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Trachoma is one of the three largest causes of ?avoidable? blindness, ruining the economic well-being of millions of families in developing countries worldwide. Our article reports on global research efforts to implement WHO?s 1997 trachoma eradication program.

Trachoma is a chronic disease of the eye caused by the bacterium Chlamydia trachomatis. The symptoms experienced by sufferers include red eye, discharge, and phobia to light, pain, excessive tearing, and--ultimately--impairment of vision. According to the World Health Organization (WHO), with 6 million people currently blind as a result of the disease, trachoma is one of the three largest causes of blindness. The disease is endemic mainly in poor rural areas of Africa, parts of the Eastern Mediterranean, Central and South America, and some countries in Asia. To control the disease, the Global Alliance to Eliminate Trachoma by 2020 (GET 2020) was formed in 1997 by WHO in collaboration with representatives from the research, governmental, nonprofit, and for-profit sectors.

Anthony Solomon is one of the many scientists that are working globally to implement WHO?s Trachoma eradication programme. Solomon is a clinical lecturer in international eye health and is affiliated with the London School of Hygiene & Tropical Medicine (LSHTM), a research-led postgraduate school of public health and an active collaborator of the WHO programme. The Clinical Research Unit (CRU) for Infectious and Tropical Diseases, where Solomon works, concentrates on diseases of major public health importance in developing countries. Staffs of the unit are involved in research in countries that include Zambia, the Gambia, Kenya, Tanzania, Ivory Coast, South Africa, India, and Bangladesh.

Over the last 3 years, Solomon divided his time between London and the Rombo district of Kilimanjaro, Tanzania. A typical day could involve working in a laboratory in London or Moshi in Tanzania, writing a paper, talking to village leaders in Swahili about future research work, or walking through fields of sunflowers on the northern side of Mount Kilimanjaro to examine and treat children with trachoma. It is work of very varied nature.

The challenges involved in working in Tanzania are familiar to anyone who has worked in resource-poor settings. Specialized supplies and equipment generally need to be imported, which can mean long waits. Technical backup is usually a long way off, and the electricity supply is unreliable at best. Solomon once had to use a frozen chicken to keep samples cold during emergency transfer to the nearby hospital in town, precipitated by a broken carbon dioxide cylinder and a malfunctioning laboratory freezer.

?The compensation for these things is that the efforts that the team makes are really appreciated by the people we serve. Communities with trachoma are amongst the poorest and most marginalized. Simple interventions, therefore, tend to have powerful effects,? Solomon said. ?In Western medicine, it is rare to go home from a day?s work feeling that you saved a life, or a limb, or someone?s sight, but that happens a lot working in Africa,? he said. ?People tend to smile a lot more there than they do in the West, too, even though their life is much harder.?

His advice for scientists aspiring to work with the developing world is to go out into the field and try it. ?Both professionally and personally, contributing to the effort to fight diseases of the developing world can be very satisfying.? For those with limited experience, the Diploma in Tropical Medicine & Hygiene of the LSHTM offers a trip to the Gambia to experience health care in a developing country. Participants will travel to rural areas, see research projects and clinical activities in progress, understand obstacles to health care, and visit communities suffering from trachoma. According to Solomon, alumni of LSHTM currently work in more than 140 countries.

Scientists from LSHTM have been involved for nearly 10 years in the trachoma research programme, Solomon recalls. They first studied the efficacy of a powerful oral antibiotic, azithromycin, versus standard topical tetracycline in the treatment of trachoma in 1993. Subsequent studies covered as many as 1800 people in eight villages in the Gambia and were approved by the joint Medical Research Council/Gambia Government Ethics Committee and the Ethical Committee of LSHTM. But the widespread use of the antibiotic azithromycin was not possible due to its cost. It was only until after the International Trachoma Initiative (ITI) was established (see box) that selected poor countries were able to receive the antibiotic treatments regularly for free.

The International Trachoma Initiative

Founded in 1998 by the Edna McConnell Clark Foundation and Pfizer Inc. (which makes azithromycin, under the ?Zithromax? brand), ITI seeks to ?achieve global elimination of blinding trachoma by putting into action the SAFE strategy, through donated Zithromax, applied research, programme evaluation, and communications and advocacy?.

Solomon?s current research projects are funded by several different sources. Part comes from initiatives like ITI, and part comes from funding organizations, such as the Wellcome Trust-Burroughs Wellcome Fund. Apart from supporting research into the major diseases of the developing world, the Tropical Medicine Programme of the Wellcome Trust aims to build research capacity in developing countries so that they can take care of their own health issues. LSHTM has recently been granted almost $US 1.5 million to evaluate and monitor trachoma control activities in eight ITI-supported countries in Africa and Asia.

The success of the GET 2020 programme depends, among other factors, on the partnerships among research institutions, governmental departments, nonprofit organizations, and private for-profit corporations. Nevertheless, Solomon believes that the scientists and doctors themselves play a very special role in this growing network to fight diseases in the developing world. This is true not only because of the scientific and clinical expertise they bring to the table but also because of their skill in mediating the various intricate relationships necessary to make things work.