14 August, 9:30pm GMT - Anyinasu, Brong Ahafo Region

Nothing remarkable happened today, so I'm going to take this entry to describe our typical day here. Around 6:45am, I crawl out of my mosquito net, fill up my 1.5L Voltic water bottle with three 500mL bags of water for the day, and take a probiotic and malaria pill (if it's Wednesday, since I got a weekly prescription). Breakfast of soggy white bread, a green onion omelette, porridge, and a hot drink (chocolate malt, instant coffee, or tea) waits for us in the dining room around 7am.  We often supplement it with our own food from home or the markets: raspberry jam, Nutella, sweet rolls, apple cinnamon oatmeal, pineapple, bananas, mangoes, and French press coffee. The van is scheduled for 7:30am, so it arrives between 7:45am and 9am, which means we can take our time at breakfast and even go back to sleep. The van arrives with our driver Adumako and Eric, then we pick up Kate and Evarist and drive 1-3 hours to the outreach site.

Between 9 and 11am we arrive at our clinic site (the village church) where a small group of patients are waiting. The group has been gathered by the village coordinator, a volunteer who advertises the visit and is rewarded by collecting a fee from every participant. Kate leads a prayer, introduces us, then gives a short talk about eye care in Twi. The only part of the eye health talk that I understand is when Kate uses words that Twi has borrowed the English for: "fish" and "carrots" for when she's explaining how to get enough Vitamin A, and "glaucoma", which she has the entire audience repeat after her, which cracks up the volunteers every time. The eye health talk is given to the entire community rather than to patients individually because Ghanaian culture is based on the community rather than the individual. If everyone hears and agrees with the lesson, then together everyone will follow the instructions. This is especially true if the tribal chief shows up to the clinic, which happens pretty often. The response during the questions period after the talk seems to correlate with how educated and health-oriented the community. In the poorest community we’ve stopped in, there were no questions. In another community, the talk took 90 minutes because of all the questions, and we had nearly 400 attendees, many of whom spoke English, an indicator of high school education.

Meanwhile, we count the number of glasses, medications, and cases and compare it to our final count for yesterday to make sure we haven't lost anything. When the talk ends, we set up our stations. At registration, a volunteer starts prepping the quarter sheets we use to record everything about each patient's visit. Here, the volunteer needs to speak Twi well to ask the patient their name (with assistance from Evarist on spelling), their age (which they sometimes make up), and their symptoms. In the next station, a volunteer asks the patient to sit in a chair 6 meters from the E chart, then to indicate the direction the E on the chart is facing with hand motions. Based on a quick diagnosis, you can determine the distance vision of the patient if they understand how to cooperate. Occasionally, you can tell that the patient is just making up directions for each E, which is either because they can't see or don't understand the E chart (usually because they missed the instructions in the eye health lesson). When this happens, we try to teach them directions using chairs as giant "E"s. The poorer the village, the more difficult it is to teach these patients (mostly the elderly) the spatial concept of 'which way is the E pointing', and the more frustrated Eric gets holding chairs upside-down over his head yelling in Twi, "Which way?? This way!!". It makes for great afternoon entertainment.

Occasionally, kids, who pick up on the E direction concept quickly without going to the talk, will stand just out of sight and help the elderly cheat by waving their hands based on the chart. The elderly aren't took good at being sly when they cheat, so we can tell, and make a game of slowly turning around so they can run away, hide, and come back. One kid even started a visual acuity exam on himself, covering one eye and pointing to the chart as he stood right below it. We let him give a visual acuity test to one of the other kids there. We had already finished all the patients for the day, so we let them play.

The next station is Kate's station, where she examines the patient's condition in the context of their symptoms using a retinoscope and other tools. Then, they are funneled through the research station, where Ricarda and Lianna ask them questions. Following that, the patient takes their complete slip to the dispensary station, where a volunteer gives them the glasses, medication, or surgery referral prescribed by Kate.

The most common eye problem here is allergic conjuctivitis from dust in the eyes, which can be treated with simple eye drops. The next most common is presbyopia, or farsightedness caused by loss of lens flexibility due to age. For this, we have a variety of reading glasses. Despite our best efforts to pick out cute frames for the patients, nearly every one picks the plain black ones if they're available, and we begin to wonder if the companies that donated these frames picked out the ugliest animal print ones in stock to give away on purpose. Myopia (nearsightedness) and hyperopia (farsightedness from birth) are rarer, but we have glasses for those as well. The distance glasses for myopia are not donated by Unite for Sight for some reason, so Kate orders them for each patient from her own supplier and covers the additional cost out of pocket.

Vitamin A deficiency is also a source of vision problems, which can be treated with regular supplements or with a healthy diet. Eggs, fish, red palm oil, and carrots are all good sources vitamin A and are common in Ghanaian cuisine, so it's not much of a problem here. Still, vitamin deficiency is prevalent, as obviated by the yellow hue of everyone's eyes, except for Kate's and the nurses', of course. Strabismus (when one eye has weaker muscles than the other, leading to double vision and 'lazy eye') is less common, but since it is rarely caught early enough to be fixed with non-surgical methods like eye patches, it is more common here than in the U.S. Glaucoma is here as well, but since it is rarely caught before it has caused near blindness and is irreversible, its treatment - eye drops for the rest of your life to keep it from getting worse - is rarely useful. We charge a small fee for these treatments: about 1 cedi for a pair of glasses, and 3-5 cedi for eye drops. This is to give the treatment some intrinsic value, and it help the patients take charge of their own health care rather than feel as if they are taking handouts. The fees we collect are used to offset the cost of purchasing the medication and fueling the van for outreach trips.

The most effective treatment we can provide is a surgical referral for pterygium or cataracts. Pterygium is wedge-shaped pink growth on the surface of the eye radiating from the inner corner. It is caused by UV and dust exposure and is rarely seen outside of Africa. If the growth is allowed to continue, it can cover the lens, blinding the patient, who is normally in young adulthood. A cataract is a clouding of the lens, which is most commonly caused by age but can also be congenital or caused by trauma. Cataracts are responsible for the visual impairment of 60% of all people worldwide who are legally blind (visual acuity worse than 6/36). Cataracts can be removed via small incision surgery (SICS), which is commonly used in developing countries because it is faster than all other techniques, allowing a high volume of patients to have their sight restored by one surgeon. We refer about ten patients a day to get surgery. Within the next few days, they are taken by van to the clinic in Kumasi, where the surgery and post-operative care are provided free of charge. (Don't worry, none of the pictures in this post show surgery or any of these eye diseases).

Between Kate's station and dispensary, most of the patients are routed through research stations run by Ricarda and Lianna. Ricarda is doing research about the use of traditional medicine. Many patients here trust traditional healers to treat their eye problems because they are members of the community and because there are no local eye care professionals. Traditional medicine involves treating vision problems or eye irritations by putting leaves, milk, or other substances in the eyes, which can lead to corneal diseases and certainly will not fix your cataract. Lianna is doing research about how mothers perceive health care for their children. Every child we saw at the clinic came with their parents, but many parents didn't bring their children because they didn't think it necessary to have their child's eye checked. Brian is also doing research, but it's about private paying patients in the Accra region, so his research doesn't begin until we return to Accra.

Both Ricarda and Lianna did their research by asking a series of questions to patients via translators. The translators were locals who spoke English, which almost always meant teenagers, who were old enough to have mastered the language yet young enough to still live in the village. They were awesome people, and we thanked them as best we could by waiving any fees and with small gifts that Lianna and Ricarda had brought from home.