1267
2. Gardosi J, Carter M, Becket T. Continuous intrapartum fetal oxygen saturation. Lancet 1989; ii: 692-93.
low baseline saturation at the beginning of labour, which we have seen in several cases of growth retardation (fig 2), could suggest diminished placental transfer and reserve. The technique could also be used to recognise fetal distress: a fall in the Sa02 trend during labour, which was observed during developing metabolic acidosis, may be due to movement of the haemoglobin dissociation curve to the right (Bohr shift); this on its own would reduce Sa02 even if P02 remained constant. These hypotheses will need to be tested in large series. Our aim was to assure the quality of our data and to exclude possible sources of artifact, to give this new fetal monitoring technique every chance to fulfil its exciting reserve: a
monitoring of
3. Damianou D, Crowe JA, Schram CMH, Gardosi JO. Artefacts in reflection pulse oximetry readings due to variations in probe to skin surface separation. IEE Abstr 1991; 89: 3. 4. Tremper KK, Barker SJ. Pulse oximetry. Anesthesiology 1989; 70: 98-108. 5. Southall DP, Bignall S, Stebbens VA, Alexander JR, Rivers RPA, Lissauer T. Pulse oximeter and transcutaneous arterial oxygen measurements in neonatal and paediatric intensive care. Arch Dis Child 1987; 62: 882-88. 6. Editorial. The trust in pulse oximeters. Lancet 1990; 335: 1130-31. 7. Peat S, Booker M, Lanigan C. Ponte J. Continuous intrapartum measurement of fetal oxygen saturation. Lancet 1988; ii: 213. 8. Johnson N, Johnson VA, Fisher J, Jobbings B, Bannister J, Lilford RJ. Fetal monitoring with pulse oximetry. Br J Obstet Gynaecol 1991; 98: 36-41. 9. Rosen M. Fetal surveillance during fetal surgery. Presented at 1st International Symposium of Intrapartum Surveillance, Nottingham, October, 1990. 10. Andrews BF, Willet GP. Fetal hemoglobin concentration in the newborn. Am J Obstet Gynecol 1965; 91: 85-88. 11. Johnson N, Johnson VA, Bannister J, Lilford R. The effect of caput succedaneum on oxygen saturation measurements. Br J Obstet
promise. This work was supported by Action Research, Nottingham Health Authority, Parkside Health Authority, Criticare Systems Inc, and Surgicraft Ltd.
REFERENCES 1. Harris AP, Sendak MJ, Donham RT, Thomas M, Duncan D. Absorption characteristics of human fetal hemoglobin at wavelengths used in pulse oximetry. J Clin Monit 1988; 4: 175-77.
Gynaecol 1990; 9: 493-98. 12. Schram CMH, Gardosi J. The effect of caput succedaneum on oxygen saturation measurements. Br J Obstet Gynaecol 1991; 98: 113-14.
PUBLIC HEALTH Africa’s 3 million blind people?
Who will operate
curably
About half the 6 million blind people in sub-Saharan Africa have surgically curable cataract. The available manpower and resources can only provide services for less than 10% of the new blind cataract patients each year, and little is being done for the estimated 3 million "cataract backlog". A serious limiting factor to the development of prevention of blindness programmes is lack of trained manpower. Despite an increase in the number of ophthalmologists trained in cataract surgery (which varies greatly from country to country), this number is not keeping pace with increased demand for eye-care services, especially in large rural popultions. Initiatives that will help to overcome this dilemma are specific post-graduate courses in community ophthalmology in Africa, plans to develop a one-year diploma in ophthalmology course for English-speaking West African countries, and a proposal to upgrade a similar course in Zimbabwe. Additionally there is a need for the training of more ophthalmic assistants, cataract surgeons, and nurses in the diagnosis and management of common ophthalmic disorders. Experienced expatriate ophthalmologists also have an important role in the teaching of doctors and ophthalmic assistants how to select patients and carry out successful inexpensive cataract surgery with appropriate technology and limited facilities.
on
Introduction There are 27-35 million blind people world wide:1 6 million live in sub-Saharan Africa, of whom more than half have surgically curable cataract. The average ophthalmologist in Africa carries out fewer than 300 cataract operations a year on about 100 blind people. Therefore, 50 000 blind cataract patients are being operated on per year in sub-Saharan Africa, but the estimated "cataract backlog" is in excess of 3 million and there is an annual incidence of at least 500 000 newly blind people due to this disorder. Thus, the available manpower and resources are providing services for less than 10 % of new blind cataract patients, and there is still the problem of the existing cataract blind. A serious limiting factor to the development of prevention of blindness programmes in sub-Saharan Africa is the lack of trained manpower. In this article I will review the present situation about available personnel for providing cataract surgical services in Africa so that I can try to answer the question, "Who will operate on Africa’s 3 million curably blind people?"
Ophthalmologists The number of available ophthalmologists varies greatly from one region of the world to another, with about 1
ophthalmologist per 20 000 population in North America and western Europe, 1 per 35 000 in Latin America, and ADDRESSES International Centre for Eye Health, 27-29 Cayton Street, London, EC1V9EJ, UK (Allen Foster, FRCS).
1268
TABLE I-OPHTHALMOLOGISTS IN SUB-SAHARAN AFRICA
TABLE II-TRAINING CENTRES FOR OPHTHALMOLOGISTS IN SUB-SAHARAN AFRICA*
*Excludmg South Afnca
in Zimbabwe in ophthalmology. course
i
i
per
100 000
in
India.
There
are
even
fewer
ophthalmologists in some African countries-eg, 1/650 000 in Kenya and 1/2-6 million in Ethiopia.1 Two recent workshops convened by the World Health Organisation (WHO)—in 1988 in Accra, Ghana, for English-speaking Africa, and last year in Lome, Togo, for sub-Saharan French-speaking Africa-reviewed the present situation with respect to ophthalmic manpower for a wide country-tocountry variation on the availability of ophthalmologists in sub-Saharan Africa-from 1 per 130 000 in South Africa to 1 per 3 million in Angola (table I). Generally there is about 1 ophthalmologist for every million population in Englishspeaking and French-speaking areas, and 1 per 2 million in Portuguese-speaking countries (figure). Most ophthalmologists work in the university teaching hospitals or in the larger cities, and about 25% of those working in sub-Saharan Africa are expatriates.3 There are post-graduate training programmes for ophthalmologists in Senegal, Mali, Ivory Coast, and Zaire for French-speaking countries and in Nigeria, Ethiopia, Sudan, Kenya, Tanzania, Zimbabwe, Uganda, and South Africa for English-speaking countries. There is no full-time training programme in Africa for Portuguese-speaking countries. About 50 ophthalmologists graduate each year from 15 training centres in sub-Saharan Africa (excluding South Africa), with 20 from 6 centres in Nigeria (table II). Despite the increase in the number of ophthalmologists being trained in Africa during the past 10 years, this number is not keeping pace with the increased demand for eye-care services, especially in the large rural populations of subSaharan Africa. New initiatives include plans to develop a one-year diploma in ophthalmology course for Englishspeaking West African countries under the direction of the West African College of Surgeons; and a proposal to upgrade the present one-year diploma in ophthalmology
eye-care services in Africa .2,3 There is
Ophthalmologist/population ratio
three-year post-graduate training
Community ophthalmology
i
OPH = ophthalmologists, POP = population
1
to a
in sub-Saharan Africa.
Post-graduate training in ophthalmology in Africa is often based on the curricula for training programmes in Europe. Because of the different ophthalmic disease patterns and the availability of resources, more attention needs to be paid to community ophthalmology in the training of ophthalmologists for work in Africa. Presently, there is no specific training course in community ophthalmology in Africa; rather, two courses have been developed at WHO collaborating centres for blindness prevention-in London at the International Centre of Eye Health, and in Baltimore at the Dana Center of the Johns Hopkins Hospital. The aim of these courses is to train ophthalmologists in community or public health ophthalmology so that they can go on to establish and assist in the development of national prevention of blindness programmes in their own countries. The introduction of community ophthalmology into postgraduate curricula in Africa is an important priority in the immediate future. General
physicians/surgeons
African countries general doctors have learnt that they can provide eye surgical services where no ophthalmologist is available. This situation is more relevant to non-governmental than to the government medical services. The difficulty with this approach to eye care is that, owing to many other demands, the general doctor cannot usually devote enough time to eye work for the development of a useful and sustainable service. In
some
cataract surgery so
Nonetheless, in
general physician or only choice in the foreseeable future for providing cataract some remote
areas,
a
surgeon who has learnt cataract surgery may be the surgery services.
Ophthalmic assistant cataract surgeons Because of the inadequate number of ophthalmologists for the population, many African countries have now established training programmes for ophthalmic assistants who are trained to provide diagnostic, refractive, and therapeutic eye-care services for a population of about 250 000. Ophthalmic assistants are usually medical assistants or general nurses who have had a medical or nursing training and who are then given a specific one-year training in the diagnosis and management of common ophthalmic disorders. Presently, there are training programmes for ophthalmic assistants or ophthalmic nurses in Ethiopia, Kenya, Uganda, Tanzania, Malawi, Zimbabwe, Sudan, Mali, Ghana, and Sierra Leone. After working for several years, selected ophthalmic assistants who have shown good judgmental and surgical skills may be offered a further one-year training in cataract surgery on a one-to-one basis with an experienced ophthalmologist. In
1269
the training (specifically in intracapsular cataract surgery under local anaesthesia with magnifying loupes for uncomplicated senile cataract), assistants carry out 100 cataract operations under supervision. Training of ophthalmic assistants in cataract surgery has been successful in several African countries including Kenya, Malawi, Tanzania, and Mali.
Expatriate ophthalmologists Many ophthalmologists from Europe and North America a genuine interest in trying to reduce the number of
have
cataract blind in
Africa. How best can these well-motivated
initiatives be channelled? Short-term surgical visits, though
rewarding to the visiting ophthalmologist and beneficial to the individuals operated on, do little for and may even have a negative effect on the development of national sustainable eye-care services. These short-term surgical visits are expensive for what they achieve and often take much time to organise with respect to obtaining medical registration and preparing the hospital and patients for the visiting surgeon. Nonetheless, there are remote neglected areas of Africa where experienced visiting eye surgeons can have a role in showing that eye surgery can restore sight to the blind. These areas are, however, usually far away from the more popular areas of Africa for the short-term visitor. The more important role for the expatriate ophthalmologist is as a "multiplier". There is a huge need in Africa for ophthalmologists who can teach doctors and ophthalmic assistants how to select patients and carry out successful inexpensive cataract surgery with appropriate technology and limited facilities. However, the selection criteria, surgical techniques, and facilities available are not the same as those of Europe and North America, and the expatriate ophthalmologist must therefore be willing to look, listen, and learn before deciding what is appropriate to teach; this takes time.
ophthalmologists over 3-4 years to provide specialist tertiary ophthalmic services in the larger city and university hospitals. Regional centres for different language groups will enable the smaller African countries to train ophthalmologists within Africa in cost-effective and good training programmes. Links between African and European or American university departments of ophthalmology (following the example of Nairobi and Munich) can be of great benefit in promoting exchange in new techniques and providing lecturers and resources for appropriate research. The establishment of one-year training programmesThere is a need for doctors to train as eye doctors/cataract surgeons in individual African countries (with populations in excess of 5 million), following the Zimbabwe model. These eye doctors/cataract surgeons will be based in the smaller cities and towns and provide eye and cataract surgery services at the secondary level of eye care for rural populations living distant from the large cities. Training of ophthalmic assistants/nurses-More emphasis should be given to the training of selected
ophthalmic assistants/nurses as cataract surgeons in individual countries. It is the ophthalmic assistants who will continue to form the backbone of secondary level eye-care services in most areas of many African countries. Suggested goals-For the next decade we need (a) one national ophthalmologist per 500 000 population in every
African country
(ie, double the present figure)(b) one (eye doctor or ophthalmic assistant cataract 250 000 population in every African country; surgeon) per and (c) cataract surgery at a rate of at least 1000 operations/ million population in African countries to approximate to the incidence of blinding cataract. To develop training programmes for manpower development in eye care, each African country needs to work out its own objectives and strategies so that appropriate regional and national planning can be defined and implemented. cataract surgeon
Conclusion
REFERENCES
Although efforts are being made to train more ophthalmologists in Africa, it is likely that with the present three-year training programmes there will be insufficient ophthalmologists available outside the larger cities in the next ten years. It is therefore important that good supervised training programmes should be developed for ophthalmic assistants or ophthalmic nurses who can provide eye-care services to rural populations in Africa and who may also be trained to deliver cataract surgery services. The promotion of one-year courses in ophthalmology so that African doctors can acquire expertise in eye diseases and specifically train in cataract surgery should also be considered; this is being done in Zimbabwe, will soon start in West Africa, and could be copied in other countries. Specific needs in the next decade Development of regional training countries
centres
for
(ie, Angola, Mozambique, Guinea-
Bissau) ; (b) French-speaking West Africa (ie, Burkina Faso, Niger, Tchad, Central African Republic, Guinea, Cameroon, Gabon, Congo, Mauritania); (c) Englishspeaking West Africa (ie, Ghana, Sierra Leone, Liberia, and The Gambia); and (d) central and southern Africa (ie, Zambia, Zimbabwe, Lesotho, Botswana, Swaziland, and
Malawi).
The
regional training
centres
Africa. Geneva: WHO, 1988. 3. World Health
Organisation. Ophthalmic
manpower for
francophone
Africa. Geneva: WHO, 1990.
From The Lancet Emotive St
George’s Hospital has
subjects
been the
scene
of a
painfully
sudden
death, which recalls a similar incident historical in the annals of the profession. Sir Frederick Roe, having attended a meeting at which the subject of the proposed change in the system of nursing was warmly discussed, he taking an earnest part in the debate, was to totter on coming out of the board-room. He was into a neighbouring room, and received all possible care, conveyed but died from apoplexy. The illustrious John Hunter died also (from disease of the heart) in this hospital after a scene of excitement in the board-room. Elderly people, and those suffering from diseases of the heart, should very carefully abstain from mental excitement of any kind; and these are two painful warnings. The sudden death of Mrs Carlyle, under circumstance of a terribly tragical character, is also attributed to sudden and excessive emotion. She was shocked by her favourite dog falling beneath the wheel of a carriage, and seems to have died from failure of the heart, unobserved, and while being driven in the ring at Hyde Park.
observed
ophthalmologists-A centre is needed for (a) Portuguesespeaking
1. Foster A. Patterns of blindness. In: Duane E, ed. Clinical ophthalmology. Vol 5. New York: Harper and Row, 1991. 2. World Health Organisation. Ophthalmic manpower for anglophone
will
train
(April 28, 1866)
2. Gardosi J, Carter M, Becket T. Continuous intrapartum fetal oxygen saturation. Lancet 1989; ii: 692-93.
low baseline saturation at the beginning of labour, which we have seen in several cases of growth retardation (fig 2), could suggest diminished placental transfer and reserve. The technique could also be used to recognise fetal distress: a fall in the Sa02 trend during labour, which was observed during developing metabolic acidosis, may be due to movement of the haemoglobin dissociation curve to the right (Bohr shift); this on its own would reduce Sa02 even if P02 remained constant. These hypotheses will need to be tested in large series. Our aim was to assure the quality of our data and to exclude possible sources of artifact, to give this new fetal monitoring technique every chance to fulfil its exciting reserve: a
monitoring of
3. Damianou D, Crowe JA, Schram CMH, Gardosi JO. Artefacts in reflection pulse oximetry readings due to variations in probe to skin surface separation. IEE Abstr 1991; 89: 3. 4. Tremper KK, Barker SJ. Pulse oximetry. Anesthesiology 1989; 70: 98-108. 5. Southall DP, Bignall S, Stebbens VA, Alexander JR, Rivers RPA, Lissauer T. Pulse oximeter and transcutaneous arterial oxygen measurements in neonatal and paediatric intensive care. Arch Dis Child 1987; 62: 882-88. 6. Editorial. The trust in pulse oximeters. Lancet 1990; 335: 1130-31. 7. Peat S, Booker M, Lanigan C. Ponte J. Continuous intrapartum measurement of fetal oxygen saturation. Lancet 1988; ii: 213. 8. Johnson N, Johnson VA, Fisher J, Jobbings B, Bannister J, Lilford RJ. Fetal monitoring with pulse oximetry. Br J Obstet Gynaecol 1991; 98: 36-41. 9. Rosen M. Fetal surveillance during fetal surgery. Presented at 1st International Symposium of Intrapartum Surveillance, Nottingham, October, 1990. 10. Andrews BF, Willet GP. Fetal hemoglobin concentration in the newborn. Am J Obstet Gynecol 1965; 91: 85-88. 11. Johnson N, Johnson VA, Bannister J, Lilford R. The effect of caput succedaneum on oxygen saturation measurements. Br J Obstet
promise. This work was supported by Action Research, Nottingham Health Authority, Parkside Health Authority, Criticare Systems Inc, and Surgicraft Ltd.
REFERENCES 1. Harris AP, Sendak MJ, Donham RT, Thomas M, Duncan D. Absorption characteristics of human fetal hemoglobin at wavelengths used in pulse oximetry. J Clin Monit 1988; 4: 175-77.
Gynaecol 1990; 9: 493-98. 12. Schram CMH, Gardosi J. The effect of caput succedaneum on oxygen saturation measurements. Br J Obstet Gynaecol 1991; 98: 113-14.
PUBLIC HEALTH Africa’s 3 million blind people?
Who will operate
curably
About half the 6 million blind people in sub-Saharan Africa have surgically curable cataract. The available manpower and resources can only provide services for less than 10% of the new blind cataract patients each year, and little is being done for the estimated 3 million "cataract backlog". A serious limiting factor to the development of prevention of blindness programmes is lack of trained manpower. Despite an increase in the number of ophthalmologists trained in cataract surgery (which varies greatly from country to country), this number is not keeping pace with increased demand for eye-care services, especially in large rural popultions. Initiatives that will help to overcome this dilemma are specific post-graduate courses in community ophthalmology in Africa, plans to develop a one-year diploma in ophthalmology course for English-speaking West African countries, and a proposal to upgrade a similar course in Zimbabwe. Additionally there is a need for the training of more ophthalmic assistants, cataract surgeons, and nurses in the diagnosis and management of common ophthalmic disorders. Experienced expatriate ophthalmologists also have an important role in the teaching of doctors and ophthalmic assistants how to select patients and carry out successful inexpensive cataract surgery with appropriate technology and limited facilities.
on
Introduction There are 27-35 million blind people world wide:1 6 million live in sub-Saharan Africa, of whom more than half have surgically curable cataract. The average ophthalmologist in Africa carries out fewer than 300 cataract operations a year on about 100 blind people. Therefore, 50 000 blind cataract patients are being operated on per year in sub-Saharan Africa, but the estimated "cataract backlog" is in excess of 3 million and there is an annual incidence of at least 500 000 newly blind people due to this disorder. Thus, the available manpower and resources are providing services for less than 10 % of new blind cataract patients, and there is still the problem of the existing cataract blind. A serious limiting factor to the development of prevention of blindness programmes in sub-Saharan Africa is the lack of trained manpower. In this article I will review the present situation about available personnel for providing cataract surgical services in Africa so that I can try to answer the question, "Who will operate on Africa’s 3 million curably blind people?"
Ophthalmologists The number of available ophthalmologists varies greatly from one region of the world to another, with about 1
ophthalmologist per 20 000 population in North America and western Europe, 1 per 35 000 in Latin America, and ADDRESSES International Centre for Eye Health, 27-29 Cayton Street, London, EC1V9EJ, UK (Allen Foster, FRCS).
1268
TABLE I-OPHTHALMOLOGISTS IN SUB-SAHARAN AFRICA
TABLE II-TRAINING CENTRES FOR OPHTHALMOLOGISTS IN SUB-SAHARAN AFRICA*
*Excludmg South Afnca
in Zimbabwe in ophthalmology. course
i
i
per
100 000
in
India.
There
are
even
fewer
ophthalmologists in some African countries-eg, 1/650 000 in Kenya and 1/2-6 million in Ethiopia.1 Two recent workshops convened by the World Health Organisation (WHO)—in 1988 in Accra, Ghana, for English-speaking Africa, and last year in Lome, Togo, for sub-Saharan French-speaking Africa-reviewed the present situation with respect to ophthalmic manpower for a wide country-tocountry variation on the availability of ophthalmologists in sub-Saharan Africa-from 1 per 130 000 in South Africa to 1 per 3 million in Angola (table I). Generally there is about 1 ophthalmologist for every million population in Englishspeaking and French-speaking areas, and 1 per 2 million in Portuguese-speaking countries (figure). Most ophthalmologists work in the university teaching hospitals or in the larger cities, and about 25% of those working in sub-Saharan Africa are expatriates.3 There are post-graduate training programmes for ophthalmologists in Senegal, Mali, Ivory Coast, and Zaire for French-speaking countries and in Nigeria, Ethiopia, Sudan, Kenya, Tanzania, Zimbabwe, Uganda, and South Africa for English-speaking countries. There is no full-time training programme in Africa for Portuguese-speaking countries. About 50 ophthalmologists graduate each year from 15 training centres in sub-Saharan Africa (excluding South Africa), with 20 from 6 centres in Nigeria (table II). Despite the increase in the number of ophthalmologists being trained in Africa during the past 10 years, this number is not keeping pace with the increased demand for eye-care services, especially in the large rural populations of subSaharan Africa. New initiatives include plans to develop a one-year diploma in ophthalmology course for Englishspeaking West African countries under the direction of the West African College of Surgeons; and a proposal to upgrade the present one-year diploma in ophthalmology
eye-care services in Africa .2,3 There is
Ophthalmologist/population ratio
three-year post-graduate training
Community ophthalmology
i
OPH = ophthalmologists, POP = population
1
to a
in sub-Saharan Africa.
Post-graduate training in ophthalmology in Africa is often based on the curricula for training programmes in Europe. Because of the different ophthalmic disease patterns and the availability of resources, more attention needs to be paid to community ophthalmology in the training of ophthalmologists for work in Africa. Presently, there is no specific training course in community ophthalmology in Africa; rather, two courses have been developed at WHO collaborating centres for blindness prevention-in London at the International Centre of Eye Health, and in Baltimore at the Dana Center of the Johns Hopkins Hospital. The aim of these courses is to train ophthalmologists in community or public health ophthalmology so that they can go on to establish and assist in the development of national prevention of blindness programmes in their own countries. The introduction of community ophthalmology into postgraduate curricula in Africa is an important priority in the immediate future. General
physicians/surgeons
African countries general doctors have learnt that they can provide eye surgical services where no ophthalmologist is available. This situation is more relevant to non-governmental than to the government medical services. The difficulty with this approach to eye care is that, owing to many other demands, the general doctor cannot usually devote enough time to eye work for the development of a useful and sustainable service. In
some
cataract surgery so
Nonetheless, in
general physician or only choice in the foreseeable future for providing cataract some remote
areas,
a
surgeon who has learnt cataract surgery may be the surgery services.
Ophthalmic assistant cataract surgeons Because of the inadequate number of ophthalmologists for the population, many African countries have now established training programmes for ophthalmic assistants who are trained to provide diagnostic, refractive, and therapeutic eye-care services for a population of about 250 000. Ophthalmic assistants are usually medical assistants or general nurses who have had a medical or nursing training and who are then given a specific one-year training in the diagnosis and management of common ophthalmic disorders. Presently, there are training programmes for ophthalmic assistants or ophthalmic nurses in Ethiopia, Kenya, Uganda, Tanzania, Malawi, Zimbabwe, Sudan, Mali, Ghana, and Sierra Leone. After working for several years, selected ophthalmic assistants who have shown good judgmental and surgical skills may be offered a further one-year training in cataract surgery on a one-to-one basis with an experienced ophthalmologist. In
1269
the training (specifically in intracapsular cataract surgery under local anaesthesia with magnifying loupes for uncomplicated senile cataract), assistants carry out 100 cataract operations under supervision. Training of ophthalmic assistants in cataract surgery has been successful in several African countries including Kenya, Malawi, Tanzania, and Mali.
Expatriate ophthalmologists Many ophthalmologists from Europe and North America a genuine interest in trying to reduce the number of
have
cataract blind in
Africa. How best can these well-motivated
initiatives be channelled? Short-term surgical visits, though
rewarding to the visiting ophthalmologist and beneficial to the individuals operated on, do little for and may even have a negative effect on the development of national sustainable eye-care services. These short-term surgical visits are expensive for what they achieve and often take much time to organise with respect to obtaining medical registration and preparing the hospital and patients for the visiting surgeon. Nonetheless, there are remote neglected areas of Africa where experienced visiting eye surgeons can have a role in showing that eye surgery can restore sight to the blind. These areas are, however, usually far away from the more popular areas of Africa for the short-term visitor. The more important role for the expatriate ophthalmologist is as a "multiplier". There is a huge need in Africa for ophthalmologists who can teach doctors and ophthalmic assistants how to select patients and carry out successful inexpensive cataract surgery with appropriate technology and limited facilities. However, the selection criteria, surgical techniques, and facilities available are not the same as those of Europe and North America, and the expatriate ophthalmologist must therefore be willing to look, listen, and learn before deciding what is appropriate to teach; this takes time.
ophthalmologists over 3-4 years to provide specialist tertiary ophthalmic services in the larger city and university hospitals. Regional centres for different language groups will enable the smaller African countries to train ophthalmologists within Africa in cost-effective and good training programmes. Links between African and European or American university departments of ophthalmology (following the example of Nairobi and Munich) can be of great benefit in promoting exchange in new techniques and providing lecturers and resources for appropriate research. The establishment of one-year training programmesThere is a need for doctors to train as eye doctors/cataract surgeons in individual African countries (with populations in excess of 5 million), following the Zimbabwe model. These eye doctors/cataract surgeons will be based in the smaller cities and towns and provide eye and cataract surgery services at the secondary level of eye care for rural populations living distant from the large cities. Training of ophthalmic assistants/nurses-More emphasis should be given to the training of selected
ophthalmic assistants/nurses as cataract surgeons in individual countries. It is the ophthalmic assistants who will continue to form the backbone of secondary level eye-care services in most areas of many African countries. Suggested goals-For the next decade we need (a) one national ophthalmologist per 500 000 population in every
African country
(ie, double the present figure)(b) one (eye doctor or ophthalmic assistant cataract 250 000 population in every African country; surgeon) per and (c) cataract surgery at a rate of at least 1000 operations/ million population in African countries to approximate to the incidence of blinding cataract. To develop training programmes for manpower development in eye care, each African country needs to work out its own objectives and strategies so that appropriate regional and national planning can be defined and implemented. cataract surgeon
Conclusion
REFERENCES
Although efforts are being made to train more ophthalmologists in Africa, it is likely that with the present three-year training programmes there will be insufficient ophthalmologists available outside the larger cities in the next ten years. It is therefore important that good supervised training programmes should be developed for ophthalmic assistants or ophthalmic nurses who can provide eye-care services to rural populations in Africa and who may also be trained to deliver cataract surgery services. The promotion of one-year courses in ophthalmology so that African doctors can acquire expertise in eye diseases and specifically train in cataract surgery should also be considered; this is being done in Zimbabwe, will soon start in West Africa, and could be copied in other countries. Specific needs in the next decade Development of regional training countries
centres
for
(ie, Angola, Mozambique, Guinea-
Bissau) ; (b) French-speaking West Africa (ie, Burkina Faso, Niger, Tchad, Central African Republic, Guinea, Cameroon, Gabon, Congo, Mauritania); (c) Englishspeaking West Africa (ie, Ghana, Sierra Leone, Liberia, and The Gambia); and (d) central and southern Africa (ie, Zambia, Zimbabwe, Lesotho, Botswana, Swaziland, and
Malawi).
The
regional training
centres
Africa. Geneva: WHO, 1988. 3. World Health
Organisation. Ophthalmic
manpower for
francophone
Africa. Geneva: WHO, 1990.
From The Lancet Emotive St
George’s Hospital has
subjects
been the
scene
of a
painfully
sudden
death, which recalls a similar incident historical in the annals of the profession. Sir Frederick Roe, having attended a meeting at which the subject of the proposed change in the system of nursing was warmly discussed, he taking an earnest part in the debate, was to totter on coming out of the board-room. He was into a neighbouring room, and received all possible care, conveyed but died from apoplexy. The illustrious John Hunter died also (from disease of the heart) in this hospital after a scene of excitement in the board-room. Elderly people, and those suffering from diseases of the heart, should very carefully abstain from mental excitement of any kind; and these are two painful warnings. The sudden death of Mrs Carlyle, under circumstance of a terribly tragical character, is also attributed to sudden and excessive emotion. She was shocked by her favourite dog falling beneath the wheel of a carriage, and seems to have died from failure of the heart, unobserved, and while being driven in the ring at Hyde Park.
observed
ophthalmologists-A centre is needed for (a) Portuguesespeaking
1. Foster A. Patterns of blindness. In: Duane E, ed. Clinical ophthalmology. Vol 5. New York: Harper and Row, 1991. 2. World Health Organisation. Ophthalmic manpower for anglophone
will
train
(April 28, 1866)
