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Editor,—The prevalence of blindness in Africa, both for adults and children, is the highest in the world.1
Cataract accounts for over half of this blindness and a large part of the remainder (trachoma, xerophthalmia, onchocerciasis, glaucoma) is preventable.2
There is on average one ophthalmologist per million population in Africa today. Most of these specialists are practising in the capital cities and large conurbations.3 Yet a majority of the population still resides in rural areas gaining a livelihood from subsistence farming. Access to affordable eye care for most people is therefore severely limited.
In English speaking Africa the penury of ophthalmic nurses and doctors is being tackled realistically with diploma and fellowship training courses available in west, east, and southern Africa. But the 19 French speaking countries south of the Sahara lag far behind, with only a few teaching centres that are incapable of meeting the shortfall of trained eye workers and whose expertise is largely unadapted to the realities of the region. Up to a third of all ophthalmologists in francophone Africa perform no surgery at all and those who do perform, on average, only 160 cataract operations each year.3
In October 1990 I was seconded to the Ministry of Health in the Republic of Benin to establish an eye service based in the provincial town of Abomey (population 65 000) 130 km north of the capital Cotonou. A new district general hospital with 200 beds had been built during the 1980s and a fully equipped ophthalmic consulting room was unused. At that time Benin had five national ophthalmologists for a population of just under five million people. All five were working in either Cotonou (economic capital) or Porto Novo (administrative capital), cities only 30 km apart on the southern coast. No ophthalmologist worked inland.
A national survey conducted by the WHO in 1990 to measure the prevalence of blindness and visual handicap in Benin revealed 0.63% and 2.5% respectively4; 54% of blindness is caused by unoperated cataract. Glaucoma 15% and corneal pathology 11% are the other major causes of bilateral blindness.
Four priorities were established for the new work in Abomey.
(1) To establish an eye service for all sections of the community by the use of appropriate technology at affordable prices.
(2) To place an emphasis on the surgical treatment of cataract and glaucoma.
(3) To train eye nurses.
(4) To develop an outreach service by holding eye clinics in peripheral towns and to perform eye surgery, where suitable facilities existed, as close to the patients home as possible.
Annual new patient registrations at the base hospital rose from under 700 in 1990 to nearly 4000 in 1995. Eye surgery rose from 50 in 1990 to over 1100 in 1995 (including 618 cataract operations and 232 trabeculectomies). All cataract surgery, except on children, was performed under local anaesthesia and was generally intracapsular using a cryoprobe. Aphakic correction was with standard +10.00 or +11.00 glasses imported from India. No intraocular lenses were implanted.
Three general nurses were given a full training both locally in Benin and at the regional Institut d’Ophtalmologie Tropicale en Afrique (IOTA) in Bamako, Mali. Each received the diploma of “infirmier-spécialiste en ophtalmologie” which is recognised throughout French speaking Africa.
An extensive outreach programme was undertaken. One day each week was devoted to holding clinics within a radius of 200 km from the base hospital. Over 40 towns and villages were visited, many regularly. Eye surgery was performed in five other hospitals. Within a period of 5 years we became the busiest surgical eye service in francophone west Africa, outside the long established centre in Bamako, Mali.
The problems encountered were as follows:
(1) No progress was made in integrating national ophthalmologists into the project. By 1994 there were 15 national ophthalmologists working in Benin, all but two working in one of the capital cities. There was no central planning in the Ministry of Health for equipping regional hospitals with ophthalmic staff or materials. Hence the accumulation of ophthalmologists in the capital cities in private practice.
(2) The training of ophthalmologists in francophone Africa did not include any concept of community eye health. Our emphasis on developing an outreach into the interior was entirely new to ophthalmologists in Benin. Rapid examinations of large numbers of patients in unsophisticated surroundings in order to recruit patients blinded by cataract or threatened with blindness from glaucoma, trichiasis, etc, does not appeal to specialists trained only in university hospitals. It is looked upon with suspicion, much as some doctors in America sneer at “socialised” medicine in the United Kingdom.
(3) The use of appropriate technology, generic prescribing, and standard spectacle corrections is similary viewed with disapproval and considered to be “second rate”. However high technology, proprietary medicines, and complicated spectacle prescriptions are financially out of reach of the majority of the population.
(4) Moderate salaries in government service do not encourage highly qualified staff to commit themselves to service in the rural areas. Private practice in cities proves too strong an attraction.
(5) International agencies have over many years “motivated” medical personnel with substantial per diem payments and other allowances. Today it is expected that every project must be similarly generous in order to interest their staff. A purely financial motivation however can never replace dedication to the task. And the long term sustainability of medical work in impoverished communities can never be guaranteed if external funding is always required.
Our 6 year project in Abomey demonstrated clearly the huge unmet need for appropriate eye care in rural Africa. We quickly became very busy. We showed that eye care need not be expensive or confined to capital cities. We hope it will encourage others to set up eye services for the millions of blind and visually handicapped people in rural Africa today.