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July/August 2008

Clinical Update: Global Vision, Part Three
The Eyes of Sub-Saharan Africa
By Denny Smith, Contributing Writer

Seth Wanye, MD, chuckled as a puppy on the porch of his clinic offered a “bow-wow!” welcome to visitors. The moment of levity was well-deserved by Dr. Wanye, who is the only ophthalmologist for more than 2 million people in northern Ghana.

His clinic is part of the Tamale Teaching Hospital, but the only way Dr. Wanye can offer care to many of his patients is to bring the care to them. “We travel to see all kinds of patients, from those with cataract and glaucoma to those needing pediatric and oncology care. But we have limited equipment so if we cannot treat them where they live, or in Tamale, we send them to Accra.”

The dangers of childhood. Trauma, particularly in children, is a considerable fraction of Dr. Wanye’s practice, and it’s not unusual for him to be awakened in the night by a family that has traveled several hours with an injured child. “We see corneal abrasions and ruptured globes, and, I’m sad to say, we also see a lot of advanced retinoblastoma. We don’t have MRI or CT scans or radiotherapy here, so if the parents cannot afford to go to Accra, and if they refuse enucleation, the next time I see them it’s too late for the child.”

But at least two problems that once confronted Dr. Wanye may be approaching resolution. Xerophthalmia has decreased steadily since vitamin A has been distributed in the schools. And Dr. Wanye is especially excited that the elimination of trachoma is on the horizon. A large intervention by the Ghana Health Service, with donations of azithromycin from Pfizer coordinated by the International Trachoma Initiative, has made possible the dream of eradicating trachoma as a source of blinding disease in this country.

Training new physicians. Ophthalmic medical training in West Africa is managed by a consortium operating among several countries, with residents rotating around various teaching hospitals. Most of the ophthalmologists who emerge from the consortium prefer to practice in the cities, leaving the vast rural regions unattended. But Dr. Wanye’s practice soldiers on. Without more doctors, what practical assistance would benefit his practice? “Biometry would be nice; A-scan and keratometry. And even just regular supplies like viscoelastics and IOL implants. The Academy and Unite for Sight have been very helpful in coordinating supply donations for our clinic.”


Vision in South Africa

South Africa is nearly 3,000 miles away from Ghana, but ophthalmologists there contend with some parallel concerns. Childhood blindness is an especially apt marker of South Africa’s national health. About 0.5 children per 1,000 are living with blindness, a prevalence about twice that of industrialized countries but only half that of most developing countries, according to Anthony D. N. Murray, MD, emeritus professor of ophthalmology at the University of Cape Town.

Dr. Murray knows his demographics. “There are 950 million people in sub-Saharan Africa and only about 950 ophthalmologists. South Africa has 280 of those, for our 45 million people, compared to Malawi’s four ophthalmologists for 10 million people.”

Looming eye disease. Dr. Murray cited figures that could make ophthalmic pathology a future crisis in South Africa: 80 percent of the population is regarded as indigent, 34 percent is younger than 16 years of age and 30 percent of mothers in antenatal clinics are infected with HIV. The ominous implication is that millions of young people are approaching their sexually active years without options that would encourage life-affirming choices. And many of the opportunistic infections associated with HIV disease, including tuberculosis, toxoplasmosis, herpes zoster and cytomegalovirus, can have serious ocular manifestations. “The danger,” added Dr. Murray, “is that the middle generation in countries like ours is just disappearing from AIDS.”

Conflicting medical paradigms. While cost is not a barrier to health care per se, in rural areas care is curtailed by a sheer lack of providers. Some African countries compensate for that by training ophthalmic assistants to perform noncomplicated cataract surgery, Dr. Murray said. “Otherwise, it simply wouldn’t get done.”

And in some countries, including South Africa, rural people often turn to traditional healers, whose recommendations frequently run counter to science-based medicine. One traditional practice involves the irrigation of a red eye with urine. Unfortunately, microbes like Neisseria are easily spread that way. “We’ve had an epidemic recently of gonococcal corneal perforation,” Dr. Murray said. “The healers may also believe that if, for example, a person has strabismus, then that’s their lot in life. So we have many people with infantile esotropia who reach adulthood without seeking treatment. And even if we can bring these patients into care and align their eyes surgically, follow-up is not good, and we may not see them for another 10 or 15 years.”

Even if patients are adherent, the task is gargantuan. Dr. Murray noted that in all of sub-Saharan Africa there are only ten pediatric and strabismus specialists. There is currently a national effort to increase pediatric ophthalmologic training. “I think one of the things we can do for the rest of Africa generally is to train nationals from various countries,” Dr. Murray said. “We may understand better what African populations need than would European or American programs. Macular degeneration and rhegmatogenous retinal detachments, for example, are extremely uncommon in people of African origin. But primary open-angle glaucoma is not uncommon and is extremely difficult to manage in young Africans. We are also disproportionately affected by chronic angle-closure glaucoma. And trabeculectomy is not as successful in black Africans as in Caucasians. All told, glaucoma is the second leading cause of blindness here. That’s why two of the best known glaucoma filtering valves were developed by South Africans—Drs. Anthony Molteno and George Baerveldt, whose names are now attached to those devices.”


Eye Care for, and by, Kenya

Preventing blindness has benefits that far exceed the investment that is made, said Daniel Oira Kiage, MD. Dr. Kiage grew up in Kenya and completed his medical training there. It was during his residency when he realized the magnitude of visual impairment that burdened his country, and that he felt compelled to change it. He is now finishing a glaucoma fellowship at the University of Ottawa and will then return to build an ophthalmology residency program at Aga Khan University Hospital in Nairobi.

Although the government of Kenya takes vision health seriously, economic priorities mean that it has not always been able to provide universal health care for its citizens, said Dr. Kiage. So charitable organizations often invite international volunteers to work for limited periods of time. As generous as those efforts are, said Dr. Kiage, the benefits are often limited, since the organizations may operate independently and leave without having interacted with local ophthalmologists. “The only way we can succeed in creating sustainable health care is to involve the local Kenyan physicians. Those are the physicians who were born there, who live there and who will still be there when everyone else packs up and goes.”

Dr. Kiage said that helping to change the infrastructure of Kenyan health care could be more productive. As in many nations, the cities have more physicians than the countryside. “Kenyan physicians who work in the big cities could be given incentives to go to clinics in rural areas for weeks or months at a time. As it is, many urban ophthalmologists are underutilized.” Building such clinics and making them attractive to city physicians would take money, of course. “But Kenyan ophthalmologists should be the driving force. Planning and executing useful programs with local ophthalmologists is the sustainable way to deliver eye medicine.”

Oculoplastic collaboration. “The Kenyans are outstanding surgeons,” said Scott M. Goldstein, MD, who visited Kenya several years ago on an oculoplastics mission. “They do very efficient 9-mm, self-sealing extracapsular cataract surgeries in 10 minutes. Plus they are all truly comprehensive ophthalmologists—doing their own glaucoma surgeries, their own corneal transplants, basic retina, cataract and strabismus.” Dr. Goldstein’s mission anticipated Dr. Kiage’s sentiments by working closely with local physicians. “They are already highly competent doctors, and when we left, they had a few more skills to handle nearly everything they might encounter.”

Dr. Goldstein is a clinical assistant professor of ophthalmology at the University of Pennsylvania and Thomas Jefferson University in Philadelphia. When word got out that his team had arrived in a small community near Nairobi, people came from all over the country to see them. One family even traveled several days from Tanzania so their baby’s orbital tumor could be evaluated.

The host of Dr. Goldstein’s mission was Kikuyu Hospital. “The ophthalmology ward there was very self-contained,” said Dr. Goldstein. “They hand-washed drapes, towels and gowns and then, after drying them outside on clotheslines, they sterilized them in bamboo steamers over boiling pots. They had a very efficient medical set-up, kind of a linear flow model, with a check-in, optometric refraction and an MD visit. The patients just came and waited, first-come, first-served. Some would wait literally all day to be seen, but they never complained.”

Ophthalmologists from around the region came to observe Dr. Goldstein and his colleagues in the operating theater and some of them scrubbed in on cases. “This is how we do a DCR, how we do a ptosis case, how we fix a complicated wound,” he explained to them. “After a few days of that, they did the surgeries and we assisted them. So they got to watch us for a few days and then we watched them for a few days.”

Pressing problems. “Two or three things came up pretty commonly—old trauma of the eyelids and face, like fractures, severe burns and lacerations that were never really appropriately treated, and we saw many people with lacrimal obstructions from a variety of causes. We had several patients with old herpes zoster ophthalmicus who were also HIV-infected and in whom neither condition had been treated—so there was severe scarring on the forehead and eyelids with retraction, lagophthalmos and corneal scarring. Another patient had a very bad squamous cell carcinoma that had grown through the eyelid into the orbit and down into the cheek and that really needed a wide exenteration and facial dissection. It was really beyond the scope of what we could do so we sent that patient to a general plastic surgeon in Nairobi.”


A Veteran Looks Back

Few U.S. physicians appreciate the state of medicine in Africa more than Larry Schwab, MD, a comprehensive ophthalmologist from Morgantown, West Virginia. In the 1970s and ’80s, Dr. Schwab and his family lived in Ethiopia, Kenya, Malawi and Zimbabwe, where he practiced his ophthalmic skills under the auspices of the International Eye Foundation (IEF). “Our mission was simple,” Dr. Schwab said. “In Ethiopia in those years there was only one ophthalmologist in a country of 40 million people. So IEF ophthalmologists provided care to patients and training to midlevel workers, clinical officers and nurses.”

Dr. Schwab’s work was comprehensive. “We had all our hats on all the time—pediatrics, cataract, retina, glaucoma and a lot of both intraocular and extraocular surgeries,” he said. “In Malawi in the ’80s there were only two ophthalmologists in the whole country: Dr. Moses Chirambo and me. People often came to care very late in a disease process. Sometimes that was just because they could not afford a 50-cent bus ride, and other times it was because they accessed local traditional healers until the problem grew unmanageable. The incidence of retinoblastoma, for example, is probably no more common in African births than elsewhere, but when we saw such children the case was often an exophytic tumor growing out of the orbit.”

Medical needs did not stop at the eye, of course, or wait for other specialists to come around. “There was no ENT service in Malawi then, so we managed many advanced carcinomas and facial tumors. I wasn’t prepared to do all of this because some of the cases were way beyond my scope,” Dr. Schwab said. “But when you’re faced with an orbital tumor that could be life-threatening, you just do what you can. If we didn’t do these things there was a good chance they wouldn’t get done at all.”

Basic amenities were often in rare supply, Dr. Schwab said. “In Europe and North America, you turn on a faucet and you get drinking water. In rural parts of many countries we had to carry our own water, and we powered an operating room light with a car battery.”

Heroes are among us. Well-placed gestures can make a difference, Dr. Schwab said, such as the generous provision of ivermectin, developed by Merck, and of azithromycin, by Pfizer, for the control of onchocerciasis and trachoma, respectively. Both companies have donated many millions of doses of their drugs.

Empathy, not apathy. For decades Africans have endured appalling and nearly unrelenting wars and displacements, with regional conflicts piling on top of crushing droughts and famines, and social and economic disruptions that almost seem to generate their own momentum. “How did we get here? Many have said that the origins are in colonialism, which left the continent with boundaries drawn crudely across tribal lines, and in part, of course, that’s true,” Dr. Schwab said. “But sub-Saharan Africa is, nevertheless, a region of 56 countries and a thousand languages and great natural resources, and that’s all held back by a lack of stability. We need to support environments in which governments can be stable. Direct aid is not a long-term answer, and yet the United States is the wealthiest country in the world; it’s our moral imperative to assist in sustainable ways. We need to help, wherever and whenever possible, to develop logical and rational societies.”