From the Cradle... A journey into universal eye care service delivery!- Preventive Eye Care Service Delivery

Social medicine, universal eye care coverage, primary eye care, preventive eye care... blindness etc. They evoke a sensation that provokes anxiety and urgency! Anxiety, because by the year 2020 there is no way Nigeria would have being able to stop avoidable blindness in the country. Urgency, because the Vision 2020 target of reducing avoidable causes of blindness to 25% in 2015 was not feasible! This is already 2018 and it can be authoritatively stated that we, as a country, cannot meet the vision 2020 target. 

What can we do to bridge the gap?

 Let's get some historic perspective of the subject matter...

The first global estimate of the extent of visual impairment, in 1975, indicated that there were 28 million blind people. In 1990, 38 million people were estimated blind and 110 with moderate to severe visual impairment. In 1996, 45 million were estimated blind and 135 million with moderate to severe visual impairment. In 2002, 45 million persons were estimated blind and 314 million with visual impairment. In 2010, visual impairment reduced from 314 million people of 2002 estimates, to 285.3 million and 39.8 million people estimated to be blind worldwide. The reduction in the number of persons with visual impairment was a result of different levels of preventive eye care measures adopted by IAPB and WHO Vision 2020 initiative and other healthcare interventions by WHO since early 1950s.

It is estimated that as at 2017, an estimated 253 million people live with vision impairment: 36 million are blind and 217 million have moderate to severe vision impairment. 81% of the visually impaired people are aged 50 years and over.  The visual impairment results from chronic eye diseases like glaucoma, maculopathies, retinopathy etc. It is estimated that the number of people with vision impairment could triple due to population growth and ageing. For example, by 2050 there could be 115 million people who are blind, up from 38.5 million in 2020. Women are 1.5-2.2 times more prone to visual impairment than men (1). The prevalence of infectious eye diseases has reduced significantly over the last 25 years.

An estimated 19 million children are vision impaired. An estimated 12 million children have vision impairment due to refractive error. An estimated 1.4 million have irreversible blindness.

Globally, chronic eye diseases are the main cause of vision loss contemporarily. Uncorrected refractive errors and un-operated cataract are the top two causes of vision impairment. Un-operated cataract remains the leading cause of blindness in low- and middle-income countries.

And down home in Nigeria...

 In 2002, 4.2 million Nigerians of 40years and above were estimated to have visual impairment.(2)

84% blindness and visual impairment in Nigeria is avoidable. Uncorrected refractive error is responsible for 57.1% of moderate (6/18–6/60) visual impairment. Cataract (43%) is the commonest cause of blindness (<3/60). Prevalence of cataract-related blindness is 1.8% and glaucoma-related blindness is 0.7%. Prevalence of blindness in Nigeria of age ≥40years+ is 4.2%. (3)

Visual impairment is associated with increasing age, being female, poor literacy, and residence in the North. The South West had the lowest prevalence while those in the North East had the highest prevalence of visual impairment and blindness.

Definitions

Vision function is classified in 4 broad categories, according to the International Classification of Diseases -10 (Update and Revision 2006):

• normal vision
• moderate vision impairment
• severe vision impairment (<6/18 to >3/60)
• Blindness. (<3/60 to NLP)

Moderate vision impairment and severe vision impairment are grouped under the term “low vision”.  Low vision and blindness represents all vision impairment.

The causes of visual impairment

According to recent estimates, the major global causes of moderate to severe vision impairment are:

• uncorrected refractive errors, 53%
• un-operated cataract, 25%
• age-related macular degeneration 4%
• glaucoma, 2%
• Diabetic retinopathy 1%.

The major causes of blindness are:

• un-operated cataract 35 %
• uncorrected refractive error 21 %
• Glaucoma 8 %.

Changes over the last twenty years 

Overall, the prevalence of vision impairment worldwide has decreased since early estimates in the 1990s. This decrease is associated with:

• overall socioeconomic development;
• concerted public health action;
• increased availability of eye care services;
• Awareness of the general population about solutions to the problems related to vision impairment (surgery, refraction devices, etc.).

The Right to Sight initiative was launched in 1999 by WHO and IAPB.  It was estimated that at least two-thirds of all blindness was avoidable (treatable or preventable) and that extremely cost-effective interventions were available to prevent or cure blindness. 
In short,

 “There was every reason to consider blindness prevention as one of the most worthwhile public health and developmental interventions that could be undertaken”. (4) 

What is prevention of blindness?

 

The prevention of blindness cannot be fully understood if we don’t understand the concept of prevention of diseases and apply it contemporarily to our eye care service provision.

Dr. VESEC, an acronym we shall use throughout our discussion to represent our primary eye care facility, is in the fore-front of applying preventive measures in tackling visual impairments and blindness. 

Preventive healthcare is a form of medical care that concentrates on the prevention of diseases or health maintenance of people. Preventive health care includes all activities aimed at promoting health, preventing illness, prolonging life, and improving the functioning of individuals. Disease prevention covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established. (5)

Therefore preventive health care can be conceptualized thus:

“Actions aimed at eradicating, eliminating, or minimizing the impact of disease and disability. The concept of prevention is best defined in the context of levels, traditionally called primary, secondary, and tertiary prevention.”

A historic perspective of the concept of preventive care...

The concept of prevention was expressed in 1959 by Herman E. Hilleboe, M.D and Dr. G. W. Larimore and has found considerable acceptance among administrators, epidemiologists, and social scientists alike.   A unified concept of prevention to the health worker embodies the application of knowledge and processes acquired from the medical, social, and environmental disciplines for the purpose of preventing the occurrence or progression of disease, defects, disabilities, and injuries.

In preventive medicine it is the individual, sick or well alike, who is the focus of attention. In public health, or community health, the focus is on groups of individuals, formed into a community, whose members face common health problems among whom an organized community effort is essential for their resolution.

In the early part of the twentieth century prevention meant mainly vaccination to avoid communicable diseases, the purification of water supplies, and the protection of food-especially milk -to avoid contamination with disease causing organisms. But as time went on many communicable diseases were largely brought under control and nutritional deficiencies were identified and became preventable. Prevention gradually came to be talked about and studied epidemiologically to include the degenerative diseases, injuries, defects, and a variety of disabilities associated with human ailments.

In the 1950s, health workers spoke of primary and secondary prevention, the latter pertaining largely to chronic illnesses. These terms had to be defined and were not self-explanatory to the uninitiated. Some enthusiasts went so far as to subdivide prevention into six or more different categories that could not easily be remembered or recalled without reference to the original articles of the writers. The spectrum covered everything in health from preconceptual counseling of prospective parents to preparing relatives for the psychological shock of the death of a loved one.(6)

Types of Prevention

a) Primordial prevention:

Primordial prevention consists of actions and measures that inhibit the emergence of risk factors.

Dr. VESEC always promotes ocular hygiene, use of sunshades by sea travellers; discourage the use of breast milk and other harmful and injurious substances in the eyes; we teach our patients and our host community at large about protecting the eyes from unnecessary trauma that could lead to blindness resulting from cataract or glaucoma, in fact we promote any measure that is not harmful to the eyes, any measure that will protect our eyes.

b) Primary prevention:

Primary prevention can be defined as the action taken prior to the onset of disease, which removes the possibility that the disease will ever occur. It signifies intervention in the prepathogenesis phase of a disease or health problem.

Dr. VESEC is a primary eye care provider. We all know that 81% causes of blindness and visual impairment can be avoided, treated or managed at the primary eye care level! Based on this, our eye care centre provides comprehensive eye care examination that is effective, efficient and affordable. In Nigeria, refractive error is a staggering 57.1% of the total visual impairment based on a 2009 international Ophthalmologists and Vision Science report! To bridge this gap, we provide very affordable consultation from $0 to $2. We also have taken steps to take our services to the people. Currently, we have an eye centre in Finima, Akiama and Cable road in Bonny Kingdom. Those areas have large number of population clusters to enable us reach to them. Our comprehensive eye care services are available in all the centres. Comprehensive eye care examination at the primary eye care level is the single most important primary preventive health care service that can identify avoidable causes of blindness!

c) Secondary prevention:

 “Action which halts the progress of a disease at its incipient stage and prevents complications.” 

Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases. Cataract, Glaucoma, Retinopathy, Maculopathy and severe refractive errors constitute severe visual impairments and can lead to irreversible blindness. 

Glaucoma, Maculopathy and retinopathy cause irreversible blindness. Dr. VESEC has prioritized them as the most dangerous causes of blindness amongst the list of the entire causes of blindness in Nigeria. We have incentivized the eye care screening and comprehensive eye examination for these conditions by making them free for all. We have severally collaborated with stakeholders to provide free Fasting blood sugar testing and free blood pressure measurements. We also provide free reading glasses for them.

Refractive errors, cataract and infectious ocular conditions including toxoplasmosis also cause blindness but with conventional management like surgery (we do referrals for cataract and refractive surgeries) and timely interventions with eye glasses and medications, their type of blindness are manageable and curable! With our comprehensive eye examination and detailed family medical history, we provide secondary preventive eye care services to help us fight blindness and visual impairment. 

Still on the issue of secondary preventive eye care for cataract, the major cause of blindness both in Nigeria and globally... 

Cataract surgery is not within the scope of Optometry practice in Nigeria for now and to access cataract surgery on the Island happens only during free medical outreaches. For those who need cataract surgery we refer and the closest referral hospitals are found in Port-Harcourt and the cost of surgery there is very expensive. Access to surgery in Port-Harcourt town is poor because of urbanization and increasing population.

Cataract causes 43% of  severe visual impairment in Nigeria and contributes about 35% of global cause of blindness. The prevalence of cataract is high on the Island. Of every 10 patients, 40 years and above, 5 have varying stages of cataract eye disease on the Island and that is a red flag! To help in this area, we are developing a process where we can invite cataract surgeons to the Island periodically, who will provide very affordable, cost-effective cataract surgeries for residents. It is a work in progress.

d) Tertiary prevention:

 “all the measures available to reduce or limit impairments and disabilities, and to promote the patients’ adjustment to irremediable conditions.”

 Intervention that should be accomplished in the stage of tertiary prevention are disability limitation and rehabilitation. It is used when the disease process has advanced beyond its early stages and cure cannot be achieved.

Glaucoma, retinopathies, age related ocular degenerations and maculopathies can cause devastating irreversible blindness and make patients become despondent and even suicidal. Others are ocular surgery complications. We provide free counseling services for these patients. We also advise them on how to embrace the new realities of sub-normal to no vision at all. It is the most challenging task Dr. VESEC has embarked on since inception. We do not wish to leave anyone behind, not even the blind or those with low vision. Of those with low vision, we provide a very effective referral system to further buttress our position on not leaving anyone behind. 

To be continued…

References and links

1) WHO 2002 report

2) Prevalence of Blindness and Visual Impairment in Nigeria: The National Blindness and Visual Impairment Survey. Fatima Kyari et al and the Nigeria National Blindness and Visual Impairment Study Group. IOVS, May 2009, Vol. 50, No. 5.

3) Causes of Blindness and Visual Impairment in Nigeria: The Nigeria National Blindness and Visual Impairment Survey. Mohammed M. Abdull et al. IOVS, September 2009, Vol. 50, No. 9.

4) International Agency for the Prevention of Blindness 2010 Report 

5) Glossary Terms used in Health for All series (N°9). Geneva: WHO; 1984.

6) Herman E. Hilleboe, M.D., M.P.H., F.A.P.H.A.  MODERN CONCEPTS OF PREVENTION IN COMMUNITY HEALTH. VOL. 61. NO. 5, A.J.P.H.  1000-1006: MAY. 1971). (https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.61.5.1000) 

From the Cradle... A journey into universal eye care service delivery!

The WHO defines universal health coverage-and hence Universal Eye Health – as “ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services”.

Murphy G et al, refers to primary eye care as a combination of activities encompassing promotive, preventive, therapeutic and rehabilitation services delivered at the community level to avert serious sequels resulting in blindness.

When I started this journey, the objective was to fight blindness. It still remains our core believe, our ideology and the very purpose we exist. 

Blindness does not have a cure. Majority of the conditions that lead to blindness are usually preventable. According to WHO, over 80% curses of blindness can be prevented.

Managing blindness is very expensive. Principally therefore, primary level care aims to deliver affordable eye care services to all, irrespective of the socio-economic abilities of the individuals.

To effectively fight blindness, I adopted these 4 activities:

a) Promotive eye care service delivery

b) Preventive eye care service delivery

c) Curative eye care service delivery

d) Rehabilitative eye care service delivery

I came to Bonny Island on February 1st 2012 as a resident Optometrist. I was contacted by Dr Omila Alagoa, MD, to work for her in her hospital in Bonny Island. Her hospital, PAN-OJ Hospital, offers varieties of health care services including eye care services. I was deployed to head the eye care service unit. I stopped working in PAN-OJ Hospital in May 2015. I needed to pursue my career. I've being fraternizing with the concept of social medicine right from when I was a student in the university. The concept of social medicine fit into my passion to study Optometry in Abia state University.

 I used to remember how in our 5th year, we go for community eye care oureaches under the tutelage of Dr Emmanuel Nwaji et al. On every visit to a different community, the faces of those in need for our eye care outreaches, the abject poverty and the indigent nature of most patients struck a cord. How can I help these indigent persons with very little access to eye care services? How can I sustain my eye care service provision when these individuals cannot pay for the services? How can I get them to easily access eye care services without putting a huge burden of debt on my head? How can I provide consumables like eye glasses & eye drops to these indigent villagers when they cannot pay? How can I provide them with cataract surgery, trabeculectomy surgery and other ocular surgeries that are sight restorative when the cost is very high?  

 Unfortunately we are in Nigeria where over 90% of medical bills are paid out of the pocket. The cost of most Ophthalmology services are very high due to governmental policies and neglect. In a country with over 63% poverty rate as at 2018 (according to a Channels TV analysis), it is not surprising that the fight against blindness may not be won.

  In February 2nd 2016, I set up a primary eye centre to bridge the gap! As it has being the practice since WHO conceptualized primary eye care as an integral part of primary health care in Almaty, 1978, at the declaration of the International Conference on Primary Healthcare, we imbibed and entrenched the concept of primary health care delivery in every aspect of eye care service delivery. 

 Primary health care consists of:

 “…essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”.

 My aim remains to fight blindness and the goal was to adopt a very cost effective method to achieve that objective while not compromising on the quality of our service delivery.
We have our target horned on two primary objectives of making essential eye care services available to all and to eliminate avoidable blindness in line with the WHO vision 2020. This was how Dr. Victor Ezebuiroh Specialist Eye Centre (Dr. VESEC) was born.

 Dr. VESEC is premised on the four fundamentals of efficient eye care service delivery by provision of promotive eye care services, preventive eye care services, curative/Therapeutic eye care services and rehabilitative eye care services. 
I will discuss each fundamental premise on its merit and  how we have tried to adopt those service delivery fundamentals in setting up Dr. VESEC.

a) Promotive Eye Care Service

 The concept of eye health promotion was first elaborated in 1986 in the OHAWA Charter. There are three areas of action:-

·        (i) Health education: Including use of mass media and face to face communication.

·        (iii) Reorientation (service improvement)

·        (iii) Advocacy.

One of the strengths of eye health education is it's ability to be a starting point for involving communities in addressing a wide range of health and social concerns.

For health promotion to be successful, it must be built on understanding of the health topic and the intended audience. Evaluation of health promotion programs provide information and feedback in a three way circle with the ultimate goal of improved eye health. Effective Eye Health promotion involves a combination of three components:-

a.  * Health education directed at behaviour changes to increase adoption of prevention behaviours and uptake of services. Dr. VESEC is in the fore-front of providing materials, documents and talks in Social media and other forums aimed at educating our host community about some practices that affects the integrity of the eyes. For instance, we use every opportunity to discuss the harmful practice of using breast milk or urine or local gin to treat conjunctivitis or any kind of red eyes. We also frown at people who visit quacks for couching (an outdated and harmful type of cataract surgery!) and practices like using onions to apply in the eyes for whatever reason. The effect and attendant behavioural changes have increased patient registrations and service uptake in various eye centres in Bonny Kingdom.

2. * Improvements in health services such as the strengthening of patient education and increased accessibility and acceptability. Dr. VESEC is poised to adopt contemporary technological improvements in the area of eye care services and equipment; improving our referral system (I will soon develop a compendium of secondary and tertiary eye care services centres and a correspondence to improve accessibility to eye care services) and we ensure that every individual in our host community accepts our eye care service delivery because we ensure that our services conform to internationally acceptable gold standard service delivery.

3.  * Advocacy for improved political support for blindness prevention policies. Human behaviour, community participation and advocacy to government for resources are paramount for successful eye health promotion.

Community participation is pivotal to successful implementation of primary health care (PHC) and hence primary eye care. 

The 1978 declaration of Alma-Ata identified community participation as:

“the process by which individuals & families assume responsibility for their own health and welfare and for those of the community, and develop the capacity to contribute to their community’s development." (WHO, 1978).

 National health policy of 1987 emphasizes on active community engagement in the provision of PHC. In our  'About us" of our eye centre, our responsibility to the host community is a major feature. It has led to the setting up of Finima Community Eye Centre, a subsidiary of Dr. VESEC, since September 2017. 

We have taken our eye care campaigns to political leaders of Bonny Kingdom. We have met with the legislative member of the Green Chamber representing Bonny/Degema constituencies on various occasions and have heard very productive discussions. One of such meetings led to the invitation of Lulu Briggs foundation sometime ago which provided free cataract surgery for over 100 individuals and provided glasses and eye drops for over 500 persons! Our advocacy led to the Finima community eye centre which was a product of our meetings with Finima community elders in 2017. Our advocacy also attracted Lions Club NLNG. We are not resting on our oars. We are planning to seek an audience with the King of Bonny Kingdom before the World Sight Day in the second week of October 2018.

To be continued...