Dispatch from the CBR Front Lines-On a Kilimanjaro Cataract Patch

By M.Miles (m99miles@hotmail.com)
 

Starting early by jeep from Moshi, we are the last pair to be dropped off, at 10.30, in Kirweni village, Mwika district, North-Eastern Tanzania.  Angelo, a Sicilian in his 30s who manages a Community Based Rehabilitation project in rural Uganda, inhales the clean mountain air and argues with me about the elevation. He maintains that we are over 2000 metres high, on the flank of Kilimanjaro. I think we're below 2000, but can't offer any supporting evidence.
 
The young man whom we will shadow is Francis Manyanga, who belongs to this area and has been doing ophthalmic outreach in the community since 1996. He briefs us about today's work: mostly revisits to existing clients, checking whether cataracts are mature enough for surgery. With all the confidence of clear-sighted youth, Francis tells us about elderly people's fear of surgery and how he tries to reassure them. From my perspective, nearer the age for an encounter with an eye surgeon's scalpel, I empathise with the worried clients!  But Francis has a pleasant manner, both cheerful and respectful. During the morning we notice that he has earned the trust of people old enough to be his grandparents.

Village Chairman accompanies tour
First, we sign the guest book in the sparsely furnished office of the Village Chairman. From that we learn that this village of 1600 people has had 15 'official' visitors in the past month. The energetic, middle-aged Chairman, small of stature and dressed in a purple suit, has learnt that we are involved in some capacity with the CCBRT training workshop for CBR managers. He decides to accompany our tour, and soon we set off at a rapid pace down a track, then branch off on a narrow path through thick undergrowth, shrubs and trees.
 
After ten minutes' walk we are greeted by an elderly man whose blind eye was successfully operated on last year with an intra-ocular lens. The presence of 'successful cases' in the village is a powerful motivator for others to accept cataract surgery. We walk on, passing a well-appointed villa with tiled roof, and reach the house of Mr S, said to be 99 years old but clearly a modern man, with his radio and electricity connection. He remains seated on the verandah of his three-room wooden house while Francis paces away a distance of six metres. From there, Francis holds up one finger, three fingers, two fingers, to check what Mr S can distinguish at that distance. Several small children gather for the entertainment. Inside the house, Francis produces a small torch and checks Mr S's eyes close up. The decision is made that he will be collected and taken for cataract surgery at the big hospital near Moshi in a week's time.

Spotting motes at a fast pace
The Chairman again sets a fast pace to the next house, up a hillside well-planted with coffee, banana trees and sunflowers. Along the way Francis spots a young man carrying a small tree on his shoulder, and somehow notices that he might have an eye problem. (Thinking back, I realise that with only the tree in my view, I would never have noticed the mote in his eye. The local eye-worker ignores the tree and spots the 'mote'...) Francis speaks to the young man, who throws down his tree and submits to an impromptu eye exam, with six metre distance check. There seems to be an early cataract. We briefly enter the young man's dimly lit two room hut and Francis gets out his torch for the close-up procedure. The lens is reactive. Returning to the bright sunlight outside, Francis fills a history sheet, writing left-handed while talking to the young man about his eyes. The young man signs a paper. I wonder how much he has understood - but with the Village Chairman and a couple of foreigners standing by, this chance encounter must
have made a serious impression.

Care and persuasion with elderly villagers
At 11:45 we are further up the hillside, checking an elderly man whose wife has already had her cataracts operated and who proudly displays her spectacles. From there we move on to a middle-aged man who seems to be totally blind and depressed, with some physical weakness and trembling legs. Alcohol poisoning is mentioned as a possible cause of blindness... it is thought that a neighbour is still supplying home-made liquor. The man's wife cares for his physical needs, but he would benefit from some exercise, and some activities to give meaning and purpose to his life.
 
The return circuit has begun by 12:15, and we talk briefly to an old granny sitting outside her mud-and-wood-frame hut. She has already had one eye operation, and wears spectacles. Francis does his six metre test, then one of the neighbours exhorts granny to get up and go inside her hut for the close-up check with the torch.  The process is repeated with a wizened old woman sitting on the ground a few hundred yards on, having at most three teeth in her head. Francis notes on his papers 'no change' from her previous check-up.
 
The next old woman, lying on a blanket under a tree, has refused previous suggestions of a cataract operation, though she has mature cataracts and a positive result could be expected. Francis seizes the chance, lines up his foreign guests as a Greek chorus, and deploys the Chairman to harangue the old woman. Under this field battery, she capitulates. Francis goes through his tests at distance and close-up, with a view to referring her for surgery. He is pleased; but as no carer is present, the old woman may yet evade the well-intentioned plot to restore her sight.
 
Nearby we meet a cheerful old man, a retired teacher, who had a successful intra-ocular lens surgery six months earlier. This time, when Francis checks six metre vision, I sit next to the old teacher and find that the test is no mere formality - without my specs I can hardly tell one finger from two. Fortunately the old man passes the test and Francis notes that he needs some more eye drops.

Returning to village office
Returning towards the Village Office after 1 p.m. we are now a party of five, as another elderly man has attached himself to us. Francis stops to check an old woman with cataracts in both eyes, who says she is too poor to afford an operation. She also has serious problems with her hands, and several fingers are missing. Francis does his best to persuade her to attend Kilimanjaro Christian Medical Centre. The woman has a young relative working there, who will be able to make some arrangements.
 
The scheduled visits are over - the day has been shortened to fit our travel needs - but there is still time for an elderly man, looking very much like a friendly old dog, to toddle out from the shade and accost us and secure a bit of attention. Francis obliges with good humour, and checks his eyes close up and at distance. There is no apparent problem.
 
At 2 p.m., back at the point where we should be picked up, the work continues. A man walks past then returns to report that he knows a child with a club foot, can anything be done? It's the wrong end of the body for an eye worker, but Francis has concerns beyond eyes. He listens with interest and encourages the man to take this child to KCMC.
 
After three hours with plenty of rapid walking up and down the hilly tracks, we lowlanders should be exhausted, but somehow we feel nothing of the sort. Seeing the battle with cataract at the 2000 metre level is certainly more exhilarating than treading the tourist path to 'conquer' the 5895 metre peak of Kilimanjaro.

Confidence in fellow Tanzanians
This is one of the better-endowed areas of Tanzania, yet there is still much socio-economic uplift needed before the traditional dignity and character so evident among these African villagers will be matched by health education, therapies and curative services within their reach, to meet the needs of their older years. It's encouraging to see this resourceful young Tanzanian hard at work on his patch. Still more encouraging, when he tells us of his schooldays and his hopes for the future, there is little mention of poverty and backwardness. He is confident that his fellow-Tanzanians will pull together and will overcome their problems.
 
Later, in discussion with the CBR managers, it turns out that we have seen most of the obstacles that deter people from available surgery. Even competent Eye Units in high cataract areas often run far below their operating capacity, because people with cataracts are afraid of the operation, are uncertain whether they can afford it, have nobody to accompany them to and from hospital, and anyway have adjusted to living with minimal eyesight. Elderly people are expected to have weak eyesight, so family budgets often give low priority to this need.  Especially with old women there is strong adverse discrimination, even in a culture that traditionally honours old people.
 
At every stage, these barriers amount to a lack of effective, accurate and credible information. Many methods have been tried for overcoming such barriers. We have witnessed one of the most effective: the trained, well informed, courteous young person, belonging to the area, backed up by a specialist supervisor, working hard to earn the confidence of the people, from the village leader to the humblest elder lying on her blanket under a tree.