Dr Jahangir Alom
Barts Health NHS Trust
Background
Bangladesh is a relatively young country, gaining independence in 1971. The majority of the citizens still live in rural farmland, 63.7% of the population are aged 15-64 years old. Bangladesh is a densely populated country in South Asia which is considered to be of low or middle income economy. Regions of Bangladesh are called division which can further split into subdivisions (districts). Each district is made up of sub-units similar to counties and boroughs known as Upazila’s.
Approximately 30% of Bangladeshi’s live below the national poverty line, which is a remarkable improvement over the past three decades. The life expectancy for men is 71 and 73 for women. The adult literacy rate is 57.7% with female literacy at around 53%.
The healthcare system in Bangladesh consists of 4 main players: government, for-profit organisations, non-governmental organisations (not for profit) and international aid organisations. Primary care services are mainly run in government funded Upazila health complexes with the addition of faith healers and allopathic providers such as drug shop retailers providing informal and unregulated medical care in the community. The secondary and tertiary services are found mainly in the urban areas. These services are not a referral only service and patient can present directly to specialists for consult. In 2013, there were approximately 64,000 registered doctors which is 3.05/ 10,000 population. Majority of doctors are based in urban areas and are inaccessible by the rural villagers. Not only does Bangladesh suffer with maldistribution but also a major shortage of healthcare professionals (both doctors and nurses).
The last national eye health survey was conducted in 2001, shortly after the VISION 2020 global initiative was agreed. The data is very much out of date and an eye health census is needed in Bangladesh.
More than 1,000,000 people in Bangladesh suffer from blindness; of that 74.6% are blind due to cataract and 18.7% due to refractive error. Across the country, there is only 32.8% coverage for cataract surgery services, 626 ophthalmologists and 618 mid-level eye care personnel. Hospitals with ophthalmic operating theatres are all based in major cities. The nearest eye care service to Beanibazar/Golapganj Upazila is an hour drive away either in Sylhet city or the Moulvibazar sub-district. There are no primary eye care services in the local region and the population have to rely on alternate medicine or informal healthcare provided by untrained local people. It is common practice to use eye drops for reduced vision over the age of 30.
A cataract is the gradual and painless cloudiness of the intraocular lens due to protein metabolism. This causes reduced light to enter the eye and eventually blinds an individual. The slow progression of blindness often confuses patients with age-related refraction errors. However, prescription glasses nor medication can resolve the symptoms of a cataract. Cataracts require highly specialised surgery that can only be performed by trained ophthalmologists. The prevalence of diabetes in Bangladesh is 7% and 37% of men are tobacco smokers. Both smoking and diabetes mellitus are risk factors for developing cataracts.
According to the Bangladeshi National Eye Operational Plan, in order to clear the cataract deficit, the nation must perform 3,000 surgeries per million per year. Although the data is somewhat outdated now, we know that the cataract burden would be much larger. If we apply this to the Beanibazar/Golapganj Upazila’s, then we must operate approximately 500+ surgeries per million per year. The Bangladeshi eye care system suffers from both lacks of human resources and poor accessibility. Avoidable blindness leads to widening socioeconomic issues. Optometry and ophthalmic assistants are quite novel in the country. Beanibazar/ Golapganj Upazila’s are mainly made up of rural villages and most of the working population are self-employed in traditional labour jobs such as carpentry, construction, farming. Women who work are usually in the agriculture domestic sector. Being illiterate, female and poor are also risk factor factors for delayed cataract treatment.
Programme
Porishkar is a cataract surgery service that runs in rural Sylhet, in Upazila’s like Beanibazar and Golapganj. The service is fully funded by the charity Selfless UK (Registered charity in England & Wales: 1147463).
The cost of each small incision cataract surgery is approximately £30 or 3000 Bangladeshi Taka (BDT). This includes the cost of biometrics, surgery, intraocular lens and post-operative care. There is a separate budget for screening and post-operative complications. The project partners with Bangladeshi ophthalmologists who are able to follow up patient’s locally when required.
Villages are screened by a trained technician who travels to hard to reach areas by motorbike. The target population are villagers who have lost their jobs because they have lost their vision. The aim of the programme is to empower people to become financially independent again and avoid poverty. Four weeks after the surgery patients are supported in getting back to work mainly as housekeepers, textile workers, tuk-tuk drivers or construction workers.
Conclusion
Tackling global blindness has been a key area of work for the World Health Organisation. The COVID19 pandemic has further disrupted the scarce eye care available in Bangladesh and it is now more important than ever for non-governmental organisations to work in partnership with local surgeons to address reversible blindness.