Minding the gap.

T he ECWA Eye Hospital in Kano, Nigeria, is a mission hospital started by Dr Hursch, an American ophthalmologist, in the early 1940s. Although there are no surviving records from the time of Dr Hursch, I would venture to say that his practice of ophthalmology in Nigeria was not much different from his practice in America. Since the cutting edge tools of his day were loupes, and a small set of instruments, those items could easily be purchased, transported, and maintained in the setting of a developing country. Now, 60 years later, the situation is very different. The eye hospital in Kano remains a bright spot in west Africa for surgery and treatment of eye diseases, and gives invaluable surgical experience to ophthalmologists in training. However, when I arrived in Kano in 2003, I expected that my practice of ophthalmology would be very different from what I was used to in America, and I was not disappointed. Consider the differences. Just a few years ago in America, I attended a seminar about improving outcomes of cataract surgery. One presenter boasted (rightfully so!) about his accurate selection of IOL (intraocular lens) power within plus or minus 0.25 dioptres, 100% of the time for a large series of patients. He did this by meticulous keratometry, immersion Ascans, and use of a third generation software package. In Africa, there are still many ophthalmologists struggling to convert to ECCE (extracapsular cataract extraction) surgery from ICCE (intracapsular cataract extraction). Many do not have operating microscopes, and IOLs are hard to come by because of cost and difficulties in importing. For those who do have access to operating microscopes and IOLs, a ‘‘standard’’ IOL power is most often used, since even fewer ophthalmologist have keratometers or A-scans. Couching of cataracts is still practised by traditional healers, even in large urban centres. The treatment of glaucoma in developed countries is aided by an ever increasing armamentarium of medications, optic nerve head analysers, computerised visual field machines, seton implants, and antifibrotic agents. In Africa, most ophthalmologists’ diagnostic tools are limited to Schiotz tonometers and direct ophthalmoscopes. Treatment for glaucoma is also simplified since timolol and pilocarpine are the only drugs readily available, so trabeculectomy is often done earlier. We will skip the comparisons for retina and refractive surgery where the disparities are even greater. An important factor in this widening gap is the information explosion and rapid pace of technology in the more developed countries. If you are reading this, you likely have access to dozens of specialty and subspecialty journals. When looking back at how cataract surgery has changed just in the past 15 years, the differences are amazing. Unfortunately, for ophthalmologists in the lesser developed countries, the ability to keep pace with the information explosion is hampered by a number of problems including the relatively high cost of journal subscriptions, and inadequate postal services. Those who do receive journals will find it difficult to implement the new technology and products because of the high costs, and the challenges of importation. The gap is growing not simply because of the rapid pace of the more developed countries, but also because of myriad complicated problems in poorer countries. Widespread poverty, poor education systems, governmental corruption, AIDS, and inadequate medical training programmes, because of lack of resources and supervision, all contribute to ‘‘holding back’’ the pace of ophthalmic care. Of course these generalisations do not always hold true. There are places where state of the art ophthalmology is practised in sub-Saharan Africa outside of South Africa, but those places are uncommon. For the majority of Africans, the ophthalmic care received is very different from what we are accustomed to in the more developed countries. One interesting aspect of the gap is that it goes both ways. Not only are Africans affected by the gap, but ophthalmologists trained in the more developed countries who wish to practise in the less developed parts of Africa are also affected by it. I was fortunate that when I did my ophthalmology training I was taught standard ECCE as well as phacoemulsification surgery. However, currently, many ophthalmology training programmes in America teach only phacoemulsification surgery. If one of those newly trained ophthalmologists wished to practise in Africa, he or she would need additional training. This too may contribute to the widening gap as fewer ophthalmologists will be qualified to practise in developing countries, and fewer will be willing to take a ‘‘step backward’’ in their field. When referring to the gap, I do not mean to imply that practice in Africa has all the negative aspects. There are several features of practice in the lesser developed parts of Africa that are superior to practice in developed countries. At my workplace in Africa I can practise ophthalmology without many of the bureaucratic headaches we have in more developed countries. Chart documentation can be brief and to the point with no worry about insurance documentation requirements, and much less concern about liability. We are forced to use only technology that is cost effective, and there is little pressure to adopt expensive new technologies with dubious clinical benefit. There are many individuals, nongovernmental organisations, and international health organisations that are working to narrow the negative aspects of the gap. Pervasive availability and usage of the internet may narrow the gap in the information explosion. Low cost educational materials provided by the American Academy of Ophthalmology have been very helpful for training ophthalmologists overseas. ‘‘Twinning’’ is an excellent method whereby collaborations between institutes in developed countries and lesser developed countries occur. Such collaborations can be mutually beneficial, and lead to practice enhancements on both sides. However, the gap between ophthalmology in parts of Africa and more developed countries remains large, and in my opinion is growing. We must do more to narrow the gap, and to build bridges to our ophthalmology colleagues, and patients on the other side. There are positive and negative aspects to practice on both sides of the gap, and we would all do well to ‘‘mind the gap.’’