Restoring Sight in Africa a Complex Affair
By JoAnne Sommers

Dr. Paul Courtright and Dr. Susan Lewallen, made a disturbing discovery while they were working at the B.C. Centre for Epidemiologic & International Ophthalmology in the late 90’s.

By pooling surveys of international blindness the two UBC faculty members found that two-third of the world’s blind are women. What’s more, 90 percent of all blind people globally (now totaling 45 million) live in poorer countries.

“We realized that those figures were no accident,” said Courtright, who, like his wife, is a member of UBC’s Department of Ophthalmology. “We also realized that if we solved the problem it would mean an 11 percent reduction in blindness globally.”

Their next step was to try to determine the cause of the problem and what could be done to address it. The search for answers began in Vancouver and eventually led the husband and wife team of Courtright, an epidemiologist, and Lewallen, an ophthalmologist, to Moshi in northeastern Tanzania, where, in 2001, they founded the Kilimanjaro Centre for Community Ophthalmology (KCCO). 

“We recognized that we needed to be at a centre with an ophthalmology residency program,” says Courtright. “And after considerable investigation we decided that Moshi, where the Tumaini University’s KCM College had such a program, would be the best fit.”

The KCCO, situated at the base of Mt. Kilimanjaro, is dedicated to helping local communities eliminate avoidable blindness through programs, training, and research that focus on community ophthalmology. It is the only training institution of its kind in Africa.

The community ophthalmology approach is based on the fact that in the developing world, there may be many people with eye disease for every one who goes to a clinic for examination and treatment.

The results of population-based surveys indicate that in much of sub-Saharan Africa there are about 10 patients blind from cataract for every patient who has cataract surgery. This, despite the fact that blindness due to cataract is routinely curable through surgery.

Surprisingly, the problem does not seem to stem from a lack of medical facilities. Many hospitals in poor countries do not work at full capacity and most blind people never visit a clinic or hospital for treatment.

Community ophthalmology training, which complements clinical ophthalmology, examines the problem of blindness from the community perspective. This involves investigating the causes of blindness and eye disease in the community, the availability of eye services, the attitudes of the people towards visual disability or eye diseases, attitudes towards the services, and the barriers that prevent people from using services. When these issues are defined, solutions can be sought, agreements reached among all those concerned, and programs can be implemented that provide solutions.

“Legions of ophthalmologists trained only in how to diagnose and treat eye diseases will not prevent blindness in most poor countries,” Courtright explains. “Blind and visually impaired people must come from communities to receive medical care; we must look at the processes they go through to receive care if we hope to make a significant decrease in the number of blind and visually impaired.”

Lewallen and Courtright, both 54, now co-direct the KCCO with the assistance of 15 Tanzanian staff members and ophthalmologists from across Africa acting as external faculty. Each year they get three or four medical or ophthalmology residents from Canada, the U.S., Netherlands, and the UK, who come for two to three months to help with specific research projects.

However, Lewallen and Courtright spend less than 20 percent of their time in Tanzania; the rest is devoted to working with ophthalmologists, ministries of health, hospitals, and non-governmental organizations in Egypt, Ethiopia, Uganda, Kenya, Rwanda, Burundi, Malawi, and Madagascar.

“As directors of the KCCO we have a wide range of responsibilities under the headings of teaching and mentoring,” Courtright explains. “We recognized long ago (the couple worked in Ethiopia and Malawi for five years before establishing the B.C. Centre for Epidemiologic & International Ophthalmology at UBC in 1995) that ophthalmologists and other eye care professionals had inadequate management systems supporting them. 

“Most eye care centres in Africa are under-performing while most people needing these services are not aware, have no access to, or do not accept these services. Thus, our work focuses on helping the eye care facilities become more effective, efficient and accessible to the local population. At the same time, we help them design the systems to make their services accessible and acceptable.”

The key to their work is tailoring programs to meet local needs. In Uganda, for instance, many people are trained as ophthalmic clinical officers and they can perform eye exams, says Courtright. “The problem is that the appalling management systems waste time and money so we need to work on getting people into the hospitals.”

The KCCO is also working to address the disproportionate number of blind women and girls in eastern Africa. In poorer countries, females of all ages utilize eye care services much less than men; as a result, more women than men are blind or visually impaired from avoidable causes such as cataract, and chronic trachoma infection, which is preventable through clean water and improved sanitation.

One complicating factor is that women who are blind from cataract are less likely to accept surgery than women who aren’t. While that seems counter-intuitive, Courtright says it’s a result of the loss of social status that accompanies blindness.

“Blind women develop a sense of dependency and lose all status in the household and community. They think, ‘why should I bother expending the energy to get surgery?’ ”

Fortunately, the KCCO is making headway against such attitudes. “In the three years we have been working with the eye care programs in the Singida Region and Mara Region of Tanzania we have seen the number of people receiving cataract surgery increase three-fold and the number of people receiving comprehensive eye care rise 10-fold. This was achieved without adding much in the way of new staff – it is a result of better management and the implementation of systems that facilitated access to services.”

Last year, Courtright and Lewallen were honoured for their efforts with the prestigious International Blindness Prevention Award for 2008 from the American Academy of Ophthalmology (AAO). The Award, established in 1992, honours individuals who have made significant contributions to the prevention of blindness or restoration of sight. 

Winning the award meant that the wider ophthalmological community recognizes what the KCCO is trying to do, says Courtright. “In many ways this is different from other kinds of foreign involvement in Africa because we’re building the African capacity to deal with important issues affecting the people’s health.”

As to the future, he added, “We plan to leave by 2014 so the next phase of our work is ensuring that there is African leadership to see that the KCCO continues to develop after our departure. That will require an entirely different organizational structure – and it will take time to develop.”