Ophthalmology in Robert
Laos
Ritch, MD; Vithoune Vissonavong, MD; David Steinberger,
\s=b\ Laos, a small, landlocked nation of 4 million persons, has only recently begun modernization of its medical services, now a national priority. Five ophthalmologists and 11 cataract surgeons are responsible for the entire country. Tertiary care is available only at two centers; the first eye hospital opened in 1990. Several voluntary organizations have recently become involved in assisting with the development of services.
(Arch Ophthalmol. 1992;110:1491-1493)
as the Lao People's Democratic Republic, is a land¬ locked nation of 4 million people, bounded by Thailand to the west, Burma to the northwest, China to the north, Vietnam to the east, and Cambo¬ dia to the south (Fig 1). It covers an area of 236 800 km2 extending approximately 1000 km north to south and 200 to 400 km east to west. Much of the north, east, and south consists of mountainous jun¬ gle, through which easy access to neigh¬ boring countries is difficult, while the cultivated lowlands and the greatest proportion of the population are located primarily along the extensive branches of the Mekong River and in the central
aos, also known
*~*
region.
About 85% of the people live in rural mostly as subsistence farmers. Vientiane (population, 378000) is the capital and largest city. Other cities are the old royal capital of Luang Prabang (population, 45000), Savannakhet (pop¬ ulation, 55 000), and Pakse (population, areas,
50000).1
The population is divided into three broad ethnic groups: the Lao Theung (Lao of the mountain slopes), speaking Mon-Khmer languages; the Lao Soung (Lao of the mountain summits), speak¬ ing Tibeto-Burman languages; and the Lao Loum (Lao of the mountains and plains), speaking Thai languages. Of the tribal peoples, the Hmong, or Meo, are the most well known to Americans. No¬ madic tribes of hunter-gatherers, such Accepted for publication September 20, 1991. From the Department of Ophthalmology, New York (NY) Eye and Ear Infirmary (Dr Ritch); Vientiane (Laos) Eye Hospital and Mahosot University (Dr Vissonavong); and the Glaucoma Foundation, New York, NY (Dr Steinberger). Reprint requests to Glaucoma Service, New York Eye and Ear Infirmary, 310 E 14th St, New York, NY 10003 (Dr Ritch).
MD
as the Phi Tong Luang (spirits of the yellow leaves), still survive in the most
inaccessible areas. Buddhism is the re¬ ligion of 85% of the population and 15% are Animist or other. A kingdom since the 13th century, Laos came under French control in 1893 by the signing of the Franco-Siamese treaty, which effectively divided the Lao people between Laos and Thailand. In 1945, under Japanese pressure, the king declared Laos independent, but with the return of the French, reaf¬ firmed the protectorate. For the next generation, power struggles were con¬ tinuous between royalists, moderates, rightists, and communists. Approxi¬ mately 25% of the population was dis¬ placed during the Vietnam War. In 1975, the Lao People's Revolutionary Party took control. For the next 15 years, Laos remained largely closed to contact with the West, a situation that is beginning to change. Laos is divided into 16 provinces (plus the autonomous prefecture of Vien¬ tiane), 112 districts, 950 subdistricts, and 11424 villages.1 The highest legis¬ lative body is the Supreme People's Assembly. Primary school enrollment is about 85%, but only about 23% of stu¬ dents receive secondary schooling and 2.5% any higher education.1 Half of the latter are studying abroad. The per capita gross national product in 1988 was only $171, one of the lowest in the world. Major exports are wood prod¬ ucts, tin, coffee, and hydroelectric power. There are only 1300 km of paved roads and no railroad. The rivers are the major avenues of communication and
transportation.
MEDICAL AND OPHTHALMIC SERVICES
The modernization and expansion of medical care in Laos has become a ma¬ jor national priority. Life expectancy at birth is only 42 years for men and 45 years for women. Infant mortality is 137/1000 (Table) (Asiaweek. Hong Kong, Hong Kong Island: Asiaweek Ltd; June 14, 1991:8, 14). Only 3.1% of the population is older than 65 years, while 42.5% of the population is younger than 15 years. In 1976, Laos had only one physician per 35 000 people. By 1984, the number of physicians had in¬ creased to one physician per approxi¬ mately 7000 people. There is one med-
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
ical school, based at Mahosot Hospital in Vientiane. As a result of an active gov¬ ernment drive to produce more physi¬ cians, the 6-year medical program now graduates 120 students annually. Aux¬ iliary physicians are graduated from a 3-year program. Medical personnel are also permitted to upgrade their qualifi¬ cations. Auxiliary physicians can be¬ come full physicians, and full-time nurses can elect to become auxiliary physicians or even 6-year trained phy¬ sicians. There is an extreme shortage of equipment and textbooks, however, and many of the present generation of students speak only Lao, making it dif¬ ficult or impossible to use foreign texts. This creates difficulty in communication between students and instructors, and those textbooks that are available may have to be translated first into French and then into Lao. Fully trained ophthalmologists com¬ plete a 3-year residency program in Vi¬ entiane. Four ophthalmologists have thus far completed this program. There are only five residency-trained ophthal¬ mologists. Four of these are in Vien¬ tiane and one is in Savannakhet. There are also 11 cataract surgeons, who are physicians who have received 10 months of training specifically for cata¬ ract extraction. There are 10 oph¬ thalmic nurses who have been trained to screen for significant eye disease. Ophthalmic care is structured into three levels. The primary level is that of the community health center, the sec¬ ondary level is that of the district hos¬ pital, and the tertiary level is that of the provincial hospital (Fig 2). There are ophthalmic services and training activ¬ ities in 40 community hospitals and five district hospitals. Tertiary care at the provincial hospital level is available only in Vientiane and Savannakhet. The first eye hospital in Laos opened in October 1990. There are two operat¬ ing rooms and 30 beds. Equipment, however, is limited in the extreme. As of August 1990, there were literally no ophthalmology textbooks or journals in the entire country. There was no applanation or Schiòtz tonometer, and only Maklakov's tonometry was performed. There were no gonioscopy lenses, pe¬ rimeters, phoropter ultrasound, or la¬ ser. There is no automated equipment for irrigation-aspiration or for vitree-
tomy, and
cataracts
are
removed ext-
racapsularly using a modified Maclntyre technique. Disposable supplies, including surgi¬ cal gloves, syringes, and needles, are virtually nonexistent. Medications are frequently unavailable or extremely limited. The only routinely available antiglaucoma agent is 2% pilocarpine hydrochloride. Chloramphenicol is pro¬ duced locally, but all other medications are imported, most of which are do¬ nated by charitable organizations. Med¬ ical services and drugs are distributed free by the government. There are also private pharmacies that sell medica¬ tions imported primarily from Thailand on a free enterprise basis. The ability to produce spectacles lo¬ cally is also a priority. There is an enor¬ mous need for inexpensive eyeglasses, with priority for children and those with aphakia, and optometric instruments for the training of qualified opticians. Aphakic spectacles are produced by a government-owned plant and are pro¬ vided at a cost of approximately $10 (US dollars). Frames must be imported. BLINDNESS IN LAOS
Information regarding the preva¬ lence of eye disease is severely limited, partly due to the inaccessibility of much of the population to any form of eye care and partly to the lack of diagnostic equipment and qualified personnel. Blindness is defined as a visual acuity of finger counting or worse in the better eye (a worse visual acuity than that used by the World Health Organization to define blindness). The prevalence of blindness is estimated at more than 1% of the population. Cataracts, tracho¬ ma, glaucoma, vitamin A deficiency, trauma, and corneal infections account for most cases. It is not uncommon in Laos for blindness to be interpreted as a sign of bad luck and, as a result, blind children are often hidden in the house to keep the family from losing face. This makes it difficult to register the blind and prevents these persons from lead¬ ing as normal a life as possible. The diagnosis of the earlier stages of such common disorders as cataracts, glaucoma, and macular degeneration presents a significant difficulty because of the lack of didactic training and diag¬ nostic equipment. For instance, most patients with known glaucoma have had either acute angle closure glaucoma or absolute glaucoma. Asymptomatic chronic angle closure glaucoma or open
angle glaucoma
are
rarely diagnosed
because of the limitations on the ability to measure intraocular pressure, the relative infrequency of routine preven¬ tive examinations, and in part to a cui-
Fig 1.—Map of Laos showing location of urban
areas.
Comparative Health and Economic Data*
Laos India Thailand South Korea
Singapore Japan United States
*Adapted
1991:8, 14).
Gross National Product (USS) per Capita 180 320 1194 4968 10 521 22 879 21 116
from information
given
in Asiaweek
Infant
People/ Physician
Mortality
6495 2522 5564 1216 888 635 413
137 87 32 20 7 5 7
(Hong Kong, Hong Kong
turai acceptance of blindness as part of old age. An example of the underutilization of available eye care services is illustrated by the district hospital at Luang Prabang, which is responsible for second¬ ary care for the six northern provinces with a combined population of approxi¬ mately 1 million people. The staff at the
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Population
Growth Rate, % 2.9 2.1 1.4
2.2
1.1 0.4 0.7
Island: Asiaweek Ltd; June 14
eye clinic is under the direction of a cat¬ aract surgeon and treats only approxi¬
mately 30 outpatients weekly. One rea¬ son for this is the lack of adequate accessibility. Roads are few and the rivers, which are impassable for about half the year, form the major means of transportation. For example, while one of us (R.R.) was in Vientiane, a 3-year-
Referral Center
Mahosot
University Provincial
District
Residency Program
Ophthalmologists
Hospitals
Hospitals
Cataract Surgeons
40
Community
Health Centers
950 Subdistricts
11 424
Fig 2.—Medical
Villages
eye services in Laos in 1990.
presented with an infected per¬ globe and eyelid laceration, re¬ quiring enucleation. The patient's father had spent 12 days carrying him through the jungle to the hospital. Educational old boy forated
and cultural factors are other reasons for the lack of utilization of services. As yet, there have been no formal epidemiologie studies of the prevalence of various eye diseases in Laos. Two small, preliminary pilot studies have been performed in Vientiane. In one of these, 5% of children between the ages of 5 and 10 years were found to have trachoma. In another screening of 127 persons (self-selected) older than 40 years, 15 had visually limiting cataract and 25 had trachomatous scarring. In 1989,900 cataract operations were performed nationwide. This represents a steady annual increase, reflecting the expanding recognition of cataracts at the primary care level and its network¬ ing into secondary eye care centers. Only 50 surgical iridectomies and 30 trabeculectomies were performed, re¬ flecting the lack of ability to diagnose glaucoma more than its incidence. Pen¬ etrating keratoplasties are rarely per¬ formed. PLANS FOR DEVELOPMENT OF EYE CARE SERVICES
The Prevention of Blindness Project was launched in 1983 with the major
objectives of providing basic eye care for all citizens and eliminating avoidable blindness. To achieve this aim, primary eye care will be integrated into the na¬ tional health plan and will contain three broad goals: (1) prevention of blindness and promotion of ophthalmol¬ ogy and education for primary eye care; (2) medical, surgical, and technical services; and (3) rehabilitation of the blind. It includes the training of manpower at all levels. Five large provinces along the Mekong River were selected, which cover more than 80% of the population (Vientiane, Kampen Nankong [Vien¬ Municipality], Luang Prabang, Savannakhet, and Champassak). Ef¬ forts were made to strengthen or newly tiane
establish eye care facilities in those provinces between 1986 and 1990. The training project has been plan¬ ned to occur in three phases. Phase 1 consists of courses for trainers of midlevel health workers, who would then be able to share their knowledge among the lower levels at provincial hospitals. This enables health workers to treat common eye diseases by medi¬ cal or simple surgical means and also refer those patients who need second¬ ary and tertiary eye care. Phase 2 consists of district courses foinurses and public health staff at com¬ munity hospitals and health centers to
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
help the staff understand the principles of primary eye care and the clinical ac¬ tivities involved in treating eye disease, the course of blindness, and the ratio¬ nale behind both registration of persons with eye disease and public health edu¬
cation. The nature of the tiered referral system and preventive/promotive ac¬ tivities are also covered. Phase 3 consists of community courses for primary health care work¬ ers, community leaders, and teachers who will be engaged at some level in the clinical activities involved in primary eye care, blindness prevention, and health education for families and indi¬ viduals. In collaboration with Peter Grand, PhD, of Lumen Mundi, a Swiss organi¬ zation, plans were begun in 1990 to cre¬ ate a Foundation for the Blind to ap¬ proach the associated socioeconomic problems. The initial project will be to develop a program for rehabilitation. Plans are also being made to open the first school for the blind in Laos. In 1990, two blind persons were sent to Thailand for training in braille. With the help of their Thai educators, they developed a Lao braille code, as the two languages have significant similarities. Various other organizations provide aid for ophthalmic services. The new eye hospital was built with funds raised by members of the Japanese embassy, and the Japanese government has do¬ nated 18 million yen ($135000 US) in equipment, which was expected to be available in 1991. This will include an applanation tonometer, perimeter, and irrigation-aspiration unit. The World Health Organization assists with infor¬ mation regarding blindness prevention and eye care management, primarily basic refraction skills. The Saeng Thai Medical Foundation and Ophthalmic Cell, a program based in Thailand, spon¬ sors teaching and educational services. Other organizations involved in Laos include the Dooley Foundation (New York, NY), World Aid (Seattle, Wash), Norwegian Church Aid (Oslo, Norway), and Christoffel Blind Mission (Bensheim, Federal Republic of Germany). Individual ophthalmologists who wish to spend time in Laos teaching and
demonstrating surgical techniques
are
welcomed. This
investigation
Foundation,
New
was
supported by
the Glaucoma
York, NY.
References 1. Stuart-Fox M. Laos:
Politics, Economics and
Society. London, England: Frances Pinter Publishers;1986.
Laos
Ritch, MD; Vithoune Vissonavong, MD; David Steinberger,
\s=b\ Laos, a small, landlocked nation of 4 million persons, has only recently begun modernization of its medical services, now a national priority. Five ophthalmologists and 11 cataract surgeons are responsible for the entire country. Tertiary care is available only at two centers; the first eye hospital opened in 1990. Several voluntary organizations have recently become involved in assisting with the development of services.
(Arch Ophthalmol. 1992;110:1491-1493)
as the Lao People's Democratic Republic, is a land¬ locked nation of 4 million people, bounded by Thailand to the west, Burma to the northwest, China to the north, Vietnam to the east, and Cambo¬ dia to the south (Fig 1). It covers an area of 236 800 km2 extending approximately 1000 km north to south and 200 to 400 km east to west. Much of the north, east, and south consists of mountainous jun¬ gle, through which easy access to neigh¬ boring countries is difficult, while the cultivated lowlands and the greatest proportion of the population are located primarily along the extensive branches of the Mekong River and in the central
aos, also known
*~*
region.
About 85% of the people live in rural mostly as subsistence farmers. Vientiane (population, 378000) is the capital and largest city. Other cities are the old royal capital of Luang Prabang (population, 45000), Savannakhet (pop¬ ulation, 55 000), and Pakse (population, areas,
50000).1
The population is divided into three broad ethnic groups: the Lao Theung (Lao of the mountain slopes), speaking Mon-Khmer languages; the Lao Soung (Lao of the mountain summits), speak¬ ing Tibeto-Burman languages; and the Lao Loum (Lao of the mountains and plains), speaking Thai languages. Of the tribal peoples, the Hmong, or Meo, are the most well known to Americans. No¬ madic tribes of hunter-gatherers, such Accepted for publication September 20, 1991. From the Department of Ophthalmology, New York (NY) Eye and Ear Infirmary (Dr Ritch); Vientiane (Laos) Eye Hospital and Mahosot University (Dr Vissonavong); and the Glaucoma Foundation, New York, NY (Dr Steinberger). Reprint requests to Glaucoma Service, New York Eye and Ear Infirmary, 310 E 14th St, New York, NY 10003 (Dr Ritch).
MD
as the Phi Tong Luang (spirits of the yellow leaves), still survive in the most
inaccessible areas. Buddhism is the re¬ ligion of 85% of the population and 15% are Animist or other. A kingdom since the 13th century, Laos came under French control in 1893 by the signing of the Franco-Siamese treaty, which effectively divided the Lao people between Laos and Thailand. In 1945, under Japanese pressure, the king declared Laos independent, but with the return of the French, reaf¬ firmed the protectorate. For the next generation, power struggles were con¬ tinuous between royalists, moderates, rightists, and communists. Approxi¬ mately 25% of the population was dis¬ placed during the Vietnam War. In 1975, the Lao People's Revolutionary Party took control. For the next 15 years, Laos remained largely closed to contact with the West, a situation that is beginning to change. Laos is divided into 16 provinces (plus the autonomous prefecture of Vien¬ tiane), 112 districts, 950 subdistricts, and 11424 villages.1 The highest legis¬ lative body is the Supreme People's Assembly. Primary school enrollment is about 85%, but only about 23% of stu¬ dents receive secondary schooling and 2.5% any higher education.1 Half of the latter are studying abroad. The per capita gross national product in 1988 was only $171, one of the lowest in the world. Major exports are wood prod¬ ucts, tin, coffee, and hydroelectric power. There are only 1300 km of paved roads and no railroad. The rivers are the major avenues of communication and
transportation.
MEDICAL AND OPHTHALMIC SERVICES
The modernization and expansion of medical care in Laos has become a ma¬ jor national priority. Life expectancy at birth is only 42 years for men and 45 years for women. Infant mortality is 137/1000 (Table) (Asiaweek. Hong Kong, Hong Kong Island: Asiaweek Ltd; June 14, 1991:8, 14). Only 3.1% of the population is older than 65 years, while 42.5% of the population is younger than 15 years. In 1976, Laos had only one physician per 35 000 people. By 1984, the number of physicians had in¬ creased to one physician per approxi¬ mately 7000 people. There is one med-
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
ical school, based at Mahosot Hospital in Vientiane. As a result of an active gov¬ ernment drive to produce more physi¬ cians, the 6-year medical program now graduates 120 students annually. Aux¬ iliary physicians are graduated from a 3-year program. Medical personnel are also permitted to upgrade their qualifi¬ cations. Auxiliary physicians can be¬ come full physicians, and full-time nurses can elect to become auxiliary physicians or even 6-year trained phy¬ sicians. There is an extreme shortage of equipment and textbooks, however, and many of the present generation of students speak only Lao, making it dif¬ ficult or impossible to use foreign texts. This creates difficulty in communication between students and instructors, and those textbooks that are available may have to be translated first into French and then into Lao. Fully trained ophthalmologists com¬ plete a 3-year residency program in Vi¬ entiane. Four ophthalmologists have thus far completed this program. There are only five residency-trained ophthal¬ mologists. Four of these are in Vien¬ tiane and one is in Savannakhet. There are also 11 cataract surgeons, who are physicians who have received 10 months of training specifically for cata¬ ract extraction. There are 10 oph¬ thalmic nurses who have been trained to screen for significant eye disease. Ophthalmic care is structured into three levels. The primary level is that of the community health center, the sec¬ ondary level is that of the district hos¬ pital, and the tertiary level is that of the provincial hospital (Fig 2). There are ophthalmic services and training activ¬ ities in 40 community hospitals and five district hospitals. Tertiary care at the provincial hospital level is available only in Vientiane and Savannakhet. The first eye hospital in Laos opened in October 1990. There are two operat¬ ing rooms and 30 beds. Equipment, however, is limited in the extreme. As of August 1990, there were literally no ophthalmology textbooks or journals in the entire country. There was no applanation or Schiòtz tonometer, and only Maklakov's tonometry was performed. There were no gonioscopy lenses, pe¬ rimeters, phoropter ultrasound, or la¬ ser. There is no automated equipment for irrigation-aspiration or for vitree-
tomy, and
cataracts
are
removed ext-
racapsularly using a modified Maclntyre technique. Disposable supplies, including surgi¬ cal gloves, syringes, and needles, are virtually nonexistent. Medications are frequently unavailable or extremely limited. The only routinely available antiglaucoma agent is 2% pilocarpine hydrochloride. Chloramphenicol is pro¬ duced locally, but all other medications are imported, most of which are do¬ nated by charitable organizations. Med¬ ical services and drugs are distributed free by the government. There are also private pharmacies that sell medica¬ tions imported primarily from Thailand on a free enterprise basis. The ability to produce spectacles lo¬ cally is also a priority. There is an enor¬ mous need for inexpensive eyeglasses, with priority for children and those with aphakia, and optometric instruments for the training of qualified opticians. Aphakic spectacles are produced by a government-owned plant and are pro¬ vided at a cost of approximately $10 (US dollars). Frames must be imported. BLINDNESS IN LAOS
Information regarding the preva¬ lence of eye disease is severely limited, partly due to the inaccessibility of much of the population to any form of eye care and partly to the lack of diagnostic equipment and qualified personnel. Blindness is defined as a visual acuity of finger counting or worse in the better eye (a worse visual acuity than that used by the World Health Organization to define blindness). The prevalence of blindness is estimated at more than 1% of the population. Cataracts, tracho¬ ma, glaucoma, vitamin A deficiency, trauma, and corneal infections account for most cases. It is not uncommon in Laos for blindness to be interpreted as a sign of bad luck and, as a result, blind children are often hidden in the house to keep the family from losing face. This makes it difficult to register the blind and prevents these persons from lead¬ ing as normal a life as possible. The diagnosis of the earlier stages of such common disorders as cataracts, glaucoma, and macular degeneration presents a significant difficulty because of the lack of didactic training and diag¬ nostic equipment. For instance, most patients with known glaucoma have had either acute angle closure glaucoma or absolute glaucoma. Asymptomatic chronic angle closure glaucoma or open
angle glaucoma
are
rarely diagnosed
because of the limitations on the ability to measure intraocular pressure, the relative infrequency of routine preven¬ tive examinations, and in part to a cui-
Fig 1.—Map of Laos showing location of urban
areas.
Comparative Health and Economic Data*
Laos India Thailand South Korea
Singapore Japan United States
*Adapted
1991:8, 14).
Gross National Product (USS) per Capita 180 320 1194 4968 10 521 22 879 21 116
from information
given
in Asiaweek
Infant
People/ Physician
Mortality
6495 2522 5564 1216 888 635 413
137 87 32 20 7 5 7
(Hong Kong, Hong Kong
turai acceptance of blindness as part of old age. An example of the underutilization of available eye care services is illustrated by the district hospital at Luang Prabang, which is responsible for second¬ ary care for the six northern provinces with a combined population of approxi¬ mately 1 million people. The staff at the
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
Population
Growth Rate, % 2.9 2.1 1.4
2.2
1.1 0.4 0.7
Island: Asiaweek Ltd; June 14
eye clinic is under the direction of a cat¬ aract surgeon and treats only approxi¬
mately 30 outpatients weekly. One rea¬ son for this is the lack of adequate accessibility. Roads are few and the rivers, which are impassable for about half the year, form the major means of transportation. For example, while one of us (R.R.) was in Vientiane, a 3-year-
Referral Center
Mahosot
University Provincial
District
Residency Program
Ophthalmologists
Hospitals
Hospitals
Cataract Surgeons
40
Community
Health Centers
950 Subdistricts
11 424
Fig 2.—Medical
Villages
eye services in Laos in 1990.
presented with an infected per¬ globe and eyelid laceration, re¬ quiring enucleation. The patient's father had spent 12 days carrying him through the jungle to the hospital. Educational old boy forated
and cultural factors are other reasons for the lack of utilization of services. As yet, there have been no formal epidemiologie studies of the prevalence of various eye diseases in Laos. Two small, preliminary pilot studies have been performed in Vientiane. In one of these, 5% of children between the ages of 5 and 10 years were found to have trachoma. In another screening of 127 persons (self-selected) older than 40 years, 15 had visually limiting cataract and 25 had trachomatous scarring. In 1989,900 cataract operations were performed nationwide. This represents a steady annual increase, reflecting the expanding recognition of cataracts at the primary care level and its network¬ ing into secondary eye care centers. Only 50 surgical iridectomies and 30 trabeculectomies were performed, re¬ flecting the lack of ability to diagnose glaucoma more than its incidence. Pen¬ etrating keratoplasties are rarely per¬ formed. PLANS FOR DEVELOPMENT OF EYE CARE SERVICES
The Prevention of Blindness Project was launched in 1983 with the major
objectives of providing basic eye care for all citizens and eliminating avoidable blindness. To achieve this aim, primary eye care will be integrated into the na¬ tional health plan and will contain three broad goals: (1) prevention of blindness and promotion of ophthalmol¬ ogy and education for primary eye care; (2) medical, surgical, and technical services; and (3) rehabilitation of the blind. It includes the training of manpower at all levels. Five large provinces along the Mekong River were selected, which cover more than 80% of the population (Vientiane, Kampen Nankong [Vien¬ Municipality], Luang Prabang, Savannakhet, and Champassak). Ef¬ forts were made to strengthen or newly tiane
establish eye care facilities in those provinces between 1986 and 1990. The training project has been plan¬ ned to occur in three phases. Phase 1 consists of courses for trainers of midlevel health workers, who would then be able to share their knowledge among the lower levels at provincial hospitals. This enables health workers to treat common eye diseases by medi¬ cal or simple surgical means and also refer those patients who need second¬ ary and tertiary eye care. Phase 2 consists of district courses foinurses and public health staff at com¬ munity hospitals and health centers to
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pennsylvania User on 06/17/2015
help the staff understand the principles of primary eye care and the clinical ac¬ tivities involved in treating eye disease, the course of blindness, and the ratio¬ nale behind both registration of persons with eye disease and public health edu¬
cation. The nature of the tiered referral system and preventive/promotive ac¬ tivities are also covered. Phase 3 consists of community courses for primary health care work¬ ers, community leaders, and teachers who will be engaged at some level in the clinical activities involved in primary eye care, blindness prevention, and health education for families and indi¬ viduals. In collaboration with Peter Grand, PhD, of Lumen Mundi, a Swiss organi¬ zation, plans were begun in 1990 to cre¬ ate a Foundation for the Blind to ap¬ proach the associated socioeconomic problems. The initial project will be to develop a program for rehabilitation. Plans are also being made to open the first school for the blind in Laos. In 1990, two blind persons were sent to Thailand for training in braille. With the help of their Thai educators, they developed a Lao braille code, as the two languages have significant similarities. Various other organizations provide aid for ophthalmic services. The new eye hospital was built with funds raised by members of the Japanese embassy, and the Japanese government has do¬ nated 18 million yen ($135000 US) in equipment, which was expected to be available in 1991. This will include an applanation tonometer, perimeter, and irrigation-aspiration unit. The World Health Organization assists with infor¬ mation regarding blindness prevention and eye care management, primarily basic refraction skills. The Saeng Thai Medical Foundation and Ophthalmic Cell, a program based in Thailand, spon¬ sors teaching and educational services. Other organizations involved in Laos include the Dooley Foundation (New York, NY), World Aid (Seattle, Wash), Norwegian Church Aid (Oslo, Norway), and Christoffel Blind Mission (Bensheim, Federal Republic of Germany). Individual ophthalmologists who wish to spend time in Laos teaching and
demonstrating surgical techniques
are
welcomed. This
investigation
Foundation,
New
was
supported by
the Glaucoma
York, NY.
References 1. Stuart-Fox M. Laos:
Politics, Economics and
Society. London, England: Frances Pinter Publishers;1986.
