The Long Game: Providing International Retinal Care as an Expatriate
Advancing retinal care in western Kenya as a full-time missionary.
In the previous installment of Global Retina, we discussed the potential role of short-term retinal surgery outreach to expand care into underserved (or unserved) populations. But, by definition, such individual outreaches cannot provide the extended follow-up necessary to address recurrent or chronic disease, fully quantify long-term outcomes, or provide extensive fellowship-styled surgical education. As we consider the advancement of international surgical retina care across all fronts, how do we fill these particular gaps?
Numerous complementary solutions exist to help provide the long-term engagement necessary to develop comprehensive retinal services. These include undertaking recurrent trips to the same location, offering teleconsultation and telementorship programs, and promoting short- and long-term fellowship training and observership (in US-based programs) for physicians from underserved areas. There is another, simpler strategy, though it requires a high degree of commitment: move to a place of need and stay there.
Long the dominant model for many charities and mission groups, living and working as an expatriate trades broader systemic work (and the comforts of life in one’s home country) for the advantages of a deliberate, focused, and sustained effort in one place. To examine that option and explore the particularities of an American retinal surgeon living abroad to provide care in a very different setting, I interviewed Benjamin W. Roberts, MD, at the Tenwek Mission Hospital in western Kenya.
Dr. Roberts completed his retinal surgical training at the University of Alabama-Birmingham in 2005 and packed up himself and his family the following year to set off to Bomet, Kenya, a small community in the former Rift Valley Province along Africa’s Great Rift Valley. Established in 1937 by the World Gospel Mission, Tenwek is the primary hospital for Bomet County and the main referral hospital for southwest Kenya.
Dr. Roberts and his wife, a pediatric nurse, first visited the hospital at Tenwek while he was a medical student, and this medical outpost kept coming to mind throughout his training. With a shared interest in international medical missions, they were seeking an opportunity that allowed their training to meet a specific need. The lack of full-time ophthalmology services at Tenwek provided just such an opportunity, and, subsequently, Dr. Roberts finished his fellowship and moved his family to Kenya for their first 4-year term.
FROM THE GROUND UP
Initial progress was slow. It took 4 months just to get a vitrectomy machine through customs and delivered safely to the hospital, during which time Dr. Roberts had plenty of doubts. “I questioned whether the 2 years I invested in a retina fellowship were worth it. …Was I really going to be able to use these skills in rural Africa?” he said. “There was much excitement when disposables and the vitrectomy machine arrived, but the challenges were just beginning.”
The Tenwek staff had never worked with a vitrectomy machine before, nor had they assisted in retina surgery. The dynamics of a handheld contact lens viewing system and the need to perform intraoperative scleral depression were initially overwhelming prospects for a support team with no surgical retina experience. Dr. Roberts described the first surgeries as “challenging for everyone.”
But the fruits of his labor eventually began to show. Surgical efficiency increased, techniques expanded, and Dr. Roberts had the opportunity to develop the talents of the Kenyan hospital staff. Most importantly, patients took notice. As locals realized they could receive excellent ophthalmic care without an expensive trip to Nairobi, patient volume steadily increased (although it took about year of consistent physician presence before this happened).
Now, more than a decade into his work at Tenwek, Dr. Roberts oversees a weekly rotation of schedules that is busy by any standards. Clinics of 100 patients or more on Mondays set the stage for 3 days of surgery, followed by a large postoperative clinic on Fridays. Yearly clinic visits exceed 16,000, and 200 to 300 retina surgeries are performed annually.
Certain practices at the clinic would be perceived as strange in the developed world, such as allowing patients to pay hospital bills with livestock or providing overnight stays for preoperative patients who have walked days to the hospital on foot. In talking with Dr. Roberts, however, one is struck not by the differences but by the similarities to US clinical practice. On the edge of the Rift Valley, patients undergo optical coherence tomography, fluorescein angiography, vitrectomy, and anti-VEGF injections. Years into developing the clinic, Dr. Roberts has labored under the conviction that every patient—whether in rural Kenya or back on his furloughs in Birmingham, Ala.—deserves the same excellent, intentional care.
Seen in this light, the retina service at Tenwek is a beachhead—and a hard fought one. It is the first cut of a plow into unturned earth. The creation, ex nihilo, of a clinic offering gold standard care was enough of a task to occupy years of daily devotion. Yet, having broken ground, subsequent turns of the plow have become more streamlined. Dr. Roberts is looking toward the future, in which he hopes the clinic at Tenwek will become a training site for regional ophthalmologists specializing in retina care. Through long-standing partnerships with supporters at home, the eye clinic is on the verge of completing an expansion, improving both patient access and training opportunities with 60 inpatient beds (facilitating higher surgical volumes) and seven operating tables.
To the question of whether high-level retina care can be delivered in the most remote locations, Dr. Roberts would give a resounding “yes.” But he notes that you may have to move to do it.
How does one make such a momentous decision, with all the implications for life, career, and family? It takes a specific calling and a strong sense of purpose, Dr. Roberts explained. “We have sought to provide excellent care with limited resources,” he said. “Though our equipment and environment may not be to the standards found in the United States, God has been very gracious in helping us deliver quality care.”
*Author’s Note: If you are interested in speaking further with Dr. Roberts about his work in Kenya, you can reach him at firstname.lastname@example.org.
Section Editor Benjamin J. Thomas, MD
• retina specialist at the Florida Retina Institute
• financial interest: none disclosed
Benjamin W. Roberts, MD
• missionary retina specialist at Tenwek Mission Hospital
• financial interest: none disclosed