National Eye Care Programme (NECP) of The Gambia
I have watched with admiration as under Dr Hannah Faal, The Gambia National Eye Care Programme (NECP) has developed to become a model of how eye care should be delivered in developing countries, making best possible use of resources. She has won international recognition. Much of the work of the NECP is supported by Sight Savers International (SSI), and it has strong research links with the International Centre for Eye Health (ICEH), London, and the Medical Research Council (MRC) facility at Serekunda, and is a WHO collaborating centre. The NECP has as its backbone Ophthalmic Medical Assistants (OMAs) - paramedical workers who increasingly are carrying out routine ophthalmic work in many parts of the developing world where there is a critical shortage of medical manpower, especially in rural areas. The service places great emphasis on outreach work - surgical teams travelling to population centres - and through the recent Health for Peace initiative the Gambia NECP is expanding into neighbouring countries. Much distinguished research has been conducted by Dr Faal and colleagues including surveys of the local causes of blindness and seriously impaired vision, which have led to improved planning and delivery of care.

Ophthalmic Care Structure
Training of workers at all levels within the system from village to hospital is expanding. Trainee ophthalmologists working for the West African Diploma in Ophthalmology are attached to the department in Banjul for part of their course. Ophthalmic Medical Assistants (OMAs) receive a year of ophthalmology training on top of their nursing diploma, and are awarded the Advanced Diploma in Ophthalmic Nursing (ADON). After practical experience those with aptitude may, after another year of special training, become Senior OMA (SOMA) or 'cataract surgeon'. Most cataracts are removed in The Gambia by SOMAs, and in several other countries by their equivalents (not by doctors). Formerly they went to Malawi for instruction but Dr Faal has recently established training of OMAs and SOMAs in Banjul. Candidates from neighbouring countries are included. It is accepted by many countries (but there are exceptions), that these well trained paramedics are an efficient, cost effective cadre of workers strategically placed to bring good quality eye care to the main bulk of the population in most African countries, and SSI has been promoting them for years. If the paramedic considers a case outside his or her capability it is referred to an ophthalmologist. They are also involved in promoting eye health in the area where they are stationed.

A regional eye centre for West Africa is being built in The Gambia in which up to date services for corneal disease will play an important part. Surveys show that corneal pathology is the second most important local cause of blindness and seriously reduced sight (after cataract). One kind of corneal treatment is corneal grafting. Another important activity is rational treatment of infected corneal ulcers by proper microbiological investigation to find the causative organism and give appropriate treatment.

Corneal Graft Programme
After discussion at a previous visit, a modest 'pilot' corneal grafting programme was started by Dr Faal and me in 2000, prompted by the obvious potential benefit to patients, the huge cost of obtaining this treatment abroad, and the likelihood that the Keratec Eye Bank might donate the all important graft tissue as previously it had for me working with Dr Keith Waddell in Uganda. Other important considerations were that Banjul has a good eye department and is easily accessible from abroad, as well as having excellent facilities for visitors and vital links to other institutions. It is a teaching centre so this branch of eye surgery could be observed by trainee doctors and paramedics, and, in a small country, patients can travel relatively easily and be followed up properly within a well established system. The Keratec Eye Bank kindly provided corneas for four grafts in Banjul in 2000 and four more in 2001.

Corneal Grafting - a few brief explanatory points.
We used lyophilised cornea successfully in Uganda in 1996 and I was convinced that this would be the best way of developing corneal grafting in Africa, as few severe opacities are suitable for penetrating keratoplasty and the logistics for using living tissue often make that surgery difficult to arrange. Most cases we see in Africa can best be treated by lamellar keratoplasty. Success rates are difficult to assess as different surgeons and units vary in the complexity of the cases they will take on. Significant improvement can be expected in 70 to 80%. Sadly many eyes are so badly damaged that corneal grafting is impossible. For them only a form of plastic lens-containing corneal prosthesis (keratoprosthesis) can help; this entails many problems as the cornea usually rejects implants (unlike a lens inside the eye) and as yet the only ones used successfully are expensive and hard to use.

Training Programme
Training local staff was a priority for the two purposes of our visit - instruction on corneal grafting, and on the management of corneal infection, as well as demonstrating that local facilities are adequate and that full use of them should be made. The hospital has an excellent microbiology service and during a previous visit in 2001, together with Dr Nellie Lloyd-Williams, RVTH Microbiologist and Dr Astrid Harrison from ICEH, we made a sincere effort to encourage local eye staff to collaborate with lab staff in investigating and delivering appropriate treatment for corneal infection. Others too have tried but results have been disappointing for understandable reasons. Identification of causative organisms, while leading to potentially sight saving rational choice of treatment, is difficult and time consuming. Proper investigation is a 'nuisance' for busy staff, patients requiring urgent investigation and treatment often arrive outside normal working hours.
Dr Faal, as Professor Barrie-Jones, founder of ICEH did years ago, likens a corneal abscess to a 'house on fire' and the eye and lab staff the fire brigade, with antibiotics and antifungals the 'water' to put out the fire before the house is demolished!
Dr Edith Ackuaku, consultant ophthalmologist, organises the corneal services in the RVTH eye department, and has worked with Dr Harrison in Ghana collaborating in an important publication about corneal infection (causes of corneal infection: bacterial 10.7, fungal 35.7, mixed 1.7, unknown 57%). With her special interest in corneal disease she was the ideal person to arrange our visit and involve all staff interested in: a.) Surgery for corneal opacity by keratoplasty, by a series of penetrating and lamellar grafts with CCTV. b.) A workshop on management of corneal infection with emphasis on microbiological investigation.

Corneal Grafts
During the first week penetrating keratoplasty was demonstrated and in the second lamellar keratoplasty, as well as lectures on grafting and the corneal infection workshop. I received the corneas on December 8th, travelled the next day and examined patients with Dr Ackacku on the 10th, and the operations began giving priority to those with the most visual disability, holding on standby two who had had successful surgery to one eye 3 years ago hoping to have their 'second' eyes done. One of these was our first graft in Gambia who was blind and now works as a Bible translator. His second operation was carried out at the end of the week. Dr Ackacku assisted at all and participated in the latter cases which included corneal dystrophy (a congenital type of opacity) and oedematous unvascularised scars. Mr Rostron arrived on Dec 12th and began surgery on the 15th. Throughout the rest of the week he and Dr Ackacku carried out lamellar grafts and one epikeratoplasty - the firm fixation of a large donor disc over a misshapen, bulging cornea to help flatten and reduce the deformity and improve vision. This surgery was watched on CCTV and in theatre by members of staff and trainees. Mr Rostron explained aspects of grafting during informal discussion and with elegant, beautifully illustrated lectures interspersed with those of the concurrent infection workshop. One lecture was to a general hospital audience.
Patients were examined daily with Dr Ackacku and other staff which included Dr Ebongo from Cameroon on the West Africa D.O. rotation, and James Lileyon a SOMA from Liberia. All patients made good initial progress, eyes settling and patients seeing better. The lamellar grafts, protected by a temporary tarsorrhaphy stitch to hold the lids closed for a few days, were harder to examine post operatively but Mr Rostron was satisfied with progress. Except for a 14 year old who had a general anaesthetic during which there was much eye movement and raised intraocular pressure, all surgery was carried out under local anaesthetic without problem.  

Corneal Infection Workshop
A programme was prepared and the group had lectures and demonstrations daily for five days. The more senior participants (SOMAs) also took time to watch corneal surgery while the more junior had other classes to attend and work to do at times. SOMAs, OMA students and Community Ophthalmic Nurses (CON) invited by Dr Ackacku participated. There was quite a wide variation in background ophthalmic knowledge but hopefully most gained from the week's content. Thirty one signed the programme passed round. The SOMAs are all old friends of mine, some first met in Malawi, all doing admirable work. Other students come from Senegal (3) Cameroon (3) Liberia (1) and Guinea Bissau, (4) as well as Gambia . Lectures were given by Dr Ackacku - 'Causes of corneal ulcer', Dr Lloyd-Evans, and Professor Addy - 'Ocular Microbiology' and they gave laboratory demonstrations. Mr Rostron lectured on grafting indications, freeze drying, post-operative management, complications and preparation of graft material. I talked about management of corneal infection, and complications.

Keynote Lecture
Dr Faal gave the keynote lecture 'Corneal Blindness and Low Vision in The Community, Aspects of Care Now and in the Future' in which she covered a wide range. There was much for all in the audience. She described the extraordinary properties of the cornea - this beautiful, uniquely clear structure through which we see and which focuses rays of light. She went on to describe some of the many causes of opacity and deformity, congenital and acquired and the often emergency nature of corneal disease treatment. The underlying causes of corneal disease are poverty, cultural practises, poor primary health care (village level) uneducated general population, poor safety regulation and little or no access to corneal surgery.
Dr Faal also discussed comprehensive eye services with graphic illustration of how relatively inexpensive primary care is, and the increasing cost of secondary and tertiary care,and the huge drain on the community. The deprivation and social exclusion of those who are blind and have low vision results in a high cost for education, rehabilitation and vision enhancement by surgery.
She described the priorities of Vision 2020 in which corneal blindness features largely in the aim of global elimination of avoidable blindness by the year 2020 (the other main priorities - cataract, trachoma, onchocerciasis or river blindness, childhood blindness and refractive errors in children). Prevention at the primary level includes measures to avoid illnesses with which corneal pathology is associated such as by measles immunisation, vitamin A distribution and health education at village level. At the secondary level prevention of visual disability is paramount, by early recognition, diagnosis, treatment and referral. Tertiary eye care includes grafting.
Dr Faal described the importance of corneal ulceration and infection which is the leading cause of blindness from corneal disease after trachoma, a main cause of ocular morbidity, pain and disfigurement, blocker of beds, and drain on resources. The poor outcome of treatment and visual loss has a negative effect on the community, risking a reduced uptake of other treatments. With an overall incidence of blindness in Gambia of 0.4% non-trachomatous corneal opacity, the second major cause fully justifies the emphasis on corneal pathology. Dr Faal outlined current strategies targeting mothers, families, the public and children through health promotion and education in schools and villages - keep eyes healthy! She questioned how well secondary eye care is working regarding the early diagnosis treatment and referral of infected corneal ulcers.
Her future objectives : - 1. Avoid the avoidable through education. 2. Visual and cosmetic restoration through corneal transplantation service. 3. Education and rehabilitation of blind and those with low vision.
Strategy includes : Promotion of nyateros - 'friends of the eye'. These are care workers promoting eye health at village level. To encourage implementation of corneal ulcer services for the 'house on fire' and local production of eye drops - antibiotics, antifungals and mydriatics etc.
Dr Faal's future plans for corneal disease in The Gambia include transplantation for the backlog and new cases requiring it through an annual service, backed up by a telemedicine link to London, human resource development (training local staff), legislation for the retrieval of donor eyes locally with preservation of corneas, both fresh and freeze-dried, and distribution of them for keratoplasty. Her plans also include promotion of corneal services including follow-up and research both basic and operational with uptake in surrounding countries and continuing links with external institutions.
These are some of the hopes of this amazing lady who left her audience that day, and I hope also those reading this, feeling that her ambitions will be realised. Perhaps it should be mentioned here that Dr Faal's plans for corneal disease reported above are only apart of her widespread activities. Her national and international work and official positions are widely known and respected.

Closing Meeting 19/12/03
Drs Faal, Ackuaku, Sanyang (SSI representative) Mr Ansumana Sillah (NEC Programme Manager) Mr Momodu Bah (Health for Peace Programme Manager) Mr Rostron and I discussed the visit and future plans. Dr Ackacku reported the operations done included 8 penetrating, 4 lamellar, 1 epikeratoplasty; all progressing satisfactorily. She had seen the main types of keratoplasty demonstrated, and others had been able to observe. She was particularly grateful for 'skills transfer' backed up by the CD on techniques of keratoplasty. She has freeze dried corneas to use and all the necessary equipment and supplies, she will practise on pig's eyes, continue training and set up an eye bank.
Dr Faal quoted Mr John Sandford-Smith's observation during a recent visit which was that the structure is in place but the reality is that it is not being fully utilised. Difficulty in motivating staff was acknowledged but Dr Faal charged those responsible to make the system work, to supervise workers to locate cases, investigate and treat them properly and promptly. Not only will treatment improve and vision be preserved but, with analysis of results, better understanding of the problems and distribution of treatment will follow.
There was lively discussion about raising awareness of organ donation in The Gambia - how to set about winning Ministry, Parliamentary and public support. A campaign for legislation was proposed by Dr Faal which will need to take into account possible religious and cultural questions which might arise. Publicity could be a potent factor in winning public support especially if focussed on patients regaining sight. We discussed how the NECP should mount a campaign to win hearts and minds over to support organ (cornea) donation. At the end of our visit we were shown around SSI offices and the plans for the new Regional Centre.
This was a particularly positive farewell, full of promise and hope for patients with badly damaged sight from corneal opacity for whom there is little or no hope now. All concerned now share a plan for a future when modern corneal surgery will be available in The Gambia NECP Regional Centre for those who need it who live there and in surrounding countries, and there will be better management of corneal suppuration.

Thanks
Chad Rostron and I thank Drs Hannah Faal and Edith Ackuaku most warmly for inviting us and the help and hospitality in Banjul and Mr Sillah, Dr Sanyang and Mr Bah for their help. Amongst the staff Mr Bakary Jarjue in the operating theatre was, as usual, marvellous in doing all he could to provide the necessities. All other staff in the theatre, ward and clinic made us welcome and looked after the patients and us. Ms Debbie Ranby and Mr Stelios Myriknas organised the vital material from the Keratec Eye Bank, and we are most grateful to them. Dr Astrid Harrison made valuable ocular microbiology teaching material available to me to borrow and distribute. Mr Peter Ackland, Mr Philip Hoare and Mrs Jaqui Barter at SSI headquarters were all most helpful and encouraging. I would also like to thank Mrs Anna Grey-Johnson, SSI Council member, and my wife Sara who helped prepare this report. Finally I would like to mention an extremely generous bequest made by Mrs Carole Snook of Caversham, Reading, in memory of her late mother Mrs Patricia Wise. Mr Ackland agreed that this sum should be used for developing the corneal services in The Gambia, and part of it supported this visit for which all concerned are deeply grateful.