Developing trachoma elimination programs requires careful planning at all levels of society. In typical situations, countries are divided into districts and then sub-divided into villages, so that interventions can be planned efficiently and effectively. But what can we do when large populations leave an area because of conflict or persecution? How do we ensure that refugees and internally displaced populations (IDPs) are included in health plans to support their right to health, when they are forced out of their homes into neighbouring districts or countries?

With over 28,000 people being forced to flee their homes every day, adding to over 22 million refugees worldwide, population centered approaches that seek to deliver interventions to selected groups of people are often more appropriate than geographical centered approaches which work to deliver services in predetermined areas. This is particularly true in areas with vulnerable mobile populations, such as refugees and IDPs who can enter or leave endemic areas in the pursuit of safety.

The global trachoma elimination program provides examples of work being done at the national level to target refugee populations. Sudan, Uganda and Ethiopia are all implementing programs for trachoma elimination as a public health problem and are increasingly incorporating refugee populations into their work.

In 2016, the Ethiopian Federal Ministry of Health, supported by the U.S. Agency for International Development (USAID) ENVISION project, led by RTI International, Administration for Refugee and Returnee Affairs, and the United Nations High Commission for Refugees, conducted baseline prevalence surveys in 10 refugee camps, which showed a high prevalence of trachoma. These surveys provided the Ministry of Health with the evidence base needed to apply for antibiotic donations from the International Trachoma Initiative and treat all at risk people within the camps.

In Uganda, also supported by ENVISION through RTI International, baseline prevalence surveys were recently conducted in six districts that house 27 refugee settlements encompassing almost one million refugees to determine if interventions were needed. Results showed that trachoma was below five percent in all surveyed camps and therefore did not require mass drug administration, but documented a high prevalence of trichiasis, the late blinding stage of trachoma, thereby demonstrating a need for the provision of urgent surgical services.

Other African countries working to treat refugees include Sudan, which in 2017, conducted baseline prevalence surveys in eight camps hosting South Sudanese refugees. The surveys, supported by The Carter Center, showed high levels of trichiasis, and gave the government the evidence base needed to mobilize resources and conduct a surgical campaign that provided surgeries to 290 people. Referrals to the regional hospital were given for those who had other eye conditions such as cataracts and glaucoma and reading glasses were provided to over 300 visually impaired people.

The collaboration between partners in Sudan provided valuable lessons for treating trachoma in refugee camps. Inside the refugee camps, The Carter Center partnered with other NGOs, including the International Red Crescent and Médecins Sans Frontières, who did not have trachoma specific expertise, but had established relationships with camp residents and established the health care infrastructure. These NGOs helped to mobilize the campaigns and managed the surgical sites, thus ensuring the quality of surgical services and helping to increase the uptake of the intervention.

In Sudan, the Ministry of Health is also working with health officials in South Sudan to have trachoma education materials in the Nuer language so that refugees can access the information needed in a language they understand. Health education is better received when materials are in the target population’s native language, which provides an opportunity for collaboration between Ministries of Health at the regional level.

By taking a population centered approach for the treatment of refugees, Uganda, Ethiopia and Sudan are supporting a collaborative model for trachoma elimination in security challenged settings that will help to ensure no one is left behind. Population centered approaches for refugees are inherently harder to implement because contexts can differ vastly between countries and regions. Numbers of refugees, the conditions in the areas they settle, the infrastructure available to them can all affect the way programs are designed. However, taking a population centered approach is more flexible, prioritizes the people affected regardless of a population’s circumstance and location.  

While Ethiopia, Sudan and Uganda's experiences demonstrate some progress for the treatment of refugees, significant funding gaps remain to provide essential health services through policies that effectively integrate the needs of refugees in domestic national plans. Program's targeting refugees are reliant on the generosity of host governments who understand the importance of expanding their trachoma programs to refugee settings. However, without firm funding commitments dedicated to population-centered work for vulnerable mobile populations, the global elimination of trachoma as a public health problem cannot be achieved. The political environment and public perception of refugees will no doubt play a factor in mobilising the political and public will to support neighbours and the health of the region.

The New York Declaration for Refugees and Migrants, adopted by the United Nations in 2016, expresses the political will of world leaders to save lives, protect rights and share responsibility on a global scale. Today, World Refugee Day, let's us recognize the important work that has been started by countries including Ethiopia, Uganda and Sudan and continue to stress the importance of shared responsibility for the health of refugees.

The elimination of trachoma as a public health problem, like many other diseases, must be done at national, regional and global levels. National level champions for the integration of refugee policies into national health plans and trachoma action plans will be particularly important to make progress for refugees. By accompanying commitments with firm indicators and other accountability mechanisms we can ensure the health of all refugees and achieve Universal Health Coverage with no one left behind. 

All data used in this blog has been taken from the United Nations High Commission for Refugees, World Bank and The Carter Center. The views expressed are the views of the author and do not necessarily represent the views of any of the organizations mentioned. 

This blog was written by Angelia Sanders, Associate Director, Trachoma Control Program, The Carter Center