The Gambia: approaches to blindness
Authors: Hannah B Faal
Journal: The Lancet (1997)

In 1986, from a population-based national survey of blindness, low vision, and eye disease in The Gambia (population 1250 000), it was estimated that the prevalence rate of blindness was 0·7% and that the major causes were cataract (55%), trachomatous corneal opacity (17%), other corneal opacity (11%), phthisis (8%), and glaucoma (2%)1Faal H Minassian D Sowa S Foster A National survey of blindness and low vision in The Gambia: results.Br J Ophthalmol. 1989; 73: 2Crossref Scopus (122) Google Scholar In hospital patients eye infections, blinding corneal ulcers, and complications of traditional eye medicines, were common diagnoses. Seasonal epidemics of viral keratoconjunctivitis were complicated by the use of harmful self-medication. To meet this huge case-load, there was just one small eye unit with one consulting-room, a seven-bed ward, and a shared operating-theatre staffed by one ophthalmologist and a trained eye nurse. The response was a national eye-care programme integrated into The Gambia's national health services. The objective was to reduce the prevalence of blindness to less than 0·5% and to make eye care available to everyone by integrating it into primary health care (PHC). The Gambia, situated in the arid Sahel belt of West Africa, is one of the world's least developed countries. Because of financial constraints prevention of eye disease could not be a governmental priority, and the UK-based Sight Savers International supported implementation of the vertical programme. There is a PHC structure in place into which primary eye care is integrated. Working alongside the community-based workers are polyvalent ophthalmic nurses bridging the community and outreach surgery points—a bridge between eye health promotion and prevention of eye disease, and treatment and surgery. These nurses are in charge of eye health for populations numbering about 50 000. At the secondary level, and supervising the community ophthalmic nurses, are the paramedics—divisional senior ophthalmic medical assistants trained in cataract surgery and in community eye health and responsible for a population of 200 000–250 000. They deliver clinical services, perform minor surgery and cataract surgery from a base secondary eye unit and provide outreach services. Referrals up from the secondary level are to the eye unit of the national tertiary hospital; this is staffed by ophthalmologists and provides training and supervision to divisional staff. Thus the structure is that of a vertical patient referral and supervision line crossed by horizontal lines of integration at each level, primary, secondary, and tertiary. Cataract, the leading cause of blindness, has been reduced by the use of paramedics, appropriate technology, and multiple cataract surgery points. Microsurgery and intraocular lens implantation are now available at base eye units. In the 1996 national survey the blindness prevalence rate had dropped from 0·7% to 0·4%. In the future the programme will address the community-based services, to increase the uptake of services, to institute eye care in towns, and to emphasise quality and equity. Training and supervision will remain the key to the delivery of a service that depends to such a large extent on paramedics.