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.

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 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 Rs. 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?”

Public health initiatives cannot succeed without the support of local communities.

Promila Gupta,

Deputy Director General, National Programme for Control of Blindness

When I held eye camps in 2008, I noticed a steady stream of trachomatous trichiasis cases in Car Nicobar. My generation of ophthalmologists has hardly ever seen trachoma, let alone treat it.

Anita Shah,

Joint Secretary, National Programme for Control of Blindness