Reflections on Global Impact Volunteering in Ghana

By Andrew Francis
Boston University School of Medicine
Global Impact Fellow

I am currently a 4th-year medical student at Boston University School of Medicine applying to ophthalmology residency programs.  It has already been two full years since I volunteered abroad in Ghana as a Global Impact Lab Fellow in Accra, Ghana for two months.  So much has happened since that time, and I have benefited tremendously from the knowledge and experience I received from being a Global Impact Fellow in Ghana.

I entered medical school with aspirations to become a highly trained ophthalmologist who possesses empathy and compassion for each patient and who is experienced in the management of a variety of eye diseases and conditions, ranging from acute traumatic injury to chronic debilitating disease.  Key to my decision to pursue a career in ophthalmology are my clinical experiences volunteering abroad with Unite For Sight in Ghana, my success as president of the Boston University Unite For Sight chapter, published research into causes and treatments of primary open-angle glaucoma, and compassionate care of patients during my ophthalmology rotations.

When I started medical school, I knew that I wanted to become an ophthalmologist, but I did not have a clear idea where to start.  Unite For Sight offered opportunities to learn more about the field and become involved in community and international volunteer outreach activities.  When I investigated the organization in more detail, I found it to be a highly respected and well-regarded non-profit NGO with a focused mission to reduce the global burden of preventable blindness through sustainable interventions in developing nations.  My ophthalmology mentor at Boston University, Dr. Edward Feinberg, supported my ambitions in ophthalmology during my first year of medical school and recommended that I travel abroad during the summer after my first year of medical school.  The goal was to gain experience with patients and ophthalmic diseases.  Thus, my interest in volunteering abroad with Unite For Sight developed out of my work as a 1st year medical student with the Boston University Unite For Sight chapter.

Preparation

Initially, the prospect of spending two months in Ghana was a bit overwhelming.  I knew only three things: (1) I wanted to learn more about the ophthalmic exam and associated pathology; (2) I wanted to complete a research project and publish a manuscript; and (3) I needed to identify and obtain institutional funding.  To achieve the first step required that I select the Ghana, India, or Honduras programs that Unite For Sight offered and apply.  I was impressed to see that Unite for Sight had become a major force of change in these nations.  They provide funding for more than 40% of cataract operations in Ghana and have treated thousands of patients in India and Honduras. 

In terms of selecting a research project from Unite For Sight's research topic options, I had an interest in glaucoma based on its high prevalence in Black populations.  The most common type of glaucoma is primary open-angle glaucoma, which is accepted as the leading cause of irreversible blindness worldwide and second overall cause of blindness after cataract [1]. The number of persons affected is estimated to be in the region of 66.8 million with 6.7 million blind [2].  This disorder is characterized by progressive optic neuropathy eventually leading to loss of central vision and total blindness in its final stages.  A 2001 population study in Ghana reported that POAG affects 7.7% and 8.5% of people 30 and 40 years of age, respectively [3].  This is notably higher than the prevalence in the United States, where 1.9% of Americans over 40 years of age are afflicted [4].  In developed nations, treatment is widely available, and most patients receive therapy before complete visual field loss occurs, but in developing nations such as Ghana, poor access to healthcare leads to a delay in diagnosis and more severe loss of vision.

According to the 2004 Eye Care Report in Ghana, the majority of the population in Ghana does not have access to basic eye care services [5]. A priority of this report was research into prevention of blindness.  As of 2004, there were a total of 41 ophthalmologists and 216 ophthalmic nurses working in Ghana taking care of the eye needs of nearly 19 million Ghanaians, leading to a national ratio of 1:463,000 people.  This ratio increases to as high as 1:2,033,000 people in the Northern Region.  The population in Ghana has since increased to nearly 24 million people.  Additionally, a total of 42 optometrists were providing optical services in the country in 2004.  Provision of eye care service remains largely institution-based with 50% of eye specialists working in the Greater Accra Region and over 85% of optometrists based in urban centers.

It is believed that more than 90% of those blind from glaucoma originate from Asia and sub-Saharan Africa [6].    Blacks are at least 4 to 5 times more affected than whites with some estimates as high as 8-10 times [7].  Because the decline in vision may be slowed but not restored by treatment, it is important that this condition be diagnosed early in its course.  Early diagnosis of POAG and reducing intraocular pressure (IOP) is, at present, the best method for preventing disease progression.   After working with Unite For Sight's partner ophthalmologist Dr. Michael Gyasi to prepare a project proposal, completing a literature review, and receiving IRB approval for a formal retrospective chart review at Boston University, I applied for summer funding and was awarded a grant by the Boston University International Summer Research Scholarship.

With the research project approved and funding secured, I set out to prepare for departure.  Unite for Sight offers exceptional pre-departure training to its volunteers through a series of integrated and interactive online modules and tutorials.  I spaced my education over the span of a few days and benefited greatly from the extensive modules, essays, videos and evidence-based literature.  When I had completed the pre-departure training, I felt a sense of accomplishment and most importantly, I felt better prepared for life abroad in Ghana.  Unite For Sight also provided additional resources, including packing lists for important items, recommendations on housing, and the names and email addresses of former volunteers who had agreed to talk to new prospective volunteers.  This was extraordinarily helpful for learning more about the programs in Ghana and the adventure ahead.  There was much to accomplish, including purchasing necessary equipment such as mosquito nets, comfortable shoes, getting up-to-date on my vaccinations and obtaining a prescription for anti-malarial medications.  Boston University (and most large universities) has a well-organized travel clinic that offered services such as vaccinations and prescriptions, and greatly streamlined much of the pre-departure paperwork.  After purchasing a plane ticket and completing my end of 1st year exams and assessments, I was ready for the adventure ahead.

Arrival in Ghana

Description: C:\Users\office\Desktop\Desktop\Main Folder\Pictures - Main File\2009-06-27 Africa Pictures\Africa Pictures 028.JPGWhen I arrived in Ghana, I was greeted by Unite For Sight staff who kindly shuttled me to the living quarters located in a suburb of Accra.  The room was clean and quiet with an air conditioner, shower and a small television.  I shared a room with a college student who was quite pleasant company.  We became fast friends.  Every morning there was a nice breakfast available, and the volunteers all had a chance to get to know more about each other.  The group was composed of mostly students in college and graduate school.  There was a family of four and also one or two physicians.  As each volunteer had arrived separately and stayed for a different period of time, there was a constant infusion of new faces into our group during the two months that I was in Ghana.  I got to know many of these volunteers quite well, and we have remained friends.

For the next 4 weeks, I participated in the village outreach program.  Each morning, we assembled as a group with the ophthalmic nurses and loaded up the vans with medical equipment and supplies for the day’s work.  We would travel anywhere from 1-3 hours by van to a predetermined village where we would perform vision screenings and ophthalmic examinations.  The adventure of traveling throughout southern Ghana was always fascinating.  Accra is a diverse and well developed city with a lot of energy and bustling activity.  In almost every alcove there would be persons selling their wares.  Just about every necessity could be purchased at one of these locations.  What most fascinated me was the artwork sold my individual artists.  These includes special cloths, wood-carvings, paintings and decorative items.  The quality was superb and reflected a sense of the proud history of this leading West African nation.  Negotiation is important, but ultimately most items are sold for an excellent price and a fraction of what they would be worth in the United States.

When we arrived at our destination each day we would unload our supplies and set up a series of screening stations in the village or school.  The village had been notified that eye screenings would take place in advance and there was usually a healthy crowd waiting for us to begin.  The first table was where a patient would register.  They would then proceed to a vision screening station where a Unite for Sight volunteer recorded their visual acuity using a Snellen chart at 20 ft (6 m).  From the eye screening station patients would proceed to be examined by the ophthalmic nurse or doctor.  It was at this station that I learned a great deal from the nurses and doctors about the ophthalmic exam and common eye conditions and became well-practiced in the use of the direct ophthalmoscope.  Finally, patients would proceed to the medication dispensing table and be registered for a future surgery if they were deemed appropriate candidates. 

Description: C:\Users\office\Desktop\Desktop\Main Folder\Pictures - Main File\2009-06-27 Africa Pictures\Africa Pictures 075.JPGAbout one day a week, we had a chance to observe surgery at the Crystal Eye Clinic in Accra, Ghana.  It was a nice experience in patient continuity because many of the persons we screened in the village outreaches would meet us again at the eye clinic.  The operating theatre was a model of efficiency.  Dr. James Clarke has nearly perfected the art of small-incision cataract surgery (SICS).  Patients would receive transportation from the village.  They would then be prepped and prepared for surgery.  In the operating room, Dr. Clarke would operate two patients at a time, each side-by-side, the first being fully prepped while the second was being operated upon.  Each surgery lasted approximately 30 minutes.  At one point, Dr. Clarke mentioned he had operated on nearly 50 patients in a single day (although 20-30 was a more typical day). Most patients were kept overnight to ensure their post-op course was unremarkable and without serious incident.

After participating for 4 weeks in the village outreach program, I was ready to begin the research project by investigating risk factors associated with progression to advanced glaucoma.  I was the first volunteer to participate with Dr. Gyasi as a research volunteer.  My mentor was Dr. Michael Gyasi, a Ghanaian-born ophthalmologist who also trained in the United Kingdom.  He was an attending physician at the Emmanuel Eye Centre in Accra.  He provided me with a comprehensive education in eye diseases.  With Dr. Gyasi as my guide, I reviewed hundreds of paper charts and saw many amazing findings for the first time.  I was taught the complete ophthalmic exam and how to assess a variety of conditions, including primary and secondary forms of glaucoma, and I became fascinated with the complexities of ocular diseases.  In the operating theatre, I observed trabeculectomies, strabismus procedures and the removal of nasal and temporal pterygium so advanced they were described as “kissing” pterygium.  Most satisfying of all, I frequently observed the sad face of a Ghanaian patient transform into a bright smile with wide, wonderous eyes after cataract surgery restored sight that had been lost for decades.   After 6 weeks of working full time with Dr. Gyasi, I had collected data on 240 patients and was well prepared to begin analyzing the information and prepare a manuscript for publication.

Research Analysis

When I returned to the United States I was excited about preparing my work for presentation and publication.  I was offered the opportunity to present my findings at the Unite For Sight Global Health & Innovation Conference at Yale and, with assistance from Dr. Gyasi, prepared an oral presentation entitled “Characteristics of Primary Open Angle Glaucoma in Ghana".  I also presented a research poster at the Association for Research in Vision and Ophthalmology (ARVO) titled “Risk Factors for Progression to Advanced Glaucoma in Ghana.”  I have since composed a formal manuscript which is currently pending publication in a noteworthy ophthalmology journal.

Reflection on Volunteering with Unite For Sight

In summary, my experience with Unite For Sight has been life-changing.   I would not be where I am today if I had not made the decision to travel abroad with Unite for Sight.  Furthermore, Unite For Sight has been extremely generous in recognizing my work both as an international volunteer and as chapter president of the Boston University Unite For Sight chapter.  I am proud to have received several awards for my leadership with UFS. These include two Volunteer of the Year Service Awards for encouraging volunteers to travel abroad and fundraise thousands of dollars for sight-restoring cataract surgeries.  Boston University volunteers have also delivered hundreds of eyeglasses to clinics in Ghana, India and Honduras.  My work with UFS to improve education at underserved local schools has also been praised and awarded with grants from the Association of American Medical Colleges (AAMC) and my home ophthalmology department.  Based on my work with Unite for Sight, I have written first-author manuscripts, published first-author abstracts, and presented research posters at national meetings. These include the Association for Research in Vision and Ophthalmology (ARVO), the Unite For Sight Global Health & Innovation Conference at Yale, and I am scheduled to present at the 2011 American Academy of Ophthalmology (AAO) Annual Meeting.  As I embark upon a career of leadership in ophthalmology, I hope to build upon my experiences in the international sector and continue to contribute to the global mission that Unite For Sight has so successfully pioneered to eradicate all forms of preventable blindness.

References

[1]. Leske, MC. The epidemiology of open-angle glaucoma: a review. Am J Epidemiol 1983;118(2):166-191. 
[2]. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol  1996;80(5):389-393.
[3]. Ntim-Amponsah CT, Amoaku WM, Ofosu-Amaah S, Ewusi RK, Idirisuriya-Khair R, Nyatepe-Coo E, et al. Prevalence of glaucoma in an African population. Eye 2004;18(5):491-497.
[4]. Friedman DS, Wolfs RC, O'Colmain BJ, Klein BE, Taylor HR, West S, et al. Prevalence of open-angle glaucoma among adults in the United States. Arch Ophthalmol 2004;122(4):532-538.
[5]. Hagan M. 2004 National Eye Care Report. Accra: Ghana Health Service Eye Care, 2005: 3-5.
[6]. Chen PP. Risk factors for blindness from glaucoma. Curr Opin Ophthalmol 2004;15:107-11.
[7]. Sommer A, Tielsch JM, Katz J, et al: Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med 325:1412–7, 1991.
[8]. Ghana Statistical Service. 2000 Census. http://www.statsghana.gov.gh/