Q&A: Dr. Seth Wanye on Eye Care in Developing Countries

BY KAI DEBUS

Seth Wanye (MD, PhD) is an ophthalmologist in Ghana, a lower-middle income country in West Africa. His focus is to make healthcare, specifically ophthalmic care, more accessible to people in remote areas. In 2005, he partnered with Unite for Sight, a non-profit based in New Haven, Connecticut, to expand his ability to reach marginalized people and perform sponsored cataract surgeries. The Yale Global Health Review had an opportunity to sit down with Dr. Wanye and discuss his work in Ghana, gaining insight on both the importance of ophthalmology and the challenges associated with practicing medicine in resource-limited settings.

Why did you want to become an ophthalmologist

[My decision to become an ophthalmologist] was because of a lot of personal experiences.

My father went blind when I was in senior high school. He was on the waiting list for 6 months and had one eye done initially, then [waited] another 6 months to have the second eye done. We didn’t have a resident Ghanaian ophthalmologist in our area, Agogo, at that time and the hospital had to recruit eye doctors from Germany who only came once every 6 months. I also saw a lot of blind people begging by the roadside; they didn’t know that they could be helped and I thought I could be of help. We have many eye diseases that can cause blindness, like glaucoma, cataracts, trachoma, retinal diseases, refractive errors, etc. But cataracts are one of those where patients see real change when you remove them. You remove the cataract and people see a different world. One might think they had been reborn if you hear their stories. I had a woman who came and said, “Please if you can help me, help me. I can’t even see what I eat.” Then the next day she felt that she was a new person. It is a life changing procedure.

How many ophthalmologists are there in Ghana?

I know of about 76. The disparity is so great; more than half of the 76 ophthalmologists are based in Accra. And then 50% of the other half are affiliated with Kumasi [the second largest city in Ghana]. There are also areas without practicing ophthalmologists [as those ophthalmologists have taken on managerial positions]. One in the Eastern Region, one in the Upper West, one in the Upper East. Here right now, including myself, there are two ophthalmologists in the Northern Region. I run the outreach now in the Northern Region.

How do you think ophthalmic care is perceived in Ghana, especially when diseases like malaria seem to dominate global attention?

We have a huge challenge. With the mismanagement of limited resources and with the way we manage our resources, it is not adequate for developing eye care. Global initiatives like the Millennium Development Goals [international goals established by the United Nations to alleviate world poverty] are concentrated more on the so-called “killer diseases.” There’s tuberculosis, typhoid, diabetes, HIV. These are globally sensitive issues that concern the death of patients. We have diseases like malaria that are killing children. Eye diseases rarely cause death so we are sidelined, and the few resources we have are given to the killer diseases. But the need for eye care is great. That is why groups like Unite for Sight, Operation Eyesight Universal, the Swiss Red Cross, CBM, etc. support groups like us in developing countries. These NGOs see it as something that can help our countries to a certain degree, reduce poverty levels, and improve the quality of health. Because if I’m a breadwinner but I go blind, the whole family suffers. So if a blind person is able to regain his eyesight, he is able to help his family and the country as a whole.

What’s your relationship with Unite for Sight?

Friends Eye Centre is a partner for Unite for Sight, and being the doctor in charge of Friends Eye Centre, I am a proud partner of this noble world-renowned organization. I am a member of the medical advisory board of Unite for Sight. Unite for Sight respects the views of its partners and there are proper checks and balances put in place to make sure that we are all on the same page in whatever we do together. Unite for Sight sponsors surgeries in the Northern Region and all other places we find people with treatable blinding diseases. The unique thing I find with Unite for Sight is that 100% of the money they fundraise goes directly into surgery, so there are no overhead costs, and that means more people benefit directly.

Where/in what regions of Ghana do you work? Why?

My focus area is in the Northern Region. Unite for Sight supports us anywhere the need for eye care is, whether it is in the Ashanti Region where my family lives, or in the Upper West where I originally come from, and now I’m trying to give back to society. Unite for Sight is very supportive in all aspects.

The North has always been considered the poorest place in Ghana. Diseases and poverty are more rampant here. All the natural resources and good pieces of land for agriculture are in the South. The South has been where development started. The South has always been higher than the North in terms of socioeconomic developments. The poor vegetation, poor irrigation system, arid environment, and poor education facilities in the North make things even worse.

We were lucky only when the missionaries started building schools and hospitals in deprived areas in the North and trying to make them free. We are more than 50-100 years behind compared to the South. It has taken a long time to catch up in terms of socioeconomics, infrastructure, etc.

The social amenities available in the South are not readily available in the North, and since health workers also want the best for themselves and their families, most of them will always refuse postings to the North. I went to the District Director in charge of health, and she was telling me that in the year 2015 the Northern Region had the worst indicators in terms of disease prevalence, maternal deaths, and infant mortality. We are last in all the indicators, which is something to worry about.

But it is also a leadership issue in terms of the healthcare hierarchy. If we have leaders who want to engage everybody and recognize that everyone is important and seek their advice, they will motivate health workers at all levels and I think they will put in their best at their various special areas .

What kind of people do you target?

We target all socioeconomic classes: those that can afford to pay for services at the clinic and those who genuinely cannot. But the majority are the poor, who we target with outreach. When you walk into the clinic, we want you to see that we need money to sustain medical facilities. When we go to outreach screen them and give them hope when they don’t have money, we are obliged to take care of them for free. If we say “for free,” it’s free for the patient, but in the actual fact, somebody is paying for them. In our case, Unite for Sight pays for all our outreach surgeries without any hesitation. But what gives me the biggest job satisfaction is when a very vulnerable person who has lost hope in life and does not have hope, through us and Unite for Sight, is able to see again. You can’t help it. When you see their facial expressions, it makes you want to do more, and I highly appreciate Unite for Sight in that they support me to do that. Without their help, I don’t think I’d be able to do that.

How are you able to reach those in need of ophthalmic care?

In ophthalmology, we have two aspects of medicine: clinical and public health. We do both curative and preventive health services. We go to screen and then we give medication and perform surgeries to cure people from blinding cataracts and other diseases. We also do preventive care by educating and advocating for projects and programs that will prevent people from going blind needlessly, especially when it comes to trachoma control. My time is spent between the clinics and outreach services.

How much do surgeries cost? How much do you charge for surgery?

Cataract surgery in my private practice costs 450 [Ghana Cedis], equivalent to about US$115, for people who can pay and walk into the clinic. However, when we go out on outreach to remote villages, all surgeries are sponsored by Unite for Sight. Unite for Sight-sponsored surgeries cost US$50 (200 Ghana Cedis).

At the end of the day, we also want people to be responsible for their health. It is very important to let patients contribute a token towards their surgery so that gradually they are sensitized and prepared to take full responsibility for their health care costs when NGOs one day pull out of the program. That makes the patient take the surgery seriously. That’s why we give one bottle of eye drops after surgery free of charge to the patient (paid for by Unite for Sight), and subsequent bottles are paid for by the patient. This encourages him/her to understand the value so he/she won’t misuse the eye drops.

How does traditional medicine play a role in eye care? Does it conflict with the ophthalmic care that you provide?

You’d be surprised to know that there are locations where traditional medicine is given official accreditation, and there is even an office for it in the headquarters of the Ghana Health Services. Some institutions and universities are still training people in traditional medicine to give treatment. It is no surprise that there are fake practitioners in medicine conniving to “treat” eye diseases and going to remote villages and cities convincing them that they have certain methods of treating eye diseases, cataracts for example, that do not involve surgery, and the people believe them. When we talk about surgery to an ordinary person, there are misconceptions and traditional beliefs that if a sharp object touches the eye, it will definitely go blind. Some also think that having surgery means that the eye is removed from the orbital cavity, the procedure is done, and then the eye is put back into the orbital cavity. People get scared of that and therefore are attracted to traditional medical practitioners who “couch” their eyes. Couching is one of the oldest methods of treating cataracts, dating back to the Roman Empire. It is a procedure where sharp pointed needles, not sterilized, are used to pierce through the limbus of the eye [the border between the cornea and the white of the eye], manipulated to break the zonules [fibrous strands connected to the lens of the eye], and then used to push the lens to drop into the vitreous[clear, gel-like substance between the lens and retina].

How does it feel when you’re exposed to new equipment and techniques that are commonly practiced in developed countries, but you’re unable to utilize them, given the limitations of working in rural parts of Ghana?

At times it makes me feel like a second- or third-class ophthalmologist when I am in the US and see all the latest sophisticated and expensive equipment for eye surgeries. But I feel good that even with limited resources, I can help many people see back at home in Ghana. Take the intraocular lens for example. In the US, you can measure the exact lens power with an “IOL Master” and even sometimes predict post-operative visual acuity. But if you want to get the best software and equipment, it can cost over $60,000. Even if we could afford to buy it, we can’t recoup the costs. But there are manual techniques that are less expensive, more cost-effective, and give good results too. That is why we do things our own way to help us in sustaining our work.

Do you feel that brain drain is a major issue in Ghana, especially in healthcare?

People who train here in Ghana with taxpayers’ money get the opportunity and then they leave for greener pastures. While that’s their choice, we aren’t doing a good job of keeping health professionals in the country. Those who are working hard to keep people alive aren’t being paid well and they aren’t being motivated. The high practice of corruption across the public sector also demotivates any professional from working hard for the betterment of the country. It is therefore not uncommon for health professionals to leave the country to work for foreign money which, when converted to the Ghanaian Cedi, is several fold more than what they would have received in Ghana. Many people believe that if you can make it to the West, you’ll live a prosperous life. While that is true, a lot of Ghanaian professionals get stranded in the West when they find out they cannot work or practice medicine without passing a certification exam, and most of them end up doing menial jobs in foreign lands.

How do you see ophthalmic care in Ghana evolving in the next 10-15 years?

I think we have a great future, but the biggest challenge is that ophthalmic care is not a priority to our healthcare system. I think we ophthalmologists should blame ourselves. In the US, ophthalmology is far, far developed. They were able to lobby and calculate how much the nation loses when a patient becomes blind. We don’t do it here. Even though Ghana is the country with the most glaucoma patients [in the world] in terms of prevalence, we don’t make the case. Visually impaired and blind people constitute a huge economic cost to the country. There’s no commitment from the government, which makes the future bleak. But people and NGOs are trying to help us, and that is exactly what Unite for Sight is doing. They mobilize and coordinate resources for a sustainable program. We believe that with intense advocacy and a clear focus on what we want to achieve for ophthalmology services, we will push the agenda forward and force the government of Ghana to contribute to providing comprehensive eye care services in Ghana in terms of providing modern equipment, developing human resources, and providing infrastructure.

What kind of steps do you believe should be taken in order to provide better ophthalmic care/awareness in Ghana?

We say that education is number one. We as eye care professionals should make people know the importance of their eyes and help them be ready to take responsibility for their own eye health. To do this education campaign properly, we should make sure the TV stations and radio station have slots for free healthcare talks instead of advertisements for alcohol. We need to develop simple local educational materials that can be easily used to explain the patient’s eye condition.

We have a glaucoma association [the Glaucoma Association of Ghana] that should get free slots for TV discussions on glaucoma and other eye diseases that are most prevalent in our country. But how many people have TV sets, especially in the remote communities, to watch and listen to that? The important thing is getting adequate resources to embark on extensive educational, preventive and curative ophthalmic outreach campaigns, just as we are doing, and replicate that in all regions of Ghana. In 2010, we had a World Glaucoma Summit in Accra here in Ghana where we invited the [Ghanaian] politicians. What they heard and learned shocked them, and they promised to help the Ghana Health Service acquire a slit lamp, a visual field analyzer, and an operating microscope for each Regional Hospital. After a long push, the equipment was eventually procured for all the ten Regional Hospitals. There are a lot of barriers to uptake for eye care services and I think we as ophthalmic professionals have to work hard, do a good job with good surgical outcomes, and break all these barriers to make people have trust in the work we do.

Do you have any advice for those who wish to pursue medicine or public health in a developing country?

There are always differences in healthcare systems in individual countries, so I think it’s good to get an idea of how the healthcare system works in any country where anyone is planning to pursue medicine or public health work. I think it’s also important to listen to the needs of the people in that country who are the direct beneficiaries of your services. Don’t think you can go and impose things just because you have better experience or more money.

While practicing there, we need to understand the behavior of the people we serve, help them identify their health problems, and facilitate the process of them finding solutions to their own problems. These can be achieved through extensive engagement with the communities, education, and advocacy. If you have an idea, let them discuss it and allow them to come up with a solution. We also have to bear in mind that people in the US and other Western countries have a greater sense of responsibility and are more conscientious of the respect that they’ll get. They want to do the right thing because if they don’t, they’ll be questioned and be held accountable. In most developing countries it is something different and we have to live by example, and I think that will draw more people toward us and will open avenues for us to effect change in the communities we serve.