"It is very much an illness of gender," said Mulat Zerihun, the eye surgeon in charge of the Carter Center's trachoma programs for the sprawling Amhara region. He worked his way through a sea of patients waiting to be screened in the Merawi clinic. When he came to Sintayhu Tegegn, he pulled his magnifying goggles into position, cupped her chin in his hands and tilted her head up. Like many suffering from late-stage trichiasis, Sintayhu had found respite by plucking her eyelashes with tweezers, which more than a few patients wore like amulets around their necks. "Pulling the lashes helps for a day or so," Mulat said, but then they grow back, sharp and bristly, and they scratch the eyes worse than before.
Mulat peeled back Sintayhu's eyelids, studied her for a moment and announced a verdict: "Both eyes will be all right. There's no clouding on the cornea. You will feel a lot better in a few days." Mulat plunged back into the silent crowd while Sintayhu's 15-year-old son led her into a small room where surgeons were already at work on one patient.
Sintayhu was lucky to fall under the care of Mitikie Wondie, 34, an ophthalmic nurse suited up in a surgeon's cap, mask and latex gloves. She settled Sintayhu on the table, draped her face with a sterile cloth and told her to hold steady. After injecting each eyelid with local anesthetic, Mitikie went to work: she threaded a needle through the upper lid of one eye, pulled it up with a loop of silk and slid in a stainless steel retractor to hold the lid in place; with a scalpel, she made a small incision along the margin of the lid and the tarsal conjunctiva; this relieved tension on the damaged eyelid, which allowed her to unfold the eyelid, freeing it from scraping against the cornea; with the lid restored to its proper position, Mitikie closed the incision, squeezed antibacterial ointment in the eye and patched it down with gauze, repeating the process on Sintayhu's other eye. All through the 12-minute operation, Sintayhu lay barefoot and unflinching on the table, watched over by four surgical assistants who handed equipment to Mitikie, swabbed blood from Sintayhu's eye and listened intently as Mitikie described what she was doing. The assistants were in training, and would soon be allowed to perform a few operations under Mitikie's supervision.
"We'll probably perform 40 surgeries in this clinic today," Mulat said, "and another 40 down the road in Dur Bete. We could do more, but we're giving these young people exposure to training, so they will be able to do what Sister Mitikie does." His honorific title for Mitikie referred to her position as a nurse, not to holy orders. When he praised her, she shrugged, pulled on fresh gloves and went to work on a new patient, one of the 67,000 trachoma surgeries the Carter Center has coordinated in Ethiopia since 2000.
Sintayhu, meanwhile, was ready for home. She stood a little unsteadily, her eyes taped with gauze, and called for her shoes, pointed and black with red stars on each toe. She pulled her shawl protectively over her head, locked arms with her son and went out into the light. With him on one side, a niece on the other and a neighbor following, Sintayhu navigated a passageway crowded with patients, stepped gingerly into the clinic's sunbaked courtyard and disappeared through a gate. Now maybe she could sleep.
The eye-saving surgery at Merawi and other rural clinics was but one component in Carter's multifaceted campaign against trachoma. The Carter Center also works with the Ethiopian Health Ministry and volunteer groups such as Lions Club International to distribute antibiotics from Pfizer, Inc., which has donated 5.5 million doses of Zithromax, its version of azithromycin. The drug not only arrests trachoma but also knocks out a wide range of other ailments, among them scabies, lice and the respiratory infections that haunt children.
The trachoma initiative also includes a public education campaign emphasizing the importance of face washing and hygiene in preventing the disease. To encourage such washing, the Carter Center and the Lions Club have drilled more than 119 community wells in the region. And in order to stop trachoma at its source, the former president has inspired an unprecedented sanitation campaign.
"I used to be known as the president who negotiated peace between Egypt and Israel," Jimmy Carter told a recent gathering of health workers in Addis Ababa. "Now I'm known as the number one latrine builder in the world."
The flies transmitting trachoma breed in human feces. In the fields where they spend all day and sanitary facilities are unknown, farmers have traditionally squatted behind any convenient bush or maize plot. "As you can see, we live in a big country," Mulat said as we drove through yellow fields and lumpy mountains bordering Lake Tana, where the Blue Nile uncoils on its long journey toward Sudan. "Our tradition is to defecate outside in the fresh air under the sky. This is what the farmers have always done."
Farmers were indignant a few years back when Mulat began talking about the link between trachoma, flies and toilet habits, and suggested that latrines could help. "Why should we change?" Mulat recalled them asking. "Our ancestors did it this way. We do it this way! We've been to cities. Their latrines smell terrible!"