The Washington Diplomat / February 2006
By Larry Luxner
For years, Bogalesh Bekele, 54, suffered from moura the Amharic word for cataracts. The cloudy whiteness of her lenses obscured her vision and made simple things an ordeal, like crossing the street or attending Sunday services at St. Michael's Orthodox Church.
The retired mother of four, surviving on a monthly pension of 77 birr (about $8.80), knew that private surgery would be out of the question, since an operation to remove one cataract alone would cost 1,900 birr, over two years' salary.
But Bogalesh was lucky. She sought help at Menelik II Hospital, a public hospital in Addis Ababa that has an ongoing partnership with ORBIS International.
Partially because she was poor, and partially because her case represented a great teaching opportunity, Bekele was shortlisted last month for cataract surgery aboard ORBIS International's DC-10 "flying eye hospital." Within days, she was operated on by Dr. John Downing, associate clinical professor of ophthalmology at Vanderbilt University, along with a local ophthalmologist, Dr. Yoseph Worku.
"Now I can be happy," says Bogalesh. "I can cross the road without fear. I can come to church again. I don't have to live in darkness."
Yet hundreds of thousands of other Ethiopians remain in darkness unnecessarily.
The statistics are truly shocking. With 72 million inhabitants, Ethiopia has only 76 ophthalmologists like Yoseph and three-fourths of them work in Addis Ababa. This means 69 million rural Ethiopians have only 21 ophthalmologists among them which translates into a ratio of one ophthalmologist for every 3.3 million people.
It's even worse when considering that Ethiopia has one of the highest rates of blindness in the world. Nearly one million Ethiopians are blind, with around 3.5 million additional adults and children visually impaired. Up to 80% of those cases could have been prevented or cured, if only blindness were given more importance on a national level.
That's why on Oct. 18, ORBIS landed its enormous DC-10 at Addis Ababa's Bole International Airport, spending two weeks performing operations and training Ethiopian doctors and nurses on the latest techniques in restoring sight to the blind. This was the second time the aircraft has visited Ethiopia.
The first was in March 2003, when more than 260 ophthalmologists, nurses, anesthetists and biiomedical technicians, as well as end users, were trained. At that time, Ethiopian President Girma Wolde Giorgis visited the DC-10 and while on board signed the declaration of support for Vision 2020: The Right to Sight. In doing so, the Ethiopian government joined the World Health Organization's campaign to eradicate avoidable blindness by the year 2020.
ORBIS spokeswoman Brooke Johnson said in Ethiopia, particular emphasis is placed on childhood blindness and cataracts, which cause 47% of all cases of blindness in the country. Other leading causes there are trachoma (23%) and glaucoma (7.6%).
"The whole point of ORBIS is not to come in and do 500 cataract surgeries in three days," she said. "We do quality surgeries to teach new techniques, or affirm techniques that are currently being used."
Since its founding in 1982, ORBIS estimates it has trained over 93,000 medical professionals throughout the developing world through training programs in 84 countries aboard the DC-10, as well as in hospital-based programs. In addition to Ethiopia, ORBIS has also established long-term country programs in Bangladesh, China, Vietnam and India.
The organization estimates that 22.5 million people have benefitted from the multiplier effect of ORBIS programs worldwide, through the skills gained and shared among colleagues, and passed onto patients by medical professionals trained by ORBIS.
Downing, who volunteered for the Ethiopia mission, said he's encouraged by the fact that Menelik II Hospital recently received a new phacoemulsification machine to help surgeons remove a cataract. The machine was donated by Alcon Laboratories, which has also given ORBIS $5 million since 1979 including a $1 million grant this year to help fight blindness in Ethiopia and other developing countries.
Other corporate sponsors include Ethiopian Airlines, FedEx, Honeywell, Standard Chartered, United Airlines and Ronald McDonald House Charities.
"I am trying to teach a more technological procedure that we hope will be applicable to some people with cataracts, particularly people who can afford to pay. They can then help support the people who cannot pay," Downing explained. "I think phaco will be a small part of the surgical schedule at Menelik II in the immediate future. However, over the next four or five years, it probably will grow to 10-20% [of all cataract surgeries]. It will take that long for it to take hold and then it will become really popular."
Yoseph said his training has additional significance, now that the proper equipment is available to perform the technique.
"I am a general ophthalmologist, and I am planning to sub-specialize in cataracts in the near future. ORBIS International has brought a lot of changes to ophthalmic practice here in Ethiopia, and in service delivery and eye care. A lot of our colleagues trained abroad and the impact of ORBIS is enormous."
ORBIS International's DC-10, the only airborne medical facility of its kind, has a complete onboard operating room, laser/exam room, substerile room, recovery room, technical training center, a biomedical technical training center and a 48-seat classroom equipped with an audiovisual system.
Interestingly, world leaders ranging from George H.W. Bush to Fidel Castro have on separate occasions visited the "flying eye hospital," which ORBIS acquired in 1991 for $14 million.
But ORBIS delicately avoids getting dragged into political or religious controversies.
"We're not a political or church organization. We just do eyes," said Johnson. "That's all we're trying to do."
And there's certainly plenty to work to go around.
During the aircraft's two-week stay in Addis Ababa, ORBIS trained all of Ethiopia's 76 ophthalmologists in the latest techniques to manage corneal diseases, retinal problems, oculoplastics, strabismus, orthoptics, cataracts and glaucoma; in addition, 46 local nurses got trained in ophthalmic nursing.
The original plan was to stay for three weeks. However, due to social unrest in the capital, ORBIS was forced to cancel the final week of its plane-based program.
In between all this, ORBIS volunteer doctors also performed 40 eye surgeries.
Downing, a veteran of 16 flying eye hospital programs, said the main objective of these programs is to "get the trainees to do more sophisticated cataract surgery, and be more efficient at it, and be able to take care of more patients."
The problem is especially serious in Ethiopia, where blindness is only one of the many public-health ills plaguing the country. Malaria, HIV/AIDS and tuberculosis are all rampant in this country, whose per-capita income of less than $100 a year makes it one of the poorest nations on Earth.
At present, ORBIS coordinates 15 projects from its Ethiopia country office, including a national eye bank established in December 2002 at Menelik II Hospital. According to an ORBIS fact sheet, an administrative directive has been issued which allows for tissue harvesting in Ethiopia. To date, 120 Ethiopians have regained their sight following transplant using locally harvested corneas.
In addition, thanks to increased public awareness programs, more than 800 people have pledged to donate their corneas after death.
ORBIS has also instituted a comprehensive rural eye care program, aimed at addressing the acute eye-care needs of Ethiopia's vast rural population. Six projects are currently underway in the Gurage, Kambata, Tembaro, Wolaita and Gamo Gofa zones, as well as in the Alaba, Konso and Derashe special woredas (districts) of the Southern Nations, Nationalities and People's Region.
Furthermore, ORBIS has conducted hospital-based programs in cornea, retina, pediatrics, glaucoma, oculoplastics and neuro-ophthalmology. Emphasis is being given to strengthening ophthalmic education and practice by improving access to books and online resources an effort that has paid off nicely in other countries.
"For example, the first time I went to Cuba about four years ago, they were still doing intracapsular surgery and using glasses for correction, which is something that in the States we stopped doing 20 years ago," said Downing. "When I went back two years later, they had already improved to the same type of surgery that we do, essentially extracapsular surgery and posterior chamber lenses. That's a huge step."
Yet Ethiopia is limited because of its poverty and the scarcity of qualified medical personnel. In the entire country besides the 76 ophthalmologists are four cataract surgeons, 93 ophthalmic nurses and medical assistants. There is one ophthalmology training institution graduating three or four doctors per year, and two ophthalmic nurse training schools.
In addition, Ethiopia has 54 primary eye care units, 21 secondary eye care centers and one tertiary center.
Despite the overwhelming challenges, Downing said "I enjoy working with the doctors, and I get an awful lot of satisfaction out of seeing patients who were blind that we have helped to see. I feel that in the developed world, we have so many things, and so much we take for granted."
He added: "There was a young lady, Lem Lem, on the previous program here two years ago. She was an 18-year-old girl, blind in both eyes with cataracts. We operated on one eye, and she was seeing well the next day and able to go back to school. That was worth the whole trip, and that's what keeps me coming back."