Have you ever been struck by the beauty of a painting or a landscape? What if, all of a sudden, your vision started to worsen and there wasn’t anything you could do about it and impending blindness was imminent? To say that your life would change dramatically would be an understatement.
According to the WHO, uncorrected refractive errors are the main cause of visual impairment and cataracts are the leading cause of blindness in middle and low-income countries. Ninety percent of the world’s visually impaired live in developing countries. Sounds grim, but the good news is that 80% of all visual impairment can be avoided or cured. OIA spoke with Dr. Peter Egbert to talk about the progress of eye care in Ghana since the inception of the Sustainable Eye Centers in 1987.
Q. How and when did you get started with the Sustainable Eye Centers?
PE: Working with my mentor, Dr. Frank Winter, we devised a plan to develop a sustaining model of eye healthcare that we hoped would be valuable and long lasting. The approach was to collaborate with a local partner to operate and manage a self contained eye center. This involved finding a local partner, signing agreements, appointing a local board of directors while we provided training, capitalization and equipment. We don’t own anything and the management resides with the local people. The goal is to train the locals and as the clinics become mature and the training from the people who sweep the floors, to the business managers and the ophthalmologists is successful, we withdraw and do less and less. We started in 1987 and this has worked nicely in many ways; today there are 4 clinics in Ghana and 1 in Honduras that are all working in varying degrees of efficiency.
Q. What challenges did you face with this initiative and how did you solve them?
PE: We worked in places where there had been no eye care whatsoever. I performed my first operation in 1989 in the town of Cape Coast, a city on the coast of Ghana. Setting up an eye operating room had its own set of challenges and we were lucky enough to have an ophthalmological nurse from Stanford on our team to help with supplies, instruments, sterilization, and organization. The local community thought it was strange that we did eye surgery as an outpatient procedure as it had never been done this way in Ghana. They were still doing it the old fashioned way that we had abandoned several decades before where the patient goes to the general hospital and stays there for about 5 days afterwards to recuperate. They had never seen cataract surgery where the surgeon inserts a lens inside the eye. Even the lead ophthalmologist for the country in charge of the National Ophthalmology Service was skeptical and didn't believe this type of surgery would work in our people.
After the surgery was performed, the follow-up care wasn't very good. Patients would return for their post surgery visits a day and a week afterwards, but not many returned for their monthly follow up visit. We didn't know if the wounds got infected or if the sutures fell apart so the following year we made a concerted effort to go out and find the patients from the previous year. The nurses knew where the local patients lived so we bounced along on these dirt roads finding 2-3 patients a day. In the end, we found almost all of the patients from the region. They were ecstatic that we cared about their well-being and agreed to return to the clinic for a full examination. We asked the patients how they felt about the surgery and they were overwhelmingly happy with the result. In the end, we proved that we could successfully perform this type of outpatient cataract surgery with minimal risk and complications.
We effectively taught young local ophthalmologists who had not previously been exposed to modern eye surgery how to operate with a surgical microscope. This was great because we had a local ophthalmologist who was there all the time, who also could speak the language and understand the culture. The difficulty is that when the doctors became good, they moved to the capital and operated on the minority of the people who could pay more. Then we had to train new doctors and the cycle started all over; it's an ongoing challenge.
Q. What has been the impact on the community?
PE: All the patients we saw had serious cataracts and they were quite brave to come forward, as this type of surgery had never been performed in Ghana before. If the surgery proved successful, word of mouth of its success spread throughout the community. Soon we had lots of people lined up in the morning and we couldn't get through them all. We operated on about 10-20 people a day and charged a month's salary for the procedure. We chose individuals that had the worst vision that had problems with daily living and required attendant care. Some of these individuals were of employment age that had lost their jobs years earlier. It was quite dramatic for people who were blind for about 3-5 years to regain close to normal vision. As Mother Theresa said, we ourselves feel that what we are doing is just a drop in the ocean. But the ocean would be less because of that missing
Q. What are some of the changes/improvements that you have seen in the quality of eye care since you started working in Ghana in 1987.
PE: We proved that the more modern way of doing cataract surgery could be successful and was not an insurmountable expense. We published our study and the news spread. We are one of the organizations that contributed to the modernization of ophthalmological care and treatment in the region and now everyone in Ghana and West Africa is performing cataract surgery this way.
For the last 15 years, Ghana’s democracy has helped the country improve economically. Business people from conflict ridden neighboring countries relocate to Ghana and doctors are returning to the country. A National Insurance Scheme has been implemented so patients no longer need to save for a month’s salary or borrow money to fund the operation.
Q. What challenges remain for the future?
PE: With the adoption of modern cataract surgery, the eye clinics don’t really need us for cataract surgery as much although Ghana still needs many more ophthalmologists for other needs. The challenges now lie in other areas where they need sub-specialist training such as glaucoma and pediatric ophthalmology. Dr. Don Budenz, a glaucoma specialist, is continuing our work in Ghana and brings a contingent of volunteer doctors from England and Australia as well as the US to teach these sub-specialties and continue to modernize the quality of eye care.