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Planning for Cuba's transition
Editorial
Taming trachoma
See Articles pages 589 and 596
Trachoma—the largest infectious cause of blindness worldwide—is caused by Chlamydia trachomatis. This appalling disease is endemic in some of the most disadvantaged populations in low-income settings. Yet rigorous adherence to a simple strategy of control offers the prospect of complete elimination within a decade or so. The current recommended regimen is called SAFE: surgery (for cases of trichiasis), antibiotics, face washing (to reduce transmission), and environmental change. This week The Lancet reports good and bad news about efforts to control this entirely preventable ocular infection. Sudan is especially in need of trachoma control strategies. Almost 4 million people need antibiotic treatment. Jeremiah Ngondi and colleagues describe the results of a 3-year programme of SAFE across five Sudanese sites, including almost 4000 children. They completed a before-and-after study in four areas, measuring the change in prevalence of active trachoma and unwashed faces after introduction of SAFE. Overall, there were substantial falls in prevalence where SAFE was effectively implemented. Important lessons were learned. SAFE was hard to apply seamlessly across all communities. When uptake of
antibiotics and education were low, there was no reliably observed fall in trachoma prevalence. Surgical treatment was low across all areas, and environmental change— improved access to water and sanitation—was similarly patchy. This kind of encouraging result prompts optimism that intensive attention to particular aspects of SAFE might add even greater benefits. In a second report, Sheila West and colleagues did a randomised trial in Tanzania to test whether insecticide spraying to control fly populations after mass antibiotic treatment could reduce trachoma rates still further. Disappointingly, there was no discernible benefit 6 months after treatment. While a great deal of global attention is focused on HIV/ AIDS, tuberculosis, and malaria, trachoma is a neglected disease that fails to catch the imagination or interest of the international community. Yet these reports show not only that interventions are available to control a needlessly debilitating disease, but also that there is a vigorous and committed scientific effort to understand an infection that affects some of the most marginalised of peoples. Both observations deserve commendation—and further financial support. ■ The Lancet
Getty Images
Planning for Cuba’s transition Since Fidel Castro’s Aug 1 decicion to temporarily delegate leadership of Cuba to his brother, there has been an escalation in rhetoric aimed at influencing the transition to a post-Castro state. Uncertainty abounds, but if there is We do not have the any consensus on what the future holds it is that Cuba will rights to reproduce experience a period of rapid and uncomfortable change. this image on the For health, the consequences are potentially dire. web. The central importance of Cuba’s purportedly efficient health system to its national identity means that health indicators will be the most sensitive measure of decline. Castro’s death, even if years from now, could herald a complex emergency: a difficult period of violence and internal divisions that put Cuba on the road to becoming a failed state. Cuba’s citizens are likely to require immediate humanitarian assistance to meet water, health, food, and shelter needs that have built up over years of neglect. Injustices and inequalities, although already present, will become more obvious and could lead to social unrest. For 554
these reasons, it is essential to national stability that a functioning health system is maintained. As Cuba’s closest neighbour, the USA must be ready to help meet immediate humanitarian needs, if the worstcase scenario arises. If suggestions made last month, by the US Presidential Commission for Assistance to a Free Cuba, are heeded, resources of US$80 million could be set aside for the task. But the challenges are immense. A massive influx of aid will overwhelm Cuba’s decrepit distribution network, and chaotic responses by Cubans in south Florida could undermine a coordinated response. To help ward off instability, what is most needed from external actors is a considered plan to strengthen Cuba’s coping mechanisms. But because of the myriad uncertainties about how robust the Cuban health system actually is, planning for transition must be based on a careful analysis—better than the current guesswork—of what Cuba’s citizens will need the most. ■ The Lancet www.thelancet.com Vol 368 August 12, 2006
Taming trachoma
See Articles pages 589 and 596
Trachoma—the largest infectious cause of blindness worldwide—is caused by Chlamydia trachomatis. This appalling disease is endemic in some of the most disadvantaged populations in low-income settings. Yet rigorous adherence to a simple strategy of control offers the prospect of complete elimination within a decade or so. The current recommended regimen is called SAFE: surgery (for cases of trichiasis), antibiotics, face washing (to reduce transmission), and environmental change. This week The Lancet reports good and bad news about efforts to control this entirely preventable ocular infection. Sudan is especially in need of trachoma control strategies. Almost 4 million people need antibiotic treatment. Jeremiah Ngondi and colleagues describe the results of a 3-year programme of SAFE across five Sudanese sites, including almost 4000 children. They completed a before-and-after study in four areas, measuring the change in prevalence of active trachoma and unwashed faces after introduction of SAFE. Overall, there were substantial falls in prevalence where SAFE was effectively implemented. Important lessons were learned. SAFE was hard to apply seamlessly across all communities. When uptake of
antibiotics and education were low, there was no reliably observed fall in trachoma prevalence. Surgical treatment was low across all areas, and environmental change— improved access to water and sanitation—was similarly patchy. This kind of encouraging result prompts optimism that intensive attention to particular aspects of SAFE might add even greater benefits. In a second report, Sheila West and colleagues did a randomised trial in Tanzania to test whether insecticide spraying to control fly populations after mass antibiotic treatment could reduce trachoma rates still further. Disappointingly, there was no discernible benefit 6 months after treatment. While a great deal of global attention is focused on HIV/ AIDS, tuberculosis, and malaria, trachoma is a neglected disease that fails to catch the imagination or interest of the international community. Yet these reports show not only that interventions are available to control a needlessly debilitating disease, but also that there is a vigorous and committed scientific effort to understand an infection that affects some of the most marginalised of peoples. Both observations deserve commendation—and further financial support. ■ The Lancet
Getty Images
Planning for Cuba’s transition Since Fidel Castro’s Aug 1 decicion to temporarily delegate leadership of Cuba to his brother, there has been an escalation in rhetoric aimed at influencing the transition to a post-Castro state. Uncertainty abounds, but if there is We do not have the any consensus on what the future holds it is that Cuba will rights to reproduce experience a period of rapid and uncomfortable change. this image on the For health, the consequences are potentially dire. web. The central importance of Cuba’s purportedly efficient health system to its national identity means that health indicators will be the most sensitive measure of decline. Castro’s death, even if years from now, could herald a complex emergency: a difficult period of violence and internal divisions that put Cuba on the road to becoming a failed state. Cuba’s citizens are likely to require immediate humanitarian assistance to meet water, health, food, and shelter needs that have built up over years of neglect. Injustices and inequalities, although already present, will become more obvious and could lead to social unrest. For 554
these reasons, it is essential to national stability that a functioning health system is maintained. As Cuba’s closest neighbour, the USA must be ready to help meet immediate humanitarian needs, if the worstcase scenario arises. If suggestions made last month, by the US Presidential Commission for Assistance to a Free Cuba, are heeded, resources of US$80 million could be set aside for the task. But the challenges are immense. A massive influx of aid will overwhelm Cuba’s decrepit distribution network, and chaotic responses by Cubans in south Florida could undermine a coordinated response. To help ward off instability, what is most needed from external actors is a considered plan to strengthen Cuba’s coping mechanisms. But because of the myriad uncertainties about how robust the Cuban health system actually is, planning for transition must be based on a careful analysis—better than the current guesswork—of what Cuba’s citizens will need the most. ■ The Lancet www.thelancet.com Vol 368 August 12, 2006