Ground Zero - In-depth reportage from The Hindu

Eyes to the island: Car Nicobar's victory over hyperendemic trachoma

Aberdeen Blair was among the 1,500-plus recipients of the MDA programme in Sawai village.

Aberdeen Blair was among the 1,500-plus recipients of the MDA programme in Sawai village.   | Photo Credit: Special Arrangement

A public health project in Car Nicobar set out to eliminate a rare occurrence of hyperendemic trachoma, an infectious condition known to cause blindness. Lalitha Sridhar reports on how an indigenous community, with the help of doctors, battled the odds to beat an invisible adversary

A narrow road winds past dense vegetation, idyllic beaches and rain-soaked villages glistening in sunshine. Along the way, profusely blooming pinwheelflowers frame prefab homes built on stilts in a likeness of their lost predecessors, the prized patis, which were handwoven with palm leaves, rattan and lalang grass.

Goats bleat, pigs grunt and hens squawk around the dwellings that were once closer to the shore but were flattened, like nearly everything else here, on December 26, 2004. Local memory divides Car Nicobar’s long and sometimes violent history more simply now: before and after the tsunami.

Aberdeen Blair (89), chief of the Car Nicobar Tribal Council, remembers more. “When I was small, we had no money, sugar or rice. We only had coconuts. My parents did not wear clothes like this,” he says, pointing to his lungi and T-shirt. Blair smiles as easily and often as he shifts between Nicobari, Hindi and English, and goes on to add, “I have jeans, too. Everything has changed.” The laminated certificates and photographs on the wall behind him document the highlights of such a lifetime.

Nicobar is India’s southernmost district. Car Nicobar is its northernmost island and headquarters. The Nicobarese are the largest (numbering 27,186 in the 2011 Census), most urbanised, and most influential among the six better-known tribes of the Andaman and Nicobar Islands. Their indigenous peers survive tenuously in the hundreds (Jarawas and Shompen) and tens (Great Andamanese, Onge and Sentinelese).

Preventable blindness

Other numbers appear in fading paint on the walls of the houses here. ‘MDA’, it says, followed by a date, for three consecutive years — 2010, 2011 and 2012. Mass Drug Administration is the medical response to a public health concern that entails treating the entire population of a specified area with a prescribed dosage of pharmaceuticals.

The first woman ophthalmologist in the Andaman and Nicobar Islands, Dr. Anita Shah (55), led such a project in Car Nicobar following the discovery of a hyperendemic and active infection of trachoma on the island. Trachoma is a contagious and preventable cause of blindness, rarely seen in India since the 1950s and 1960s. Blair and his 21-member tu-het (extended matrilineal family units of up to 100 people) were among the over 1,500 recipients of the MDA programme in the village of Sawai (Öt-ka-sip in Nicobarese), west of the island.

“When I held eye camps in 2008, I noticed a steady stream of trachomatous trichiasis [sight-threatening conjunctival scarring, for which Blair was later treated] cases in Car Nicobar. My generation of ophthalmologists has hardly ever seen trachoma, let alone treat it. Yet I kept meeting young people in their twenties who had their lashes growing inward and eyelids fused. They lived in great pain, in darkened homes because they couldn’t bear sunlight. I am a surgeon, not a community medicine specialist, but I knew a survey had to be taken up immediately,” says Dr. Shah, Joint Secretary in the National Programme for Control of Blindness (NPCB) since 2008. She is a diminutive woman in the habit of providing precise instructions to her team, essential given the problems her location poses.

Eyes to the island: Car Nicobar's victory over hyperendemic trachoma
 

The Andaman and Nicobar Islands endure severe inadequacies in intra-island transport, telecom, electricity, potable water and garbage disposal. Healthcare infrastructure is far from perfect. Nevertheless, a measure of confidence is inspired by the bustling sprawl of the G.B. Pant Medical College and Hospital in Port Blair, the referral medical institution for all the islands. This is where Dr. Shah is Deputy Director-Ophthalmology. The airy and clean B.J.R. Hospital in Car Nicobar, which she visits regularly, is one of two such district-level facilities.

Dr. Shah had to tenaciously follow up for over two years to mobilise support for the ‘Trachoma Rapid Assessment (TRA) in Nicobar 2010’ survey by the All India Institute of Medical Sciences’ (AIIMS), Dr. R. P. Centre for Ophthalmic Sciences (RPCOS), New Delhi, and the Directorate of Health Services (DHS), Port Blair, with backing from the NPCB, Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare. “Islands are easily forgotten,” she says matter-of-factly.

In a far corner

The Nicobar archipelago is separated from the Andaman cluster by the Ten Degree Channel, a minor international shipping route named so for its latitude north of the equator. The Indian Ocean tsunami arrived here at 7 a.m., roughly 40 minutes after the earthquake off the coast of Sumatra, and two hours before it reached the subcontinent’s southeastern coast. Car Nicobar, part of the Nicobar and Andaman Tribal Reserve Area and ringed by 51 km of silvery beaches, is approximately 1,450 km from mainland India.

In Car Nicobar, the disused iron bridge in Kimious stands as forlorn evidence of the devastation. As a percentage of the total population, in India, the Nicobar Islands lost the most lives in the tsunami. The villages of Malaka and Kakana had the highest casualties. Mus was cut off by a subsidence of land and the pooling of backwater in several places. Tribespeople from Sawai, Arong and Teatop were pushed into the forests at the centre of the island, where they survived for a week without food or water before evacuation. They were moved out of overcrowded relief camps in Port Blair and elsewhere in the islands and resettled in Car Nicobar nearly two years after the tsunami. Dr. Shah’s surgical outreach began after their return.

Two teams investigated Dr. Shah’s concerns by examining 7,277 inhabitants of 10 clusters selected for the highest risk of developing trachoma. The TRA found a very active trachoma infection rate of 50.8% in children aged 1-9 years, with the proportion of infected children in the surveyed villages ranging from 37.5% to 73%.

“We were shocked and surprised by the magnitude of the trachoma burden in Car Nicobar,” says Dr. Praveen Vashist, Professor and Head, Community Ophthalmology Department, RPCOS, AIIMS, who made four trips to the island over the course of the project. “I did not realise that the location was so difficult to reach. An MDA covering an entire tribal population in a remote location was a first for India. It was a different experience for us. Active trachoma infections in children occur without any symptoms. If they are not treated, they lead to irreversible blindness in adulthood. We found that, due to the tsunami, there were no children under the age of six in Kimious village.”

Trachoma occurs upon repeated infections from the bacterium Chlamydia trachomatis. It thrives in congested living conditions among populations that have limited access to water and healthcare. It is transmitted by flies, and aided by poor personal hygiene and fomites (shared objects such as towels, utensils and bedding, which are likely to carry the infection). The 2010 TRA also notes, “Co-habitation of Nicobari people with animals like pigs, hens, goats, dogs, cats etc. could be a contributory risk factor.”

Going the distance

Doctors travelled for the MDA by helicopters with few seats. Services were often called off in uncertain weather. There is no scheduled ferry to Car Nicobar and administrative personnel posted here face frequent shortages in the supply of basic groceries, including vegetables, which come from Port Blair. Dosage had to be measured individually (20 mg per kilo of body weight). Dispersed neighbourhoods were covered simultaneously to prevent the recurrence of infections. It was tedious and tiring work.

Dr. Vashist says: “The local team led by Dr. Shah was exceptional. Our work was made easier by the friendly Nicobarese people. We only had to explain to the chiefs, and the villagers would follow the instructions.” Each of the 15 villages in Car Nicobar, distributed over 127 sq. km, elects a ‘Captain’ for a five-year term. Blair is the head of their council for his lifetime.

The first woman ophthalmologist in the Andaman and Nicobar Islands, Dr. Anita Shah, led a Mass Drug Administration project in Car Nicobar following the discovery of trachoma on the island.

The first woman ophthalmologist in the Andaman and Nicobar Islands, Dr. Anita Shah, led a Mass Drug Administration project in Car Nicobar following the discovery of trachoma on the island.   | Photo Credit: Special Arrangement

The operation to treat trachoma is quick and is performed under local anaesthesia as a day-case procedure. Patients can get back to work very quickly (a point emphasised before surgery, since lost working time is a major concern for them). The risk of wound infection is relatively low because of the good blood supply of the eyelid and therefore surgery can be performed in patients’ own villages.

The medical team set up slide shows on the World Health Organisation’s (WHO) SAFE (Surgery for trichiasis, Antibiotics for infections, Facial cleanliness, and Environmental improvement) guidelines in schools and community halls, and at venues near churches, such as the rebuilt chapel in Mus, a pilgrimage site that has the grave of Bishop John Richardson, after whom the district hospital in Car Nicobar is named.

The late Padma Bhushan awardee was the first Nicobarese to be ordained an Anglican priest. He’s credited with establishing the village councils and authoring a primer on the Car language, into which he also translated the Bible. Blair has Bishop Richardson’s laminated photo in his living room.

“Public health initiatives cannot succeed without the support of local communities,” says Dr. Promila Gupta, Deputy Director General, NPCB, adding that blindness comes with considerable economic costs in terms of livelihoods lost.

Blind curve

Well over half a century ago, from 1959 to 1963, trachoma was a major public health problem in three States — Punjab (79.1% occurrence), Rajasthan (74.2%) and Uttar Pradesh (68.1%) — show data from NPCB. The National Programme for Control of Blindness was launched in 1976. The flagship Central government initiative emanated from what was originally the Trachoma Control Programme of 1963. It no longer lists the disease as among the leading causes of blindness in India, which today are cataract (62.6%) and refractive error (19.70%). The trachoma outbreak in Car Nicobar has been the only recent exception.

“On the days we had asked everyone in a village to be present, we would sometimes work till 9 in the night,” says Yashumeri, 34, a cheerful staff nurse at the B.J.R. Hospital. Team members recall being welcomed with sweet tender coconut water everywhere they went. The Nicobarese call themselves holchu (friend), although the term can be used pejoratively by the islands’ settlers.

Yashumeri’s familiarity with the area came in handy when refrigerators had to be commandeered to maintain the tricky cold chain for liquid azithromycin, a broad-spectrum antibiotic that had to be transported from mainland India to Car Nicobar. A tablet substitute was eventually found for the second round of the MDA programme in 2011.

Meticulously maintained registers list absentee and sick residents (for follow-ups), pregnant women (who were not included), and deaths. “If someone missed a dosage, we would return to make sure they took it,” says John James, 44, the first Nicobarese ophthalmic assistant on the island.

“I was so nervous when a prevalence survey was conducted in 2013, after the third round of MDA,” admits Dr. Shah, who was hugely relieved to find that the active trachoma infection in children was down to 6.8% from the 50.8% that it was in 2010. This was, however, still above the 5% allowed by the WHO. Meanwhile, patients who had got their vision back and were free from pain began asking for eye drops. They took delight in how big their eyes suddenly appeared. ICE (information, communication, education) outreach and eyelid correction surgeries continue even now.

Trachoma is “hyperendemic in many of the poorest and most rural areas of 41 countries of Africa, Central and South America, Asia, Australia and the Middle East,” says the WHO, which has been pushing the GET 2020 (Global Elimination of Trachoma by 2020) alliance since 1996. India is a partner. When Car Nicobar was again assessed in February 2017, trachoma prevalence was down to 1.6%.

India moved to apply for ‘trachoma-free’ status over a meeting with WHO officials on January 11, 2018, after the release of the National Trachoma Prevalence Survey 2014-17 by Union Minister of Health and Family Welfare J. P. Nadda in Delhi on December 8, 2017. The survey covered 10 districts from seven States and Union Territories, among them East Delhi, Bikaner, Banaskantha and Car Nicobar. It shows that the overall prevalence of active infection among children below nine years is only 0.7%. “We expect to meet the 2020 target,” Dr. Vashist says.

Eye on the future

Time moves differently on Car Nicobar. The roar of the ocean is audible as a small group of men and women work silently. They are preparing the soil outside an (also prefabricated) elpanam or ‘death house’, next to a modest cemetery with a handful of crosses on cement platforms. The community gets involved in funerary tasks as it does with wedding festivities and shared parenting, the latter a custom known as haruk, which ensures that no child is orphaned. Access to Car Nicobar is highly restricted under the Andaman and Nicobar (Protection of Aboriginal Tribes) Regulation, 1956, and provides some protection to indigenous ways of life.

The 2004 tsunami was not the first to devastate the islands: patchy records exist for major earthquakes in 1847, 1881 and 1941, and another tsunami that originated in Sumatra in 1861. But the last one has altered life here.

The Central government adopted a one-size-fits-all rehabilitation policy to build nearly 10,000 twin (instead of freestanding) homes across 11 islands. Reinforced cement concrete, aero-con blocks and corrugated galvanised iron sheets imported by large contractors from mainland India at an average cost of ₹10 lakh per unit replaced locally sourced, natural building materials. Not enough thought was given to subsistence-specific locations, gender-sensitive land rights, natural ventilation suited to the tropical weather, and the ability to effect repairs with local materials.

On the white-sands Malaka beach, named for the strategic strait near Aceh in Indonesia, a lush jungle has already claimed what used to be, before the tsunami, beachfront residential quarters for Indian Air Force officers. The island is no longer a family station for them. Nicobarese leader Edward Kutchat, it is said, granted land for this airbase in exchange for the coat that Jawaharlal Nehru was wearing when they met sometime in the early 1960s.

The sun rises as early as quarter past five even on a January morning, and lights up the pristine coastline. The scattered debris of plastic garbage washed up by the waves is not immediately obvious, quite like its environmental implications. Even the twinkle in Aberdeen Blair’s eyes will only hint at them. Dr. Shah, who appreciates his gentle way of speaking, never fails to visit the elder on her trips to the island.

Blair’s ‘Prototype twin unit designed and constructed by Central Public Works Department’ is one of the 3,941 ‘permanent shelters’ allotted to Car Nicobar in 2006. Rendered frail by age, Blair is mostly confined indoors these days. He credits the doctors at B.J.R. Hospital with treating a fracture of the tibia and saving his life when he had a stroke, some years after his close call with trachoma and blindness. “Oh, I am very lucky,” he adds, his hand making a sweeping gesture that included his sofa, TV, Nicobarese Bible, and polite grandson serving tea in ceramic cups. “At least I have a place to live, you see?”

A letter from the Editor


Dear reader,

We have been keeping you up-to-date with information on the developments in India and the world that have a bearing on our health and wellbeing, our lives and livelihoods, during these difficult times. To enable wide dissemination of news that is in public interest, we have increased the number of articles that can be read free, and extended free trial periods. However, we have a request for those who can afford to subscribe: please do. As we fight disinformation and misinformation, and keep apace with the happenings, we need to commit greater resources to news gathering operations. We promise to deliver quality journalism that stays away from vested interest and political propaganda.

Support Quality Journalism
Related Topics
This article is closed for comments.
Please Email the Editor

Printable version | May 27, 2020 12:40:36 AM | https://www.thehindu.com/news/national/other-states/eyes-to-the-island/article22637703.ece

In This Series
A new fault line in post-war Sri Lanka
Changing the stripes of conservation
A drop in an ocean of debt: how farmers have benefited from Rythu Bandhu
Telangana’s ‘villages of widows’
The sinking island of Kerala
Punjab’s burning problem
In Kolar, a parched land in a sea of sewage
Crimes against women in Haryana: as they rise, men push them back
Ground Zero | Kerala floods replay the catastrophe that hit the ancient sea port Muziris in 1341
Ravaged by a caterpillar: on the armyworm invasion in India
Out of joint: Documenting the repercussions from Johnson & Johnson's faulty hip implants
Punjab’s new addicts: on the rise of female drug addicts
Kerala floods rescue: A chopper, a boat, and a prayer
Indian bull frog: the Andamans’ new colonisers
In the city of refugees: Rohingya camps in Bangladesh’s Cox’s Bazar
Nipah virus: Anatomy of an outbreak
A cure for medical malpractice
Ground Zero: Cauvery, a river in distress
A piece of Jharkhand in Kerala
Red Earth and fine dust: political choices in the 'Republic of Bellary'
Shivani Reddy, SpiceJet
Women who fly
Voting against alcohol
The champions of clean air
The silent sufferers: on Maharashtra farmer suicides
For here or to go? Existential question for Indians pursuing the American dream
You are reading
Eyes to the island: Car Nicobar's victory over hyperendemic trachoma
In Odisha, schools are the dropouts
The ghosts of Adichanallur: Artefacts that suggest an ancient Tamil civilisation of great sophistication
The lost Jews of Churachandpur
The alien fruit that took over Karnataka
Rohingya prefer to travel by boat from Myanmar to Bangladesh as the the land border, though open, is manned by trigger-happy Myanmar soldiers. A Bangladeshi man helps Rohingya Muslim refugees disembark from a boat on the Bangladeshi shoreline of the Naf river after crossing the border from Myanmar, in Teknaf
Rohingya's hope floats on a boat
The parivartan brotherhood: How three young men have queered the pitch for the BJP in Gujarat
The flaming fields of Punjab
Chronicles of a carnage foretold
Bihar floods: when home is a highway
Kala-azar: The disease that just won’t go away
The cyber con 'artists' of Jharkhand's Jamtara district
Maximum support, maximum price
A spike in the footprints of time
How genetics is settling the Aryan migration debate
Toiling for a toilet
The Sasikala web: how a maze of shell companies link up to her, her family and friends
Forced out of the forest
How Bidar beat back the drought
Betrayed by their own blood
Agents of death: female foeticide in Maharashtra
The long healing of 1971
The Andhra flavour in Gujarat’s fish
Unabated practice: “To date, the police have arrested 12 people who conducted the sex determination tests.” Swaranjali and Pranjali, the daughters of Swati Jamdade who died following a botched-up abortion in Mhaisal village, with their paternal grandmother Padmini Patangrao Jamdade in Manerajuri village.
No country for baby girls
They came, they fought, they stayed
Ear to the ground
Betraying the oath: the rot in India's medical education system
The groundwater beneath their feet
Reluctant mothers
Encounter killings of another kind
The ground beneath their feat
The hyena has the last laugh
The sisterhood of wrestlers
The ‘witches’ of Jharkhand
A leap into the digital world
The empowerment diaries
Students leaving after finishing their school exams in Srinagar.
The class must go on
In search of the new red corridor - glimpses
In search of a new red corridor
The marriage vows between Bhatkal and Karachi
Border town blues
The warp and woof of demonetisation
Escape from nowhere: Undertrials under fire
“Two huge bottle palm trees and a coconut tree overshadow the 140-year-old house... In the middle stands a pink bicycle... with a faded black Rexin school bag on the rear carrier. ‘It was her last day of school when she had parked her bicycle with the bag there,’” says Moitree Chakravarty, Navaruna’s mother.”
Waiting for Navaruna
In Telangana, a farewell to arms
The bane of a bumper crop
Nayeemuddin’s grave besides his brother’s grave on the premises of the dargah close to his house in Bhongir town of Nalgonda district. Inset: A file photo of Nayeemuddin
From a revolutionary to a renegade
Serial killer: “When he was finally arrested on August 11, one of the first things senior police officers noted about Pol was his eerily confident, almost supercilious nature.” Santosh Pol being investigated in Wai town, Satara district. — Photo: Prashant Nakwe
Pol plot unmasked
The race to light up the last village
Samantha with her mother, Patricia Tavis. Photo: Special Arrangement
Desperately seeking Mariyamma
After ban, in a state of low spirits
FEEDING DRIVE: A woman of Tala Nagada village gives her child with ‘Energy Dense Nutrient Rich Food’ distributed by the government health department to the villagers of Nagada hills in Jajpur district. Photo: Biswaranjan Rout
The lost tribe of Odisha
The Supreme Court on Friday refused to entertain a plea for Governor’s rule in the strife-ridden State of Jammu and Kashmir.
Behind the rage in south Kashmir
The fisherfolk weaving hammocks, swings, and other products at a community centre on the beach in Kovvada village of Srikakulam district. Photo: K.R. Deepak
The coast isn’t clear for India’s nuclear power quest
Mystery of the missing twenty-one
A child being vaccinated at a Primary Health Centre near Malappuram town. The district’s immunisation rate is 84 per cent, one point lower than the State average. Photo: K.K. Mustafah
The fallacies of the faithful
The battle lines are drawn in Punjab. Photo: Akhilesh Kumar.
Can the Aam Aadmi Party win Punjab?
Capital project: The making of Amaravati
Enemies of the States?
Life in the Mathura cult camp
Next Story