A host of programs address blindness in Africa

A global plan to eradicate preventable blindness by 2020 is in motion, but much work remains to be done.

MOMBASA, Kenya — On the coast of East Africa, patients gather here outside the doors of the Lighthouse for Christ Mission and Eye Center, the only eye clinic in this city of 1.5 million people.

“People from neighboring villages and countries travel to receive free care for their blindness and low vision due to cataract, glaucoma, trachoma and onchocerciasis,” said N. Dean Larson, MD, medical director of the nondenominational eye hospital.

“Unfortunately, sometimes people come to us too late, when they are in the advanced stages of glaucoma or some condition that is irreversible,” Dr. Larson told Ocular Surgery News.

Dr. Larson’s situation – running the only eye clinic to serve a population of more than 1 million people – is unfortunately not unusual in sub-Saharan Africa. The ratio of ophthalmologists to population in this area of the world is generally reckoned to be 1 per million.

People involved in blindness prevention efforts in Africa speak of avoidable and unavoidable blindness. Glaucoma is the leading cause of unavoidable blindness in Africa because it is not preventable or easily treatable.

Avoidable blindness, on the other hand, is caused by conditions that are either preventable or treatable. Cataract is the leading cause of treatable blindness here — affecting more than 3 million Africans — followed by the preventable eye diseases trachoma and onchocerciasis.

“These treatable and preventable illnesses constitute up to 80% of all cases of blindness in Africa,” said Daniel Etya’ale, MD, ophthalmologist and coordinator of the World Health Organization’s Vision 2020 initiative in Africa.

The mission of the Vision 2020 program, launched in 1998, is to eradicate all avoidable blindness by the year 2020.

“We are coordinating a network of organizations and ministries of health in countries to help develop strategic plans for action, which will become an integral part of everyday life,” Dr. Etya’ale said.

However, coordinating and facilitating is only part of the effort. In the cities and the rural areas of Africa, it is the determination of individual ophthalmologists from Africa and volunteers from throughout the world — like Dr. Larson — by which these initiatives reach the population.

“Ophthalmologists play a social and medical role of great importance,” Dr. Etya’ale said. “They have the power to reduce the suffering of 45 million blind people worldwide.”

This year at the American Academy of Ophthalmology meeting, a symposium entitled “Be An International Volunteer” will be held, directed at ophthalmologists interested in volunteering time and effort to help reduce blindness in developing countries. In advance of the AAO meeting, this article reviews some of the challenges of addressing the problems of blindness in Africa and some of the programs that are attempting to meet those challenges.

Trachoma prevalence

Vision 2020 programs are already in place to eliminate the leading cause of preventable blindness in Africa – trachoma.

“Currently, in sub-Saharan Africa, an estimated 15% to 20% of children under the age of 10 have trachoma,” said Jeffrey Mecaskey, program director at the International Trachoma Initiative (ITI).

Trachoma is caused by the bacterium Chlamydia trachomatis. It is a condition that produces inflammation and distortion of the upper eyelid, which leads to a thickening of the conjunctiva, scarring and opacity of the cornea.

“Trachoma is a disease of poverty,” said Joseph Cook, MD, executive director of ITI. “It can be easily spread through hands, clothing, nasal and eye discharge. Where there is a lack of clean water and sanitation, the disease will be found.”

The burden of trachoma is heaviest in the northwest African countries of Mali, Niger and Nigeria, and in the southeast strip of Ethiopia, Kenya and Tanzania. In addition to affecting children in high percentages, it also strikes women at disproportionately larger rates than men, Dr. Cook explained.

“Three of every four onchocerciasis patients are women,” he said. “This is because women are the primary caregivers in families, and they come in the most contact with children and those who are sick.”

SAFE combats trachoma

Since 1999, ITI has worked closely with WHO, the Carter Center Trachoma Initiative and the Edna McConnell Clark Foundation to develop and support the SAFE strategy.

“The SAFE strategy is our basic method of help. We use Surgery to correct lid deformities, Antibiotics to treat infection, Face washing to reduce disease transmission, and we also facilitate Environmental changes to clean the water and improve sanitation,” Dr. Cook explained.

Through this program, samples of the antibiotic Zithromax (azithromycin), supplied free by Pfizer Inc., are distributed to thousands of people on a daily basis.

“This is a tremendous stride forward, because Zithromax is a single-dose systemic drug that can treat a critical threshold of the population at risk and bring down the prevalence of the disease. This ultimately contributes to its elimination,” Mr. Mecaskey said.

Currently, the SAFE program is being used in 8 countries in Africa.

“Morocco is on course to become the first ITI-supported country to eliminate blinding trachoma by 2005,” Dr. Cook said. The organization’s efforts have helped to reduce the rate of trachoma infection in Morocco from 26% to 6.5% in just 3 years, he said.

However, obstacles still exist. “The access to surgical services is a big problem. People are either hindered by the cost of travel and the distance required to receive care or by their own skepticism as to the effectiveness of the surgical procedure available,” Mr. Mecaskey said.

Part of ITI’s mission is to spread awareness and strengthen the capacity of local caregivers to provide services. However, there is still a need for global recognition of trachoma as a realistic threat to vision.

“To effectively combat the disease, it must be fully recognized. Many people, even ophthalmologists, don’t recognize that trachoma is still a major cause of blindness,” Dr. Cook said.

Onchocerciasis endemic

Another major cause of blindness, affecting nearly 125 million people worldwide, is onchocerciasis. More than 96% of those infected with this disease reside in Africa, Dr. Etya’ale said.

Onchocerciasis is endemic to 30 African countries. “In many hyperendemic areas with blinding onchocerciasis, almost every person will be infected, and half the population will be blinded before they die,” Dr. Etya’ale explained.

Onchocerciasis, or river blindness, is a disease spread by the parasite Onchocera volvulus. The parasite is transmitted by female black flies. Farmers, fishermen, sand diggers and people who live near stagnant bodies of water or coastal regions are most easily infected.

“When someone is bitten by a black fly, thousands of microfilariae enter the body and produce clinical manifestations of punctate keratitis, early uveitis, chorioretinitis or acute optic neuritis,” Dr. Etya’ale said.

Since 1974, WHO has been managing the care of 11 countries in West Africa where river blindness is rampant.

“Through our Onchocerciasis Control Program [OCP] we have worked with numerous nongovernmental organizations, the World Bank, and other United Nations agencies to successfully meet our objectives by treating those affected,” Dr. Etya’ale said.

Effective methods of treatment incorporated in the OCP program include vector control and large-scale chemotherapy with ivermectin.

Ending river blindness

Since the program’s inception, 600,000 cases of river blindness have been prevented and more than 16 million newborn children have been spared the risk of contracting the disease.

The OCP has also paved the way for other onchocerciasis initiatives, specifically the African Programme for Onchocerciasis Control (APOC), an additional initiative under the direction of WHO.

The main component of the APOC is the distribution of Mectizan (ivermectin) donated by Merck & Co.

“This donation is a real landmark. It has been given to millions of people for as long as they need it,” Dr. Etya’ale said.

In conjunction with the APOC program, the Carter Center assisted in treating 923,954 people in Uganda with Mectizan in 2001. Other organizations such as Helen Keller Worldwide, the Nippon Foundation and USAID, actively provide services through the APOC program to countries including Ghana, Mali and Burkina Faso.

Since 1992, Helen Keller Worldwide has assisted with information and communication strategies to support onchocerciasis control.

“Our onchocerciasis department oversees Mectizan distribution, but also spreads awareness of the disease to those at risk by teaching local trainers and providing educational materials. We increase the capacity to recognize those who are infected quickly,” said Alec Rowe, of Helen Keller Worldwide. “We can then effectively treat and prevent the spread of the disease.”

Long-standing programs like the OCP and the APOC allow other blindness initiatives to be easily incorporated into the structure of a community’s health care program, Dr. Etya’ale said.

“When [local health care workers] already know what blindness is all about, it is easy to build on their knowledge to combat other diseases. All they need is a little more training to take out cataract or screen for glaucoma,” he said.

Glaucoma not easily cured

“Glaucoma is a difficult eye disease to effectively treat in Africa,” Dr. Etya’ale said. “It is challenging to screen for because it cannot be easily diagnosed, and the tools for treatment are not as effective as for cataract.”

Dr. Etya’ale said the most successful outreach programs are those that aim to treat diseases with a definite cause and solution. Because glaucoma is a condition that needs treatment over time and is not easily amendable, governments and organizations are still searching for an effective method of treatment for the general population.

“We are eagerly trying to find the most effective way to fight glaucoma. For now, we incorporate glaucoma screenings in our cataract programs,” Dr. Etya’ale said.

“Glaucoma is also a problem causing permanent blindness in our region,” said Charles R. DeHaven, MD, a U.S. surgeon who has volunteered for the Lighthouse for Christ Mission and Eye Center for nearly 30 years.

“Unfortunately, we cannot afford to give patients modern drugs like latanoprost for their glaucoma because they are just too expensive for us to get. So we make intraocular pressure-lowering drops in our clinic, which work moderately well,” Dr. DeHaven said.

According to Dr. DeHaven, filtering procedures to lower IOP work best for glaucoma patients who may not be compliant with eye drop regimens and cannot afford to travel to a clinic for refills.

“This is sometimes the best treatment for glaucoma in this population because it is an effective, one-time therapy,” Dr. DeHaven said.

Controlling cataract in camps

The leading cause of blindness that is most easily treated in Africa is cataract. But that does not mean the problem of cataract blindness is easily addressed.

“The magnitude of cataract is immense,” Dr. Etya’ale said. “In the big cities, where most ophthalmologists are based, cataract is a problem that is gaining control.”

However, while these measures help city dwellers, the biggest challenge for cataract lies in reaching remote villages, where there are no health care programs in place and most of the blindness is caused by cataract.

“This is why it is so important to travel into rural areas,” Dr. DeHaven said.

SEE International is one of many NGOs working with Vision 2020 to eradicate cataract in remote areas of Africa.

“These countries really need help. People are suffering from the densest cataracts that I have ever seen,” said Michael Wong, MD, an ophthalmologist who recently joined SEE International’s outreach program. “In Namibia, we performed nearly 160 cataract surgeries in the village of Oshakati in just 1 week.”

“Developing countries have very little money left over for ophthalmology. They are in desperate need for help, especially in the brush,” said Michael Colvard, MD, another ophthalmologist working on African expedition programs sponsored by SEE International. “Every little bit counts.”

For patients in Kenya who can not travel to the city of Mombasa, where the Lighthouse for Christ Eye Center is located, there is also help available. Ophthalmologists and medical workers from the eye center travel to remote areas of the country once a month to perform surgery in the brush.

“We load up our trucks with medicine and equipment and take a staff of about 6 people into small towns and villages. In a few days time, we can treat between 400 and 500 people,” Dr. DeHaven said.

For complicated cases that require complex surgery, the surgical team may take patients back to the clinic, perform surgery and then return the patients to their villages.

Outreach rewarding

“When people see us coming into the villages, they are overjoyed. On my first trip, I was overwhelmed by the immense gratitude from the postoperative patients who had nothing and then were given the gift of sight,” Dr. Wong said.

“It is truly one of the greatest gifts that we as doctors and human beings can give,” Dr. Colvard agreed. “With a little money and effort, we can make a substantial impact.”

According to Dr. DeHaven, there is “always a need” for more visiting doctors to perform services in clinics and rural eye camps throughout Africa.

“Surgeons come to help and leave saying that they’ve gained a wealth of knowledge and experienced one of the most rewarding experiences of their lives,” Dr. DeHaven said. “Each year, I become more humbled and more enlightened by the kindness and love of those receiving care.”

For Your Information:

• N. Dean Larson, MD, can be reached at the Lighthouse for Christ Mission and Eye Center, P.O. Box 81465, Mombasa, Kenya; +(25) 411-226-179/ 220-018; fax: +(25) 411-316-115; e-mail: tghrist@maf.or.ke.
• Charles R. DeHaven, MD, can be reached at the Lighthouse for Christ Mission and Eye Center, P.O. Box 8318, Tyler, TX 75711 U.S.A.; +(1) 903-561-7072.
• Daniel Etya’ale, MD, can be reached at the World Health Organization, Prevention of Blindness Unit, Avenue Appia 20, 1121 Geneva 27, Switzerland; +(41) 22-791-2642; fax +(41) 22-791-4772; e-mail: etyaaled@who.ch.
• Joseph Cook, MD, can be reached at the International Trachoma Initiative, 441 Lexington Avenue, 16th Floor, New York, NY 10017 U.S.A.; +(1) 212-490-6460; fax: +(1) 212-490-6461; website: www.trachoma.org.
• Jeffrey Mecaskey, can be reached at the International Trachoma Initiative, 441 Lexington Avenue, 16th Floor, New York, NY 10017,U.S.A.; +(1) 212-490-6460; fax: +(1) 212-490-6461; website: www.trachoma.org.
• Alec Rowe can be reached at Helen Keller Worldwide, 352 Park Avenue South, 12th Floor, New York, NY 10010 U.S.A.; +(1) 212-532-0544; e-mail: arowe@hkworld.org.
• Michael Wong, MD, can be reached at the Princeton Eye Group, 419 N. Harrison Street, Princeton, NJ 08540 U.S.A.; +(1) 609-921-9437; fax: +(1) 609-921-0277.
• Michael Colvard, MD, can be reached at the Colvard Eye Center, 5363 Ballboa Blvd., Suite 545, Encino, CA 91316 U.S.A.; +(1) 818-906-2929; fax: +(1) 818-906-0567.