Nepal : sight for the blind / by Nedd Willard

NEPAL Sight for the blind § ir John Wilson's speech to the annual meeting of WHO's Regional Committee for South-East Asia in 197 6 had deeply moved all those present as they heard of the tragic situation facing the blind in developing countries. And Sir John, then President of the International Agency for the Prevention of Blindness, went on to pose the ques- tion: "After smallpox eradication why not the prevention of blindness?" One of those who took up this challenge was Or Ram Prasad Pokhrel, a dedicated Nepali ophthalmologist, who was convinced that Nepal might be the place to launch a nationwide campaign against blindness, even though Nepal was one of the most physically arduous and economically least developed countries in the world. And, if the campaign could succeed in Nepal, would it not be a sign that it could succeed elsewhere under less daunting conditions? Equally convinced was Or Nicole Grasset, who had just completed her job as leader of the smallpox eradi- cation programme in South-East Asia, where she had seen children and adults robbed of their sight by small- pox. Both of them were aware that in developing countries more than two- thirds of all blindness can be prevented or remedied. The first task was to assess the situation accurately. In the beginning there were no hard data about how many people were blind and what was the distribution of blindness. The one thing that seemed sure was that the vast majority of cases of blindness could be either prevented or cured by treatment or operation. And that was a good reason to press on. Planning is the least glamorous, but in many ways the most vital part of a A tragic situation faces the blind in developing countries; yet a little preven- tion can save sight. W ORLD HEALTH. March 1990 by Nedd Willard health campaign. Some had surmised that the main problem in Nepal might be trachoma. However if, as an early pilot study seemed to show, the real problem was unoperated cataract and trachoma represented only a small part of the problem, that meant a different sort of programme had to be set up. Dr Nedd Willard, fo rmerl y a Publi c Info rm ation Office r at WHO 's Geneva headq uarters. is now a member of th e Board · of D irect o rs of th e Seva Foundation in San Rafae l. Californi a. USA. To work more effectively, Or Grasset and former colleagues from WHO's smallpox eradication programme set up a voluntary non-profit organization devoted to the relief of suffering, called the Seva Foundation. Funds were made available by the Dutch government to carry out a survey and to begin the eye pro- gramme. It was to be executed by WHO's newly formed Prevention of Blindness programme, working in collaboration with the Nepalese Min- istry of Health. International organizations were already working in Nepal, but their work was largely confined to the main eye hospital in Kathmandu or to specialised centres. This new project was an ambitious scheme to survey the entire country and eventually furnish Nepal with the means to tackle its problems on a nationwide scale and become self-sufficient in personneL Nepal lies like a bumpy blanket 110 miles wide and 500 miles long, Nepal: sight for the blind stretching from the world's highest mountains to the flat, hot plains that border India. With a population today of over 18 million, it has a high infant mortality rate of 130 deaths for every 1,000 live births; a sure indicator of poverty and under-development. Life expectancy is only 48 years. The nationwide survey of blindness in 1980 was the first ever carried out in a developing country. Right from the beginning, Nepalis were associated at every step of the way. For several young people, their work in the survey proved to be the first step towards a professional career in saving sight. For example, some who had acted as census-takers went on to become ophthalmologic assistants. And these men and women represented the broad ethnic and cultural tapestry that forms the Nepalese nation. Survey results In all, 105 villages were visited and half of them required the arrival of the doctors by helicopter. Other staff arrived on foot after hard days of trekking. The survey results helped to determine the pattern of blindness in Nepal. Two-thirds of the cases of blinding trachoma, for instance, oc- curred in one area of the T erai, the flat region bordering India, in a district not more than 75 miles in circumference. But the main cause of blindness showing up starkly was that of unoper- ated cataract. The first major under- taking was to train Ophthalmic Assistants (OAs) to work under the supervision of ophthalmologists, both to find cases needing attention and to assist during surgical operations. Even before the survey was completed in 1981, the training of OAs had begun. Many of them went to the Aravind Eye Hospital in Madurai, India, which is famous as a model of kindly, low-cost care and efficient skills in action. Aravind agreed to train these young people without charging fees for tuition. The setting up of the WHO/ Nepali national programme for blindness pre- vention involved - besides the Nepal Red Cross, Lions Club and Rotary - such groups as the Association for Ophthalmic Cooperation in Asia, the Christoffel Blinden Mission, the Many villages visited during the Nepal survey required hard days of trekking by the census-takers. Top: Dr R.P. Pokhrel checks returns from a national blindness survey. 10 Japanese International Cooperation Agency, the Netherlands government, Norwegian Church Aid, the Organi- sation pour la Prevention de la Cecite, Operation Eyesight Universal, Seva in Canada and the United States, and the Swiss Red Cross. From a modest office on the out- skirts of Kathmandu the programme went to work. There was need to do a great deal with few trained people, and . in a hurry, if goals were to be met and results were to justify the programme. Medical facilities had to be built, in keeping with the scale of the project and the climatic conditions. Nepali doctors had to be trained in oph- thalmology and other skills. Eye opera- tions had been few in number; they had to be drastically increased and made available to remote regions. But the effort called forth new dedication, and resulted in moulding an eager group of people with a variety of specialities and backgrounds into a winning combination. Foreign consul- tants and volunteers with experience in eye surgery were flown in, often at their own expense, to work in remote h @ centres, doing Operations in se ools :€l and tents, often during the night in the o gleam of flashlights. Meanwhile more ~ Nepali counterparts were being trained ~ who would soon take over. e "Remember," Or Pokhrel explained, ~ ~ "in 1980 the number of people blind in Nepal, a country of only 15 million people, was equal to that of the United States with 230 million." The number of operations had to be greatly increased to cover people needing operations each year, as well as the backlog of those who had long been waiting for an operation. In 1980, with only about 1,200 operations in all of Nepal carried out by seven ophthalmo- logists, that seemed an impossible dream. Taking a leaf from India's book, eye camps were scheduled in rural areas. These large temporary camps are set up so that operations could be carried out en masse. The camps are effective; they bring physicians to rural people and demonstrate dramatically and conclusively that such operations can restore sight. In the one year 1987, nearly 78,000 cataract operations were performed. This was enough to take care of new cases and help reduce the backlog of those who were waiting. In 1981, when the programme began, there were only seven ophthalmologists in Nepal, most of them working in the capital. Today there are 45 eye surgeons to cover the whole country. From 28 beds for eye W ORLD HEALTH, March 1990 patients, the number has risen to 625. From three small rural eye depart- ments, the number has risen to 17 well-equipped eye hospitals and centres. Or Pokhrel has now taken over full responsibility as manager of the national programme. He is also a member of WHO's Programme Advi- sory Group for the Prevention of Blindness. Under his leadership, a national committee has been formed and this includes several non- governmental organizations which now work in Nepal following up the initia- tive taken by Seva. N EPAL is a kingdom set in the Himalayas. w ith Kathmandu as its capital Bordered by China and India. its area is 56.1 00 square mi les and its population 18.760.000 • Above all, Nepal has become almost self-reliant in eye-care personnel in little more than eight years. In addition to eye-care specialists, 332 District Medical Officers and 48 health inspectors have been trained about Nepal: sight for the blind Eye-camps demonstrate conclusively that mass cataract operations can restore sight. A young relative leads a woman patient home after her operation. preventable blinding conditions. Pri- mary eye-care delivery at the village level is being expanded through the training of various types of community health workers. That doesn't mean there are no problems left to solve. There is con- siderable ignorance about cataract blindness; many people consider it is an irreversible and inevitable result of aging. To deal with the problem of ignorance, continuing campaigns of health education use radio, posters and word of mouth. And to pull the patchwork of eye services together in this country sepa- rated by arduous miles of mountains, citizens from many countries are working together under leadership from the Nepalis to ensure that every person in Nepal who requires an . operation to restore the precious gift of sight receives it. • 11