Australia is the only developed nation endemic for trachoma, a blinding bacterial infection of the eye. Developing countries such as Morocco and Cambodia have recently eliminated the disease. However, in Australia, one of the wealthiest countries in the world, trachoma remains highly prevalent among Indigenous Australians living in remote communities, due in part to a crisis in appropriate housing. The isolation of endemic trachoma to Indigenous communities reflects a broader trend of health inequality between Indigenous and non-Indigenous Australians. Australia has committed to eliminating trachoma by 2020, per the WHO’s Global Elimination of Trachoma by 2020 (GET2020) initiative. With this deadline rapidly approaching, I argue that long-term elimination requires urgent focus on environmental improvement, including boosting housing standards and increasing the speed of repairs.
WHO endorses the “SAFE” strategy for trachoma elimination: Surgery for trichiasis, Antibiotics by mass drug administration (MDA) for infection, Facial cleanliness to reduce transmission and Environmental improvements to increase hygiene. By focusing on the “A” and “F” elements of the strategy, Australia has seen substantial progress toward trachoma elimination. The number of communities at-risk for endemic trachoma has decreased by more than 50% over the last decade, and experts report elimination may be achievable within two years.
However, to minimise the risk of re-emergence the underlying environmental causes of the disease must (also) be addressed. Overcrowding in housing remains a key concern in remote Indigenous communities and is a known risk factor for trachoma. The most recent data (2014-15) shows 41% of Indigenous people in remote communities still live in an overcrowded house. Notably, 28% live in a house where one or more facilities are broken or otherwise not available for washing people, clothes and bedding, and enabling safe food preparation. A recent scan of hygiene priorities in remote Indigenous communities found that it is not uncommon for up to 20 people to live in a three-bedroom house. Overcrowding limits hygienic practice, as critical facilities such as showers, baths, toilets and taps regularly break due to overuse and the cost of providing sufficient consumables such as soap can become prohibitive. These issues are compounded by water contamination in some remote communities, making safe hygiene practices difficult or impossible.
The low hanging fruit in terms of environmental improvement is making sure that hygiene facilities such as showers and toilets are repaired rapidly. Many maintenance programs have historically been based around a reactive model where repairs only occur when the tenant notifies the landlord. Workers often travel long distances to make repairs. These programs are unreliable due to poor communications in remote areas, high travel costs, and seasonal inaccessibility in long wet seasons. Planned cyclical maintenance addresses these issues, and is 50% less expensive than responsive maintenance.
Most cyclical repairs could be undertaken by local community members recruited as environmental health workers. This would reduce costs and delays associated with repair, provide local employment, and increase community engagement in improving environmental health. The notion of recruiting local repair workers has long been considered, but there has never been sufficient political will to roll out a large scale program. In my view, local workers could perform a dual role by also promoting safe hygiene practices, complementing existing high quality health promotion programs. Given that 41% of Indigenous people living in remote communities have a first language other than English, local workers would be a strong asset for health promotion. This type of health promotion activity would need to undergo substantial community consultation to ensure cultural safety, particularly given the colonial history of children being forcibly removed from their families under the guise of hygiene concerns.
Overcrowding will not be addressed simply by building more houses under a one-size-fits-all approach. It is crucial that housing is responsive to social, cultural and environmental needs. For example, under Indigenous kinship practices the sharing of accommodation with some relatives is a social responsibility. Relatives may stay for days to months. This highlights the need for housing to be designed through a process of community consultation with those who will live in it. This could include building housing that is capable of hosting visitors for extended periods. Community consultation has been undertaken with success in some locations. This should be the standard.
Clearly environmental improvement is urgently needed, and indeed required for WHO certification of trachoma elimination. These improvements are also key to SDG 6, which calls for “sustainable management of water and sanitation for all”. The Australian Government has set aside A$1m per year for environmental improvement of communities at-risk for trachoma until 2021. Time will tell if this is sufficient to make a meaningful impact, particularly given the GET2020 goal is impending.
Ultimately, even once trachoma has been eliminated there will still be much work to be done in terms of Indigenous health in Australia. There is still approximately a 10 year gap in life expectancy between Indigenous and non-Indigenous Australians, and the burden of infectious disease is high. Environmental improvements have the potential to be of high impact because they inherently target all infectious disease. Health equity will not be reached until every person in Australia can access the same high standard of sanitation and hygiene that dominant culture takes for granted.