has crafted online courses tailored to the needs of each country’s ophthalmologists, residents, nurses, biomedical engineers and technicians who would have been joining us on board the Flying Eye Hospital. So they’re still getting critical education and support to help save sight in their own communities.
Moving the Flying Eye Hospital projects online is something that’s possible because of yet another Orbis program: Cybersight. Cybersight is our distance learning and telemedicine platform. It was created in the early days of the internet, it’s grown and expanded over the years, and it’s taken on all new importance during COVID.
In the past, Cybersight allowed us to continue to provide training and support in places where our plane or our team couldn’t go due to cost, logistics or security. Now, as the world manages a global pandemic, this technology has been essential to allowing Orbis to continue our mission.
We’ll explore all of this and more throughout this series. To get started, today we’re going to take a close look at how the fight against COVID intersects with the fight against another infectious disease: blinding trachoma. To help us do that, I invited Dr. Danny Haddad, Chief of Programs with Orbis, on the show. Here’s our conversation.
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Dr. Hunter Cherwek: I’m really, really excited to have Danny Haddad as our guest. He is our Chief of Program. Danny has a very interesting background in global ophthalmology. You started and joined the Orbis family in 2016. Maybe you can talk a little bit about your career before that and what led up to your joining Orbis.
Dr. Danny Haddad: So after I graduated as a medical doctor, I started working as a volunteer in West Papua, Indonesia, managing a cataract program there. From there on, I went to Niger and became the regional coordinator for river blindness or trichiasis and trachoma and that really introduced me more into the neglected tropical diseases, as we call them now. It's a handful of diseases, that are infectious diseases, that are easy to treat and prevent and that are on an incredible path to being eliminated out of this world.
And one of the ones that I've worked mostly in is a disease called trachoma. And the first time that I got, at least that I still remember as kind of my first patient that I saw with trachoma, was a patient in 1996 in Ethiopia. And basically, I was spending a day in the outpatient department with an Ethiopian ophthalmologist, and then there was this one patient who had complained that every morning when she woke up she had to put margarine underneath her eyelids to make the blinking go smooth. I had no idea what that was, so when we examined her, we saw that her whole eyelid had rotated inwards and all the eyelashes were scratching over the cornea. And her cornea had already completely gone white. So normally when you look at somebody, you see kind of the clear parts – the window of the eye, behind which you have the colored parts, the iris. And in this patient it was completely white. It was so scratched, scarified that she couldn't see anything anymore.
And the ophthalmologist explained to me: well, this is trachoma and this is an infectious disease that starts very early in life. It's a bacterial disease. And it starts in your children and you get re-infected over your life. Every time you get infected, you get these little blisters on the inside of your eyelids that will heal with a tiny little scar. But over your life, since this disease is so endemic in these communities, you get so many of these little scar tissue formations in the inside of your eyelids that your eyelids strings on the inside and makes your eyelid rotate inwards. And that condition, where the eyelashes scratch over your cornea, is what we call trichiasis.
And actually on the next day, we were traveling together to one of the clinics where they were doing outreach, where they were seeing patients, much closer to their home, to screen them to see who needed treatment surgery and to take them back to the base hospital. And we passed this field with a couple of young boys herding cows. And the ophthalmologist told me and said I bet if we stop and examine these children all of these boys are going to show signs of trachoma. I said I would love to see that. So we pulled over, called the boys over, and we flipped their eyelids and looked for the signs of trachoma and, indeed, all of them were infected with trachoma. And it's so amazing to see that now – I mean this was in 1996 – the incredible progress that we have made in this area with these communities to make sure that blindness due to trachoma is very soon going to be something from the history books.
Dr. Hunter Cherwek: That's fantastic. I mean, obviously, this is something you've been fighting for 25 years and, before Orbis, I know you were leading a lot of the international efforts to eliminate trachoma. Maybe you can talk a little bit more about how trachoma is treated both medically and surgically, and how Orbis, especially in Ethiopia, is doing both.
Dr. Danny Haddad: So when you're looking at trachoma and the different pieces of the disease, you're looking at the active infection with the bacteria, you're looking at those eyelids that are rotated inwards. We have a strategy that is called the SAFE Strategy that really addresses all the different components of attacking the disease in a very holistic way. So in the SAFE Strategy the S stands for surgery. So, once that eyelid is rotated inwards, we do a surgery to invert the eyelid again, to make sure that those eyelashes are no longer scratching over the cornea and that progression towards blindness is halted.
The A component stands for antibiotic and this is where we look in a country at the district level, to see if this district is endemic for trachoma. Is there a level of infection within the communities in these districts that warrants us to treat the whole district? And with this disease, we are not looking for individual patients and treating with an antibiotic the individual patient. The antibiotic that we're using is Zithromax, which is produced by Pfizer, and it's a very well-known antibiotic and very safe to use. And Pfizer is donating all the Zithromax that we need to target this disease. Basically what we're doing is that those districts, where there is trachoma, we treat everybody in the district to make sure that we treat each person that is infected and reduce that way the burden of the disease in such a way that you do not transmit it to each other anymore.
And then we have the preventive voice. We want to make sure that, once we have suppressed all the infections in the community, that it stays that way. We do that by face washing (the F component) and the E component is environmental improvement. Basically this means that we are doing a lot of work in schools, training children to everyday wash their face and wash the discharge away from their eyes and from their nose, because that is really a way to transmit the disease from one person to the next. We are working at these communities to look at how can we make sure that these communities have access to water, because if you have to walk for an hour or two to get a bucket of water, the last thing you want to use that for is washing your face and using that for hygiene purposes. So, we really making sure that people have access to water closer by and that they will actually use that water for hygiene purposes for washing their face and making sure then that way we prevent the spread of the disease within the communities.
Dr. Hunter Cherwek: No, that's fantastic. And I mean, just so our viewers and our listeners know, we’ve had an Orbis Ethiopia office for more than 20 years. Today it has over 70 people, full time employees, that are really, really focused on this disease that Danny was just talking about called trachoma. Every year we distribute over $200 million worth of the Zithromax antibiotic, that is donated by Pfizer, and we're going out to the most rural communities, the ones that are at most risk, to help reduce the burden of this bacteria that causes this blinding disease called trachoma. And correct me if I'm wrong, Danny. Obviously you're a trachoma expert, but, I mean, trachoma was even in Ireland 50-60 years ago.
Dr. Danny Haddad: Absolutely in Netherlands, in Amsterdam, in certain ports of Amsterdam, up to the Second World War, there was trachoma in the city. And there is still there a lot of literature from those days about trachoma in Europe. Trachoma has been around for thousands of years. If you're looking at some of the pyramids in Egypt, they're actually hieroglyphs, where there is a sign of a pair of tweezers, because people knew that with trachoma with the eyelids rotating inwards and the eyelashes scratching the cornea that you had to epilate your eyelashes to make sure that you prevent going blind.
And we've seen evidence that this already happened back in the days of the early Egyptians, so this is a disease that has been with us for a very long time. In America and Europe, we've been able to overcome this disease by the preventive measures around hygiene. By making sure that we have flushing toilets, that we have running water, and that we're able to provide to the whole community that level of hygiene that will protect us from getting the disease and from transmitting the disease. And I always love it to look at– We’re here in New York, the Ellis Island, the island where all the immigrants from Europe used to come and where they were screened. And one of the elements that people were screened for was trachoma. And most of the people that were refused entry to United States, in those days, were actually sent back to Europe because they had trachoma and it was one of the most feared elements at Ellis Island to introduce into community.
That's actually part of one of my favorite movies, The Godfather. And in the Godfather Part Two, where Vito Corleone arrives in New York at Ellis Island, you see in the movie how they flip his eyelids and they examine him of signs trachoma and you also see that they gave him a chalk mark on his coat and he's sent away, but somehow was allowed to come into New York with all the consequences afterwards. But it does show the importance that this disease has in our community here in the US and in Europe in those days as well.
Dr. Hunter Cherwek: I think one of the things that's been most exciting is that you're very strategic with how we're tackling trachoma in southern Ethiopia and you have this beautiful map where we're looking at the prevalence before and after treatment and surveillance, even after the mass distribution of these antibiotics. Can you talk a little bit about how far we've come in Ethiopia, with the mapping and all the epidemiologic studies that you've been doing? Could you just talk about how much success we've had in Ethiopia?
Dr. Danny Haddad: Absolutely! This is something where, over the past 10 years, we've made a lot of progress around looking at how long does it take to get rid of trachoma in an endemic district. We're looking at what is that baseline that we're starting at in these districts, so how much of the community is infected. And we do that by going around a district where we select at random around 20 villages. And in those villages we select a random number of households, and in those households we examine everybody. And then we look at children 1-9 years, how many of the children that we've examined have signs of trachoma. And that is what we're using as a baseline of where we are in that district. And based on that, we will determine how many years of treatment we need to do with Zithromax before we assess that district again, to see what our impact has been.
And we really want to make sure that we show the progress that we've gone from, say 40% of the children have trachoma, to, five years later, that we are reaching a goal of less than 5% of those children have a trachoma signs. And when we are reaching that level of a district and, in less than 5% of children having signs of trachoma, that's where we can say we think we've done it. And then we wait for two years and after two years we assess again. Is it still gone? Or did it come back? Do we need to start treatment again? Or can we really declare that we have eliminated trachoma in this district?
What I'm most excited about is that when we're looking at the map of Ethiopia and a lot of the original – what we call mapping so those assessments and really looking at what districts are endemic – when we're looking at the map of when we've finished all the mapping in Ethiopia back in 2013, there were an incredible amount of districts that were colored red of being very endemic for trachoma. When we're looking now, it is incredible to see how many of those districts have turned green, where we've eliminated the disease, and it's just incredible to see the amount of progress that we've made over the past years, and that we're continuing to make in Ethiopia. And for this year, we're hoping to look at treating again about 10 million people and bringing those communities really closer to the elimination of blinding trachoma.
Dr. Hunter Cherwek: And obviously, all of us now in today's world are very aware of infectious diseases and how to prevent the spread of transmission of diseases with COVID. Danny, we are going to be talking with the team in Ethiopia, as well, but could you just talk about how COVID has impacted our work in trachoma?
Dr. Danny Haddad: Right! And this is, of course, where we are looking at as Orbis, especially in Ethiopia, for this year to treat about 10 million people in the Southern Nations and Nationalities states in Southern Ethiopia. And one of the elements that we're looking at here is we have developed an infrastructure where we work together with the Regional Health Bureau of that state to train, at the district level and at a community level, volunteers that will go around and hand out the Zithromax. And the most fascinating part is that we actually do the dosing based on height. So they will walk around with a dosing pole to measure the height of the person that they're treating and, based on the height, either a child will get a specific amount of oral solution, a drink of Zithromax, or adults or all the children will get the exact number of tablets that they need. So, this training and, of course, the distribution in the community is something that we're very carefully looking at how do we do that in a safe way. How do we make sure that when these volunteers, these distributors, go house to house or bring people together in the center of the village, that we are not spreading the disease? So we are looking very carefully and we have a whole risk assessment strategy where we’re looking at: how do we make sure that the distributors that we are using and that we are training will be having the protective equipment that they need to protect themselves? Because we want to make sure that those people that help us do the distribution – and also of course the people that we serve – that everybody is staying healthy and safe during this distribution program. And we’ve looked at it, we’ve discussed it with the Ministry of Health in Ethiopia, we’ve discussed it with our partners and the World Health Organization to come up with a strategy for us to be able to do this in a safe way. As it stands right now, we think we can do it and we think we can do it in a safe way to make sure that we are not going to eliminate trachoma, but start spreading COVID, because that would of course be counterproductive, counter of what we are standing for. We want to make sure we can do the distribution of Zithromax in that safe way.
Dr. Hunter Cherwek: And I mean, it's incredible to see what you've built with the team in Ethiopia. We have this incredible network for supply chain for community education and for community volunteers. Do you think there's an opportunity where the Ministry of Health, and in their COVID response, could piggyback or use the already existing Orbis infrastructure and networks to help with COVID education and prevention, especially with all the hygiene work we're doing with trachoma?
Dr. Danny Haddad: Absolutely! And this is work that we've been doing over the past months. We're looking at how do we adapt the messaging that we had for facewashing. They are very similar but not identical to the messages that we want to have around handwashing. So, we've been working with our volunteers around changing the messages for some of the posters, educational materials for facewashing to include the handwashing messages. So, this has been work that we've been doing over the past months since the early days of COVID to really enhance the awareness and the hygiene creation that we need to do in these communities to make sure that we keep COVID at bay.
But I would like to actually take it a step further. One of the discussions that we're having as well is, of course, the success of the trachoma program. In a program in Ethiopia, we're looking now at trachoma is endemic in the majority, almost all, districts in Ethiopia. And right now 70% of the world's burden of trachoma is in Ethiopia. Is this infrastructure going to be an opportunity for us to look at using for when there is a COVID vaccine? We are, with our strategy around distribution of Zithromax, able to reach more than 90 percent of the population in those districts.
That is totally different than other vaccination programs. The current vaccination programs are really targeted at children, they're not targeted at a whole population. And this is where I see an incredible opportunity for us to look at how do we use this network that we have developed in all the communities and all these districts in Ethiopia to facilitate the vaccine distribution, the vaccination campaign around COVID-19 in Ethiopia and other places where we're working around trachoma. Because we're also doing work on trachoma in Zambia, although at a smaller scale than Ethiopia, but we're also involved in Zambia in trachoma elimination. And what are the opportunities for us to use that incredibly strong infrastructure in other ways as well.
Dr. Hunter Cherwek: This vodcast, just so everyone knows, was made possible by the generosity of an anonymous donor who wanted more people to know about Orbis and our fight against avoidable blindness. Danny, from your perspective, why is this fight so important, not just to you and Orbis, but for society and the world? Why is this fight against avoidable blindness so important?
Dr. Danny Haddad: We're looking, first of all, with prevention of blindness and restoring sight, which is possible in patients with cataract, still about half of the people in the world that are blind, are being blind because of cataract, a very simple surgery.
We are working with diseases that, once they've blinded somebody, you cannot restore anymore. Unlike cataracts where once you blind you can restore that sight again, the patients with diabetes, if they go blind because of diabetes disease, you cannot restore their sight. With trachoma, if somebody goes blind because of trachoma, we cannot restore their sight. When we're looking at the economic impact that blindness has on communities, we need to address prevention of blindness. We need to make sure that it becomes part of the health system structure in these countries, to make sure that we break through the vicious cycle of poverty.
When you're looking at individual level, and the studies even here in the US have really shown that somebody who is blind is four times more likely to be depressed, to really value their life much, much less as people that have sight, so we're looking at the quality of life of people. When you see somebody who was blind for seven years and then the bandage goes off and you see the change in their smile – that they're smiling for the first time in ages. When you see that change in their face, you know that this is something that has just got an incredible impact, but it's not just on that individual level, it is on the community level, it is on a whole different scale that we have an impact with prevention of blindness.
Dr. Hunter Cherwek: Yeah, and I think that's what so many people don't realize is how much of the world's blindness could be prevented or treated and that's what Orbis does and so much of that blindness right now is in low- and middle- income countries where exactly we're focused. Now is the best time, ever, to be in medicine where we have all this amazing technology, we have this amazing connectivity and now research, academics, everyone is focused on how their solutions can be globalized. And so, I'm really excited and I want to, obviously, thank this anonymous donor, because this is the first time we've had a platform to talk about our fight and that it's something that we can achieve in our lifetime. Where we're going to be able to give people hope and give people sight where, 20 years ago, we wouldn't even think that would be possible.
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Dr. Hunter Cherwek: That was Dr. Danny Haddad, Orbis’s Chief of Programs.
From helping to establish pediatric eye care centers across the country to eliminating blinding trachoma, Orbis Ethiopia has had a huge impact on helping millions of people to have access to eye care in the country. I recently had the pleasure of speaking with Dr. Alemayehu Sisay, Country Director for Orbis Ethiopia, to get his perspective on the impact that COVID-19 has had on delivering eye care programs – especially in the rural communities of Southern Ethiopia.
Here’s some of our conversation.
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Dr. Hunter Cherwek: Maybe you can just tell a little bit about Orbis Ethiopia. How big is the team and the kind of the role of a country director?
Dr. Alemayehu Sisay: Orbis Ethiopia has been operating in the country for the last now 21 years. A model eye care program was developed, mainly in Southern Ethiopia, providing cataract surgery, refractive error service and trachoma management. So, since then, our program has been expanding, providing eye care service to more than 20 million population in the southern region alone. If you add the national program, our total beneficiaries will be increased to more than 30 or 35 million, because we have projects in the northern Ethiopia, in Oromia region in southwestern Ethiopia and other regions as well.
So, when we all started, it was only the country director and few supporting staff. Now, we have more than 72 staff and 27 of them are based in the Addis office. The remaining are based in the project area, where we have the actual implementation going on. I'm very fortunate and privileged to have my team with me, very supportive, very dedicated, committed and they are working hard to meet the noble cause of Orbis. In Ethiopia, trachoma is the leading cause of blindness, second to cataract, so that indicates the huge burden of trachoma. And, as you know, blindness and poverty are interlinked, so they create a vicious cycle. So, if a person is blind from trachoma, the likelihood of its effect on the family is massive. People have to take care of the blind person taking to, you know, religious places, markets and other social events. So the consequence of being blind from trachoma is tragic.
Mothers and children are affected disproportionately than men. You know culturally, the mothers have close proximity with the childcare, so the cycle of infection between mothers and kids are so severe that mothers at age of 35-40 could develop the blinding form of trachoma. At Orbis, we are trying to provide services closer to a community, so that accessibility could be improved. And we encourage mothers and kids to come forward for services. In our trachoma control program, our data indicates that more than 75% of the beneficiaries are mothers and kids. That is a huge progress in terms of addressing the gender imbalance.
Dr. Hunter Cherwek: In the years that we've been present in Ethiopia, we've had a huge impact in lowering the community burden of trachoma. Maybe you can talk about how COVID has slowed that down, but also how you plan to start back up. How do we plan to tackle now both COVID and trachoma in these communities?
Dr. Alemayehu Sisay: So, both trachoma and COVID require personal hygiene. So how can we leverage the information, the resource in doing that. So I think we are bringing in that light, we are merging the message through radio sports, through our health cadre at community level, at the district level, and so on. In fact, we are sponsoring radio sports in some of our projects to propagate about the importance of sanitation for both COVID and trachoma. We have also provided a handwashing facility to some of the primary eye care unit, including secondary eye care units. That indicates how we can work in the face of COVID by addressing the water sanitation aspect of the problem.
Dr. Hunter Cherwek: That's a great answer! Obviously, you've been working now for years on rural outreach, community education, drug distribution, screening and evaluations. So do you see an opportunity for the Ministry of Health and the Ethiopian health leaders to piggyback or use our backbone and network that we're already doing for Trachoma to address COVID response, COVID education and COVID control measures?
Dr. Alemayehu Sisay: Absolutely, Hunter! I mean we have to use the existing system to propagate information to address the problem. So the healthcare system and health professionals are the same. The reporting lines, the district offices, the regional office, the health bureau – they are all the same. So they are coming up with an integrated approach to address COVID situation and trachoma, particularly as I have said, on the infection prevention side, the sanitation and hygiene component. We are using the existing policies and resources to leverage, you know, the COVID on top of that. So in that way we are trying to address in a very integrated and concerted way for both trachoma and COVID.
Dr. Hunter Cherwek: Now, that's fantastic. I mean, I think all of our viewers can see the similarities, whether you're trying to contain the disease of trachoma, which Ethiopia has been a leader in for years, or now COVID, which the entire world is affected and looking at the response.
I remember when I first was there more than a decade ago and we were talking about what would it take and when would we achieve success over trachoma and I've never thought that would be possible in my lifetime. And, you know, certainly there's still a lot of work, and COVID has made that work more difficult. I am very confident that with your leadership, Alemayehu, that we are going to win this war in my lifetime and make the Ethiopia state just like the UK and the US and Ireland, where we've rid the disease, so no child has to worry, no parent has to worry about their child going blind because of a disease or an infection they got as a child.
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Dr. Hunter Cherwek: That was Dr. Alemayehu Sisay, the Country Director for Orbis Ethiopia. Before that, we had Dr. Danny Haddad, Orbis’s Chief of Program. I want to thank them both for being a part of this episode.
Thank you for joining me for Sightlines today. I hope you’ll join us for the next episode and for the entire series. If you would like to learn more about Orbis and the Flying Eye Hospital, please visit us at Orbis.org.
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Until next time!
