A survey provides an improved understanding of the unique problems faced by retina doctors in Sub-Saharan Africa.
In the quest to extend vitreoretinal care to all populations, few challenges are as imposing as those posed by conditions in Sub-Saharan Africa. Geographically massive, culturally diverse, and marbled with zones of extended conflict, the region encompasses populations that range from the new urban wealth of Nairobi, Addis Ababa, and Accra, to the nomadic populations of the western Sahel. Today, a few dozen individuals scattered across the continent (excluding South Africa) provide vitreoretinal surgery services to the entire region. Providing a greater level of retina care across Africa will require myriad creative treatment strategies organized on a number of fronts.
I wanted to know—apart from being outnumbered by their patients by a million to one—the main challenges confronting surgeons in Sub-Saharan Africa. I learned more about the obstacles to acquiring training and starting and maintaining a practice in the region by collaborating with Asiwome Kwesi Seneadza, MD. Dr. Seneadza has recently begun a vitreoretinal practice in Ghana; he spent the previous 14 years practicing as the only retina surgeon in Zambia, a country of 14.5 million people. Dr. Seneadza and I conducted a survey of physicians practicing vitreoretinal surgery in any capacity in Sub-Saharan Africa.
We identified 15 vitreoretinal surgeons working in the geographic region extending from Senegal to Kenya, Ethiopia to Tanzania, and sent them a survey covering their medical training, practice capacity, and subjective assessments of the challenges of retina practice in Africa. Six African surgeons and one expatriate surgeon replied; they were from Ghana, Ethiopia, Kenya, Tanzania, and Zambia. This is what we found.
African vitreoretinal practice is a young endeavor.
Although the respondents’ ages ranged from their 30s to their 50s, all respondents were in the first decade of postfellowship practice; more than half (57%) were in the first 5 years of practice.
One can complete a full course of training entirely in Africa, but it’s not easy.
Of our seven respondents, only one (the Tanzanian respondent) had completed medical school, residency, and retina fellowship entirely in Africa. All others—excluding the expatriate surgeon—cobbled together a training course across multiple countries and continents. Additionally, two of the surgeons completed short fellowships in nonretina subspecialties (ie, glaucoma, pediatrics) because they assumed that vitreoretinal surgery would be only one part of their eventual practice.
Limited subspecialist availability makes for enormous catchment areas.
The minimum distance reported for patient referrals was 400 km (250 miles). Most of those surveyed reported a catchment area of 800 to 2,000 km (500 to 1,250 miles). Nearly all respondents reported treating patients from other countries, some of whom traveled 2,500 miles to be seen. (To grasp the distances involved, the US reader may consider experiencing a retinal detachment in Atlanta and knowing your closest available surgeon is in Seattle.)
Training comes with its own set of challenges: 83% of respondents said that family and financial issues were the most common challenges they faced when undergoing training. Many of our African colleagues pursue vitreoretinal training across multiple continents, which requires significant time away from family and imposes financial burdens as trainees step away from a paying practice to train. Several of those surveyed cited limited availability of fellowship programs accepting African trainees. To add to these difficulties, training at programs outside of Africa does not fully approximate the unique considerations of an eventual African practice.
Upon the completion of training, the central challenge shifts to establishing and maintaining a practice. Six of our seven responding physicians chose an urban location, and their practices were evenly distributed among academic, nonprofit, and faith-based institutions. Six physicians also reported that obtaining proper equipment and consumables was the largest challenge they faced when starting a practice. Less than half said that training support staff, recruiting appropriate patient referrals, and navigating regulatory red tape were among the greatest initial hurdles to starting a practice. These challenges continue with time: Most of the physicians surveyed cited equipment maintenance and establishing a source for reliable delivery of consumables as the primary challenges in the long-term.
Cataract, trachoma, and glaucoma have been the leading causes of blindness in Sub-Saharan Africa; only recently have we seen the need for retina services in the region. Retinal diseases are increasing in frequency, and conditions such as diabetic retinopathy, sickle cell retinopathy, and retinal detachments have become larger issues. Also, the need for surgical follow-up from retina surgeons will rise as the rate of cataract surgery increases. Hence, the need for retina services in Sub-Saharan Africa cannot be overemphasized.
In order to address the issues raised in our survey, retina must be prioritized in residency training programs. Training centers need retina specialists who can demonstrate the elegance of retina practice to resident doctors. Once exposed to the field, more residents will be encouraged to specialize in retina. Additionally, identifying training centers within Africa that offer retina fellowships can help to create a network of fellowship leaders and alumni who can offer postfellowship support.
Private-public partnerships with training centers may make up for the limited resources currently available in such training centers. Although the cost of retina service is high compared with cataract service, costs will go down if governments, nongovernmental organizations, and private institutions work together to address problems inherent with procurement costs. Such collaborations may result in industry reducing prices for medications and supplies. Even if this coordination proves too difficult, individual vitreoretinal surgeons should consider buying in bulk or as part of a group to reduce costs.
Asiwome Kwesi Seneadza, MD
• medical director, consultant vitreoretinal surgeon, Dr. Agarwal’s Eye Hospital, Ghana
SOLUTIONS THROUGH COLLABORATION
Dr. Seneadza and I wonder whether reconstructed fellowship schedules (so-called “sandwich” fellowships) or remote tele-mentorships could alleviate training barriers. Incorporating equipment maintenance into fellowship curricula could address some of the problems our survey identified. And we propose that low-cost suppliers such as Aurolab, a part of the Aravind Eye Care system in southern India, may help answer the question of creating reliable supply chains for consumables.
We asked for suggestions from our surveyed doctors, and one answer stuck out as particularly incisive: “Set up active regional and subregional vitreoretinal societies.” Although this would not be a panacea by any means, creating networks of like-minded African vitreoretinal surgeons would allow rapid dissemination of solutions to retina-specific problems; would connect the community of physicians as it develops; and would facilitate collaborative research projects, epidemiologic surveys, and novel treatment initiatives.
There is opportunity for collaboration among existing vitreoretinal societies and nascent organizations of African surgeons. The challenges identified in our survey can be addressed through such collaborations, with the aim of shaping the development of vitreoretinal surgery across Africa.
Section Editor Benjamin J. Thomas, MD
• vitreoretinal surgeon, Florida Retina Institute, Jacksonville, Fla.
• financial interest: none