Lessons learned in the implementation of programmes to eliminate trachoma within conflict zones

Introduction

Eliminating trachoma as a public health problem requires inclusive actions for all people living in endemic areas.

In places where there is armed conflict, the strategy for approaching populations and implementing activities requires special precautions to be taken, but above all a situational analysis on a case-by-case basis. Not all contexts are the same. Indeed, when a group of people in general decide to take up arms and entrench themselves, it is to conquer or destabilise power. Various reasons may be given, including social injustice, corruption, oppression, dictatorship, poor distribution of national wealth and nepotism on the part of those in power; in short, bad governance. Alternatively, they may have less obvious motives, such as the exploitation of natural resources for themselves or for the benefit of other groups or powers to whom they give allegiance.¹ These two categories of people, fairly well organised and structured, with different aspirations, will behave in different ways to the communities and health workers in the field.¹

Analysis

The first category, sensitive to the health of the local population they will administer tomorrow in the event of victory, and to their own health, will take care of their image as much as possible within the population where, moreover, they have meanwhile forged connections and family ties. The second, with little regard for the interests of the local population, prioritise their own interests and those of their supporters by creating a reign of terror. Between these two entities, the fight against trachoma, like the fight against other tropical diseases, finds a common denominator. It is the elimination of this disease as a public health problem through implementation of the SAFE (surgery, antibiotics, facial cleanliness, environmental improvement) strategy in the locality, regardless of the status of the people living there. This is the message that must always be conveyed if all parties are to be convinced.

In this fight against trachoma, it is not the beneficial antibiotic mass drug administration, free of charge for all, that will pose a problem, nor the evaluation or supervision missions, nor education about facial cleanliness and environmental improvement, still less the activities to provide surgery for trachomatous trichiasis, which give satisfactory, immediate and visible results, if carried out properly. Rather, it is the baseline and impact surveys that constitute the real challenge, because of their enumeration of the population, use of mobile phones and geolocation of households via GPS, which are essential for determining the need for antibiotic mass drug administration but are very poorly understood in the eyes of these armed men, who suspect espionage and intrusion into their area.

The recommended strategy consists in convincing all the stakeholders that health is a common good and that disease is apolitical and makes no distinction, no ideological, hegemonic, religious, ethnic or other judgement on whether people will be affected.

In large rural towns and even in some capital cities, it is possible to make contact in an informal but discreet way with the intermediaries of armed groups and to negotiate through them with some of their ‘chiefs’ in the field, the freedom to move around in the occupied areas, by first detailing to them the reasons for the proposed mission. If negotiations are successful, the campaigns can take place, sometimes with the help of armed gangs. Some ministerial departments discreetly use these same channels to establish contact and undertake dialogue with such groups.²

In the field, health officials at all levels are indispensable resource persons, as they are familiar with the daily realities and are able to provide valuable and reliable information on the security situation in their respective localities. These health managers are often in contact with the leaders of armed groups because they have at some point treated and even saved the life of one of them; they are able to continue contact provided that they maintain an unfailing neutrality. This then allows the possibility of moving freely in the so-called ‘difficult’ areas for national programmes. Combatant leaders frequently instruct health officials on certain circuits to be covered and even provide the logistics to cross dangerous zones in vehicles that are well known by the belligerents and can therefore circulate easily, unlike others, which risk being targeted for kidnapping.

It must be recognised, however, that in certain special circumstances, misunderstandings can arise due to unpredictable and regrettable behaviour on the part of certain uncontrolled or stray elements. Fortunately, such instances are rare. However, important precautions must be taken including avoidance of external signs of wealth, such as the wearing of designer watches, the display of state-of-the-art mobile phones or gold jewellery, which may attract a certain amount of covetousness on the part of men-at-arms. In many localities it is even advisable to make use of locally hired vehicles as well as National Programme vehicles or even two-wheeled vehicles rather than four-wheel drives. Use of vehicles bearing logos that have clear links to one or other faction should be strongly discouraged.

An important consideration is whether armed guards, from either the government or a rebel group, should accompany the field team when it is doing its work. This is often a difficult decision. Employing armed guards may provide staff with the impression of protection, but (a) is likely to be outnumbered by combatants in any situation in which risk of actual conflict arises; (b) may be seen as a provocation; and (c) could lead to fear in and non-cooperation by the target population. Balancing the pros and cons may be difficult, but the author maintains that a health team, made up of real health workers, wearing appropriate work clothing, in a vehicle well-marked with a red crescent or cross that is clearly visible from afar, provides greater safety.

Conclusion

In general, the medical corps enjoys a certain respect and consideration on the part of the belligerents for the services rendered to both sides. This is what has enabled the medical teams, with measured caution, of course, to carry out mass drug administration campaigns in the communities in the Central African Republic.^3,4 Activities requiring a field visit cannot be programmed in times of active fighting. It is necessary to wait for the right moment when people's minds calm down and then undertake them with all the precautions outlined above. In this way, we can continue to ensure that we leave no one behind in the fight to eliminate trachoma as a public health problem.

Author's contributions

GY has undertaken all the duties of authorship and is guarantor of the paper.

Funding

No specific funding was received to complete this work.

Competing interests

The author declares that there are no competing interests.

Ethical approval

No ethical review was conducted for this opinion piece.

Data availability

Not applicable.