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THE grim statistics tell their own story. People in Africa are ten times more likely to lose their sight than are people in the developed world and an estimated 80% of blindness on that continent is preventable. It was precisely this ongoing tragedy that in 1987 prompted two French Rotary Club members, Marcel Jouandet, a former high school principal in Northern Cameroon and Dr Michel Chateauneuf a French ophthalmologist in Blaye near Bordeaux , to take action. Together they formed a new non-governmental organisation, Ophtalmo Sans Frontières (OSF) dedicated to fighting blindness and low vision in Francophone Africa. By raising funds from the international Rotary Association, OSF sought to build and equip health centres where people could get affordable medical and surgical modern ophthalmic care. Cataract surgery, which has been described by the World Bank as "the most highly cost-effective" surgical intervention that can be offered in the developing world, provided an obvious starting point for OSF. But other maladies also needlessly claim eyesight in Africa . Effective, low-cost preventative measures are available for trachoma, river blindness and vitamin A deficiency, but without the necessary resources many Africans are simply left to their fate.
OSF's initial efforts concentrated on Cameroon , in large part due to the fact that Marcel Jouandet, the current honorary president of OSF, has strong links with the country. "We've been making a huge effort in Cameroon for the past 15 years and I think we can be proud of what we have achieved there, although there is always more work to be done," said Marcel Jouandet. "I have Cameroonian origins and I have a great interest and affection for that country. I worked for many years in Cameroon and saw that there was a real need for something to be done to help the people." As well as Cameroon , OSF, whose volunteers include some 280 ophthalmologists, 63 nurses and orthoptists, has gradually extended its influence into other countries as the organisation's resources have grown. The organisation has five ophthalmology centres operating in Cameroon , as well as operations in Madagascar , Morocco and Mauritania . In terms of working methods, OSF has concentrated its efforts primarily on rural areas where pathologies such as trachoma, glaucoma and onchocerciasis (river blindness) are rife. In North Cameroon, for instance, over 3.1 million inhabitants, most of whom are extremely poor, live dispersed over an area of 150 000 km2. For such people, life expectancy is 49 years for men and 53 years for women. OSF provides primary eye care – including diagnosis, surgery and provision of eyeglasses – for the populations in these remote regions. Since 1988, OSF has carried out more than 221,994 consultations and 42,472 operations, almost 35,000 of who which were for cataracts. However, an equally vital part of OSF's mission is the training and teaching of local eye doctors and nurses, to enable them to operate self-sufficiently. Since 1997, 32 doctors and 185 nurses have been trained in primary ophthalmic care, and another six doctors and eight nurses have qualified to perform microsurgery. Lionel Stork MD, a French ophthalmologist who has carried out voluntary work with OSF since the early 1990s, says that the organisation now places great emphasis on giving young African doctors the necessary skills and training to provide primary eye care for their own populations. "In the beginning, OSF sent many expatriate ophthalmologists, nurses and orthoptists, most of whom were French, to fulfill its goal in Northern Cameroon . Some young African ophthalmologists also volunteered for missions and they got the opportunity to get a broader surgical experience under the supervision of more experienced older French colleagues before establishing practices in their own countries," he said. As the eye centres were developed and public health structures improved in cooperation with the health authorities of Cameroon , OSF teams discovered that the African nurses who had worked with them for many years were becoming more interested in ophthalmology. Indeed, some of them were even skilled surgeons when performing minor procedures under supervision.
However, as Dr Stork explains, the process of sending expatriates for short time missions proved to be more and more complicated due to the shortage of volunteers, and centres could stay many weeks without performing a surgical procedure. "It then became obvious that providing a medical and surgical ophthalmic experience to our African nurses could allow the centres to operate all year round. So, in cooperation with the health authorities of Cameroon , the more highly skilled nurses were sent to the Institut d'ophtalomologie Tropicale Africaine (IOTA) in Bamako , Mali , where they trained for two years to become ophthalmic nurses." Such a strategy has been an unqualified success and points the way forward for other regions in Africa , noted Dr Stork. "All the centres are now run by African nurses who can perform up to 1000 surgical procedures a year, and many people come from neighbouring countries such as Chad , Nigeria , and the Central African Republic to get access to ophthalmic cares provided by the centres," he said. Like other non-governmental health organisations working in the developing world, OSF is well aware that there is no room for complacency in the battle to turn the tide on preventable blindness. It has been estimated that the 45 million blind people in the world today could increase to 76 million by the year 2020 if left unchecked. Marcel Jouandet points out that the absence of basic hygiene is largely responsible for the proliferation of diseases such as trachoma, which is endemic in northern Cameroon . Furthermore, although the surgical treatment of a disease such as trichiasis is relatively straightforward and can be performed by nurses in the rural clinics, its prevention requires the active participation of a broad spectrum of health workers and authorities as well as thorough knowledge of the way of life of the affected population. Poor hygiene practices also pose considerable problems for postoperative patient care.
Postoperative follow-up after surgery is also especially difficult in Africa , where patients with few material resources are often reluctant to make what is often a long and arduous return journey to the clinic for a check-up. OSF estimates that 85% of patients return eight days after surgery for check-up, but only 45% at the one-month period. Presbyopia, aphakia and hypermetropia are among the most persistent refractive problems encountered by OSF in Francophone Africa. Patients can get discounted corrective lenses or glasses in the eye centres. The centres are all fully equipped – visual acuity charts, slit lamps, ophthalmoscopes, etc – to perform a proper examination and diagnosis by medical experts on site. For the future, OSF is looking to consolidate its presence in Francophone Africa and continue its programme of education and training for local nurses and doctors. In addition to its ongoing efforts in the battle against perennial problems such as glaucoma and trachoma, OSF is also drawing up contingency plans to deal with the increase in posterior capsule opacification (PCO) rates after cataract surgery. "Our aim has always been to try to provide the best ophthalmic cares, and in recent years, we have widely used intraocular implants in cataracts. "We are now concerned by the PCO that might develop after manual extracapsular extraction and its consequences on the sight of operated people. We are currently undertaking a study to evaluate its rate and to determine the best ways to prevent or to treat it, as no YAG laser is available in Northern Cameroon ," said Dr Stork. According to Dr Stork, the next goal for OSF is to build a dedicated school to train Francophone African nurses in ophthalmology, because it is no longer possible for them to train in IOTA. The project is being developed in conjunction with the health ministry of Cameroon and after completion of their training, students will be offered OSF logistical support to create ophthalmic centres along the lines of those already established in Northern Cameroon .Marcel Jouandet agrees that OSF's work is, in some respects, only beginning. "In an ideal world, there would be no need for an organisation like OSF to exist. But the unfortunate reality is that there is plenty more work to be done – there are always more cataracts, more glaucoma cases, and more local doctors and nurses in need of training," he said. For Lionel Stork, the bottom line is that working with OSF allows him to use his skills and training to help those less fortunate than himself – and that's more than enough recompense in itself. "There is nothing more rewarding for an ophthalmologist that to give back the sight to the blind. I can't afford to spend a long time on missions far from my family any more, but I know that each time an African blind person can see again thanks to the people who work with us, I'm a small part of it." Ophtalmo Sans Frontières www.opht-sans-frontieres.org Lionel Stork, MD,
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