Restoring Sight, Reviving Lives: Asia need sharper focus on cataract surgery

Restoring Sight, Reviving Lives: Asia needs sharper focus on cataract surgery

By Margot Cohen
 
In villages across Asia, poor vision is often accepted as an inevitable part of growing old. Dutiful family members sacrifice countless hours of work and study to care for blind or otherwise visually impaired grandparents, parents, and spouses. Homebound and isolated, such elderly citizens sorely miss the responsibilities of looking after grandchildren, raising crops, and attending religious services or other community events.
     
Yet this huge drain on human resources and happiness can be reversed if Asia's public health policymakers, charitable groups and private donors step up their efforts to broaden access to cataract surgery. As the primary cause of blindness worldwide, cataracts can be treated with a relatively simple, cost-effective operation. Experience shows that this quick surgical procedure can be profoundly liberating—not only for those whose sight is restored, but also for caretakers transformed into breadwinners.
 
That’s quite a bargain, given an operation that costs as little as $20 to $30 in countries such as India and Vietnam. “I feel happy that my mother-in-law can manage on her own,” says 31-year-old Vo Thi The, a rice farmer in Vietnam's Quang Nam province and mother of two young sons. “Now I can go to the field to work and she can take care of my children.” According to British charity Sight Savers International, developing countries could achieve a $376 billion boost in economic productivity over the next 20 years if they adopt proven measures to reduce cataracts and other causes of blindness. 
 
Derived from the Greek term for "white water falling," cataract is a degenerative eye condition akin to watching the world through a waterfall. The lens becomes so cloudy that it can no longer focus light on the retina, which in turn sends signals to the brain. The affected pupils tend to look white or yellow. Cataracts particularly afflict people in East Asia and South Asia. The main cause is high exposure to the sun's ultraviolet rays. In coastal areas, tropical sunlight reflected off sand can prove particularly harmful. Smoking, poor nutrition, and aging are also contributing factors. “Surgery to remove the opacified lens is the only effective treatment for cataracts,” according to a comprehensive public health guide, Disease Control Priorities in Developing Countries, second edition (DCP2).
 
Multiple strategies are required for efficient provision of cataract surgery, especially a sustained community education campaign, a regional supply system for equipment and drugs, and a uniform data collection system, according to the authors of DCP2. Such measures would go a long way toward helping the globe's 18 million people who have been blinded by age-related cataracts. 
 
While often overshadowed by other public health concerns, the problem is acute: Every five seconds, another person goes blind. Seven out of every 10 blind persons reside in Asia. Changing demographics make the issue all the more urgent. More than 80 percent of the blind are those age 50 or older. Researchers estimate that the number of people blinded or severely impaired by cataracts could more than double, reaching 40 million by 2020 as societies age more rapidly. In Indonesia, for example, where blindness is already the leading cause of disability, the number of citizens over 50 is slated to increase 414 percent between 1990 and 2025. Today, more than 2 million Indonesians are still waiting for surgical relief from cataracts. In Vietnam, the backlog amounts to 800,000 people, despite a dramatic increase in the number of operations over the past decade.
 
Within Asia, only India has scored substantial gains in reducing blindness. There, the number of cataract surgeries more than doubled between 1992 and 1997 from 1.2 million to 2.7 million surgeries. Yet India has learned the hard way that quality must accompany quantity, or the public will lose trust in the restorative benefits of surgery. In 1998, following widespread complaints about infections and other complications after operations performed by government mobile teams, the Indian government banned mobile eye camps in all but the most remote areas. Poor results in the northeastern state of Assam continue to underscore the risks of remote outreach work. Today, most countries, including India, are striving to conduct basic screening in community-based health centers, and subsequently to transport patients to permanent operating rooms in district or provincial hospitals with reliably sterile conditions and better high-tech equipment such as an operating microscope. 

Progress has been uneven across Asia, according to experts at the International Agency for the Prevention of Blindness (IAPB). “I think significant progress has been made in India and Pakistan, some progress has been made in Bangladesh and Vietnam, and I believe that in countries like China and Indonesia we are still struggling to improve accessibility of services,” says IAPB president Gullapalli N. Rao, who is based in Hyderabad, India.
 
Rao expresses concern that China continues to charge its citizens up to $300 for cataract surgery, which most rural dwellers cannot afford. Chinese surgeons performed only about 400,000 cataract operations in 2005, compared with more than 4.5 million procedures done that year in India, Rao reports. Moving forward, Rao would like to “plug the loopholes” in service delivery. That includes making sure that those identified with cataracts during screening actually proceed with surgery and receive good follow-up care.
 
The challenges of meeting such goals are reflected in two pilot projects in Indonesia and Vietnam that form part of a “Seeing is Believing” campaign, led by Standard Chartered Bank and funded with $6 million in donations. Working with local government authorities and international NGOs, bank officials aim to announce 1 million sight restorations by October 2007 in 12 countries across Asia and Africa.
 
Both initiatives face significant constraints. In Indonesia, project leaders are grappling with a public health system fraught with miscommunication and turf battles linked to a broad decentralization drive. In Vietnam, problems include scant experience in data collection and a poorly paid network of village health workers. Yet both projects are making major strides that can inspire action elsewhere.
 
Vietnam
 
The Vietnam cataract surgery program has significantly increased access to surgery, thanks to efforts by the Australia-based Fred Hollows Foundation (FHF) to train surgeons and provide six district-level hospitals with modern equipment and other medical supplies. In an effort to keep costs relatively low, cataract surgery kits are purchased from India and lens implants are largely sourced from Nepal. It is a solid step toward the regional supply network recommended by the authors of DCP2.
 
Over the past three years, the program has facilitated 5,200 cataract operations. At Tam Ky General Hospital, for example, the number jumped to 600 in 2006 from just 70 in 2004. Two freshly trained eye surgeons are on duty, in contrast to the previous dependence on visiting surgeons from Da Nang city.
 
“The most important factor behind the increase in patients is that the quality of the surgery has greatly improved,” says Tam Ky General Hospital director Dinh Dao. But Dao says that he is still worried about the provincial backlog. He would like more funding to build a separate wing for eye surgeries, and a bigger budget to help village health workers go door-to-door to recruit patients.
 
Despite the successes already achieved, the cataract program in Vietnam continues to face a number of critical challenges. Follow-up care and corresponding data, for example, are both sorely lacking in the Vietnam project. In Quang Nam province, which has a per capita annual income of just $300, many villagers say they don't have the money to return to a district hospital for repeated follow-up examinations up to three months after surgery. Unlike the project in Indonesia, the budget does not include free transport. Some villagers even hesitate to return to the hospital to get a second eye operation because they say they can’t afford the cost of food during a four-day inpatient stay. (Doctors operate on one eye at a time. While the surgery could be done on an outpatient basis, doctors ask villagers to remain for four days to ensure at least short-term follow-up.)  
 
There are also problems with the incentives for health workers to participate effectively in the program. As it stands now, village health-care providers work part-time on dismal government salaries of 40,000 dong (US$2.50) per month in exchange for promoting all of Vietnam's public health programs from HIV/AIDS and tuberculosis to family planning and child vaccinations. In theory, they are supposed to receive an extra 10,000 dong per cataract patient, but it remains unclear whether they actually receive even this small sum. “For me, 10,000 dong is too little,” complains 41-year-old Ca Thi Lieu, a village health worker in Truong Xuan hamlet who participated in a two-day training course sponsored by FHF. She finds her other occupations more financially rewarding, including farming, making rice pancakes, and brewing traditional liquor.
 
“The health worker should pay more attention to the households. I don't feel their effort is enthusiastic enough,” says Truong Xuan resident Luong Thi To Trinh, whose grandmother lost her sight gradually over the past decade. Luckily, the family learned about the FHF-sponsored surgery at a recent village meeting, and brought the 78-year-old woman to Tam Ky general hospital last June. Once her grandmother’s primary caretaker, 16-year-old Trinh now has more time to study and pursue her goal of becoming a journalist.
 
To reduce dependency on the village health workers, the cataract project leaders have explored other methods of grassroots communication. They have prepared television and radio broadcasts, sponsored music shows, and offered information for broadcast over village loudspeakers, still a staple information provider in rural Vietnam. “Whenever we have a successful case [of cataract surgery], we announce it over the loudspeaker,” says Dung Van Luu, head of Truong Xuan's local health clinic. “The loudspeaker reaches more people,” he explains. “Not all households can afford to have TV and radio.”
 
Indonesia
 
Community outreach has been a crucial component of the cataract surgery campaign on Indonesia’s Lombok Island, which is supported by Helen Keller International (HKI), a U.S.-based nonprofit organization. The island has a backlog of 21,000 people who require cataract surgery, yet many villagers don’t understand that blindness can be cured with modern medicine. In Teratak village, 61-year-old Amaq Aspaluddin described his frustrating visits to five different folk-medicine practitioners, who all told him that his eyes were possessed by evil genies. He was given “blessed” water and told to mix it with rice powder and smear the concoction on his face. That advice cost him some rice, betel leaves, and cash, but did nothing to restore his sight.
 
Aspaluddin’s mood brightened in mid-December after learning that HKI would provide free transport to a nearby health clinic where he would receive free cataract surgery. “Is it really free?” he repeatedly asked Ulil, the local health worker who conducted preliminary cataract screening on a simple bamboo platform in the village. Ulil peered into each eye with a small flashlight, looking for the telltale white pupil. Then, after measuring off distance with a six-meter length of rope, he stood back and twirled a cardboard card in his hands, asking villagers to indicate with a sweeping gesture whether the letter “E” appeared upside down or sideways. Arrangements were made to take the group by flatbed truck to a health clinic just two days later.
 
Workers like Ulil get paid twice: once for bringing cataract sufferers to the clinic for examination, and once after completing surgery—a system that provides incentives for outreach workers to make sure that action follows identification. “Helen Keller is giving us a lesson in how to be pro-active,” notes Lalu Sapwan Saladin, a local village official. “If the health workers just receive a regular salary, maybe they will just sit at home. They could become lazy.”
 
Still, outreach workers express frustration that dozens of candidates renege on surgery, largely due to fear. Many villagers still believe that doctors extract the eyeball, scrub it free of bacteria, and replace it in the socket, a gruesome myth that points to the need for more detailed education sessions at the grassroots.
 
Perhaps the best method to reduce fear is spreading the word about contented patients and heir relieved families. In Beber village, for example, 17 people immediately agreed to undergo cataract surgery after 70-year-old Haerudin received treatment for both eyes last July. When he came home for a celebratory dinner, the whole village heard about the way his gleeful younger sister garlanded his neck with a grilled chicken—a gesture to give thanks to God in this devout Muslim community. Haerudin's youngest son, who had abandoned a job on a tobacco plantation in Malaysia to return to Lombok and stay home with his blind father, now has ample time to pursue construction jobs in surrounding villages. Haerudin himself now contributes to the family income by crafting rope sold in the market, and plans to start growing rice this year.
 
Such stories are also heartening for the two young surgeons who work at the local health clinic in Kopang village, which was renovated by HKI and refurbished with modern surgical equipment. “If the equipment is not good, the quality of surgery is not good,” warns Roy Tjiong, Asia-Pacific regional advisor for HKI.
 
In an innovative twist, HKI has recruited fourth-year residents from Jakarta's prestigious University of Indonesia medical school to come to Lombok for six-week intervals to perform cataract surgery. The strategy aims to compensate for the country’s grave shortage of experienced eye surgeons, and encourage young doctors to move to more far-flung areas of Indonesia where they can help so many villagers regain their sight.
 
“Most of them would never go to such a remote area on their own,” explains Tjahjono Gondhowiardjo, president of the Indonesian Ophthalmologists’ Association. The experience boosts their confidence and dexterity, he adds. To prove their worth, however, the recruits must first perform 10 cataract surgeries back-to-back in Jakarta with no mistakes, while being supervised by senior doctors.

Anggun Rama, 28, says he was “shocked” by the prospect of operating without supervision when he first arrived in Lombok on Nov. 5, 2006. But he soon came to relish his schedule of eight operations per day, compared with the once-a-week opportunity he had at his university clinic. Another doctor found the experience so compelling he decided to relocate to Lombok. “I feel more useful here compared to Jakarta. There are too many ophthalmologists there,” said 30-year-old Referano Agustiawan.
 
Given the move to the most modern cataract surgical techniques, local doctors see an advantage in recruiting young surgeons. “I’d rather have a resident who is good at operations than a specialist who doesn’t know how to operate,” says Siti Farida I.T. Santyowibowo, one of just four active ophthalmologists based in Lombok, home to 2.7 million people.
 
One of the most impressive aspects of the program is its data collection system, which uses specialized software to track the quality of surgery and performance of each surgeon. Working from a data sheet that surgeons and nurses fill in by hand, two computer operators input the same information, which is then rechecked by a supervisor. The system aims to avoid human error, while follow-up examinations are carefully recorded.

The gains and obstacles encountered in Asia can help other regions develop comprehensive and cost-effective cataract surgery programs. The progress so far in Vietnam and Indonesia shows that inexpensive cataract operations can add years of productive life for millions of adults, which can boost family incomes. Asia's traditional respect for elders would be well served by a concerted push to offer more surgery to those in need.

Margot Cohen has worked as a journalist in Asia for two decades, including stints in the Philippines, Indonesia, Vietnam, and India. She is currently based in Bangalore, and may be reached via email at Margot.Cohen@gmail.com.