Eye hospital

Eye Hospital What is special. about the Khartoum Eye Hospital is that it trains ophthalmic health workers for the whole country, and particularly the ophthalmic medical assistants who take eye care and b~indness prevention out to the people-even in the remotest parts of Sudan by Diana Gibson ru hartoum Eye Hospital stands on the banks of the Blue Nile close beside the railway bridge linking the capital with the north-east of Sudan. The trains that rattle past from time to time hardly disturb the peace of the one- and two-storey buildings, set in a spacious garden protected from Sudan's strong sun by tall shady trees. Yet the exterior calm is somewhat decep- tive: inside, the hospital is a hive of en- thusiastic activity and a training centre unique of its kind in Africa. Eye diseases are widespread in Sudan- mainly trachoma and bacterial conjunctivitis, together with glaucoma, a high rate of cataract and, in the south, many foci of onchocerciasis (river blind- ness). What is special about Khartoum Eye Hospital is that it trains ophthalmic health workers for the whole country, and in particular one category- the oph- thalmic medical assistants or OMAs- who take eye care and blindness prevention out to the people even in the more remote parts of the country. "I honestly don't know what we 16 should have done without their help", says Dr Abdel Gadir Hassan, Director of the Hospital. "They go to every part of Sudan, they work in rural communities in the district hospitals, and they are able to diagnose the endemic diseases and deal with them." The OMAs are proposed for training by the province health authorities, and 60 of them arrive every other year in Khar- toum for the two-year course. They are all qualified and experienced nurses but still have to pass an exam to enter the course. Once admitted , they study ana- tomy, physiology and diseases of the eye. In their last year they are already giving sterling service in the Eye Hospital itself. The out-patients' department at Khar- toum receives an amazing 500 to 600 patients a day, and even 700 to 800 during seasonal epidemics of eye in- fections . The only way all these people can be treated is by a "sorting" system which rests heavily on the OMAS. They screen every patient first and treat a ll the cases they can. A smaller number of patients with more complicated condi- J A schoolgirl's eyesight being tested at the Khartoum Eye Hospital. ( Pho10 WHO/ Department of Health Educa- tion, Sudan) tions go on to be seen by the ophthalmic medical officers, or if necessary the con- sultant. But the main burden is shoul- dered by the OMAs who, probably because of this solid practical training, have acquired a very high reputation as diagnosticians . However, the main work of the OMAs is not in Khartoum but in the districts they return to after their training. Equipment is provided for them, and they work with a general medical officer in a hospital or in the school health service. Mr Hillary Ladu Lokudu comes from Eastern Equa- toria province in the south of Sudan and will go first to the province-level hospital at Juba, then to the district of Torit. " I can deal with simple chronic conjunctivi- tis , allergic conditions, spring catarrh, trachoma, corneal ulcers, styes and for- eign bodies. Any case of cataract or glau- coma I refer to the medical officer." \ Mr Presser Yuro Poul will also go back to his native Juba and expects to be transferred later to a district. At Juba he will work in the eye department with a trained ophthalmologist. The patients there come from as far as 30 miles away, but Mr Poul will also visit them in their round grass houses (called tokuls). Some of them sleep near their animals and, because of this habit, blepharitis (inflam- mation of the eyelids) is common. He will encourage them to keep their ani- mals at a distance, and to wash their hands and eyes in the mornings with medicated soap. Looking back on his 25 years at Khar- toum Eye Hospital, Dr Hassan recalls when it was the only one caring for eye patients throughout Sudan, Africa's largest country. "We gradually decentra- lized, and now we have opened eye departments in every provincial hospital and even in some district hospitals. The emphasis has changed. It used to be on diagnostic and surgical improvements, but now we are entirely geared for train- ing eye health workers for the whole country, and lately we are also starting to do research work on the endemic eye dis- eases of Sudan, with visiting scientists from abroad." Mr Gala! El Tahir Abu Hawa is Prin- cipal of the Hospital's Institute of Op- tometry and Visual Science. His optome- trists' training course was, until a similar one started recently in Lagos, the only one of its kind in the African or Arab countries. Optometrists are the techni- cians who test for sight defects and pre- scribe glasses. Like the OMAs, they do ex- tremely useful work , becoming the right hands of the ophthalmologists in the eye departments. Mr Abu Hawa's students come from various parts of Sudan and need good marks in maths, science and English lan- guage to enter the Institute. They learn anatomy, optics, ophtahlmology, ocular pharmacology, physiology, orthoptics and refraction. The refraction room where they work in the practical part of their course has a long row of cabins on one wall with a variety of equipment for testing sight. Besides working in hospi- tals, says Mr Abu Hawa, the qualified refractionists will take part in a new countrywide survey of schoolchildren's eyesight. "This is very important, because some of the children may be defective in one eye and concentrating on the other, or they may squint, and unless the refractionists go to examine them many of these defects are never dis- covered." Unfortunately glasses are difficult to get in some parts of Sudan and people from the rural areas are often obliged to send for them through friends in the main towns. Nevertheless, there is an in- crease in the number of people who now want glasses. Dr Hassan explains: "Edu- cation is becoming more widespread, people are starting to work, the number of those seeking to correct their vision is on the increase and people are getting used to wearing glasses. It is quite dif- ferent from what I experienced about 25 years ago. " In 1973, a new course started at Khar- toum Eye Hospital for ophthalmic operating theatre attendants. Like the oMAs, these are experienced nurses select- ed by means of an entrance exam, and in the six years since the course started 75 of them have graduated. During two years of training they learn about surgi- cal instruments, sterilization, how to select instruments for an operation, and how to assist the surgeon. When they qualify they work either at Khartoum Eye Hospital or with the eye department surgeons at the provincial general hos- pitals. In Khartoum itself they will certainly never be short of work since, in the un- founded belief that health care is better in the capital, numerous patients persist in travelling the long distances to Khar- toum even though they could get the same operation, equally well performed, in the provincial hospitals nearer home. "Still the patients come to Khartoum Eye Hospital" , says surgeon Dr Hadi El Sheikh, Associate Professor of Ophthal- mology at the University, "because they believe there is better service here. That's why there is such a backlog- our waiting list for cataract is about 1400-and- something and we can never finish that, they keep on coming. Yet there are beds available in the provinces. I think we need some sort of education of the popu- lation to convince them that they would get just the same service there." 17 Cataract is very common in Sudan, and Dr El Sheikh believes this may be in some way related to the flatness of the country. "Definitely it has a geographi- cal distribution- very common in the north, where it is very sunny and the country is flat , and rare in the south. It is also common in Pakistan and India, with the same latitude and the same sort of geography, so it may be related to the reflection of light, the amount of illumi- nation, the flatness- no one knows for certain." In-patients at Khartoum Eye Hospital are cared for by nurses who take a one- year specialization in ophthalmic nursing before going out to the districts. The women's, men's and children's wards each have two sections, one for "clean" cases- mJuries, operations- and the other for infectious conditions. In the children's wards, mothers stay with their children throughout the treatment, and every child's cot has a bed beside it for the mother. Sister M. M. Ibrahim, the Deputy Matron, says the children's wards get 18 • ... .. very crowded in summer during the epi- demics of eye infections. " We receive the patients from out-patients and I make arrangements for the mother to feel com- fortable in this hospital, because most of them come from outside Khartoum. Many of the eye problems of children seen here are due to malnutrition, so we chek the child's condition, weigh it to see if it needs supplementary feeding, tell the mother how to prepare milk, and in- struct her how to apply the medication to the eye when she leaves. We also tell her to keep the home environment clean and not let the child use the same towel as other children." In one cot lie twin boys only one month old, with opaque green eyes. Sis- ter Ibrahim explains that their mother noticed something wrong when they were only one day old, and the local medical assistant advised her to see a consultant. "She is very intelligent, so af- ter two weeks she came here and the babies were admitted as cases of congeni- tal glaucoma. Their eyes were examined under a general anaesthetic and in a Eye Hospital Left : The out-patients' department at Khartoum receives an amazing 500 t<t 600 patients a day, and even up to 800 a day during seasonal epidemics of eye infections. Right: What is special about this hospital is that it trains ophthalmic health workers for the whole country, and in particular one cate- gory, the ophthalmic medical assistants, who take eye cani'and blindness prevention out to the people in the more remote parts of the countryside. (Photos WHO I Departmentof Realth.Edu- cation, Sudan) month she will come back to check their progress. The doctor has given her some drops for them and I have told her to come back in good time." Another patient is a chubby little girl of eight months from the Gezira area, bouncing happily on her mother's knee. "This lady noticed when her daughter was one month old that she wasn't looking round in the proper way, but her relatives and neighbours told her she would grow out of it. After two months the mother was certain it was abnormal; she saw the medical assistant and he advised her to go to hospital. You see, the child is blind, she can't see anything. Her mother doesn' t remember having taken any drugs during her pregnancy. The little girl is under observation but she is well, active, has a normal weight, and smiles all the time! " Sister Ibrahim hopes to set up a nursery here for the children of the staff. One nurse actually has her tiny baby, born prematurely and now three months old, here with her in the ward, as she has no one to leave it with at home. Such a nursery will also provide jobs for women experienced with children. This is anoth- er demonstration of the "family" atmo- sphere in this friendly hospital, which also has a mosque in the garden- "to help the patients feel at home", as Sister Ibrahim says. Since eye diseases are so common in Sudan, Dr El Sheikh, responsible for un- dergraduate and postgraduate training, feels that trainee doctors in general medi- cine should get a much better prepara- tion in this field. He regrets that during their hospital-based training they do not always see the actual conditions present in the community outside. "They should go out and diagnose cases in a village with a minimum of equipment and real- ize that they have a service to offer out- side the hospital" , he says. The curricu- lum is already being modified : when they come to the Eye Hospital in their fifth year, some of the undergraduates do small research projets, on the rate of blindness in the community, for exam- ple, or on the training of paramedical eye staff to improve eye care. The modern development of Khar- toum Eye Hospital, to the point where 80 per cent of its effort goes into training of staff for eye departments around the country, goes back to its foundation in 1955 in rather dramatic circumstances. Until then Sudan had only an eye depart- ment, headed by Dr Hussein Ahmed Hussein, which was located in the out- patients' section of the civil hospital. The present site was at that time the base hos- pital for British troops. " I had the ap- proval one evening at 11 o'clock", recalls Dr Hussein. "I rang the Chief Clerk to hire soukh (market) lorries and we began at first light to evacuate the female wards and bring the equipment and patients here. By 8 a .m. everything was finished- we had occupied at dawn!" This was how Sudan's Eye Hospital began its exis- tence, with Dr Hussein as its founder- director. He has never really retired and still works with undergraduates in the com- pany of such former pupils as Dr Has- san, the present director. Dr Hassan is proud of the decentralization he and his colleagues have achieved, but would like to take it still further, so that there would be two or three other eye-care centres of equal importance competing with the capital. Already Wad Medani, the second largest town, has a really good eye department and Dr Hassan would like to establish others in the far west and the far east. Finance is the main prob- lem, not staffing, since nowadays eye health workers are not interested in stay- ing in big towns and prefer to live thecal- mer life of the provinces. Khartoum Eye Hospital is a living proof of what can be done with willpow- er and enthusiasm. The Ministry of Health pays for the basic running of the hospital, including food and salaries. Everything else- training, research and development-comes from private bene- factors or large firms . Their generosity, and the dedication of both the staff and the many hundreds of trainees who have passed through the Hospital's doors, have created an efficient and far-reaching service for eye patients all over Sudan. • 19