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Eliminating Trachoma in Developing Countries

Trachoma in developing countriesTrachoma, an unsung yet highly infectious disease, is listed by the World Health Organization (WHO) as the leading cause of blindness across the world. Data from March 2020 indicates that 137 million people live in areas that put them at risk of trachoma. It is estimated that several million people suffer from the disease worldwide, across 44 different countries. The disease is easily transmitted between two people and its effects can be devastating. The WHO has prioritized the elimination of trachoma in developing countries, where trachoma is common.

Trachoma and its Effects

The WHO reports that “transmission occurs through contact with infective discharges from the eyes and nose, particularly in young children, who harbor the main reservoir of infection. It is also spread by flies which have been in contact with the eyes and noses of infected people.” If left untreated, it can cause irreversible blindness. Trachoma also deeply affects the quality of life of families and entire communities where it is present as people with trachoma are often prevented from working and providing for their families. Additionally, women get trachoma at much higher rates than men because they are much more exposed to potentially infected children.

Trachoma Elimination Progress

Over the past two decades, significant work has been done in countries where trachoma is endemic, in order to eradicate the disease once and for all. This work has been extremely effective. Since 2002, those at risk of trachoma in developing countries and across the world have dropped 91%. Although that equates to 142 million people, the number is down from 1.5 billion people in 2002, which is progress on an incredible scale. Anthony Solomon, a medical officer in charge of WHO’s global trachoma elimination program, states that “We should be able to relegate trachoma to the history books in the next few years but we will only do so by redoubling our efforts now. The last few countries are likely to be the hardest. This is great progress but we cannot afford to become complacent.”

The Carter Center

In addition to the WHO, a number of different NGOs have been working to lower rates of trachoma, in developing countries especially. The Carter Center, founded by former U.S. president, Jimmy Carter, is an organization with a huge scope. Causes that the organization supports include peacebuilding, healthcare and human rights across the globe. The Carter Center’s commitment to ending trachoma is integral as it has provided resources such as eyelid surgery and other medical services for trachoma and is working to improve the environmental conditions of trachoma endemic countries. The Center states that “Over the course of 20 years (1999 to 2019), the Center has assisted national programs in providing 846,219  trachomatous trichiasis surgeries in Ethiopia, Mali, Niger, Nigeria, South Sudan and Sudan.” Although Trachoma can be potentially life-changing if left untreated, there are definite medical steps that can be taken before it reaches that point. The Carter Center and other organizations like it are providing crucial resources in order to save lives and eliminate trachoma in developing countries.

Trachoma’s Link to Poverty

Ultimately, eliminating trachoma in developing countries not only means improving the physical health of those who are currently at risk but it would greatly lower poverty rates in those same countries as well. Trachoma hurts the local economy, which in turn has a global impact. Providing the necessary healthcare and aid to those struggling with trachoma will in turn boost the quality of life in dozens of countries, therefore improving the global economy and allowing trade to flourish worldwide. The WHO Alliance for the Global Elimination of Trachoma by 2020 (GET2020 Alliance) set a target to eliminate trachoma entirely by 2020. While that goal may have been missed, significant progress has been made and blindness rates are likely to continue falling rapidly in the coming years.

– Leo Posel
Photo: Flickr

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Trachoma Treatment Reaches 85 Million

Trachoma Treatment A new initiative by the World Health Organization (WHO) has allowed access to antibiotics for those impacted by world’s leading cause of infectious blindness.

Almost eight million people are visually impaired due to trachoma in some of the world’s most marginalized countries. Five hundred million people are currently at risk of blindness in 57 endemic countries without proper trachoma treatment. The WHO estimates that approximately six million people have been blinded by trachoma.

Trachoma is the world’s leading cause of preventable blindness. It germinates in areas with a lack of adequate access to water and sanitation. Trachoma is caused by the bacterium Chlamydia trachomatis, is highly contagious and is easily spread through the eye, eyelid, nose or throat secretions of an infected person.

A total of 85 million people were given antibiotic trachoma treatment, an increase of 63 percent in people treated with antibiotics between 2014 and 2016. Patients were treated with the antibiotic azithromycin, a medication used specifically to fight different types of bacterial infection.

“The availability of free and quality-assured azithromycin enables us to support countries in their efforts to save the sight of millions of vulnerable people,” Minghul Ren, WHO’s Assistant Director-General for HIV/Aids, Tuberculosis, Malaria and Neglected Tropical Diseases, said.

Pfizer, an American-based organization that develops, manufactures and markets prescription medication, donates the antibiotic through the International Trachoma Initiative (ITI). Working with the WHO and other partners, ITI manages distribution alongside other assistance for trachoma treatment.

In addition to an increase of antibiotic trachoma treatment, the period between 2014 and 2016 showed an 87 percent rise in the number of people receiving operations for advanced trachoma to ensure no further eyesight loss.

Kirk Engels, Director of the Department of Control of Neglected Tropical Diseases, said that he found the number of people who were receiving trachoma treatment—both surgically and through antibiotics—is “tremendously encouraging.”

“We encourage countries to prioritize interventions and make the much-needed additional investment to achieve the elimination of blindness due to trachoma,” Engels said.

The WHO hopes to eliminate trachoma by 2020 using a pioneering public-health strategy known as SAFE. The acronym stands for:

  • Surgery to correct trichiasis, the blinding stage of the disease
  • Antibiotics to treat active symptoms of trachoma
  • Facial cleanliness and good hygiene practices
  • Environmental improvements through water sanitation in both the community and household to reduce disease transmission.

The implementation of the SAFE program increases the effectiveness of trachoma treatment. Good hygiene practices and environmental improvements are crucial to ensuring the elimination of the disease in affected areas. With this additional aid from Pfizer and ITI, the WHO should have cause for hope.

– Drew Hazzard

Photo: Flickr

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Deworming Scheme in Ethiopia: An End to Tropical Diseases?

Deworming Scheme in Ethiopia
Recently, Dubai Cares, a humanitarian organization based in the United Arab Emirates, declared its decision to launch a deworming scheme in Ethiopia. This program is estimated to last for two years and is projected to benefit approximately 15.6 million school children in Ethiopia.

The deworming program is targeting the elimination of harmful conditions such as schistosomiasis, trachoma and onchocerciasis. Schistosomiasis is caused by worms, and the condition can be transmitted through infected water. This mechanism of transmission places school-age children at heightened risk of transmission because of their tendency to swim and play in public water grounds.

As a tropical infection, the prevalence of schistosomiasis infection exceeds 90 percent in Ethiopia, with age ranges 10-14 and 15-19 years being disproportionately affected by the disease.

The deworming scheme in Ethiopia forms an integral part of a five-year plan that aims to protect all school children at risk from the onset of neglected tropical diseases. The implementation of this scheme in Ethiopian schools also reflects the concerted public effort by the Minister of Health in Ethiopia, toward the eradication of conditions that have severe impacts on quality of life.

Intestinal parasitic worms, the root cause of most of these conditions, reside in the intestines where they quickly reproduce in ambient conditions. Children in developing countries are more prone to developing infectious diseases caused by worms because of poor hygiene and interaction with unclean water.

Trachoma, schistosomiasis and onchocerciasis all form part of a larger group of diseases referred to as the neglected tropical diseases. Trachoma is an infectious eye condition, which is transmitted relatively quickly in conditions with poor water supply, dense insect populations and populous living areas. In advanced stages, trachoma can lead to blindness. Ethiopia is constantly deemed as the country most affected by trachoma globally.

Onchocerciasis, otherwise known as river blindness, is transmitted through the bite of black flies that reside in hordes near free-flowing rivers. Onchocerciasis can result in reduced vision, blindness, skin conditions and itchiness. Globally, it is deemed as the second most common infectious cause of blindness, with trachoma being the leading infectious cause of blindness in the world.

Dubai Cares is certainly not a new organization on the philanthropic front. Previous initiatives by Dubai Cares have similarly involved a focus on children’s health, such as the Home Grown School Feeding Program, which was implemented in Ghana a few years back. The deworming scheme in Ethiopia offers hope in terms of reduction of mortality and suffering associated with the debilitating neglected tropical diseases.

The eradication of neglected tropical diseases is an important objective in developing countries such as Ethiopia. These diseases impose a serious cost on the economy in terms of lost potential growth, poor health and reduced human resource availability.

School children, in particular, need to be healthy and capable of absorbing the knowledge that is taught to them in schools. These children are representative of a better, brighter future and it is part of social responsibility to optimize and maintain child health.

– Tanvi Ambulkar

Photo: Flickr

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Mozambique Sees Success in Fighting Trachoma

Fighting TrachomaFighting trachoma can be a dicy and delicate task. According to the World Health Organization (WHO), the trachoma epidemic is sweeping 51 countries and impacting the vision of about 2.2 million people globally.

Trachoma is an infection of the eyes that originates from the bacterium Chlamydia trachomatis. The infection is most prevalent in low-income, rural areas of Africa, Asia, Central America and South America where people often lack adequate sanitation facilities and clean water.

Fighting trachoma matters in the fight against global poverty for a variety of reasons. Children suffering from the disease are often unable to continue studying or working due to the symptoms of the illness, which include intolerable pain and constant itching. Older family members experiencing the same symptoms may struggle to support and care for their families and be unable to continue in their lines of work. Eventually, if left untreated, the infection will cause permanent blindness which significantly impacts the livelihoods of its victims.

While trachoma is easily spread, it is both preventable and treatable. The case of ENVISION in Mozambique demonstrates the potential impact prevention and treatment measures can have in the spread of this disease.

The WHO recommends the combination of preventative measures and treatment through the SAFE strategy (Surgery, Antibiotics, Facial-cleanliness and Environmental improvement). Mozambique’s government, with the help of USAID’s Neglected Tropical Diseases Program, launched ENVISION in 2012 and aims to end trachoma in Mozambique by 2020. While this timeline may seem ambitious, there have already been significant signs of improvement in Mozambique.

According to USAID, in 2013, ENVISION distributed and successfully administered the antibiotic Zithromax in the 10 districts of Niassa, the most remote province of Mozambique. Since then, rates of trachoma in Niassa have dropped to below five percent. This is low enough to end the mass drug administrations in the area.

ENVISION leaders are also collaborating with NGOs working in the areas of sanitation, water and hygiene to aid in establishing preventative measures. While trachoma has yet to be completely eradicated, the leaders behind the ENVISION initiative have made great progress in fighting trachoma in just five years.

– Jordan Rose Little
Photo: Flickr

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Pfizer Announces 500 Millionth Trachoma Treatment

Trachoma_TreatmentAccording to the International Trachoma Initiative (ITI), trachoma remains the world’s leading infectious cause of blindness. Pfizer Inc., along with several partners has been working to provide critical trachoma treatment, particularly for patients in developing countries.

What is Trachoma?

Trachoma is an infectious disease caused by bacteria. It is spread through contact with eye discharge from an infected person – via hands, towels, sheets and in some cases, eye-seeking flies. The infection thrives in areas with poor sanitation and limited access to water for personal hygiene.

Without treatment, trachoma develops into a condition called trichiasis. Trichiasis causes the upper eyelids to turn inwards and scrape the eyeball, a painful condition that eventually leads to blindness.

In 2014, the World Health Organization (WHO) estimated that 232 million people were at risk of developing trachoma. Studies indicate that trachoma is endemic in 51 countries with more than 80 percent of sufferers concentrated in 14 countries.

To help combat the spread of trachoma, Pfizer along with ITI and the International Coalition for Trachoma Control announced the corporation’s 500 millionth donation of the tablet Zithromax, a trachoma treatment antibiotic used in countries across Africa and Asia.

The partners are working together as part of an Alliance for the Global Elimination of Trachoma by 2020 (GET 2020) led by the WHO. The Alliance is an expansive collaboration of more than 100 governments, non-governmental organizations and private sector partners.

The SAFE Strategy

Together the group has implemented a WHO recommended strategy called SAFE:

Surgery to treat the blinding stage of the disease

Antibiotics to treat infection

Facial cleanliness to help reduce transmission, and

Environmental improvement including access to water and sanitation.

 

ITI pointed out trachoma was once endemic in Europe and the United States. Before the use of antibiotics, trachoma disappeared due to improved living standards.

Today, antibiotic treatment provides a short-term cure, especially when the whole community is treated. However, reinfection can occur, typically within six months if hygiene and the environment don’t improve. For this reason, it is essential that the full SAFE strategy is in place in trachoma-endemic communities.

Paul Emerson, the Director for ITI said, “Trachoma traditionally affects the people at the end of the road, they’re the forgotten people, they are people with a very little political voice. Because trachoma is a hidden disease it is very difficult for people to care. Well, we do care. And we want to reach all of those people.”

– Kara Buckley

Sources: Carter Center, Sight Savers, Trachoma Coalition, Trachoma.org
Photo: Google Images

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Trachoma in Ethiopia: What It Is and What Is Being Done

Trachoma_in_Ethiopia
Trachoma is an endemic disease in Oromia, the largest and most populous state of Ethiopia. The disease has caused an impairment of vision in 2.2 million people in the world as the leading infectious cause of blindness.

The combination of poor sanitation and minimal access to clean water increases the risk of infection and nearly 229 million people in the world live in high-risk areas. Women are more susceptible to infectious trachoma than men because of their higher exposure to young children who are typically the bearers of the disease.

Eighty percent of Ethiopians live in rural areas with poor sanitation and little access to clean water. Seventy-six million people in Ethiopia are at risk of contracting blinding trachoma and another 800,000 people are at risk of irreversible blindness if they do not receive surgery.

Ethiopia only has 120 ophthalmologists and the majority of them work in Addis Ababa. The country is ill-equipped to destroy the disease on its own although the surgical procedures are simple and quick.

The Fred Hollows Foundation is a non-governmental organization focused on eliminating preventable blindness. The organization’s work in Ethiopia is focused mainly on the implementation of the SAFE strategy recommended by the World Health Organization in Oromia’s 225 endemic districts.

SAFE is an acronym for Surgery, Antibiotics, Face-washing, and Environmental improvements. Changing the way people manage personal hygiene has been one of the ways they are trying to reduce the risks of trachoma.

The Fred Hollows Foundation and its partners treated 5,637,226 people with antibiotics and performed more than 7,000 lid surgeries in 2014 alone. They also trained 36 surgeons and 10 clinic support staff as well as supplied $126,747 worth of equipment used to treat trachoma in Ethiopia.

According to the Fred Hollows Foundation website, “What is needed [to eliminate trachoma in Ethiopia] is a significant scale-up of the SAFE strategy, including resources, expertise and commitment from regional and local governments and development organizations in the water, sanitation and hygiene sectors.”

– Iona Brannon

Sources: Al Jazeera, The Fred Hollows Foundation, World Health Organization
Photo: Flickr

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Global Trachoma Mapping Project

Global Trachoma Mapping Project
“The Global Trachoma Mapping Project is the largest infectious disease survey in history with the aim of eliminating the disease by 2020,” says BBC.

This initiative is led by Sightsavers and has been active in 22 countries in Africa, Asia and the Pacific. It aims to uncover where Trachoma is most active so treatment can be focused there, eventually eliminating the disease by 2020 and meeting the World Health Organization’s goal to eliminate Trachoma.

Trachoma is the leading cause of preventable blindness in the world. Though it can be prevented through antibiotics, surgery, face washing, and a sanitary environment, today 39 million people suffer from blindness. 80 percent of these cases could be prevented or cured and 90 percent of these cases reside in the poorest region in the world.

In the early 1900s, Trachoma was endemic in the United States and Europe. Immigrants to the United States were thoroughly screened for Trachoma infection when the arrived at Ellis Island, and nine out of ten who were diagnosed were sent back to their original country. Trachoma has disappeared in Europe due to improved living standards, without the aid of antibiotics.

Today around 232 million people live in trachoma-endemic regions and are in desperate need of treatment. TrachomaAtlas estimates that 7.2 million people live with advanced Trachoma— where the eyelashes turn inward and scrape the cornea, an extremely painful condition. These individuals will be blind or visually impaired if they do not receive a simple surgery— something that Sightsavers, with the help of the Global Trachoma Mapping Project, aims to provide.

Trachoma is not a widely known disease— it is rampant in isolated, rural regions where people have very little to no access to healthcare and water. The Trachoma Coalition says that “In some communities, the disease is so common that blindness from Trachoma is simply accepted as a fact of life.”

Trachoma is known as a Neglected Tropical Disease (NTD). These diseases are referred to as ‘neglected’ because they impact the poorest regions in the world as well as the world’s most vulnerable— remote rural areas, urban slums and conflict zones, according to SightSaver’s website.

Data from the Global Trachoma Mapping project has starkly illuminated that NTDS are just as impactful in terms of sickness, disability and death as more well-known diseases (HIV, Tuberculosis and Malaria). The need for information on where these diseases are most prevalent is dire.

The Global Trachoma Mapping project aims to also combine technology with medical research. Data is uploaded through smartphones onto a virtual Trachoma Atlas. Then, the data is instantly available for governments, NGOs, and other aid agencies to target treatment where it is most urgent.

The initiative began in 2012 and is funded by the United Kingdom, which has provided over ten million pounds towards the effort.

In 2014, Sightsavers implemented over 13.8 million eye examinations, over 296,000 operations to restore sight or prevent blindness, and helped over 9,000 children with disabilities attend school. The Global Trachoma Mapping Initiative hopes to increase these numbers by finding where the most vulnerable are and helping them.

Seven countries where Trachoma used to be endemic (Gambia, Ghana, Iran, Morocco, Myanmar, Oman and Vietnam) have claimed to have been in some stage of eradicating Trachoma as a public health endemic.

– Aaron Andree

Sources: BBC, Trachoma Atlas, Trachoma Coalition, Sight Savers

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Tropical Diseases are Killing Millions

tropical diseases
Neglected tropical diseases are diseases that are either bacterial or parasitic and infect around one in six people around the world. Over half of a billion children are infected with these diseases.

These diseases are considered “neglected” because they do not receive very much attention or funding from governments or medical communities around the world.

These diseases tend to be especially widespread in areas with high levels of poverty, bad sanitation and poor access to health care. These diseases tend to especially affect women and children.

While they are grouped together, neglected tropical diseases can be very different from one another. Some kill quickly while others will infect for years or simply harm, but not kill, their victims. Some are parasitic, caused by parasites, and spread through mosquitoes, snails or flies. Others are bacterial and are spread through water or soil.

Treatments for these diseases also vary. Some have cheap treatments available (although this could potentially lead to drug resistance), others have no treatment or a very expensive or difficult treatment.

According to the World Health Organization there are 17 neglected tropical diseases. Here is a brief description of the seven most common neglected tropical diseases. These seven diseases account for 90 percent of global cases of neglected tropical diseases.

1. Ascariasis (roundworm) is the infection of the small intestine that is caused by a roundworm. The eggs of the roundworm are often ingested and the eggs then hatch in the person’s intestine. They then reach the lungs through the bloodstream. The worms can grow to be longer than 30 centimeters. Roundworm causes about 60,000 deaths each year.

2. Trichuriasis (whipworm) is spread and moves through the body like roundworm. Around the world about 700 million people are infected with whipworm.

3. Schistosomiasis (snail fever) is caused by parasitic worms. A person can become infected by coming in direct contact with contaminated fresh water. Over 200 million are infected with snail fever around the world.

4. Lymphatic filariasis (elephantiasis) is transmitted through mosquitoes and damages the lymphatic system causing painful, visible disfigurations. More than 120 million are infected around the world.

5. Trachoma is an infection of bacteria in the eye, causing the yield to turn inwards, eventually resulting in blindness. Six million people are blind due to trachoma.

6. Onchocerciasis (river blindness) is a parasitic disease caused by flies that carry larval worms that grow to cause blindness, lesions and loss of pigmentation in the skin.

7. Hookworm is spread and moves through the body like whipworm and roundworm. Around 600 million people throughout the world are infected with hookworm.

Although neglected tropical diseases affect millions, they are relatively inexpensive to treat: for around 50 cents a year, one person could be treated and protected for all of the seven most common neglected diseases.

– Lily Tyson

Sources: Reuters, Global Network, CDC, WHO
Photo: EndTheNeglect

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UK to Donate £39 Million to Help Eliminate Trachoma

The British Department of Development announced on June 24 that is it set to donate £39 million to help support the elimination of trachoma. The funding is designed to support implementation of the Surgery, Antibiotics, Facial Cleanliness and Environmental Improvements (SAFE) strategy, which has seen considerable success in helping to eliminate the disease.

Trachoma is an infectious disease of the eye caused by the bacterium Chlamydia trachomatis. The disease has a variety of clinical manifestations, but the most common one is an acute infection that results in mild itching, irritation and inflammation. Repeated infections and inflammation can cause visual impairment, scarring and, eventually, blindness. As is typical with such diseases, children are especially susceptible to contracting it. Trachoma is responsible for 3 percent of global blindness, with 230 million people at risk of contracting the disease, and 70 percent of those who are affected are women

The £39 million will be implemented by a consortium of International Coalition for Trachoma Control (ICTC) members and will be managed by SightSavers. The ICTC was established in 2004 with two main goals: contribute to the global effort to eliminate blinding trachoma and to advocate for and implement the SAFE strategy. The ICTC consists of a wide variety of organizations committed to trachoma control and is endorsed by the Wold Health Organization (WHO.) One of those organization is SightSavers. Their work has already spread to 37 different countries, helped over 120 million people and it currently has over 200 active projects.

The biggest concern regarding trachoma is that as a result of blindness, those who contract the disease are unable to work. As a result of this, the inability to work traps those who catch the disease in a cycle of poverty. As the International Development Minister Lynn Featherstone explains, “Stopping trachoma before it gets hold [sic] can make a significant difference to people’s lives, especially women. Up to 90 percent of blind people cannot work, making their poverty worse and leading to greater financial insecurity and lower standards of living.” Hopefully this donation can help those in need and turn the tides on this entirely preventable disease.

— Andre Gobbo

Sources: SightSavers, International Coalition for Trachoma Control, Department for International Development
Photo: Medical Ecology

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5 Most Common Neglected Tropical Diseases

5 Most Common Neglected Tropical Diseases
Neglected tropical diseases (NTDs) affect 1 billion people, or one out of every six individuals, every year. Half a million people die from NTD related effects, the majority of whom are impoverished children, women and persons with disability. Although methods of prevention and treatment are available, these diseases remain extremely common in parts of Africa, Asia, Latin America and the Caribbean.

The following list of NTDs represents approximately 90% of the global NTD burden, along with methods of treatment and prevention.

1. Onchocerciasis

Also known as “river blindness,” this disease is transmitted via black flies carrying the onchocerca volvulus parasite. The parasite causes debilitating itching and upon reaching the eyes, visual impairment and eventually blindness. It is the second leading cause of infection-induced blindness, behind Trachoma, with 37 million people infected with the disease.

A single, annual dose of Mectizan controls the disease and relieves symptoms. Some countries in Latin America successfully eliminated disease transmission after administering the drug for twenty years which lends hope to its possible elimination in the African continent.

2. Trachoma

One of the oldest infectious diseases known to mankind and the leading source of global blindness, is caused by the bacterium Chlamydia trachomatis. Eye-seeking flies transmit the disease from an infected person’s eye discharge to uninfected hosts.

Repeated infections result in a scarred interior eyelid thereby forcing eyelashes to turn inward thus scratching the cornea, all of which is followed by blindness. It affects about 21.4 million people, of whom 1.2 million are blind.

It is hyperendemic in remote poor rural areas of Africa, Central and South America, Australia and the Middle East.
The World Health Organization (WHO) recommends the SAFE strategy (Surgery, Antibiotic treatment, Face washing and Environmental changes) to limit its spread.

3. Schistosomiasis

Or, snail fever, is a parasitic disease transmitted by freshwater snails to bathing or swimming humans. Urniary schistosomiasis progressively damages the bladder, ureters and kidneys. Intestinal schistosomiasis enlarges the liver and spleen, damages the intestines and creates hypertension of the abdominal blood vessels. It affects 200 million people, and in children can impair growth and cognitive development.

A single dose of praziquantel with repeated community distribution treats and controls the disease.

4. Soil-transmitted helminthes

Affects more than 880 million children around the world. The intestinal worms may result in diarrhea, abdominal pain, anemia, general malaise and severe infection can impair growth and cognitive development.

Improved sanitation, health education and the periodic administration of anthelminthics to at-risk groups limits the rate of transmission.

5. Lymphatic filariasis (LF)

Also known as elephantiasis, is a mosquito-borne disease which results in painful swelling of the limbs and genitals. Over 120 million people are currently infected and nearly 1.4 billion people are at risk in 73 countries.

The WHO recommends yearly large-scale Mectizan and albendazole doses for four to six years to interrupt transmission.

This information was compiled from the Neglected Tropical Disease NGDO Network, World Health Organization and the Center for Disease Control.

– Emily Bajet

Sources: Neglected Tropical Diseases (NGDO) Network, WHO, WHO Programmes, Center for Disease Control and Prevention(CDC)
Photo: Bullion Street

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