Aiming to cure blindness
The Himalayan Cataract Project (HCP) has been helping to eradicate preventable blindness and restore sight to people throughout Asia since 1995. Ophthalmologist Geoffrey Tabin co-founded and is co-director of HCP. He is professor of Ophthalmology and Visual Sciences and director of the Division of International Ophthalmology at the John A. Moran Eye Center, University of Utah, Salt Lake City, USA. Geoffrey Tabin was interviewed for Share International by Jason Francis.
Share International: How prevalent is blindness throughout the world and what are its primary causes?
Geoffrey Tabin: Blindness affects relatively few people in the developed world – about three per thousand who are considered ìlegally blind.î That's someone who can see the eye chart and read only the top two lines. The causes of blindness in the developed world are mostly things that we can't prevent, like age-related macular degeneration, and other diseases of old age.
In the developing world, the blindness rate is three per hundred, about 10 times greater. About 90 per cent of the blindness in the developing world is easily preventable or treatable. The World Health Organization defines blindness as ìfunctionally blindî, where you are unable to perform the tasks of daily living. You can't see to do the basic things that an average person needs to do to survive. About 55 per cent of blindness is from cataracts, which is completely treatable and people can have perfect vision restored.
The second leading cause of blindness – difficult to prevent but preventable – is glaucoma. After that is a blindness called trachoma, caused by infection with Chlamydia Trachomatis – a very easily prevented and cured infection of poor hygiene and bad water that leads to irreparable scarring of the eye.
The next leading cause of blindness is having minor trauma with no treatment. For example, you get a little scratch on your cornea and with no antibiotics it develops into a bad ulcer. River blindness, or Onchocerciasis, is caused by an infection carried by a parasitic worm, and is also easily preventable. Merck, a large pharmaceutical company, is giving out unlimited amounts of a medicine called Mectizan. The drug completely prevents the occurrence of river blindness and it's purely a matter of getting it to the people who need it.
The final cause of blindness, and the leading cause of blindness in children, is vitamin A deficiency, or xerophtalmia, lack of vitamin A in the diet. The cost of supplementing vitamin A to a child is 75 cents per year. And with 75 cents per year it also reduces infant mortality by about 30 per cent.
SI: How is someone's life expectancy affected when blindness sets in?
GT: In the developing world, the life expectancy of the blind is very short. There have been several studies based on age and health-matched peers that have shown that the life expectancy once you go blind is one-third that of a sighted person; blind children fare much worse.
SI: Are some causes of blindness more prevalent in certain regions of the world?
GT: There are more cataracts in regions where people are exposed to intense UV [ultraviolet] sun exposure, and have low antioxidants in their diet. People who tend to eat just rice and barley and have very intense UV sunlight exposure develop blinding cataracts at a much higher prevalence. In much of the developing world – southern India and rural China, for example – people have these problems. As for some of the infectious blindnesses, which are endemic in only a relatively small region of the world, in places like southern Sudan and Congo, these nevertheless affect a very high percentage of the population. The same is true for trachoma, a disease of very poor hygiene and dusty climates. So, places like Kenya, Tanzania, Ethiopia and Sudan have very high levels of trachoma.
SI: What countries does the HCP work in and how many people are treated in any given year for blindness?
GT: I've been very fortunate because I've had a couple of amazing partners. My partner Sanduk Ruit is one of the most brilliant, gifted surgeons and he has chosen to remain in Nepal. [Ruit is co-founder of HCP and medical director of HCP's Tilganga Eye Centre in Kathmandu, Nepal.] One of the big problems in the world is that the best qualified doctors leave their countries and many who don't leave still want to live in the best situation in their part of the world. So, you have a lot of places like Nigeria where one qualified ophthalmologist treats the rich of the country.
When Sanduk Ruit and I began our work together 15 years ago, he already had an idea of how to reach people in the most remote places of Nepal. We started teaching one doctor at a time to do high quality cataract surgery and developing a system where we were training ophthalmic assistants and nurses to support the doctor. We developed a system of really high quality delivery where no one does anything that somebody with a lower skill level can do.
When we started, in all of Nepal there were only 15,000 cataract operations done the whole prior year. At that time, we estimated the backlog to be about 300,000 blind people, and there were about 80,000 new cases with people who were going totally blind from cataracts per year. Last year, after 14 years, a total of 170,000 cataract operations were performed in Nepal. Not only is Nepal now the only country in the region that is significantly reducing its backlog, but we're actually treating a lot of people from the Bihar region of India as well. In terms of HCP's direct care, we've done an increasing number of operations, from 10,000 a year when we were starting, up to 33,000 last year. That's our direct care. But our main accomplishment is teaching and developing the training systems. I think these are responsible for the level and quality of cataract surgery in Nepal.
We started out teaching one doctor at a time to do good, high quality cataract surgery. We expanded from there, taking some of our best cataract surgeons and sending them for Fellowship training to become subspecialty ophthalmologists, training pediatric ophthalmologists specializing in treating diseases of children – crossed eyes, pediatric cataract – training corneal transplant specialists and starting an eye bank. Once we had a full cadre of specialists – ocular plastics, glaucoma and retina specialists – we then began a full program to train full ophthalmologists. In addition we realized we needed very high quality support staff, so we started a program that is now a full three-year accredited program with Kathmandu University training ophthalmic assistants. They come out after three years, basically doing the work that an optometrist does in America and providing really high quality, basic primary eye care and supporting the doctors. So, the doctors can work at a much higher volume than most places. Then we started working in other regions.
In 1994, we started the Himalayan Cataract Project in Nepal and in 1996 we began training doctors from Tibet. In 1999, we started working in Bhutan, and the following year in surrounding regions of India. Over the last eight or 10 years, Fellows come for training from Cambodia, Myanmar [Burma], North Korea. For about a year and a half I've been working in Africa with the UN Millennium Development Program. We have 12 research villages and are working with Jeffrey Sachs and the UN Millennium Development Project learning how to reach people in Africa. We are also doing a survey of blindness in Africa.
SI: HCP seems to be working hard to eliminate all preventable and treatable blindness.
GT: Cataract is the most dramatic because people are cured for ever – and particularly in the Himalayan region it's the leading cause of blindness. But worldwide and even in Nepal there are infectious and nutritional causes of blindness that are very easy to prevent. You don't get the same ëbang for the buck' because you see a poor child who keeps on living and seeing rather than taking them from being blind to seeing. But we have a national vitamin A distribution program in Bhutan. We're working with an already existing vitamin A distribution program in Nepal. A big part of our focus is training the primary eye-care personnel and the people who are training these three-year trainees out of high school to staff primary eye stations where they prevent infectious causes of blindness, give vitamin A and work to treat and prevent the blinding complications of trachoma. Once you go blind from vitamin A deficiency, unfortunately, there is nothing that can be done; you never get your sight back. Everywhere we work, we're working very hard to prevent all of the causes of blindness.
SI: Can you talk about the eye surgery camps that you have established in remote areas?
GT: In Nepal, we have large pockets of populations that don't have access to roads. They have to walk for three days to get to a road and then take a bus for a day and a half to get to the hospital. So, we've established a system of outreach camps to serve these people. Ophthalmic assistants go from village to village screening patients. When they have found a high volume of patients who are blind from cataract they call in a team from the main hospital. We send doctors in and do a high number of cataract surgery and cure everyone who is cataract blind in that small area.
The other thing we do is use our high volume cataract camps for training. Let's say we're training a doctor from Tibet; we bring him to Nepal to do a microsurgery course, where he really learns to do basic microsurgery. The doctors learn, observe and practice on model eyes. They don't actually practice on live eyes in Nepal. Then they go back to their local area and prescreen a very high volume of people – maybe 200 or 300 people who are blind in both eyes from cataracts. Then we come over and an experienced teaching surgeon will restore sight to all of the first eyes with the local doctor assisting. Then the local doctor can safely, under supervision, begin doing surgery on second eyes. In the course of a high-volume, skills-transfer cataract program, the local doctor will often do as many cataract operations as an American resident will do in a full three-year residency. So, they'll gain quite good skills.
SI: Is this all a part of creating a ìsustainable eye care infrastructureî?
GT: There are a couple of aspects. Our programs in Nepal are self-sustaining through doing very high volume and bringing down the cost, and through capturing the market of people who previously would have left the country. Prior to the Himalayan Cataract Project and Dr Ruit, everyone with any means, if they went blind from a cataract, would go to New Delhi for their cataract surgery. If they had more money they would come to the US or Australia. Now, 100 per cent of the people in Nepal, including the wealthy elite, come to the Tilganga Eye Center for their cataract surgery. About 60 per cent of our patients are charged nothing. Twenty-five per cent pay full cost, which is about $100 for a cataract surgery. With the volume that we do and with the low cost, we're not only able to completely sustain the hospital but we're able to pay our doctors a higher salary than would be typical of an eye surgeon in Nepal. We pay our nurses more, we pay our cleaning people more, we pay our drivers more. So, everyone takes a lot of pride in being part of the system. Our innovative model allows us to fund the Himalayan Cataract Project and buy a lot of the big equipment purchases for Tilganga. I have not had to pay a penny for any of the care, outreach, salaries, anything at Tilganga for about eight years.
We're working with a lot of hospitals in Nepal, and the majority are now becoming self-sustaining through this small amount of cost recovery from capturing the elite of the country. Part of it is having high volume and part is keeping the cost low, but the biggest thing is keeping the quality very high. What we've really been striving to do is distill down state of the art, high-quality, Western surgery and deliver it in a high volume and a very high quality way at a very low price.
SI: How does a person's life change once their sight is restored?
GT: It's dramatic, particularly for older people. In Nepal, it used to be the accepted idea that a person gets old, their hair turns white, their eyes turn white and then they die. People looked at a blind person as a mouth with no arms: they can't contribute to the family, they can't help, and people get very depressed. They shrivel up and there's a huge depression that comes with going blind in the developing world. After sight restoration they come back to life. A large number of people go blind at an early age and with restored sight are able to go back to full employment. But even those that don't are able to contribute to their family – they're able to bring water, take care of the children, clean and cook. And this makes an enormous difference in their lives. There is a huge impact both on the person's life and on the community.
For more information: www.cureblindness.org.
From the March 2008 issue of Share International magazine
Jason Francis is a Share International co-worker based in Massachusetts, USA.