Carolyn Ahlers
Barriers to Ophthalmic Health in Kenya
Carolyn Ahlers
As a third-year medical student at Vanderbilt University School of Medicine, I participated in a global health rotation at Lwala Community Alliance (LCA), a non-governmental organization in Lwala, Kenya that provides healthcare to the surrounding rural community. Built on a model of empowering the community, LCA trains community health workers, leads sessions on gender-based violence, teaches about the importance of latrine sanitation to prevent disease, provides family planning resources, and delivers outpatient and inpatient healthcare services. As an aspiring ophthalmologist, for the final essay of my global health course, I wrote about barriers to ophthalmic care in Kenya. It is my hope that this essay raises awareness about the need for ophthalmic health in Kenya and sub-Saharan Africa (SAA). This topic is important, as although Africa is home to approximately 10% of the world’s population, it accounts for 19% of the world’s blindness.1
In this essay, I explore the need for ophthalmology in Kenya by providing examples of two common ophthalmic diseases – one adult and one pediatric: diabetic retinopathy and retinopathy of prematurity. I also describe how financial restraints are a major barrier to eye care in the country.
One of the major diseases that ophthalmologists treat is diabetic retinopathy. Diabetic retinopathy is an eye condition that can cause vision loss and blindness in people with diabetes due to damage to blood vessels in the retina.2 Diabetes is a major health problem in SSA, where it is the leading cause of cardiovascular disease and disability.3 In fact, SSA “continues to face the highest rate of mortality from diabetes in the world due to limited access to quality diabetes care.”3 Not only is the prevalence of diabetes high in SSA (7.1% of the population), but awareness, treatment, and glycemic control rates are low. The high burden of diabetes in this region of the world is demonstrated by the fact that 75% of diabetes-related deaths in SSA occur before the age of 60. This is a major health issue for SSA, and the situation is expected to worsen, with estimates that the prevalence of diabetes will double in SSA by 2045.3
Minimum standard of care guidelines for the management of diabetes have been created by the International Diabetes Foundation. These guidelines cover a myriad of important diabetes management strategies, one of which is providing eye screening for patients with diabetes.3 This is an important recommendation, as every person with diabetes is at risk of potentially blinding diabetic retinopathy.3 However, according to the article, “Adapting Clinical Practice Guidelines for Diabetic Retinopathy in Kenya: Process and Outputs,” there are “currently notable gaps in diabetic retinopathy screening, diagnosis, referral, treatment, and follow-up.”4 This is a major issue for Kenya, as the vision loss associated with diabetic retinopathy is associated with increased morbidity and mortality, partly due to increased frequency of falls and fractures and difficulties with taking medications for other conditions.4 Diabetes and diabetic retinopathy are also a significant burden on the economy of Kenya, as these conditions are associated with high health care costs.4 Screening and laser treatment are cost-effective interventions for the prevention of diabetic retinopathy in Kenya, but many Kenyans face inequities in accessing them.4 This is due to a multitude of reasons, including sub-optimal referral practices of diabetes care providers, inadequate screening practices, poor integration of services, unsatisfactory quality of services, and poor level of awareness among patients.4 Diabetic retinopathy is one ocular disease that highlights the barriers to providing eye care in Kenya. Only through increased awareness about diabetes and diabetic retinopathy can the country preserve the vision of many at-risk Kenyans.
Another ophthalmic disease that demonstrates challenges to ocular care in the region is retinopathy of prematurity (ROP). Pre-term birth is a major risk factor for ROP, and Kenya currently experiences about 188,100 preterm births each year.5 Despite the large burden of ROP in the country, only two public hospitals in Kenya, Kenyatta National Hospital and Moi Teaching and Referral Hospital, screen for and treat ROP. Screening for ROP is relatively new in Kenya, as it began in 2010.
There are not any national guidelines in Kenya regarding screening and treatment of ROP, but the Kenyatta National Hospital recently introduced written guidelines that were borrowed from other medical centers. ROP screening is limited in Kenya because “disease awareness is lacking” and “resources are strained.” However, this is certainly an important health issue for Kenya to address, as ophthalmologists in Kenya have reported increased numbers of children experiencing blindness due to ROP.5 A barrier to pediatric ophthalmic health in Kenya is the lack of resources, as currently the country lacks the capability of conducting laser procedures and ocular surgeries to treat diseases such as ROP for a large portion of the Kenyan population. Furthermore, a major challenge for pediatric eye health in Kenya is the lack of awareness in Kenya about retinopathy of prematurity (and other pediatric eye disorders), and the importance of prevention (careful use of oxygen therapy for pre-mature infants), screening, and treatment. Similar to diabetic retinopathy, to address these challenges, education of both local clinicians and the general public needs to be a central focus.
Another barrier to eye care in the region is financial restraints. One study titled, “Costs of Eye Care Services: Prospective Study from a Faith-Based Hospital in Zambia,” found that for ocular care, overhead costs were approximately $31/consultation and mean total costs amounted to $128 per cataract surgery and $86 per refractive error correction. While these procedures cost less than they likely would in the United States, these costs are certainly not insignificant,6 as 1.4 billion people live on less than $1.25/day, and in total, about 40% of the world’s population lives on less than $2.00/day.7 Financial restraints within Kenya are likely a barrier to people accessing ophthalmic care, as according to the Kenyan Economic Update, over 35% of Kenyans live below the international poverty line (US $1.90 per day).8
The article, “Poverty and Blindness in Africa,” illustrates the reasons why ophthalmic care is Africa is lacking with this quote:
“The state of eye care in Africa stands in alarming contrast to that in the rest of the world. Poor practitioner-to-patient ratios, absence of eye-care personnel, inadequate facilities, poor state funding, and a lack of education programs are the hallmarks of eye care in Africa, with preventative and treatable conditions being the leading cause of blindness. Eye diseases causing preventable blindness are often the result of a combination of factors, such as poverty, lack of education, and inadequate health-care services.” 1
Continuing to fight poverty, educating the general public and local providers, and working to increase the availability of eye care within the region is essential for improving eye health in Kenya.1
Providing ocular care in Kenya would certainly not be without its challenges. However, by increasing awareness about the need for eye care and the barriers limiting care, we can work towards a future of better eye health for Kenyans. Through these efforts, the vision of many patients in Kenya and SSA can be saved.
Bibliography
1. Naidoo K. Poverty and blindness in Africa. Clin Exp Optom. 2007;90(6):415-421. doi:10.1111/j.1444-0938.2007.00197.x
2. Institute NE. Diabetic Retinopathy. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/diabetic-retinopathy.
3. Pastakia SD, Nuche-Berenguer B, Pekny CR, et al. Retrospective assessment of the quality of diabetes care in a rural diabetes clinic in Western Kenya. BMC Endocr Disord. 2018;18(1):97. doi:10.1186/s12902-018-0324-5
4. Mwangi N, Gachago M, Gichangi M, et al. Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs. Implement Sci. 2018;13(1):81. doi:10.1186/s13012-018-0773-2
5. Bowe T, Nyamai L, Ademola-Popoola D, et al. The current state of retinopathy of prematurity in India, Kenya, Mexico, Nigeria, Philippines, Romania, Thailand, and Venezuela. Digit J Ophthalmol DJO. 2019;25(4):49-58. doi:10.5693/djo.01.2019.08.002
6. Griffiths UK. Costs of Eye Care Services: Prospective Study from a Faith-Based Hospital in Zambia. 2012.
7. Denno D. Global child health. Pediatr Rev. 2011;32(2). doi:10.1542/pir.32-2-e25
8. World Bank. Poverty Incidence in Kenya Declined Significantly, but Unlikely to be Eradicated by 2030. https://www.worldbank.org/en/country/kenya/publication/kenya-economic-update-poverty-incidence-in-kenya-declined-significantly-but-unlikely-to-be-eradicated-by-2030.
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About the Presenter:
Carolyn G. Ahlers is a third-year medical student at Vanderbilt University School of Medicine. She is from Le Mars, Iowa and graduated from the University of Notre Dame in 2017 with a degree in Science Pre-Professional Studies and minors in European Studies and Peace Studies. She is grateful to have had the opportunity to spend a month abroad in Lwala, Kenya at the Lwala Community Alliance in February 2020. She hopes to pursue a residency in ophthalmology or internal medicine.