Going Beyond Cataract Camps

Last June, three people sat under a tree in a village in a remote region of Mozambique, in southeastern Africa. They spoke with community leaders about the importance of eye care and how it should be accessible to everyone. Those three people were Filomena Ribeiro, Mark Wevill, and Tom Ogilvie-Graham, visiting one of the charity projects supported by the ESCRS in Sub-Saharan Africa, following the mission of providing eye care for everyone globally.

According to the World Health Organization (WHO), eye healthcare is a vital issue in Africa. Around 26.3 million people are visually impaired, and among these, 20.4 million have low vision and 5.9 million are estimated to be blind. WHO reports the continent holds 15.3% of the world’s blind population. While most vision issues affecting the African population are treatable, the average number of ophthalmologists per million people is 2.5, compared to 76 per million in Europe.

As our world becomes increasingly interconnected, global ophthalmology has shifted its focus to developing sustainable systems for eye care delivery in resource-limited settings. ESCRS heard the call and concentrated efforts on projects in Africa, working shoulder to shoulder with skilful partners, carefully chosen from an extensive list according to their expertise and experience.

Currently, the ESCRS has two major projects in Africa: one in Mozambique with Eyes of the World, a Spanish organisation that has worked there for many years, and the second in Malawi with the Blantyre Institute for Community Outreach (BICO). A smaller project in South Sudan supports Dr Lado, a Sudanese ophthalmologist.

“A principle we have is we want to support organisations that already have a good record providing services because they are experts,” said cataract and refractive surgeon and surgical trainer Mark Wevill.

There is also financial support, maximising the benefit to people in need of eye care, but ESCRS wants its support to go somewhere deeper.

“We want to be able to partner in a fuller sense, offering our expertise to add value with some of these projects,” said Tom Ogilvie-Graham MD, managing director of the ESCRS.

ESCRS President Professor Filomena Ribeiro has demonstrated this aim by going to Mozambique to see how the project is going and to speak directly with locals. “It is incredibly good for ESCRS members to see our president, early in her term of office, taking time out to go all the way to Mozambique to visit one of our projects,” Dr Ogilvie-Graham remarked. “It demonstrates the level of commitment that we have in this area.”

A change of approach

Being on the front line means having a winning strategy. In the past, charity projects involved surgeons going to these remote places in Africa, organising cataract camps, and performing surgeries, then returning home. While it is true that some people benefit from this approach, it is not sustainable, Dr Ogilvie-Graham pointed out.

“What we are looking to do is to provide sustained support and to build on something,” he said.

So, the focus is on training ophthalmologists and the ancillary staff—the nurses, technicians, and optometrists.

“The emphasis has shifted a lot now—it is on upskilling and training African surgeons to do more surgeries and to do them better,” Dr Wevill said. Moreover, African countries often have stricter regulations regarding permission to perform surgeries, while training does not involve any bureaucratic issues.

The focus on training is particularly important in another ESCRS project with the Community Eye Health Institute at Cape Town University in South Africa.

“It concentrates on training the trainers and bringing people from all Sub-Saharan Africa to Cape Town, where they have an intensive three-day [workshop] in dry labs using artificial eyes and even simulators to improve their skills and pass on some of that knowledge to others in more remote areas,” Dr Ogilvie-Graham said.

The catalytic effect of this project can really be effective, Dr Wevill said, adding ESCRS members can take an active part in training their African colleagues, maximising the benefits and the impact. ESCRS also supports the College of Ophthalmology of Eastern Central and Southern Africa (COECSA), which dedicates a great part of its annual meeting to wet labs and training, specifically on phaco surgery.

The challenges to overcome

Yet challenges remain numerous in Africa. First, it is important to evaluate the risks and be careful.

“We would avoid conflict zones and do a risk assessment,” Dr Ogilvie-Graham explained. “Occasionally, there are certain regions with groups that might be criminal or politically motivated. We want to avoid taking personnel from ESCRS and exposing them to that kind of risk.”

It’s precisely for this reason that ESCRS secures a trusted partner. Reaching remote locations within African countries poses a real challenge because of the difficulties of travelling by road or finding an aircraft: sometimes roads are impassable due to the weather conditions or the lack of transportation—something that already undermines patient accessibility to hospitals and clinics in the main cities to receive proper eye treatments.

“The projects aim to make eye care accessible and set up more rural eye clinics. For some people, it is a long or expensive journey to the city,” Dr Wevill said. For example, Eyes of the World trains people in the villages to recognise eye problems and refer to experts on those who need help.

Unfortunately, there are more disadvantaged categories than accessibility, such as the elderly, disabled people, and, above all, women. Women’s health is regarded as less important than that of men, as both Dr Ogilvie-Graham and Dr Wevill mentioned.

Traditionally, men are the breadwinners who decide where to allocate the scarce family resources.

“In Africa, healthcare is paid out of pocket, without insurance or government provisions, so the man gets the most benefit,” Dr Wevill said.

“It is a cultural change, which was also the aim of that meeting under the tree: to make men understand that women’s health is also important and to make women understand they have the right to have family resources spent for their healthcare.”

For this reason, gender equality is another selection criterion for partners in these projects for ESCRS.

Finally, raising awareness of eye care is extremely important. Many people in remote areas do not know they can get their visual impairment, such as cataracts or uncorrected refractive errors, cured. In his experience, Dr Wevill noted many refer to the local herbalist for a cure or accept blindness as a natural part of life, which in most cases it is not.

What the future holds

ESCRS wants its charity projects to last and to expand their benefits to reach the highest number of people. Both Dr Wevill and Ogilvie-Graham stressed the Society plans to continue the Mozambique, Malawi, and South Sudan projects while strengthening the Cape Town project for more extensive training possibilities. The ESCRS also wants to expand its reach beyond anglophone countries, as indicated by the programme in Mozambique, where Portuguese is the primary language. New collaborations will come out in the future, especially with innovative technologies.

“Telemedicine can help. Surgeons from Europe can assist their colleagues in Africa. One just needs good connectivity, cameras, and bandwidth,” Dr Wevill said. “But that is something for the future.” Training is the key strategy to follow.

“We took out this new strategy and are investing a lot in it,” Dr Ogilvie-Graham said. “And despite the difficulties, this is a long-term commitment for ESCRS.”

Filomena Ribeiro MD, PhD, FEBO is head of ophthalmology at Hospital da Luz Lisboa, Portugal, and ESCRS president.

Tom Ogilvie-Graham MD is managing director of the ESCRS.

Mark Wevill MBChB, FRCS (Edinburgh), FCS (SA) is a cataract and refractive surgeon in Birmingham, UK, and a surgical trainer at the University of Cape Town Community Eye Health Institute Surgical Skills Laboratory.