Getting Back on Track: Humanitarian Eye Health Post-Pandemic

STARTING FROM SCRATCH

Cambodia Vision, a team comprising ophthalmologists, optometrists, nurses, general practitioners, pharmacists, and other volunteers, has been carrying out cataract procedures, free of charge, for Cambodians since 2007 and, more recently, general medical care, hearing and speech therapy services. That was until COVID-19 interrupted.

Due to travel restrictions, and safety concerns surrounding COVID-19, in 2020 and 2021 Cambodia Vision was unable to undertake its annual mission. Now, however, there is light at the end of the tunnel.

When we went to check on our stock in June, unfortunately all of our consumables were either expired or damaged

In June this year, a seven-person strong delegation travelled to Cambodia, for the first time since 2019, with three important objectives – to check on the stock and equipment left behind, visit a new location, and scope out the current COVID-19 situation – the outcomes of which would determine the viability of a 2022 mission to Cambodia.

When mivision spoke to organiser Thida Yang upon the delegation’s return, she was pleased to report that plans for a mission in December were underway, though not without considerable changes to the usual approach, and with the addition of new and daunting obstacles to overcome.

“Upon our return in December, things will certainly be different. Five months is not much time to plan and there’s a lot of planning that goes into it. It can be a logistical nightmare,” said Ms Yang.

“When we went to check on our stock in June, unfortunately all of our consumables were either expired or damaged, so we no longer have GP supplies in the country.”

These supplies were supposed to service the patients who visit the pop-up clinic for general health needs, a component of the program that has expanded in recent years. Knowing that these GP supplies are no longer available, the team has decided to scale back on the care provided.

“This smaller scale means we will focus on ophthalmic surgeries and maybe prescription glasses, depending on whether we can get a donation of lenses and frames and get a technician on board. Because we don’t have the supplies for the GP services, we will probably only require one or two GPs to come along and do the pre-op check,” says Ms Yang.

Ms Yang expects a significant reduction in volunteers able to make the journey. In 2019 there were 84 people involved from Australia alone, as well as local volunteers and additional surgeons from China, Hong Kong, and Taiwan. This time around, the surgeons from Asia will be unable to join because of COVID-19 restrictions and, although all six Australian surgeons are keen and ready, other factors – including the ability to mobilise enough people at such short notice, and the hesitancy of some to travel – has made recruiting other volunteers difficult. At this stage, Ms Yang says she is hopeful to establish a team of between 40 and 50 people.

Despite scaling back, the duration of the mission will remain the same, with six days of surgery expected to take place. Regardless of the size of the team, the number of patients expected to flood through the doors of the provincial hospital in the Kampong Cham Province, where the Cambodia Vision team will set up, will show no mercy.

“This particular province is a new location for us and is one of the largest provinces in the country. Its population is almost one million,” said Ms Yang.

“Wherever we are, however far, people from Kampong Cham always travel to us. They’re very keen. And people will now travel from all over Cambodia to meet us in this new location.”

In previous years, it was not unusual for the Cambodia Vision team to welcome up to 600 people a day. Given services haven’t been provided since 2019, Ms Yang is expecting demand to be even higher.

“People have been contacting us as to when we’re going to get back. It’s going to be one of our biggest challenges to scale back the service despite the demand.”

Further complicating things, all patients will have to be rapid antigen tested (RAT) upon arrival.

“Normally people could come on any of the six days, register on the spot, be issued a number, then sent for the various scanning stages, followed by surgery, should they require it, and for post-op. But now we will have to create a new team responsible for RAT testing everyone prior to registering. If they test positive, they can’t go through the system.”

If supplies weren’t already enough of an issue, COVID-Safe precautions require extra personal protective equipment. This is on top of the need to buy updated surgical equipment. And then there’s the mammoth task of transporting it all from Australia to Cambodia.

“Normally we would send a container over around July, if we were going in October. But we are not able to do that this time due to pricing and availability. Instead, we will have to carry our supplies by hand, and, with fewer volunteers with us, our baggage allowance will not be a lot. It’s not just the supplies, it’s also the equipment. Our optometrists will carry their equipment along and our surgeons will carry phaco machines, microscopes etc.”

The COVID-imposed challenges don’t end there.

“People also talk about the mass resignation. Well, a lot of the suppliers, donors, and sponsors we’ve built relationships with have left the companies. So, we’re now trying to find replacements and build relationships with new people again. As well as this, our fund-raising ability is also more limited. Many people are frightened still by COVID, and some have lost their businesses and are, understandably, not in a financial position to donate.”

While all these challenges lie ahead, Ms Yang and her team are not deterred. “Although the December trip is like starting everything again from scratch, we’re really excited to get back and continue making a massive difference to the people in Cambodia. We’re a strong and proud team.”

NEW TERRAIN

For Eyes4Everest, an organisation kickstarted in 2013 by Sydney optometrist Shaun Chang after his visit to a Sherpa hospital in Khumjung, Nepal, the pandemic has also changed the nature of how services are provided in this remote part of the world.

Before the pandemic, the Everest region thrived on tourism, most of which disappeared overnight, Shaun told mivision.

“Additionally, Everest had zero COVID cases, and the government wanted to keep it that way. That’s why the region was closed to visitors for about 12 months.”

While this turbulent time signalled the end of Eyes4Everest’s usual volunteer trips, Mr Chang continued working closely with the Himalayan Trust Nepal (HTN) and the Rural Municipality in the Everest region.

“We have worked with Nepalese optometrists ever since Eyes4Everest began. In 2017 and 2018, Tashy Sherpa came to Sydney and completed her Master of Optometry. Thanks to COVID, we are still fortunate to have her here.

“Tashy has gained a wealth of experience working in independent optometry and ophthalmology at the Save Sight Institute, thanks to our previous volunteer Wendy Berkeley and our Treasurer, Grace Wee.

“We also had Rickchen Sherpa optometrist, who joined us in 2018 and 2019. He learnt a lot about how we conduct eye testing and understood what needed to be done. During the pandemic, when we had no volunteer trips, I trained him to do some remote optometry work for my practice. The quality of Rickchen’s work is something I can attest to.”

At the request of the HTN, an all-Nepalese optometry team was sent in April this year. Rickchen Sherpa took two optometrists with him, as well as the main guide and two assistant guides from previous volunteer trips.

All up, the team saw a total of 83 patients at the Khunde Hospital, built by Mr Chang’s childhood role model, Sir Edmund Hillary, and, following a five hour walk, another 90 patients at the Phortse Health Clinic. Fortyfive patients were identified with refractive errors, including presbyopia, and 16 were identified with cataracts. A case of bilateral ectropion was also detected, and referrals and spectacle prescriptions were provided.

Mr Chang noted that there were some differences compared to the pre-pandemic volunteer trips.

“For one, there was less emphasis on binocular vision testing because we didn’t have the numbers to do this comprehensively. You might ask why we didn’t have enough optometrists? The truth is, I didn’t know how many patients would turn up after two years of absence!

“We also didn’t offer a dispensary service, partly because of the same reason. In the past, we would take a small fee for the glasses and send the patient’s prescription back to Kathmandu, where it would be made up. A guide or assistant guide would then take the glasses back up to the village later. This doesn’t sound like much, but logistically it’s a big task, with lots of costs involved.”

Inspired by the presence of the Eyes4Everest team in the region, in 2019, an eye clinic was set up within a private hospital at Namche. Mr Chang had met with the ophthalmic technician there who saw roughly two patients a day and provided vision screening to the local villages.

“I was glad that there was a permanent eye clinic – somewhere people can go to any time of the year, so I was incredibly sad to learn that the hospital had to close due to the pandemic. This was still the case when our Nepalese team visited in April.”

Mr Chang believes that it is likely conditions are being left untreated due to the closure. This belief is further supported by the fact that, last year, the Tilganga Eye Institute sent a team to Khunde Hospital, where they did 45 cataract surgeries.

“That is heaps for one region, considering the last time something happened at Khunde, they only did five surgeries. I suppose we won’t know for sure the extent of unmet need until we return again,” said Mr Chang.

The nature of this return, for Mr Chang and his Eyes4Everest team, is uncertain. Government red tape has complicated how volunteers operate in the Everest region. As well as this, volunteers face barriers in terms of the costs involved, and the health risk of catching COVID in a low oxygen environment – something insurance won’t cover.

Mr Chang says, in the meantime, he will work with the HTN to provide scholarships so one of the region’s nurses can be trained in vision screening, as well as commence a plan to extend the Khunde Hospital to convert it into an eye and dental clinic.

“There is still a mission that my team and I have to go back for. I have to oversee some projects, and I will take the necessary precautions to keep myself well. That is all one can do,” he says.

ON HOME SOIL

When the pandemic began, keeping Aboriginal and Torres Strait Islander people safe from the spread of COVID-19 became a main priority for Indigenous leaders and those who provide health services to remote parts of Australia. For the Fred Hollows Foundation, this meant the cessation of access to vulnerable communities for extended periods of time.

This challenge greatly affected The Foundation’s work in remote communities, where over one-third of Aboriginal and Torres Strait Islander people have never had an eye exam.

“In Australia, the pandemic has widened the gap in eye health between Aboriginal and Torres Strait Islander peoples and other Australians, adding to the already-large backlog of surgeries needed,” Ian Wishart, CEO of The Fred Hollows Foundation, told mivision.

When elective surgery re-commenced, The Foundation’s focus was on ensuring fair representation for Aboriginal and Torres Strait Islander people, to ensure they were not at the back of the cataract surgery waitlists.

“We also held a cataract surgery intensive to help clear the backlog for Aboriginal and Torres Strait Islander people in the Darwin and Palmerston region in partnership with Healthscope and Royal Darwin Hospital,” said Mr Wishart.

The peak of the pandemic also had a significant effect on the outreach program undertaken by Doctor of Optometry students from the University of Western Australia (UWA). To protect communities where outbreaks occurred but the vaccination rates were not as high, clinical placements were delayed until June this year.

Khyber Alam, Senior Lecturer and Course Director at UWA, travelled with two students to the Ngaanyatjarra Lands in Western Australia – an area that makes up 3% of Australia, with a population of 3,000 people.

Reflecting on the cancelled trips, and the cases seen in his recent visit, Mr Alam said, “I think about the impact of the delayed services because, on this trip, we saw patients who had missed earlier clinics. For example, there was a man who turned up to the clinic when I was there who had a really painful corneal infection.

“He had waited about four days for the clinic to arrive… if you cancel services and the usual gap of about two or three months extends to six to 12 months – imagine what happens in the communities. It’s absolutely crucial that the service delivery is maintained throughout the year, disruptions like COVID significantly impact those communities,” said Mr Alam.

UNMET NEED

Mr Alam is no stranger to the unequal distribution of eye health services, and indeed health services in general. Having travelled to Australia from Afghanistan at the age of 13, he has lived experience of the disadvantages, and a unique insight into the devastating situation that many Afghans have faced for decades.

“In Afghanistan, there is a lack of structure, from the local level right up to the central government level, and when it comes to health delivery, it’s equivalent to nothing. As an example, during the pandemic, for a state of about two million people, there was one hospital with one intensive care unit,” said Mr Alam.

“For a country of 38 million people, you have about 150 ophthalmologists, and there’s a complete absence of an optometry workforce. There is a middle level of insufficiently trained nurses or people helping the ophthalmologists. Even then, you have about 74% of the population that lives in rural communities in Afghanistan and the service delivery is still limited to the larger cities such as Kabul, Herat and Kandahar. But in communities where people need care the most, there is absolutely no access.”

Mr Alam spoke of a girl who required an eye examination as she was experiencing severe headaches and eye pain – possibly due to eye tumours, angle closure or other serious life or sight threatening pathology. Because there were no services in Afghanistan, the patient was required to travel to neighbouring Pakistan.

“However, because of the government change that happened in Afghanistan, obtaining a visa has become more difficult. We couldn’t get her through to the other side for care. There was a huge delay,” said Mr Alam.

While the danger caused by an unstable government and continuation of a war that has spanned nearly 50 years has placed Afghanistan in the ‘too hard basket’ for many, when it comes to providing outreach eye care services, Mr Alam says the task is not impossible.

“If you have the right people coming together, I’m quite certain that someone would be able to design a program to intervene and at least provide some base-level service in the communities. It’s important to start somewhere,” he said.

Mr Alam could well be the person for the job. With a lack of data being the main obstacle in strategically planning an initiative, he hopes to one day undertake a myopia study that will provide an evidence base that leads to programs to provide glasses and screening tests to school-age children across the country.

“Unfortunately, there seems to be no end to the war, the instability will continue. And therefore, I think people have to intervene regardless. If we don’t intervene now, the further you delay it, the more eye health complications we will have to deal with as time goes by.”

ADAPT AND OVERCOME

Despite the challenges, around the world and in Australia, people and organisations continue to work together to adapt as they come to terms with the new terrain.

Last year, while disruption continued, The Fred Hollows Foundation and their partners were able to screen more than three million people around the world and support more than 330,184 eye operations and treatments.

Impressive, considering the circumstances.

However, for some programs, new terrain has led to far different changes. After 23 years of optical service, Equal Health, an organisation responsible for providing free multi-disciplinary health services to people in need, will sadly no longer include eye care in its health direction.

Hero image: Mally Nun with patients. Image courtesy of Cambodia Vision.