Lecture: Special Eyecare Considerations on the African Continent

Join us for a groundbreaking webinar, “Special Eyecare Considerations on the African Continent,” where leading eye care professionals from across Africa converge to discuss the unique challenges and innovative solutions in both resource-restricted environments as well as markets that are growing rapidly with premium care offerings. The speakers will talk about their unique experiences in patient care and surgery while including the importance of cultural and social determinants of health. They will also include tips and successful models that they have used in their practices to help with patient outcomes and engage the family and community to create virtuous cycles of hospital growth, trust, and quality. (Level: All)

Moderator: Dr. Malik Kahook, Ophthalmologist, UCHealth Eye Center Anschutz Medical Campus, USA

Lecturers:
Dr. Abeba Teklegiorgis, Ophthalmologist, Addis Ababa University, College of Health Sciences, School of Medicine, Ethiopia
Dr. Ciku Mathenge, Ophthalmologist, Rwanda International Institute of Ophthalmology (RIIO), Rwanda
Dr. Daniel Kiage, Ophthalmologist, Innovation Eye Centre Kisii, Kenya

Transcript

DR. KAHOOK: Hello, good morning to all of you and thank you for attending this Cybersight webinar. I will also say Ramadan Mubarak for those celebrating. And thank you for allowing us to share the air waves, if you will, with great panelists. And in particular, I would like to thank Andy and Lawrence, behind the scenes doing a lot of the organizing for this session. I want to remind all of you to visit Cybersight.org. There’s a wealth of educational material, a huge library of information that is free for use. And I would ask you to take advantage of that. I am Malik Kahook, professor and vice chair of ophthalmology at the University of Colorado. My sub-specialty is glaucoma. Today is going to be a little bit different than the usual webinars they host on this platform. The goal of this webinar in particular is to discuss special eye care considerations on the African continent. This is a very big topic and we hope it’s the first of many such topics where we cover regions around the world. Some of the topics include unique challenges and innovative solutions to care on the African continent. Talk about tips and successful models that have been used perhaps some of the learnings of whatnot to do versus what to do. And the unique challenges and innovative solutions are different from one region to another. And we will try to take a deep dive into those with the expert panelists that we have before you. I’m gonna go ahead and share my screen here and start with a introduction on the three panelists. Very lucky to have three ophthalmic leaders from the African continent to join us and share their expertise. Dr. Abeba is ophthalmologist and glaucoma specialist at Addis Ababa University. Ciku Mathenge is known by many of you. Professor and program director at Rwanda international Institute of Ophthalmology. And Dr. Daniel Kiage is at the innovative eye center in Kenya. And I want to thank all three of the panelists. And I’m going to allow all three of the panelists 3 minutes to do a basic introduction of where they are, what they do, some of the challenges that they may be facing in their area, unmet needs and anything to share with us and get to questions sent in by the audience as well as experts around the world. Let’s start off with you, Dr. Abeba.
DR. ABEBA: Thank you. I would like to thank international Cybersight for involving in this very important discussion. And I am also privileged to be here with you all great people. And having said that, just going into my background. I — first I did by glaucoma fellowship in 2009 with George — with Dr. George Spaeth at the Willis Eye Hospital in Philadelphia and then after as a glaucoma specialist I have been teaching mainly residents as well as medical students in providing glaucoma service at the Department of ophthalmology at the Addis Ababa University. And we have established a glaucoma fellowship program in my department. And I did that for three years. And I have been also training glaucoma fellows in addition to the residency and ophthalmology. And additionally, I have been also providing training, particularly on glaucoma surgeries, hands-on training to residents and ophthalmologists in the institutions in the other parts of the country. And the other activities that we have glaucoma wait lab at our department which was established in 2022. And using that wait lab, we trained mainly on glaucoma surgeries of ophthalmologists practicing in the countries, and ophthalmologists from the other African countries. And the other point is our department is the department that was starting the residency program in the country. And the majority of the ophthalmologists that are practicing in the country are graduates of the department. Including myself. And this — and we have — as I mentioned — we have the glaucoma fellowship program. In the other programs that we have in the department is two programs on the fellowship programs on oculoplasty and collaboration. And these programs have been run in collaboration with HCP, the cure blindness. So, having said this just to mention, you know, some of the challenges that I would like to mention is the other points just I want to mention with as part of my introduction is I have been working with our ophthalmologist society of African on public glaucoma awareness since 2008. And also, I have a private practice at the general hospital in Addis Ababa. And after saying this, the challenge that I would like to mention, this is a general challenge for all the, you know, the ophthalmologists practicing in our country. Number one is the challenges are, you know, for several years and as far as I know the number of activities have been done on improving the eye care with involvement of the development partners. But as far as our country is concerned, our population is huge, and the country is also among the low-income countries. And the need for the eye care is still — there is a huge, a huge gap. So, in this regard, I would like to mention the challenges. One is the accessible to the acute eye care center, at all levels of eye care. And the other is training at different levels. Still, there is a huge limitation. And the other challenge is the availability, accessibility, and affordability of medications. Especially those medications that should be taken for a long period of time like glaucoma medications. And the other limitation that just I want to mention as a challenge or limitation is we know, you know, the advent and the fast growth of technologies. But there is marked limitation to access for the new technologies in our country. And I believe that applies for all Africa. So, that’s all I would like to mention. Thank you.
DR. KAHOOK: That’s great. And we’re gonna touch on many of those aspects that you just brought up. It’s a good way to make sure that we touch on all of those things that are top of your mind. Move to Dr. Ciku and do s similar introduction and let us know how things are working in your area of the world.
DR. CIKU: Thank you so much, Dr. Kahook, I’m intimidated being surrounded by so many glaucoma specialists. My specialty is medical retina. I’m from Kenya. I live and work in Rwanda. And I’m quite familiar with eye care in both those countries. They are similar, but also quite different in many aspects. So, I like to say I practice as a comprehensive ophthalmologist because that is really the reality of eye care in my part of the world. It doesn’t matter what your sub-specialty is. You will still do some cataracts every day. You’ll still treat some allergic conjunctivitis, and remove some, and hopefully get a case in your sub-specialty. I consider myself very lucky that I’ve had a career that’s taken me into academia. Into the NGO world. As you mentioned, I am a medical adviser for Orbis. I’ve done the same — had the same role for a foundation for many years. I am involved in research and as I said, I am a full-time clinician. If you ask me what is on top of my mind today, my 13 residents who all have major international exams coming in June. And what I’ve learned is probably in all of those roles that I’ve had, being a program director is the most challenging, but also the most fulfilling. When we graduated our first batch of four ophthalmologists two years ago, we increased the number of ophthalmologists in Rwanda by 40%. And that’s very satisfying. And to realize that they were able to literally hit the ground running and working in district hospitals unsupervised, that has been one of the most satisfying aspects of my career. In research, I — one of my interests is artificial intelligence. And I have been involved in projects looking at screening, especially for retinal diseases, using AI and been very fortunate to have access to Cybersight AI which is a free of charge product. And which I was privileged to be able to work with a developer and really get a product that was customized for my needs and could really solve my problem, which is a rare privilege. Usually we use what we get. But my research interests also go to school screening. So, we have a major school screening project coming up in Rwanda. And my role in that will be right from training the screeners, developing the protocols, the data collection tools. So, that’s kind of how my everyday life looks like. I’m very honored to be the current President of the African Ophthalmology Council which is like — it’s the supranational society for Africa. It’s one of the newest. This is similar to APAO, this is the new one for Africa, I’m the first woman President. And getting ready for the conference in Kigali July 27 to 29. And I invite everyone in the audience to come and visit Rwanda. Rwanda is really quite a special country to visit. And just two weeks ago, I became the only African on the academia ophthalmology, I count that up there and I’m lucky. So, thank you for having us on this webinar, Kahook, and thank you for choosing Africa to be the first panel that you have.
DR. KAHOOK: That’s amazing. Thank you for all that you’re sharing. And I’ve had the privilege of working with you on some of the AI work. It’s important to thank Nicholas and Gabriella, and it’s free for anybody who wants to go into Cybersight.org. Take a look. Last, but not least, the introduction, Dan, if you could take a couple minutes to tell us what you’re doing and then we’ll move on to some of the questions.
DR. KIAGE: Thank you. Thank you, Dr. Kahook for the kind invitation. I was born and brought up in Kenya. And I was educated in Kenya at the University of Nairobi. That’s where I met my senior — even though I look obviously much older. I was born in a village and didn’t have the chance to go to school on time. So, after that, I proceeded — later on I proceeded to Ottawa, Canada, for a fellowship in glaucoma. As far as my experience, I’ve worked in the government of Kenya for a long time. Worked in the mission hospitals and later on — and then joined the University, the University of Nairobi. A federal private university in Nairobi where I worked for a number of years and I was the head of the Department of Ophthalmology. And during that time, I was quite involved in society leadership within the region and in Africa. And that gave me an opportunity to travel a lot, attend conferences across the world and speak in conferences. And one of the most common topics that could be given to talk about is the opportunities and challenges for glaucoma in Africa. What can be done with the blindness from cataracts in Africa? And being at the University of Nairobi, being in a few clinics a week, I could see down and go through the Google and prepare the topic. And made my presentations good and I presented very interesting topics. And I could feel like a solution. And I know what the challenges and opportunities are for cataract care or glaucoma care. But when I come back to the University, I could feel very bad because I’m sitting there. I’m in Nairobi. And I’m not doing much of what I said in the talks. And so I happened to come from about 300 kilometers west of Nairobi in this area of Kisii, it’s a densely populated area. And unfortunately the ophthalmology care was very minimal. And I checked and it was about 3, 400. And when I went home, I just see a lot of blind people from cataract. And because I worked in Nairobi, I had operated on them and I had nothing to do about this. So, that continued to make me uncomfortable. And as we, you know, kept giving these talks and I realized that the one who has to do this thing is me. So, I resigned from my very nice job at University and headed to my hometown and started a hospital. I thought the best thing I could do was a social enterprise where it was — tried to give high volume, low-cost, sustainable, high-quality kind of high-care services. And I felt it was interesting to be involved in glaucoma. But I didn’t feel like I was doing a lot in glaucoma because even when I tried to do studies like glaucoma, I was just faced with cataracts, cataracts, and cataracts. I wanted to do things in glaucoma, I think I need to focus on cataracts as well. So, coming down to Kisii. We started this with a lot of challenges because there was so the so much support because it was kind of a private institution. There’s nowhere to do a social enterprise. So, it was just a limited liability company and tried to use my savings and some support here and there and some loans. And I started the Centre. But I must say, 12 years down the line, I feel very good with what has happened. We have been faced with — in this region, initially we were covering about 2 million population of the community they come from. And so, now I’ve got four physicians who work for me, it’s good for a 2 million population, especially in the rural areas. About 85 start in total. We do about 400 operations every month. And reaching to the poor. And ensuring that we are, you know, reaching to the people who could not get these services. I think it’s something I could say is probably the best thing for the future in Africa. One of the issues that — one problem I had in all the places I worked. I felt like most of my bosses country ophthalmologists and they weren’t understanding the things that I felt could make more sense to our practices. And I think in a region like Africa where, you know, the systems and the institutions are not very well developed, I think it’s important that the people understand that the ophthalmologists should head some of the institutions and do the things without being impeded by institutions and individuals at the leadership who probably don’t understand so well where we’re headed and the problem we have. So, this is where I am and trying to expand and collaborate to cover more I think in the next couple of years we’re looking to cover about 6 to 8 million people. We’re opening new branches and doing vision centers and outreaches. So, it’s going up. And still very encouraged to be doing what I’m doing. Thank you.
DR. KAHOOK: And I’m struck by how many of the topics that you three brought up that are part of our reality in the United States on a daily basis. There are things that are very similar and things that are significantly different. And that’s part of the learning process that I hope we’re gonna go through today. One of the reasons I wanted all three of you to take some time to cover where you are is that there’s this perception sometimes outside of Africa that Africa is a monolith. That Africa is a country. And that it’s similar from top to bottom. I hear that unfortunately at some meetings that I attend nationally and internationally. But when you travel and you talk to ophthalmologists from the continent, you can see how different things can be from one area to another. So, I appreciate all of you taking the opportunity here to express that to the audience. So, I do have a series of questions. I also want to mention that a few people have helped with the list of questions. I got some help from Hunter Cherwek from Orbis as well as Doris from Orbis and a bunch of friends who are in ophthalmology who also sent me some questions that they wanted me to share with you. This first question I’ll throw over to Ciku from an educational standpoint and then I’ll ask the — for Dan and Abeba for you to comment as well. The first question is: Tell me about training in ophthalmology in your area. How do most clinicians go through training and what are some of the needs in educating the future group of ophthalmologists in your area?
DR. CIKU: Yeah, thank you for the question. So, like in any other part of the world, ophthalmologists start off by being doctors and in almost every country in Africa, the medical education is somewhere between 5 years or 7 years. It is expected that after that you go and serve in a rural area. So, you kind of pay back for your education by serving as a district medical officer. And many of the programs will not admit you for sub-specialty if you haven’t done that two years of service. After that, you then join the residency program. A lot of ophthalmology training on the continent is run as masters of medicine programs in universities. And it’s only in a few areas where there are fellowships. So, there are colleges of education, of ophthalmology that have been started. And South Africa is one of the oldest, West Africa is another one. And recently in our region also we have one. And my own program is not under a university. But we are able to train fellows at our college. And those trainings can range from three to five years. After that, it’s up to you to kind of sort yourself out and decide which sub-specialty you want to pursue. And there is very little sub-specialty training on the continent. So, most people will go out. And there’s usually a dilemma between visiting a center like yours, Dr. Kahook, or going to India. And the dilemma is because we want hands-on practice and we may not be able to get that if we come and train under you. So, that’s kind of where we have to make our choices. It is becoming increasingly unattractive for people to have to go out for one or two years to seek further education. And so, this is kind of the time when we do need to start thinking about developing our own trainings for sub-specialties. And a lot of the colleges are now working hard on that. They’ve developed curriculum and are starting to recruit candidates. As Dr. Abeba said, she’s running a glaucoma fellowship. Then the challenge in training is not just with ophthalmology. Ophthalmology is very unpopular in Africa. Unlike other regions. So, in my first year of running Rio, I admitted four residents. I only had four applicants and I basically took what I got. It — it’s becoming better. Last year we did a joint recruitment and I think we had about 70 applicants. And I think it — that’s a bit unique. I would like to think it’s because of the popularity of our program. But ophthalmology is just — just not that popular in this region. In — there is challenges in training the others. We do have a lot of gaps in service. If you ask me today what do I long for most? I wish I had an ophthalmist so I could measure all the muscles and my job would only to be to do the screen surgery. We almost have none on the continent. Biomedical engineers, optometrists. Optometrists in many countries in Africa tend to work in the public-private sector. They run private shops rather than being part of an ophthalmology team. I’ll stop there. But I think that gives a flavor of the kinds of systems that we have.
DR. KAHOOK: Yeah. And you raised also maybe another ten questions that I need to ask. So, this is, you know, we could spend the whole webinar just talking about this part. I want to go to Dan next because of the relationship that you have with Ciku’s program. So, it sounds like there’s a joint training that’s happening. So, maybe, Dan, you could talk a little bit about education in your area and how this collaboration is working. Because it sounds like it’s pretty unique.
DR. KIAGE: Yeah. I think one of the best things that happened is — most of you know that this is the college that is part of a training. Your training wherever you are, whatever institution you are in. So, now there’s an opportunity that we can do all that. And the reason I partnered with Ciku is because our program was up and running, mine was a little bit coming up. So, I wasn’t ready to start on my own. So, it was easier to partner. And that is the thing — the opportunity that we all have to utilize to increase their numbers. And a little bit on the sub-specialty level. I think the time we train it was also an opportunity to use a sandwich program which I think Abeba and I used to train. I did that in Canada, Abeba did that in the US. But as many of us now are back in Africa and working, and that was program that it gives you a chance to be more grounded in your country. So, now I think that people are working in the high-volume units have gotten an opportunity also to develop this sub-specialty programs. And accredit programs and ensure they are given it. And a lot of credit goes to them for making these opportunities happen.
DR. KAHOOK: Yeah. It’s very interesting from a collaboration standpoint how you can leverage the success and the — maybe the earlier start of another program to get yours up and running. And then you can feed off of each other and really help. So, for Abeba, you have a particular experience with George Spaeth and getting some of your training in the US. How would you contrast that with training where you are and some of the challenges that you might be facing from training the next generation?
DR. ABEBA: Okay. Thank you. No, it was an opportunity to be exposed not only to what is being done in the western countries. And with the great people as well. So, it was not only Dr. George Spaeth, but eight other great ophthalmologists there. So, it was a great opportunity for me to learn from each of them. So, and then when — when just the — I was back home, what I have been trying to do is — is to apply what, you know, what I have — I have been told in relation to my people. With the setup we have. So, I modified everything I saw. So, almost I have been doing, you know, my modified surgery. Usually I called my surgery a modified — it’s really good to expose to the great people. But what really matters is the problem you have in your country. The problem, it could be similar. But there could be a difference in different aspects. So, when you bring, you know, your experience from abroad, it should be applicable to the — to our community. I have been working with teaching as well as the existing conditions in my country. The types of physicians we have, the type of setup facilities. The machines and recruitment. And everything. So, everything should be based on what we have. So, and I always like, you know, to do everything in a simple way, in a real way. And with what I have. So, this is my experience. So, if you want me to talk about the training program in our country, currently we have seven institutions with ophthalmology residency program. So, nowadays, the number of ophthalmologists is increasing in our country, which is great and good. But most of the ophthalmologists are working in the large cities. So, when go down to, you know, the communities and even some regions the number of ophthalmologists become so scarce, or quite low as compared to the population. So, there is this problem — existing problem. I think it’s similar for most of the African countries as well. The other is residency program. And four years training. And the fellowship, the sandwich is one year, which is good. Glaucoma is two years. Two years. And we have also pediatric fellowship that’s on the way and hopefully in the future we have a second university-owned sub-specialty training in — at our university or at our department. So, I think that’s all I would like to say.
DR. KAHOOK: You know, the idea of not having access to ophthalmic care, any medical care outside of big cities is pretty ubiquitous around the world. And it might be augmented in specific areas like on the African continent because of mobility issues that don’t exist to the same scale in the US. But we have the same issues with — even if you look at Colorado and Denver, main city in Colorado, you have a lot of ophthalmologists. But once you get into the mountains and beyond, we have people driving in for a couple of hours to see us. We’re fortunate they have the mobility to do that. But that doesn’t exist everywhere. So, for Ciku, you said something that’s near and dear to my heart. And this is the idea that if you come in for training and you can’t do hands-on training, how good is that training? So, if somebody is coming to visit with me and shadowing me for a month, after the first couple of days, I feel bad. Because they’re not able to do as much as they’re capable of doing. That’s gonna be a constant struggle for getting the right amount of training. How does that influence sub-specialty care in your area? Where do people get their sub-specialty care? Do you have sub-specialists in your area? It sounds like you’re doing other things and the others around you are doing other things. How do you cover sub-specialty and get new sub-specialists to be trained in your area?
DR. CIKU: Yeah. Thank you. You are absolutely right about the frustration of observerships, as they’re called. But I think they do have value. I can give an example. An ophthalmologist did a fellowship and he did — I don’t know if it’s a sandwich or what you call it, it’s a layer of things. So, he did a bit of it in India and went to Nepal and came to the US. And he always tells me that he’s very grateful that that’s the order that his fellowship went. Because he — he already had enough of the — of the hands-on training to really maximize his experience in the US by now observing kind of beyond what he already knew. And I guess that must be also what Abeba experienced when she did her fellowship. So, nothing is useless when it comes to training. That’s what I always say. Everything is useful. It just has to be timed well and you have to be realistic about what opportunity exists in that different situation. So, we — we do have only a few sub-specialists in the country where I work. For some reason now every African ophthalmologist wants to be a VR surgeon. Maybe because it’s the great big mysterious sub-specialty out there. As comprehensive ophthalmologists, we do a little bit of cornea and glaucoma, the only thing we don’t work is in the retina. A lot of them come home and don’t have the setup, VR is equipment-intensive and consumable-intensive. And a lot of people are in for training and unfortunately no longer practice VR retinal surgery today. We have to be purposeful in choosing what sub-specialty our young people are going for. And I almost feel like the onus is also on the person giving the scholarships and opportunities to ensure that they support after training. I think it’s really frustrating to be trained and then not be able to practice. Yeah. But because of that shortage, that’s why we kind of all push ourselves to learn more and more skills so that we fill in those gaps which a sub-specialist would fill. And I think there’s great value in that model of skill upgrading rather than doing full fellowships in Africa at the moment.
DR. KAHOOK: Yeah. It’s interesting, there’s the sandwich-type fellowship that Dan did, which I know talking to Dan was hugely valuable. But what you just described is a little bit different. It’s more like a ladder that could be India, Nepal, US, or whatever might make sense. And then get a little bit of information from each. Some can be hands-on, some is more informational. Probably the most important thing with this is creating a network. People that you can call on. People will digital might play a role, Cybersight where you’re doing consults. It helps if you know the person and you can communicate more directly. Dan, just maybe a brief comment about your sandwich fellowship and how that worked. And are you still in touch from time to time with Karim Damji? And how does that work? And then I’ll switch topics going more towards the healthcare system. But I want to hear from you, Dan, about that specific experience.
DR. KIAGE: I think that the sandwich system that they did was very well-structured. Because we were brought about it. And the deal was that you get to know your preceptor very well. And he understands where you’ve come from. And then — then whether you go there, you kind of spend the first few months — like three, four months — kind of trying to understand the circumstances of the work, the education, the research. Then you come back and you stay for six months or something like that. And during that time, it’s important that your preceptor actually visits where you are. And the idea is to now — now that you know what can happen. So, how does — how do you get support in the place where you work? To get some of those equipment? It’s not all of them, but at least the most essential equipment. And I think the preceptor then being maybe a more senior person would encourage or work with them and talk to your seniors and be able to ensure that you’ve got your setup. And you work with you in your own setup so you can compare how things go in the other setup and your own setup. And in your setup, you have more opportunity to do more cases, you have more opportunity to explore more things because you’re more in charge and they ask more questions more freely because you’re the preceptor there yourself. And then you go back now to kind of take things to the high level. So, at least so that when you finish you are at the same level with the people that stayed there it whole time. And you take, you know, so that you can tie up the loose ends and then after you’ve come back, you still continue getting support in terms of visiting and, you know, sharing research and sharing ideas and producing it together. And just checking that you have done the right thing. And then, of course, it proceeds to now getting other people with a like mind or like institutions to also send people for sandwich. And then going towards the end, then you become, you know, the person to take care of the — the students when they are back home here. So, if they are — and they’re going to a developing country and once they’re back and the preceptor is not visiting all of them. You will be the one to visit and share your experiences and work with them. So, I think it was a very good idea. And it was obviously enabling people to actually come back to an enabling environment where they don’t have to feel so frustrated that have been here for two years. It’s a very nice place. I’m going back to almost nothing. None of these things are there. These systems are not there. Their staff is not there. Their equipments are not there. So, you come back to an environment where you can thrive. And that was the whole idea and it worked very well. But as I said, it should still continue in some countries. But maybe there’s some countries where it should be seen now as we increase the number of specialists in those countries.
DR. KAHOOK: Yeah, one thing that strikes me too any travels — I’m spend a fair bit of my time outside of the country visiting with different clinics and teaching and in some cases operating depending on where it is around the world. One thing that’s changed over my 18 years in ophthalmology, when I show up at a place, cataract surgery is pretty routine and there are a lot of great cataract surgeons around the world. Whereas when I first started, I was teaching basic phaco. Now it’s teach me how to do a trab or a barbell or an HVG. It’s much more focused on the sub-specialty, and we have very adept surgeons. That continues to get better, but needs help in certain areas. I think from, you know, a sandwich fellowship standpoint or some of the other infrastructure that’s been placed around education, a lot of it is around an individual. Somebody who is leading — somebody like a Karim Damji, who is passionate about a sandwich fellowship. And see if we can take it to the system level where you can use multiple people and it survives even if somebody moves practice from one area to another or out of an academic center, similar to what Karim did over his career.
But let’s switch gears a little bit and talk about healthcare delivery in general. And we’ll go to you, Abeba, for starting off this question. So, in the US, ophthalmology is often part of a sub-specialty organization of eye care, but not necessarily tagged along to cardiology, gerontology, family medicine. It can be free standing, similarly in private practice. Is ophthalmology ingrained in the healthcare system or standing alone and not getting much help from the hospital system and the healthcare system in general?
DR. ABEBA: Okay. I prefer to talk about the public healthcare system in the country.
DR. KAHOOK: That sounds good.
DR. ABEBA: Almost all of the eye care service coming down from the community to the public level is with the other healthcare system together just as part of a hospital. It’s almost like that. And it’s good to work together for the general care of the patient and to collaborate with our colleagues in the other fields. That’s a good one. There is a bottleneck. Why is that? Most of the time, eye care in general, you know, is just a small area. A small area like the eyeball. It’s a small area which needs a small attention. This is the general understanding of — by the other physicians. So, if there is an eye department or eye clinic within a hospital, the opportunity or the attention begin to that eye care is too small. This is really not what I’m saying. That is what has been happening in our country. So, it’s a big, big limitation. So, for example, in the hospital, the hospital is, you know, it’s a referral hospital where our department is situated. But if any of the eye care is the huge service of the hospital. But still, the attention given to the eye care is quite small. For example, there is one, you know, research which is a published one in one zone of the region of the country. And in that study, what they have identified is the budget for the eye care of the whole area is .7%. That’s quite small. So, this is — this is a problem. So, the other area that I would like to mention with this is this WHO strategy of integrating eye care into the integrated center of eye care to be integrated with the general health system. That’s a great idea. That’s a great idea, a great one. But there should be, you know, an attention to the eye care. It should not continue as it has been. If we want to change or improve the eye care in Africa. So, and, you know, just to improve the eye care as part of the general health coverage system or not. The eye care system, I would say, should be a self sustained one. Even if it was within integrated with the other health systems. It should be a self-sustained. If it’s self-sustained, it can cover its own. It can cover its — it can have all the recruitment and many, many things. So, it should be a kind of semi-autonomous. I would say. In that case, every aspect of the eye care could be improved. This is a huge problem that has been going on in our country. In the private sector, for example, just an example. You know, Dr. Ciku was mentioning retina surgeries are not being done in the public centers for obvious reasons. They need very expensive and it’s emergent. This is in the public sector. This care are being given in some of the private centers. But I can’t imagine how many of the patients, how many of the diabetic patients, how many of the people with retina problems can’t afford eye care service at the private sector. This is really a problem. I think it should be —
DR. KAHOOK: That last point, that’s my next question, and maybe for Ciku. How are patients paying for care in your clinic? And is there any semblance of a state, national health insurance, you know? How does that affect the way that you’re delivering care and able to address some of the unmet needs from a healthcare standpoint?
DR. CIKU: Yeah, I’m kind of happy that question landed on me yeah because Rwanda is really quite amazing in the way that their health system is organized. And as Kenyans, we don’t like to say anybody else is amazing, but I’ve had to admit that. And, you know, we — we have universal health insurance here. It’s one of the projects that government is very proud of, very determined that it doesn’t collapse even when aid is suddenly pulled away because of politics. Government always says the health system must not collapse. And so, every — I would say about over 90% of Rwandans have some form of medical insurance and eye care is included in the packages that it covered. So, something like cataracts you can go into a district hospital and your health insurance will pay for your care. At the same time, if you’re employed in formal employment, whether you’re a policeman, a teacher, a professor, then your employer is obliged to provide you with a private medical insurance. That’s kind of the way it’s organized here. And the challenge for us as eye workers is to make sure that we get as many eye care tariffs into those programs as possible. So, one of the things I’ve learned is that as eye care workers, we have to be present. Because if you are not there when those decisions and those things are being described, whether it’s indicators for performance-based financing, whether it’s tariffs for different procedures, you have to somehow find your way on to that table so that you talk about things in eye care. So, that is not the situation in the whole of Africa. And a lot of eye care is from out of pocket payments. And that is a big barrier. And especially in a specialty where a lot of the care is in private clinics as Abeba said. And it’s in private clinics because of how much it costs to invest in setup. So, that is a challenge. Within the health system we have to kind of always fight to make eyes be felt. And I remember when I worked before I moved to Rwanda, the eye department was as neglected as Abeba said. And then I realized that the charge for any surgery in the hospital was the same because it was a government hospital. But then I also realized in one day I could do 20 cataracts while my colleague, the general surgeon, could maybe do two fractures. And therefore my unit was generating a lot of money for the hospital. And when I realized that, I started pulling my weight. I was wearing size 7 gloves, and the government hospital wanted to buy the same for everybody. And I remember one day, I need size 7 gloves. And I got a call from the medical superintendent saying, hey, we have no money to buy gloves for maternity. What does that have to do for me? Or the income from eye has been buying gloves for maternity. And I didn’t have size 7 gloves. From that day, I literally got what I wanted. So, I do think we have opportunities to kind of be felt, even in a hospital where we are really looked down upon. But we have to identify where our strengths lie and be present at the decision making tables.
DR. KAHOOK: Yeah. And sometimes you have to speak up. Sometimes as ophthalmologists we also are not ingrained with the rest of the healthcare system. We speak a different language, almost, in what we do. As Abeba said, we’re a small area within the body and people think of us that way. But we do carry a significant amount of weight when it comes to the quality of life of the patient as well. Which I think matters a great deal. Dan, I want to take this next one to you because, you know, part of delivering healthcare is getting patients to the clinic. You’re — you can do some things by digital, but a lot of times you have to get patients to where the healthcare is actually being delivered and you mentioned that you moved into a more rural area — it sounds like there are a lot of patient there is — but more rural. And I’m wondering about mobilities and getting patient the to the clinic. And have you done anything to improve access to get patients from more distant areas into your clinic system?
DR. KIAGE: Yeah. Thank you. I think that’s something we are really doing every day so it’s good to discuss that here. Even when you are within that small community, you don’t expect that people just walk in just because it’s a good eye center there. So, there are still a lot of that they want us to do, talk to them, build their confidence, you know, that they can get quality eye care. And find out what the barriers are. Some of them is just some health-seeking behavior that’s not acceptable. But you have to engage and find out what are the barriers. For example, we still do a lot of alternative programs or what we call eye — or eye safaris. We did some research to see what are the characteristics of the patient. When we go out to the outreach, about 60 to 65% are women. But if people come to our hospital because we have a high level thing where we also have a phaco. And when people walk in and say they want to have phaco surgery, it was the other way around. It was 65% men. We figured out that there’s some movement and communication issues with the women in the villages. So, they could benefit more. And the same thing has happened with the visual centers that we have set in the communities. So, we tend to get women from there more than men. And the people working in the hospital, we tend to get more men than women. And this is just how they are. And so, some of the things we’ve done even if it’s in close proximity — close proximity means it’s like 50 kilometers away. It’s not obvious they’ll come. We still do outreach. We still do outreach to patients on radios. We still try to get vision centers to places where they can get nearby. We still work with what we call community health volunteers who were active sometimes house-to-house programs to tell them about eye care and then encourage them to go to the vision centers. And we are especially doing that around the vision centers. When we set up the vision center to popularize it, you get the community health volunteers to go house-to-house to tell things about eye care and they have a problem, they can go to in vision center. And sometimes they take vision. And they have three simple criteria for them. If they have disables, if they have poor vision because they take vision. If they have an in-obvious eye problem, or they are an obvious cataract. For those, they use us quite simply now for — we need our volunteers to do so. We have to involve the community a lot. And it’s interesting that we with all that effort, we still feel we are not in the CSR that’s happening in India and other places. It’s an effort that I think is worthwhile because a lot of success has happened with it. So, there must be — obviously with the giving good quality care program in terms of the outcomes, in terms of how you receive them. Because it’s interesting that the poor people — you slight a poor person, they take it very badly when you slight another person. We have to be very careful to actually give very high quality care to the people even if they can’t afford — even if we have done the surgery for free. Maybe with support from some donor or something. So, but they still get very high-quality care and they thought well of the decision.
DR. KAHOOK: So, it’s not just trying to get people in, you have discovered that you also have to go to them and make sure that it’s working both ways. Which I think is the case with many, I guess, where the service is not as, you know, catering to a specific rural area. You can’t expect that the mobility is gonna be always coming in. You have to reach out. I’m thinking a parallels as I’m saying this that partners in health in Haiti, for example, you know, there’s a pretty famous example of them not just creating a hospital, but also going out to the villages and screening and finding the disease and then bringing it in. So, there are a lot of parallels outside of ophthalmology I think that also fit. Abeba, for you, do you have similar challenges from a mobility standpoint? Patients getting in to see you? And in particular, not a fun topic to talk about, but also in areas of conflict. You know, unfortunately there are some areas of conflict around Ethiopia. How has that influenced some of the care with patients being able to come into different areas? From a public health standpoint if you have insights on that. Answer any part that have that, that might be comfortable for you. Oh, that’s for you, Abeba. You cut out a little bit and maybe you didn’t —
DR. ABEBA: Yeah, can you please repeat.
DR. KAHOOK: Yeah, I saw your screen actually went out for a little bit. Dan just told us a little bit about mobility and going out to different areas to screen patients and find disease and do eye surgery camps. Are similar things happening in your area? And how might conflict in the region influence the care of patients from a public health standpoint? Are they still able to access healthcare?
DR. ABEBA: Yeah, the access to healthcare generally, it’s good. But still, as to the coverage, there is a limitation. So, coming to the eye care, you know, the areas, or, you know, the areas — most of the areas the eye care is given by the community eye care health workers. And there are a number of campaign programs. Campaign programs, you know, they have been caring with on why — mainly in partnership with this partners. And the — the local or regional eye care service responsibilities. So, mainly the campaign programs, they have been focusing on cataracts. So, that’s a huge — a huge help to the public in general in terms of handling this number one cause of blindness. But there are some limitations with this one. One is, you know, there’s such eye care programs are mainly focusing on cataracts. And the other blinding eye condition can be easily Joseph looked. And the other drawbacks I would like to say is, you know, people just living in the area, even living in cities, they may wait until the campaign comes. So, while they are having other blinding — this is other than cataracts. Because of just waiting, they may lose their vision. Like glaucoma. Just simple example.
And the other disadvantage of such campaigns that it’s, you know, the question of feeling of as I mentioned before, the feeling that eye care is the responsibility of the partners. Okay. So, you know, these are the points I would like to mention. So, the coverage — the need is huge. From community level to high level. The eye care need is huge. So, to achieve eye care system, there are many areas as should be addressed. Like in terms of — and in terms of available service and the collaborative work between lab partners and the public and the communities. Yeah.
DR. KAHOOK: Okay. And Ciku, I want you to answer that same question. But also if you could add a little bit about technologies that might have been introduced or medications that have been introduced that have created the most impact on eye care. So, it’s kind of two separate things. Talk a little bit about mobility, access to care, and then in your tenure, both in Kenya and Rwanda, what has been introduced that really influenced and scaled up the eye care in the region?
DR. CIKU: Sure, thank you. Yes, I think access is always a big problem in Africa. You know, when I moved to Rwanda, I thought access is not going to be a problem in this country. It’s small — and everybody — you know, government is paying for everything. So, how can there be a problem? And it’s only after really getting to know my patients and doing a rapid assessment of blindness, yeah, Rwanda is small, but it’s hilly and transportation systems are very difficult. It’s much harder to get to a facility in Rwanda than it is in Kenya. So, I think blind people getting to services — services that are very scattered is a problem everywhere. And sometimes they make efforts, they get to the service, it’s on the wrong day. It’s not the day the ophthalmologist is visiting or the person who they meet at the health facility doesn’t know anything about eyes. So, when you ask about things that have made an impact, I think primarily eye care training has made an impact. And this is training of nurses who are in the front line health facilities to know what to do with eyes. And, you know, a few years ago I was challenged by WHO to produce a curriculum for Africa. It was a bit weird for me because I do medical retina. And I thought, okay. What we produced is something that allows the nurse — and my feeling is if a nurse can pull out a baby from a woman, surely they can treat a sticky eye. And so, I divided the curriculum into things that nurses should be able to do. And things that they should at least give some first aid and things that they should refer. And I have experience in Rwanda because we rolled it out across the whole country, 582 primary health facilities, trained two or four nurses at each facility and we really saw the impact on numbers of patients now reaching the district hospital where there is a trained eye health personnel. They just increased. And to me, that was the one program that really changed things kind of on a permanent basis because the danger of eye camps and a lot of these partner-supported programs is they have temporary high impact. But as soon as they stop, the impact also stops. So, integrating things into the health system seems to be — it’s slower, it might be more frustrating, but it causes more long-lasting change. I think we like to leverage on technology in Africa. And we are early adapters of everything. Because if the technology fills a gap, it’s probably easier to look for resources to get the technology than to — to train humans is very expensive and very tiring. So, an example I could give is like because I’m a medical diabetic retinopathy is of interest to me, we don’t have national screening programs in most of this continent. And when I got interested in a project that was supported by Orbis in artificial intelligence, I really like grabbed on to it. Because I saw an answer to this problem. Previously, if I had to screen people with diabetes, I have to go and sit at the diabetes association clinic. I have to dilate everybody, look at their eyes, refer them. But on that day I’m not working at the hospital where other patients are waiting. And we don’t have enough people who can look at retinas to be able to screen. But now we have a camera there with artificial intelligence and I had to just train the general nurses there on how to interpret the results after they upload the funders images. And, you know, give them really basic interpretations of what that color-coded report is saying in Kenya-Rwanda, translate that into a handout that the patient can look at and say, oh, this is what all this red means. And we found that really increased the uptake of people who do come for care after they’re told you have retinopathy. So, I think technology can be a game changer. The unfortunate thing is that technology is expensive. But expense should not be the barrier that makes us not take on technology in Africa.
DR. KAHOOK: Right. And potentially could save money down the road. If you’re decreasing the burden and severity of disease, then from a quality of life and an economic impact, it might actually make money at the end day for the system. So, Dan, similar question, but sort of building on the artificial intelligence side of things. One of the questions that came in from the audience is, you know, there are so many needs on the continent should we be focused on something like artificial intelligence? Or should we be looking at other, more basic needs? You know, my answer to that would be the answer is yes, we should try and do everything. And that AI does have a role. But I’m wondering, Dan, what you think about that? And then also, any other technology that you want to share that you think has really been a game changer for you.
DR. KIAGE: Yes, it’s always interesting listening to Ciku, also my mentor, as I said. We have not embraced technology as much as she has done. We look for that one time. In times we’ve tried to do that, we always found both the hardware and the software very expensive. So, and especially thinking about where you’re going to place it. So, if you have to get a really good camera, we get a software that can really work very well. Then nobody’s giving you this. So, that has been the challenge. But indeed, it’s a way to know if this is your hardware and the software can be helpful. Having said that, I think technology has to be there to help. I mean, you look at the phone, the penetration of the phone, and the phone can do amazing things. When my friend Andrew came out with that, to me it’s a game changer. We have the opportunity to use it here, and, you know, very simple way of just taking the vision and then the other things which you enter and feed in so that you can see simply — even if you just simply see what is the vision people have out there? So, we start from there. So, and I guess it could be developed further and do other things. I think there’s plans to do that. But I think to me at the rudimentary level of technology, I see things like this being the winner in terms of something being able to cover widely and able to use widely to address poor vision, whether it’s from retractive errors or from cataract or whatever, and simply inform these people, you have poor vision and this vision is not good enough and hopefully direct them where they can get care. So, I think if — because I mean, there are challenges in Africa. You know, with some of these things and upgrading them and using them properly and maintaining them. So, if something is there that can be widespread and be available easily and quickly, it’s a thing.
DR. KAHOOK: Yeah, it’s been very difficult to find a mobile camera, a phone camera, that is consistent enough that AI algorithms can uniformly gauge disease, no disease, referable, non-referable. I think Peek is one technology that’s showing promise. But also one of the issues is being solved by Orbis in creating an AI system on Cybersight that’s free. The software part is being solved. The hardware is an issue for multiple areas, getting quality photos that can be interpreted. I think very good points, Dan. Abeba, of course feel free to answer that same question about technology. And then I’m wondering if you can talk a little bit more about the human resources outside of ophthalmology that might be hindering care. So, nurses, technicians, of course, we haven’t talked much about optometry which is super-important to talk about. And all of the resources for eye care, whether it’s surgeon, non-surgeon, ophthalmologists, technician. What are some of the needs, unmet needs in your area for that part?
DR. ABEBA: Okay. Just regarding the technology. My point is while just we are working for having, you know, the basic — the basic things or requirements just to improve eye care service in Africa. We have to look for this technology. You know, the new technologies as well. Because, you know, even if we have some limitations, we need quality care as the rest of the world is. So, I believe, you know, we Africans, we need all the new technologists. So, the availability, the cost issue may remain challenging, but we have to keep on working on that. So, this is — I would like to — you know, my comment on the new technologies. Coming to the human part, you know, the human part we need, and they are very important. Not only the ophthalmos. It’s teamwork. And the eye is the eye, it’s unique and it needs a special care. So, for this organ that needs a special care. We need trained people. The trained people. And various at different levels. Community eye workers. Assistant, nurses, optometrists and the others. So, we need all these people at all levels. But when we come to, you know, to the real life, these are very limited. Just a simple example in my glaucoma clinic, I never had an ophthalmic nurse. It’s a general nurse working with us. They don’t know how to measure the eye opening or all the pre-questions when you’re measuring and the others. Even in the OR, most of the nurses working in the OR are general nurses. So, there is a huge limitation. And another example, there is the one region that, you know, they told me they only have one optometrist for the whole region. So, there is a huge gap. As I said, the number of ophthalmologists is increasing and we have, you know, seven in this situation. But the other programs in eye care, they number is quite low. So, to implement these strategies and for just in the — and all the points we have been discussing in eye care in Africa, we need these at all levels. We need them in large number as to the proportion of the people. These are quite important. Even I would say, you know, most important for — to improve the eye care while, you know — and while just having the assistance of the new technology. The new technologies, they make just life easy. You know, they may help in easy in the detection. But unless we have the trained human power, the change or coordinated referral system with responsive — at each level of eye care, you know, just to meet what we have been talking, you know, it may be impossible. So, we need to work on having in all categories an adequate number at all levels to improve the eye care in Africa.
DR. KAHOOK: So, Ciku, same thing here. We have a need for technicians, for more people in our eye center. So, we are facing some of the same issues of the talent pool. And, you know, where can we find people to join us? So, I think it is something that we’re all dealing with on some level. In your teaching institution, is it just teaching ophthalmology? Or do you have recruitment and teaching programs for ophthalmic technicians, ophthalmic nurses? Do you have anything that covers that part of the need?
DR. CIKU: So, thank you, Malik, it’s like residency training. But we did start off as a training center for eye care. We have it in the region. Which I think is one of the innovations that come from Africa, called Ophthalmic Clinical Officers. Or in the French part of Africa, TSOs. And these are non-doctors who are trained to do basic ophthalmology. And I would say in many countries they are the backbone of eye care in Africa. So, in Rwanda, for example, we have that category in every district hospital in the country. They are seeing many more patients than ophthalmologists will ever see. So, when we started, I was interested in kind of gauging their standard against global standards. And one of the first programs we had at Rio was preparing them for — I don’t know if you’re familiar with the eye commission for allied. And I prepared three cohort for the exams. I’m proud to say they all got through all their certificate exams. That was very comforting to see that they could be on par with global standards. Those kind of allied personnel are really very, very critical if our populations are to access eye care. But like I said at the beginning, we do have gaps. When we started, we partnered with an Indian chain of eye hospitals and I used to work there as a medical retina specialist. And the first thing I noticed is how good India was in completing the eye team. So, for the first time in my life, I could do surgery and before I even said what I needed, the nurse knew which instrument to hand me or to hand over to me. And that — Abeba is talking about nurses because they are just so important. And we don’t have a lot of investment in training the other part of the eye team. I think it does need to be something that we prioritize. And, you know, for me as President of AOC, one of the things that I’ve done is opened up AOC to the entire eye care team. So, our membership includes all the careers. And when I asked them what is it you want AOC to do for you? Everybody just wants skilling training. So, there is a real need at all levels. If someone needs an artificial eye today, we don’t have Oculus. We just have to use generic prosthesis. It’s right across the spectrum. And my vision is that one day we will be able to offer the whole spectrum of training. Because in some ways those short skills training are much easier than running a residency program.
DR. KAHOOK: Yeah. And they can feed off the residency program and then you have multiple teachers that are in the same program. And it’s a much more fulfilling experience when you have the whole ecosystem around you. So, we don’t have a ton of time left and I wanted to touch on one topic that the whole audience, I think, can learn from. I do want to say thank you to the audience for some of the questions that came in. I think I was able to feed some of them into the general discussion. But this topic is so broad that I don’t think there’s any way we can answer all of the questions in 90 minutes. But just to close off, this is a question that I got from multiple colleagues in the US. And also from outside of the country and it’s a common thing that people who are visiting other healthcare ecosystems wonder about. And that is what do you wish each one of you — and I’ll start off with you, Dan — what do you wish volunteering doctors from overseas knew or did before coming and working with you? First of all, do you want them coming and working with you? And what do you wish they knew or did before coming to spend some time with you under the auspices of helping? They want to help in some way. What do you wish in that regard?
DR. KIAGE: Yeah, I have been fortunate enough to have many volunteers visit me here in TC or other places where I have worked like in the mission hospital or at the university. And I think one thing that I’ve always wished if I was to tell them one thing, is that they should have a mindset that they want to develop a relationship. They should not have this free break for one week or two weeks and say, let’s just go there and do that and maybe there’s some satisfaction they get or help they get. They give. It’s like visiting some nice site and then you go and probably don’t go there again. So, eye care should be maybe a little different when they come. They should have that mindset that they’re coming here to meet some people, to meet situations that they can develop long-term relationships. Maybe at that point they’re not able to be there for a long time, like a month or two months. Maybe it’s just a short time. But then they should maybe then understand with the name of understanding, what are their needs here? How can we work together? Are there some research opportunities? Are there some training opportunities? Is there some joint proposal we can make for funding? Is there some technology transfer that can be of long-term? So, that when they go back, then they still then can develop this further. And so that their relationship can be more beneficial. Hopefully to both sides. We are talking about research, if you’re talking about research opportunities and the proposals so that it becomes a long-term and mutual. So, that’s one we can see. I mean, there are a few other things. But that one stands out for me.
DR. KAHOOK: I think that’s beautiful, Dan. I agree with everything you said. There is this sort of air of being on vacation for some visiting people. It’s kind of the tourism and going to visit and not really delving in and make tag long-term relationship. And that’s one of the concerns that I have when I’m it having places. I don’t want to visit 20 places and have a superficial relationship with 20 places. I would rather visit a couple places and be involved in those places. But it’s a struggle for both sides for sure. Abeba in your case visiting faculty members, visiting specialists, what do you wish they knew? And what do you wish they might have done before visiting? Is there any prep or anything you want to share? Similar to what Dan was asked.
DR. ABEBA: Thank you. What they knew is they shouldn’t — so, my suggestion is just to get the information before they come to the area. Information on the person they are going to meet. And information about the area, the community, the eye care service. So, they may come with full mindset. So, it’s good to know each other before they come. And so know what’s the facility? What’s the expectation? And to get, you know, prepared and ready for that one. For the other point, you know, I may take an example just to explain. And my example is Dr. Karim. We met in 2006 during Orbis flying hospital in our county. So, our relationship started there. Then. And since then, you know, his support was tremendous. I personally — even if I am formal, even if I am a fellow of Dr. Spaeth, I’m a second fellow of Dr. Karim. So, he developed the sandwich program to train, you know, Africans in glaucoma. The sandwich program. So, in addition to the other colleagues in Kenya, three of my colleagues, they got their training, the Sandwich Fellowship training in Canada. And they are — and the other is he was, you know, a major supporter in development of our glaucoma fellowship program and also during the training. He was, you know, one of — one of the mentors with us. He’s bond or relationship, you know, it has been a long time. Long time. So, his support was in multiple aspects. He supports us like with recruitment, with some of the devices, with education. He has been always in touch with us. So, I would say kind of lifelong from starting from one moment attachment. So, I wish even the others to be like him. So, it’s a good example to mention.
DR. KAHOOK: Yeah, I wish to be more like Karim Damji. We would be all that lucky. I had a chance to visit him when he was still in Canada. Very sincere. I think we’re lucky in ophthalmology to have a lot of good souls who are seeing patients and working with each other. We’re a small community. Even globally we’re a small community. I think that’s exhibited by how much you’ve worked with each other and know each other. And how much we’ve interacted in the past. So, I think these are great insights and, you know, Ciku, we’ll go to you to close off the session if you have any insights about this specific thing. So, if I were at the end of Ramadan, I’m done with my fasting and I have more energy and I want to get on a plane and come and visit with you and do some stuff with you, you know, and surgery and clinic, what’s a perfect scenario for you with people who are coming to collaborate?
DR. CIKU: Yeah. I mean, I agree with everything that Dan and Abeba have said. And what I would say is, number one, ask. Ask the host. If I am coming to your house, I will ask you about any rules that you may have. So, just that conversation, and I guess it’s related to the relationship. Just ask me what is it I need most? Yeah. And because that way you succeed and I succeed. And it gives you a chance to prepare the best for your visit. And, you know, don’t prescribe what I need. Just let’s have that conversation. And we’ll both thrive. So, please come with the Kahook plates. And then — and I will prepare perfect patients who will benefit the most from that procedure. So, that’s what I always say. So, if you’re coming and you want to help me with cataract surgery and you — you probably haven’t done a manual small incision, which is what we would do when we go in outreach, then that shouldn’t be your goal, because it will not be of great benefit to my patients and it may be a struggle for you too. But I could say, I will prepare a few patients for phaco, because I’m not that good in phaco. And you will do the phaco on one table and I will continue with the small incision on the other table. And this way we both end very satisfied. And probably you will get to teach me some phaco and I will get to teach you some small incision. And my other is every place in the world has rules. And just respect the rules that we have. There’s nothing like a free for all because it’s Africa. Every country has almost identical rules to what exists in the West. To what extent people follow those rules, that’s what changes. But we all need to be following. You must come and demonstrate best practice to me even my own country. And in fact if I’m not doing things to the standard I should be doing, then let — point that out to me. But we do have rules about who can operate on what. So, as a glaucoma surgeon, do not come and tell me you want to do oculoplastic because this is the chance you have to touch a lump, yeah? So, I think that mutual respect is really important. And, you know, like today Dr. Kahook, you have a panel from East Africa. If I was to visit West Africa, I do need to talk to people in West Africa and understand what are their needs? Because as you said at the beginning, we are a continent. And we are extremely different. And everything we’ve described today here may be the correct picture for East Africa. But it may be completely different if you will a panel from West Africa or South Africa. So, I think just having conversations and treating each other with mutual respect, then everybody thrives and benefits.
DR. KAHOOK: Yeah. So, beautiful way to I think end the discussion. And it’s really that idea of respect. So, respecting colleagues from different areas, respecting the patient and the patient’s need. Respecting culture I think is super-important and maybe something we don’t talk about as much. I think you also pointed out another dilemma for these sessions. So, we’re focused on East Africa. And it could be a completely four or five our discussion in West Africa. Sub-Saharan Africa versus Northern Africa, talking to a surgeon in Morocco versus a surgeon in Rwanda. It’s very, very different. It’s one of the challenges I had presenting the sessions to the Cybersight team. Had a discussion with Hunter Cherwek about it. But it’s a necessary one. Can we go to South-East Asia next and how to get people together when it is very different? It might make sense to have a panel of people from different areas and not just the same area. But we’re gonna play around with that and see what works the most. And as long as the Cybersight team allows, I’m going to try to continue to do these outside of the normal discussion about how do I do my trap? How do I do my phaco? I think it’s important to learn from each other about delivery of care. I would encourage the three of you to send me a note afterwards on what was done correctly, what could have been done better, which questions were good and what questions I should have asked. To the attendees, you sent in wonderful questions that I tried to weave into the discussion. Please continue to give feedback so we can get better. And, you know, maybe we’ll do another session with the three of you with some of the follow-up questions in the future. So, I want to thank all three of you for taking time out of your afternoons and evenings. It’s the start of the day, the sun is out here in Denver. But you’re getting towards the tail end of your day. Thank you for your time. Thank you Cybersight and Orbis for hosting. And I want to wish all of the attendees a wonderful day.
>> Thank you.
>> Bye.

Last Updated: March 15, 2024

5 thoughts on “Lecture: Special Eyecare Considerations on the African Continent”

  1. Am motivated with Doctors align on webinar especially Dr Ciku for what did to the community where thought of giving service close

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