Expanding outreach: a look at the Himalayan Cataract Project's past, present & future

Source for all images: Rex Shore, Michael Amendolia, Ace Kvale, or Michael Lewis

In the modest, no-frills waiting area of the Quiha Zonal Hospital in Mekelle, Ethiopia, post-op cataract patients assemble on benches—some under cover, others on grass—lining the building. On this sunny day, the weather mirrors the patients' dispositions. A few locals are on their feet, joyously dancing together in circles and singing. Others ululate from their seats while clapping their hands in celebration. Nearly everyone is smiling, and with good reason. Up until a few days prior, these patients were partially, if not completely, blind from age-related cataracts and had no means of getting proper treatment. In one of the poorest areas on the planet, they lived life in darkness, wholly dependent on family members and the community for the most basic of human needs.
Thanks to a team of doctors from the Himalayan Cataract Project (HCP), in conjunction with local ophthalmic nurses, ophthalmologists, and administrators, those patients will be dependent no more. The team had spent the last week in Ethiopia, spending 8-12 hours a day performing high-volume cataract surgery on hundreds of Ethiopians.
Geoffrey Tabin, M.D., and Sanduk Ruit, M.D., officially started HCP in 1995 with the seemingly impossible dream of eradicating as much preventable blindness as possible in the areas of greatest need. They began with Nepal, Dr. Ruit's home country and a place where cataracts are responsible for 70% of blindness. The numbers Dr. Ruit and Dr. Tabin were up against were astounding. "At that time, there was a backlog of about 200,000 people who were bilaterally blind from cataracts in Nepal," said Dr. Tabin. "They had a very short life expectancy. There were about 60,000 people going blind a year."
In 1994, there were 1,500 cataract surgeries performed in Nepal, only 1,000 of which utilized intraocular lenses, and none in Tibet, Bhutan, or Northern India. To say that Drs. Tabin and Ruit had their work cut out for them would be an understatement. Curing that many blind people in such an impoverished, rural area would be a massive, perhaps generations-long undertaking. "We called the program the Himalayan Cataract Project because we thought it would take a lifetime to get a handle on it," Dr. Tabin said frankly. Amazingly, thanks to the hard work and dedication of the HCP team and local doctors and support staff, it didn't. Fast forward 15 years and Nepal has become a model of success, transformed into a training ground for ophthalmologists, eyecare workers, and administrators.
"The culmination of a great dream"

Many of Nepal's accomplishments are due to the infrastructure HCP has worked to implement. That's what HCP is really about—infrastructure, training, and education, not just fly-by visits in a vacuum. These doctors dig in, training local practitioners and leaving behind a legacy of cataract surgery excellence that continues to benefit the area well after the HCP team returns to their countries.
"The clinical work that Geoff and [Dr.] Matt [Oliva] do abroad, if it's not done in concert with a trainee or partner that actually lives and works day in and day out in a place of need, then it's not worth the expense of having them go," explained Job Heintz, chief executive officer of HCP. "If there's no one learning from them, it's an empty effort."
HCP's focus on teaching, training, and infrastructure is best represented by the Tilganga Institute of Ophthalmology, HCP's home base in Kathmandu, Nepal. Tilganga was established by Dr. Ruit in 1994 as the first outpatient cataract surgery facility in the Himalayan region and has since been converted into an enormous 130,000-square-foot center of excellence, housing both the Fred Hollows Intraocular Lens Laboratory and Nepal's first eye bank. The transformation of Tilganga took place over five years when the center doubled in size during a substantial renovation, thanks to HCP benefactors, including The United States Agency for International Development (USAID)'s Division of American Schools and Hospitals Abroad and The Fred Hollows Foundation. Before the expansion, the amount of training the center could accomplish was extremely limited because of the space constraints. If a trainee was shadowing a doctor or an ophthalmic tech, it was like they were "in this elevator jammed together," Heintz said. "Now that we've increased the square footage of the facility, space is much less of an issue. Tilganga went from exclusively outpatient to a full service center of excellence." In addition to a comprehensive eye surgery center, Tilganga also has an education and training department that runs an M.D. residency program in ophthalmology, a certificate of health science in ophthalmology, and short applied training for local and international medical personnel and eye health workers.
The Tilganga Eye Center expansion "was a major milestone for HCP," said Matt Oliva, M.D., HCP board member and associate clinical professor, division of international ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore. "It's a beautiful, state-of-the-art, modern, well-equipped eye hospital that's going out and continuing to do outreach, not only in Nepal, but in North Korea, Northern India, Bhutan, and Tibet. It's serving the needs of the region in a leadership role as a center for training." The Tilganga Eye Center has become such an ophthalmic leader that it's allowed Nepal to sustain itself in eyecare to the point where Dr. Tabin's skills are almost unnecessary. "Nepal is spiraling upward and providing high-quality care. Last year in Nepal they did over 200,000 cataract surgeries," said Dr. Tabin, noting how far Nepal has come since 1994. "It's gotten to the point where the quality is so good, things are really sustaining themselves."
When speaking of the great work the Nepali surgeons are doing, Dr. Tabin cites with an almost parental pride examples of innovative, state-of-the-art surgical procedures he brings to Nepal from America and how quickly and efficiently they're implemented. "I'll come back six months later and our corneal specialist in the main hospital in Katmandu will be doing in 40 minutes what it takes me an hour to do," Dr. Tabin said. "On a personal level, I love being [in Nepal] and spending time there, but there's almost no need for me."
The fully expanded center opened on April 30, 2009, and "is as state-of-the-art as can be," said Heintz. "It was the most important thing we could ever imagine accomplishing. We created a facility in the developing world that is of the highest quality. It's the culmination of a great dream."

Africa: a place of incredible need

Even with all HCP has accomplished in Nepal and the Himalayas, its goal of eliminating preventable blindness on a global scale was far from reached. According to Unite for Sight statics, around 7.1 of the world's 38 million blind people live in Sub-Saharan Africa. Fifty percent of blindness in Sub-Saharan Africa is due to cataract, 15% is due to glaucoma, and 10% is caused by corneal opacities. An estimated 2.2 million Africans are blind due to trachoma. "Africa is similar in many ways to Nepal, where there are a lot of remote areas," explained Dr. Tabin. "Much of the population lives outside the city, but the doctors all want to live in the city. You go to the remote areas and there's nothing [in the way of health care]."
Because Nepal and the Himalayas have their cataract blindness in a sustainable, manageable state, HCP is now in a position to begin chipping away at Africa's preventable blindness epidemic. HCP recently partnered with the Millennium Villages Project (MVP) and is currently in the middle of conducting eye interventions in 12 of the 14 Millennium Villages sites. To fully appreciate the HCP team's involvement in this project, you have to first understand what the Millennium Villages are all about. The project was developed by Jeffrey Sachs, Ph.D., director of the Earth Institute, Columbia University, to demonstrate that the United Nation's eight Millennium Development Goals—which range from reducing child mortality to combating HIV/AIDS—could be met in rural Africa within five to 10 years through community-led development. Dr. Sachs chose 14 "Millennium Research Villages," sites located in 10 African countries. They are Bonsaaso, Ghana; Koraro, Ethiopia; Ruhiira, Uganda; Sauri and Dertu, Kenya; Pampaida and Ikaram, Nigeria; Mayange, Rwanda; Mwandama and Gumulira, Malawi; Mbola, Tanzania; Potou, Senegal; and Tiby and Toya, Mali. The 14 sites encompass multiple villages, each containing about 5,000 people. In total, there are 88 Millennium Villages clustered into 14 sites, totaling roughly 440,000 people. "The idea is that in an extraordinarily poor community, in order to get out from under extreme poverty, you need to help the people put in all the different components of what makes a community thrive," explained Sonia Sachs, M.D., pediatrician and medical director, MVP. "We work on five pillars: health, education, infrastructure, connectivity, and business development. The idea is by investing in all of these areas together at the same time you derive some synergy for a holistic approach and are therefore more likely to achieve success." Originally, the Millennium Villages were not considering adding non-communicable diseases, such as cataract and glaucoma, into the health component of their project because the Millennium Development Goals fail to address them. "The reason for that is not because non-communicable diseases are not important, it's because the Millennium Development Goals are a stopgap measure. They first and foremost focus on the things that are disproportionally burdening people in Sub-Saharan Africa," Dr. Sachs explained.
Eye interventions

It soon became clear to the Millennium Villages team, however, that blindness has a devastating economic and health impact on the African people. "They found in their village in Ethiopia that almost one in 50 people was blind," Dr. Tabin said. Realizing that curing blindness was critical to their overall mission, the Millennium Villages team approached Dr. Tabin in 2006 and asked if HCP would be interested in working together to complete eye interventions in 12 of the villages. HCP looked at this partnership as a great opportunity for outreach and accepted the offer. HCP's first eye intervention for the Millennium Villages was in 2007 in Bonsaaso, Ghana. There, HCP screened 4,600 people, performed 160 cataract surgeries, and gave out 1,100 glasses. Over the last three years, HCP has held eye interventions in other Millennium Villages sites. In Koraro, Ethiopia, HCP screened 3,650 people and performed 129 cataract surgeries and more than 100 trichiasis surgeries. In Ruhiira, Uganda, 4,669 people were screened and 107 cataract surgeries were performed. In Sauri, Kenya, HCP screened 3,000 people and preformed 125 cataract surgeries. HCP has also gone to Pampaida, Nigeria; Mayange, Rwanda; and, as recently as July 2010, Mwandama, Malawi. Between all three locations, 6,400 people were screened and 450 cataract surgeries were performed. In Rwanda, HCP was able to do additional work, performing 21 corneal transplant surgeries. "What Dr. Tabin did, which is incredibly remarkable from my point of view, is he and his team came in in a very short amount of time—a week or two—and examined all 5,000 people's eyes" in each village they visited, Dr. Sachs said. "They basically sorted the population's eye problems into three compartments: infections, eye glasses, and cataracts, which there was quite a large number of because of the huge backlog." What's possibly the most remarkable thing, in addition to HCP's hard work and dedication, is the participation of the Nepali people in the African effort. HCP arranges an exchange program where ophthalmologists from Nepal come to Africa and teach the doctors based there the art of high-volume cataract surgery and how to organize eye interventions. "It's something the Nepali people know how to do," Dr. Oliva said. "For them to come and teach Ethiopians their organizational techniques and systems has been really helpful." "People are in awe of the fact that it is Himalayan doctors teaching," Dr. Sachs said. "It's not just Dr. Tabin from the U.S., it is Himalayans coming to Africa to help do the training."
HCP doesn't only have ophthalmologists from Nepal come to Africa. HCP also arranges for African ophthalmologists and ophthalmic nurses to go to the Tilganga Center for training. "Our strategy is to take some of the best young ophthalmologists and ophthalmic nurses from Ghana, Ethiopia, and Rwanda, and send them to Nepal," Dr. Tabin said. "Right now, we have four African doctors training in Nepal. We'll probably have a constant stream of three to five doctors training there. In the next year, we're probably going to take ophthalmic assistants from Nepal and bring them down to show how to develop ophthalmic nursing programs in Africa."
Building up infrastructure

HCP's partnership with the Millennium Villages has provided HCP with a gateway into building a rapport with local ophthalmologists in Africa, enabling HCP to perform additional eye interventions outside of the Millennium Villages program. "Our foot in the door was the Millennium Villages Project," Dr. Oliva said. "The vast majority of the Millennium Villages have led to ongoing relationships with local eye doctors."
These relationships have helped HCP develop in Africa the lynchpin of HCP's overall eyecare strategy: constructing centers of excellence, similar to the Tilganga in Nepal. Currently, HCP is leading the creation of an eyecare surgical center at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. The facility will be integrated as part of the hospital, serving as a training location for ophthalmologists and eyecare specialists for the entire West African region. "What we're doing is enhancing the opportunities for training" in Africa, said Heintz, noting that not everyone who needs training can be sent to Nepal. "It's going to accommodate four tables and will drastically increase the time for the ophthalmologists to be in a surgical setting," he said.
Ground on the Ghana center of excellence was broken in July and construction is currently underway. Heintz expects the building to be finished by May 2011, with a fully functional facility ready to go by August 2011. "That's fully functional with an asterisk," Heintz said. "We'll need quite a bit more furniture and equipment."
Heintz has sent a proposal to USAID citing the facility's equipment and furniture needs but won't find out if the proposal is approved until July of next year. "We know we have enough equipment to get by," he said. "We'll definitely be surgically up and running by August 2011, which is thrilling. It's the beginning." HCP is also exploring the option of building a center of excellence in Rwanda as a training location for East Africa, but that's still in the pipeline stage. "I've sent in the proposal to USAID," Heintz said. "We won't know until July 2011 if we can get the core support for bricks and mortar." Despite having an impossibly long way to go in Africa before they get a true handle on the extreme eyecare need there, Dr. Tabin and his HCP team see only goals, not roadblocks. "I feel excited about the challenges," he said. "I'd get discouraged if I couldn't think of any more to do. Overall, we want to duplicate what we were able to do in the Himalayans in Africa: create great training programs for cataract surgery and all areas of ophthalmology. And we want to create training programs for ophthalmic assistants.
"In one way we're expecting instantaneous results," Dr. Tabin continued. "Our instantaneous results in Nepal took 15 years." Eliminating cataract blindness in Africa will be far from instantaneous, but HCP has put the hardest part behind them: beginning. "Success really comes down to the local partners," said Heintz. "The people in the region who say, 'I want to learn this, I want to make this happen,' without them, we wouldn't be anywhere."
Contact information

Heintz: jheintz@cureblindness.org
Oliva: moliva@cureblindness.org
Sachs: ssachs@ei.columbia.edu
Tabin: Geoffrey.Tabin@hsc.utah.edu