March 20, 2017
Two hundred and eighty-five million people are estimated to be visually impaired worldwide. Thirty-nine million of these people are blind. Ninety percent live in low-income settings (1). Globally, cataracts and glaucoma remain the leading causes of blindness in low-income countries. However, these conditions are treatable, and low-cost remedies are available: a 15-minute operation can restore sight for cataracts patients, and eye drops can slow the progression of glaucoma. So why are there still such high rates of blindness in low- and middle-income countries like Ghana? If each cataract surgery only costs $50 and there are millions of dollars in donations (Unite for Sight alone has received $2.23 million thus far (2)), what other barriers prevent patients from seeking treatment?
I wanted to find out. During the summer of 2016, I traveled to Ghana to complete a service project with DukeEngage and Unite for Sight that aimed to relieve the backlog of patients in need of eye screenings and surgeries. There, I helped local doctors conduct screenings in remote villages to find patients in need of eye surgery and assisted with their postoperative care in attempt to come closer to answering some of these questions.
Fear and Distrust
For many patients, financial barriers are the most commonly cited reasons patients do not follow through with ophthalmic surgery (3). Not only is the $50 surgery beyond many patients’ budgets, but “hidden fees” also amplify the cost. For instance, patients must account for accommodation costs for accompanying family members, lost work income, and postoperative medication fees.
While conducting screenings, many patients are reluctant to obtain medication for damaging, progressive conditions, such as glaucoma, merely because the cost is unforeseen. Many did not come to the screening expecting to pay for their medicine and are averse when presented with these unanticipated costs. Aside from experiencing the same financial barriers as their male counterparts, Ghanaian women also find it more difficult to obtain funds for their medicine, especially those who are widowed. Confronting patriarchal values, women who reside in rural communities are even more reluctant because they have little to no control over household finances (4).
Even when the patients learn about the life-threatening consequences of these conditions, many are still disinclined to seek treatment because of a widespread fear of eye doctors. This apprehension develops from many reasons, including the thought of being under the knife, rumors about past surgical results, and hospital myths. When the notion of having an eyeball sliced open in an unfamiliar procedure is compared to receiving traditional, painless (albeit ineffective) treatments, many patients opt to go for the latter. Some patients even approached our clinics looking to buy refills for herbal remedies. This highlights that basic eye health is not commonly understood.
This lack of understanding often manifests itself in the spreading of rumors. Often, out of fear, patients see a physician too late. Despite this, they may still blame their vision loss on the clinician. When the clinic fails to educate the patient on the reason behind his vision loss, myths propagate, thereby affecting a whole village’s impression of doctors. Patients are also plagued by other myths: examples include believing that surgeons will replace their eyes with animal eyes during surgery, and that foreign physicians will purposely try to ruin their vision since they are from a different tribe.
The villagers’ distrust also stems from foreign involvement. Villagers are often affected by surgical safaris—expeditions in which foreign surgeons travel to low-income countries for a short period, perform surgeries, and depart without adequate follow-ups. When visiting doctors do not work with their local counterparts, no follow-up care is provided and infections that may arise after the operating surgeons depart cannot be treated. According to Unite for Sight, countries like Ghana are often victims of these surgical safaris (5). These well-intentioned trips often lend to disastrous consequences: the ramifications of botched surgeries affect more than just the surgical patients and their families. A single poor surgical outcome can lead an entire village to fear doctors and surgery on a long-term basis (5).
During the months I spent in Ghana, I saw several examples of such irresponsible expeditions. There were the failed cataract cases from an Italian surgeon who never checked on his patients before leaving. Patients even asked us volunteers to perform their surgery instead of the local doctors because they believed the doctors practiced witchcraft in the operating room. The UFS Global Impact Corps has partnered with local ophthalmologists to efficiently address these issues and provide care to those who stand behind such barriers. As a result of this partnership, four of the United for Sight-sponsored ophthalmologists have now provide almost 50% of all surgeries provided to Ghanaians, and the organization has quadrupled the annual number of surgeries performed by clinics in the country (4).
The Next Generation of Eyes
While there are ongoing efforts to provide eye-restoring surgeries for adults in Ghana, there is comparatively much less work to provide aid to children. During my stay I became curious about the impact of family attitudes on the eye health of their children. As a follow-up on my work in Ghana, I researched perceptions and barriers in childhood eye care in Ghana and sought to uncover a relationship between childhood teachings about eye care and the number of preventable blindness among older populations.
In a 2015 study, Ramai et al. showed that 95% of patients from Ghana, Honduras, and India (all countries with similarly high prevalence of preventable blindnesses) acknowledged that eye exams were beneficial to their children’s eyes (6). Interestingly, 67% of participants reported to have never brought their child in for an eye examination. What was the cause of such an obvious mismatch?
The primary reasons for a lack of eye screenings for children were that the child was at work/school or lived away from home. Child labor is, unfortunately, quite common in Ghana, especially in the fishing industry. During my travel with the Unite for Sight team to Kafaba, a village situated by the banks of Lake Volta, I saw 10 rickety fishing boats in the lake, each with at least one boy inside scooping lake water out of the leaky boats to prevent the vessels from capsizing. The locals explained to us that these children were either abducted or sold by their families at a young age and spent their days at the lake helping fishermen. Many children were sold or leased by their parents to fishermen for as little as $20 a year. This type of indentured servitude is not uncommon in West African families and it is seen as a survival strategy. Parents often cannot afford to feed their children at home, so they “rent” their kids out to fishermen in the hope of receiving them back in a few years.
Unfortunately, the locals told me with shaking heads that the living conditions of these kids are often very poor during their time in servitude. The children suffer frequent beatings, are fed meager meals, and are generally seen by their bosses as tools for labor. Further, the children miss a host of educational opportunities during their time working for these fishermen. And since they work so often under the sun where strong winds over the lake blow sediment into their eyes, many kids develop cataracts early on, and pterygium, a condition in which a layer of skin grows over the cornea causing discomfort and obstructing vision. Providing them with adequate eye care was completely out of the question. Although there are organizations, such as the Mercy Project, that are working to bring these kids back to their families and help them return to school, the absence of children from the home is prominent in Ghana, constituting a major reason for their lack of eye exams.
Young girls and women in Ghana face an entirely different set of barriers: Ghana has one of the highest child marriage prevalence rates in the world. Half of Ghana’s female population experiences motherhood by the age of 20. Like the boys who were absent from home to alleviate their home’s financial burden, girls often became pregnant from transactional sex to obtain money or basic needs. Other reasons including sexual violence or wanting pregnancy to command respect from others also persist (7).
Upon delivering the baby, many women are likely to be more preoccupied with childrearing than education, making them less likely to seek treatment themselves. Their early transition into domestic livelihood is even more concerning because girls who cook to feed families often use unsafe indoor cooking methods that promote pterygium and cataract growth in their own eyes. A 2013 study showed that only 7% of women who had kids correctly answered questions related to eye health care and eye disease prevention (8). In fact, the twenty women in the study who were not mothers had the highest rate of success on the survey. This suggests that children are not receiving the care they need because their mothers are not able identify their symptoms of vision problems (7). Since the children themselves do not complain of symptoms, this, coupled with their mother’s inability to recognize their vision problems, compounds the false notion that the children have no eye problems (8). Furthering the understanding of vision impairment in Ghana, especially for mothers and removing crippling societal norms for children are imperative for the future generation of Ghanaian eyes.
Looking to the Future
Ghana faces the immense job of healing its many citizens who are visually impaired. But, as I have seen first-hand, there are a multitude of hurdles to overcome. Many of these barriers were not immediately obvious to me prior to working in Ghana, and are deeply rooted in the society itself. The image of a line of eager patients standing outside the Unite for Sight’s camp waiting to see clearly again was stained by the realities of the situation—the associated costs, the fear of being “sliced open,” and the perception of doctors as witches.
The future does not look promising for the coming generation of Ghanaians either; Ghana’s children are no better off than the adults. The prevalence of indentured servitude and early motherhood in girls are preventing families from seeking eye treatment. These factors are contributing to the onset of cataracts and pterygium. Ongoing efforts through non-profit organizations, such as the Mercy Project and Unite for Sight Global Impact Corps, are making encouraging improvements. However, preventable vision loss is still common in Ghana. Interventions need to be installed upstream of the problem – these include taking measures to keep young children in school, educating citizens about basic eye hygiene, and informing families on the process of identifying impairing eye conditions before they grow into larger issues. Involvement from the government is critical because, as I have seen, non-profits can only do so much. However, I am confident that if the right steps are made now, Ghanaians can create for themselves a clearer and brighter future.
- “Visual Impairment and Blindness.” World Health Organization. World Health Organization, n.d. Web. 20 Jan. 2017.
- “Unite For Sight.” Donation FAQ. Unite for Sight, n.d. Web. 20 Jan. 2017.
- Gyasi, M.E., Amoaku, W.M.K., and Asamany, D.K. “Barriers to Cataract Surgical Uptake in the Upper East Region of Ghana.” Ghana Medical Journal.4 (2007): 167-170. Accessed on 8 January 2009.
- “Unite For Sight.” Volunteer Abroad in Ghana, India, and Honduras. Unite for Sight, n.d. Web. 20 Jan. 2017.
- “Unite For Sight.” The Importance of Eye Health Education – Evidence Based Community Eye Health Online Course. N.p., n.d. Web. 20 Jan. 2017.
- Ramai, Daryl, Ryan Elliott, Shoshanna Goldin, and Tejas Pulisetty. “A Cross-sectional Study of Pediatric Eye Care Perceptions in Ghana, Honduras, and India.” Journal of Epidemiology and Global Health2 (2015): 133-42. Web.
- Gyesaw, Nana Yaa Konadu, and Augustine Ankomah. “Experiences of Pregnancy and Motherhood among Teenage Mothers in a Suburb of Accra, Ghana: A Qualitative Study.” International Journal of Women’s Health5 (2013): 773–780. PMC. Web. 27 Jan. 2017.
- D Ramai, T Pulisetty. Maternal And Caregiver Perceptions To Childhood Eye Care In Ghana. The Internet Journal of Epidemiology. 2013 Volume 11 Number 1.
- Lewallen, S. and Courtright, P. Gender and use of cataract surgical services in developing countries. Bulletin of the World Health Organization. 2002; 80(4); 300-303.