EyeNet Magazine


 
Clinical Update: Global Vision, Part Six
From Armenia to Tanzania: The Eyes of Hope and Change
By Denny Smith, Senior Editor
 
 

Nestled on the slopes of Africa’s highest mountain lies an incu­bator of innovation—The Kiliman­jaro Center for Com­munity Ophthalmol­ogy (KCCO). The KCCO was founded in Moshi, Tanzania, in 2001 by Susan Lewallen, MD, and Paul Courtright, DrPH, for the purpose of building ophthalmic medical capacity throughout eastern Africa. “The amount of government funding for health care in Tanzania, and other countries in the region, is quite small, with the majority coming from donors to the gov­ernment. There is no universal health care system,” said Dr. Courtright. “There is a small health insurance scheme, but it primarily covers government workers. Africa continues to look for the right mix of finan­cial support for health care, and multiple models of service delivery are likely to be required in the coming years.”

Government/NGO discrepancies. Government funding for health care is lopsidedly outpaced by nongovernmental and international agencies, Dr. Courtright said.

Tanzania, like most countries in eastern Africa, is divided into administrative regions of 1 to 2 million people, and none of these areas can rely on government resources alone. “This is fairly typical throughout eastern Africa. The most productive eye units are nongovernmental ones. One of KCCO’s major goals is to help strengthen the productivity of the governmental sector throughout eastern Africa.”

Innovation: one model. Although the KCCO was created to expand ophthalmic care delivery in eastern Africa, its mission is not to provide care directly but to build the capacity of eye care programs and hospitals, and to improve what in Melbourne, Munich or Miami might be called practice management, said Dr. Courtright.

Ophthalmologists and other eye health professionals learn at the KCCO how to develop and manage programs serving populations of 1 to 2 million people, how to hire and use a manager, how to account for financial and material resources and how to resolve gaps in care delivery, Dr. Court­right said, adding that the major goals pursued by the KCCO could be summarized as follows:

  • Increase programs that enable rural people, particularly women, to have access to eye care services. Many of the programs nurtured by the KCCO have doubled or tripled the number of cataract surgeries in rural areas.
  • Create management systems that improve both productivity and efficiency. He noted that despite increasing services these programs have largely not added staff.
  • Enhance childhood cataract treatment. Some hospitals have tripled the number of children getting cataract surgery and have adopted strategies that have improved follow-up for the provision of spectacles or low vision care.

Tangible results. The quotidian successes of the KCCO are evident in entries from its quarterly “Activities Reports.” Some examples from last spring:

“Ms. Tionenji Ng’ong’ola spent two weeks training at KCCO to gain skills needed to be the coordinator for the newly developing Child Eye Health Tertiary Facility at Queen Elizabeth Central Hospital in Blantyre, Malawi. A bonus for Tionenji was attending the training session in Mbeya to learn how such a training session is conducted.”

“Dr. H. Hassan and Dr. Al-Attas are following up on patients identified on the RAAB survey as blind in one or both eyes due to glaucoma. The point is to learn whether they ever sought treatment earlier in the course of the disease and what care they have received. They are also encouraging first-degree relatives of these patients to come for screening. This information will be helpful in trying to identify strategies to find glaucoma patients in the community before it is too late.”

Calling all friends. The bricks and mortar for such accomplishments has come from far and wide. “KCCO is completely grant-driven,” said Dr. Court­right. “Funds and support for projects come from many organizations from multiple countries, including the Nether­lands, Canada, Australia, Germany, the United Kingdom and the United States. Late last year, we finished construction of our new three-story training center, which has really helped our ability to conduct the many training programs we offer.”

Obstinate obstacles. Barriers to high-quality, consistent eye care are still in place, Dr. Courtright said. Some of the current obstacles:

  • A lack of appreciation by some donors, service clubs and visiting ophthalmologists that providing “free eye camps” in most settings in Africa paradoxically undermines local attempts at establishing some degree of organizational or financial sustainability.
  • A lack of collaboration or coordination among the major eye care NGOs in eastern Africa, with the notable exception, said Dr. Courtright, of Ethiopia. This has led to considerable fragmentation of services, large areas left unsupported, adoption of policies that are regressive in nature and the languishing of “best practice” models.
  • Weak management in governmental services, including a lack of supervision, lack of accountability, lack of planning and a disempowering of local service providers by national coordinators.

Just as the KCCO is greeted each morning by the lofty summit of Mt. Kilimanjaro, it smiles back with its own lofty ambitions to transport ophthalmic medicine in what has been called the “continent of blindness” into the 21st century. Dr. Courtright is clearly excited about the growth of the KCCO model. “KCCO has led the discussion on how to set up and manage programs for children with congenital or developmental cataract, recently publishing a manual titled ‘Childhood Cataract in Africa.’ And we have ophthalmologists coming from Asia as well as Africa to learn how to develop a comprehensive approach to childhood cataract. We’re pushing hard to get governments and NGOs to realize that simply increasing resources won’t solve the problem; we’re focused on using existing resources more efficiently.”

Looking for Care, Caring to Look

CUFig1
Dr Ohanesian examines a patient in Yerevan.

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Excellence Flowers in Armenia

Like other nations in the Caucasus, the history of Armenia brims with both sadness and aspiration. Foreign domination and ethnic mistrust have provoked bitterly tragic events between neighbors in the region, and, as recently as the mid-1990s, Azerbaijan was at war with its largely Armenian enclave of Karabakh. When wounded Armenians were transferred to Yerevan and overwhelmed the capacity of local physi­cians, the Minister of Health issued an urgent call to the international Armenian diaspora. Physicians of Armenian descent around the world were invited to come help, and Roger V. Ohanesian, MD, associate clinical professor of ophthalmology at the University of California in Irvine, was one of the first to respond.

“Karabakh had been deeded to Azerbaijan by Stalin years before, but the Armenians had no control over that transfer,” said Dr. Ohanesian. “Many people fighting for independence from Azerbaijan were killed or injured in the war. And many, many doctors from around the world, from neurosurgeons to ophthalmologists to orthopedic surgeons, came to help. When we arrived by helicopter we assisted Armenian doctors performing triage and emergency surgery. We saw terrible, amazing things—penetrating wounds, lots of injury from explosions, corneas tattooed with gunpowder. I remember one boy struck by a missile that flew straight into his eye. Remarkably, the missile didn’t explode, and he was able to pull it out. But his globe and orbit were mutilated and required exenteration. And there was almost no medical equip­ment around. I once used a Swiss Army knife to remove sutures.”

Blinding war. Many people presented with wounds that were long past benefiting from primary repairs. “One day I went down a line of about 60 soldiers who had untreated ruptured globes. They each held their eyes open with their fingers, and through these ugly, scarified corneas, all I could do was determine if they had light perception.”

Land mines are ubiquitous in this part of the world, said Dr. Ohanesian, and, unfortunately, the United States has refused to sign the international treaty banning these weapons. “Land mine injuries were awful. Many of today’s mines are cleverly made: They don’t just go off when you step on them—they actually jump up when encountered and then explode at face level. There are grape arbors in Karabakh that have fruit dying on the vine because no one dares to venture into the mined vineyards. Many of these devices were even planted in schoolyards and playgrounds. Sun Tzu, in his classic, The Art of War, says that it’s useful in war to attack your enemy’s children because it takes four people to care for an injured child, and only two to care for an adult.”

One child had been spirited from Karabakh through a refugee corridor at great risk to himself and his parents. They obviously thought Dr. Ohanesian could help. But both the boy’s eyes had already been destroyed by missile trauma and enucleated. Distraught himself, Dr. Ohanesian gestured to the sobbing parents, “What can I do?” An interpreter finally explained their foundering hope to Dr. Ohanesian. “They thought you brought new eyes from America.”

Restoring a nation. The war finally calmed into a stalemate, but by then Dr. Ohanesian had already decided to champion ophthalmic care all over Arme­nia, and so he founded the Armenian Eye Care Project. “Doctors there are very intelligent, very receptive to new ideas and eager to learn, and they wanted to know the way to bring modern ophthalmology to Armenia.”

But the state of eye medicine after Armenia left the Soviet Union was ambiguous. “They had some good surgical methods that they inherited from the Soviets and also had some questionable ones that had survived from many years gone by. To treat macular degeneration, they would isolate a branch of the internal carotid artery and connect it to the central retinal artery. This not only didn’t help but caused great suffering to the patient. Another procedure was called circular drainage, in which the physician would place a large 6.0 suture through the cornea and into the anterior chamber, just inferior to the pupil, and tie it loosely, so that one end was posterior to the cornea and the other was exteriorized, like a wick. That was their treatment for hyphema and hypopyon.”

Blueprint for progress. The Armenian Eye Care Project is propelled by a formula that engages the skill of visiting physicians with the enthusiasm of Armen­ian physicians. Five points roughly describe the formula:

  • Physicians visiting Armenia through the Eye Care Project pay their own way to fly and stay in Yerevan, the capital.
  • Armenian physicians learn from the visitors fresh approaches in various ophthalmic subspecialties.
  • When new skills are mastered, the American physicians step aside and assist the Armenians. The Americans also tutor Armenian primary care physi­cians on the essentials of eye medicine.
  • Ophthalmic care is brought to rural patients with a mobile eye hospital staffed by Armenian ophthalmologists. Rural ophthalmologists are brought back to Yerevan to learn new skills.
  • Some Armenian physicians are sponsored for expense-paid fellowships in the United States, with the stipulation that when they return to Armenia, at least 50 percent of their practice will serve economically needy patients.

When surgeon and student trade places. That simple strategy appears to be working very well. The goal, Dr. Ohanesian said, is for the Eye Care Project to go out of business. “We want to work ourselves out of a job here. If a case brought before an American doctor is unique, then my rule of thumb is that the American doctor does the surgery with an Armenian doctor assisting,” he said. “If it’s not unique, then the Armenian doctor does it, with the American as the assist. We’re finding more and more that the Armenian doctors are able to do these cases. They are incredibly quick students. One of our Armenian fellows once noted that in one patient she was dealing with Wegener’s granulomatosis type 2. And the American physician turned to me and said ‘I didn’t even know there were two types of Wegener’s!’” Now Armenia has experts in all the ophthalmic subspecialties, Dr. Ohanesian said, and those experts are themselves teaching other Armenian doctors.

Guests of America. “We have had ten young ophthalmologists come to the U.S. for hands-on fellowships, with all their expenses paid by the Armenian Eye Care Project. We brought their families, too. And we have sent them back to Armenia with millions of dollars worth of equipment, some donated and some new. Alcon, Allergan, AMO, Bausch & Lomb, Iridex, Ocular Instruments and Volk, among others, have been just amazing with generous donations. And Pfizer donated a six-station wet lab for our education center.”

Dr. Ohanesian believes the Armenian Eye Care Project can be a model for other countries, especially for those with underserved rural populations. “We created an 18-wheel mobile eye hospital, which includes two ORs, an ambulatory surgical suite and two lasers, both a YAG and an argon. One entire rural tour of the country takes about two years. We only treat people who are poor—we do not want to compete with ophthalmologists who treat paying patients. We just want to address the wave of blindness that the country had, and offer education to ophthalmologists.”

Dr. Ohanesian is deeply moved by the willingness of U.S. physicians to donate such generous portions of time and skill. “We’ve had over 50 American ophthalmologists come, on their own dime, and pay for their own hotel. They work hard there and they are very excited about the experience. They often say ‘These are cases I never see in America. When can I come again?’”

The physician as world citizen. The project has not gone unnoticed by neighboring governments, said Dr. Ohanesian. “We were invited, and went, to Iran and to Syria and have also been invited to Estonia and Georgia. We also now have patients and doctors from neighboring countries coming to Armenia for care. In fact, foreign doctors will often send tough cases to Armenia for treatment.”

Remembering a remark by colleague Richard Hill that a child going blind means pretty much the same thing in every society, Dr. Ohanesian suggested that ophthalmologists have the potential to become ambassadors of sorts. “I don’t care how much you hate your enemy, if they’re going to save your kid’s eyesight, everything changes.”

CUFig2
A young Armenian man who sustained severe orbital trauma from a missile in the Karabakh conflict.

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