Lessons learned from history

A queue of Samburu people awaiting medical attention

With hindsight, we were not surprised that the Samburu had been hit by cholera; trachoma is endemic and the two diseases affect very similar socio-economic groups. Indeed Moorfields Eye Hospital was founded in 1805 to deal with an epidemic of trachoma in London, just before the world’s first cholera pandemic also hit London in 1835. However once the sewerage and public health of the capital were improved, both diseases faded out in the UK; those esteemed surgeons at Moorfields had to find other ophthalmic diseases to treat!

There is an important lesson to be learnt from this historical vignette; education and public health, such as improving water supplies are far more critical than medicine and surgery in eradicating this type of disease which is spread from person to person through lack of hygiene or contaminated water.

I feel enormously privileged to be given the opportunity to work amongst these people and spend time in Africa this year, thanks to the Keeler Scholarship. I will look back at my experiences this year with great fondness as I put to good use all the skills I have learned in Cardiff, our new home.

The Cardiff Millenium Stadium

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Blinding trachoma endemic

Trachoma is a chronic kerato-conjunctivitis caused by Chlamydia trachomatis and is the leading infectious cause of blindness worldwide. Globally, active trachoma affects an estimated 150 million people, most of them children. About 5.5 million people are blind or at risk of blindness as a consequence of trachoma. Repeated episodes of re-infection within a family cause chronic follicular conjunctival inflammation (active trachoma), which leads to tarsal conjunctival scarring. The scarring distorts the upper tarsal plate and leads to entropion and trichiasis (cicatricial trachoma), which, in turn, results in corneal scarring and ultimately blindness.

The root of this infectious and preventable disease is poverty. Households affected by trachoma characteristically have young children living with unsafe water and inadequate sanitation. Transmission from eye to eye is by fingers, fomites (e.g., shared towels) and flies. When we did our first World Health Organisation (WHO) rapid assessment survey back in 2003, we found trachoma to be endemic in the community at levels the WHO described as a “serious public health problem”. So we set about implementing a trachoma program in the region using the SAFE strategy (surgery, antibiotics, face-washing and environmental improvement).

Having almost completely eradicated trachoma from one region, the Ol Malo eye project moved into the Kipsing last year, a beautiful but remote area inhabited by the Samburu. Last year we had a successful surgical camp last run entirely by Kenyan staff. We have a group of Samburu trachoma monitors who distribute antibiotics, educate the people to wash their hands and cover their waste as well as keep their manyattas clean. This helps reduce the number of flies which transmit trachoma.

Our trachoma program came to a temporary halt this year following the cholera epidemic; saving lives rather than eyesight became the priority. However cholera occurs for the same reasons as trachoma so the epidemic has strengthened our resolve to find new ways to improve the public health of the Samburu. The trachoma monitors continue to distribute leaky tins for cleaning hands, special trowels for burying waste and recording all new cases of trachoma. A surgical camp is planned for early next year for which we are now fund-raising.

Active trachoma with follicles visble in a Samburu child

Flies that transmit trachoma buzz around a woman and her child

Samburu women await removal of their bandages the day after surgery

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Educating people to help themselves

Primary schools are as difficult to get to as hospitals in this area, often requiring days of walking. Education is at the heart of improving the Samburu people’s health and environment so we are building a network of semi-permanent schools to provide basic primary school education for the nomadic Samburu children. While I was visiting two teachers from New York were completing a month at Ol Malo training their Samburu colleagues in the Waldorf/Steiner style, especially adapted to Samburu culture. They had been working hard and I was amazed to see how enthusiastic the kids were to learn and how quickly the Samburu teachers were picking up new skills from their mentors. This exciting project is using local people to both build the schools and teach in them, providing sustainable education for the children. And when school finishes at lunchtime, adult classes are held to teach the older Samburu about protecting their environmental and health issues such as sexually transmitted diseases, trachoma and cholera.

One of the new nursery schools from the air

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Drought strikes the Samburu again

The Samburu region of northern Kenya is a harsh, inhospitable place and unfortunately the rains failed again this year; it was drier than I have ever seen it. This drought, combined with endemic trachoma, malnourishment and the cholera epidemic reinforced the need to provide sustainable clean water supplies and educate the people on how to avoid these diseases in a manner that is sensitive to their cultural differences.

Water is the key factor for disease-free survival in this environment. When the rains fail, life becomes hard for everyone and disease can spread rapidly through the malnourished populace. So why not just put down lots of boreholes? Unfortunately this is a simplistic short-term solution for a nomadic people and has failed many times before.

Instead we are building a network of open water reservoirs to provide a sustainable supply of water without interfering with the Samburu nomadic lifestyle. They provide water for people, livestock and migrating wild animals such as elephants. They also provide a micro-environment for protecting other endangered species of flora and fauna.

I was able to see the first reservoir completed providing water for the local community with preparations for the second well underway. Our long term goal is to build 60 reservoirs which will allow the Samburu people access to clean water forever. This is a pioneering way of providing water which directly affects all our other projects.

Clean water is the key to disease-free survival- here a Samburu man collects water from a dwindling supply

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Samburu nomadic pastoralists

The Samburu are a tribe of nomadic pastoralists who live in the remote lands north of Mount Kenya. They live in small settlements called manyattas, consisting of a cluster of huts encircling a central area used to house the livestock. Manyattas are surrounded by a thorny boundary to keep marauding wild animals out. Once the grazing in an area has been exhausted, the Samburu move on, creating a new manyatta somewhere else.

Samburu men are initiated into warrior-hood following circumcision in their late teens. The circumcision ceremony is quite a spectacle; the men are able to agitate themselves into an almost trance-like state prior to the actual circumcision. Any movement or sound during the procedure is a sign of weakness and brings great shame onto the warrior’s family. However the ensuing parties go on for days while the warriors recover from their ordeal.

The women are noticeable by their beautifully intricate beadwork; beads are a form of currency and each set of beads indicates some significant part of their life, such as the birth of a child. When a woman is in the prime of her life she may have over 5kg of beads around her neck and they often unsurprisingly present to our clinic with a sore back!

Although the Samburu lead a simple life, they are an honest, kind and hospitable people who are always smiling and have an amazingly intricate culture, which is both fascinating and awe-inspiring. The charity I work for, the Ol Malo Trust, aims to improve their standard of living whilst being sensitive to their lifestyle and culture by providing basic sustainable healthcare, education, water and food.

Samburu women with their many beads

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Kenya- A land of lions, mountains and tribes

Kenya lies along the Indian Ocean and is bordered by Ethiopia, Somalia, Tanzania, Uganda and Sudan. The capital city is Nairobi or “Nai-robbery” as it is affectionately known. As the population rapidly increases, the city has become ever more dangerous, with car-jackings and kidnappings an everyday occurrence; the best advice is to stay in Nairobi as little time as possible.

Kenya is best known for its wild animals, especially the “big five” of lion, elephant, buffalo, rhino and leopard; the Kenyan game reserves have been popularised by television programmes such as the Big Cat Diaries, set in the Maasai Mara. Certainly when you first visit Africa, your senses are assaulted by a myriad of strange sights, smells and sounds and the animals are truly amazing. But once you have grown bored of watching lions scoffing gazelles and crocodiles snapping up buffalo, the people of Africa emerge as a far more interesting subject; it is truly humbling to watch them smile and laugh through massive hardship and adversity.

The country is named after Mount Kenya, the second highest mountain in Africa, which also lies on the equator. The ascent of either of the summit twin towers remains a formidable rock climb at high altitude and the weather is notoriously fickle. The great Rift Valley carves through Kenya and recent fossil finds made by people such as Richard Leakey suggest that our ancestors originated from this area.

Although Kenya is a presidential democratic republic, trouble is never far from the surface with allegations of deep-rooted corruption and last year’s post-election rioting, murder and looting which made international headlines. There are strong ties between the UK and Kenya in these post-colonial times, indeed it has become a popular tourist destination and most of Marks and Spencer’s vegetables are grown in the lush fields under Mount Kenya!

The straight lines delineating African countries were imposed by colonialists and bear no resemblance to the many different tribal boundaries within each nation. The Kikuyu tribe dominate Kenya but there are many other tribes represented, many of which are small in number and far away from the skyscrapers of Nairobi, such as the Samburu tribe.

Mt Kenya, after which the country is named, is an old volcano and stands at over 15,000 feet

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Cholera hits the eye project area

There’s not much time to contemplate the stark contrast between the squeaky clean operating rooms of Vancouver and the dusty tent I am now working in, surrounded by Samburu children clinging on to life while their bodies are gripped by cholera, causing violent bouts of vomiting and diarrhoea. Buckets of putrid green bodily fluids stand in the corner awaiting proper disposal and the smell pervades everything.

I arrived towards the end of this cholera epidemic; my colleagues have a haunted look in their eyes as they describe the helplessness and feeling of being overwhelmed as more and more people contracted this terrible disease. Luckily they were able to help most with oral and intravenous fluids as well as antibiotics, but many still died, mostly children.

When this visit was planned a year ago, my goal was to run a surgical camp to treat trachoma, conduct a randomised trial into the best surgical technique for the cicatricial entropion caused by trachoma and strengthen our education program on hygiene and environmental improvement. However this is Africa and things rarely go to plan.

The hallmark of cholera is violent vomiting and diarrhea leaving the patient dangerously dehydrated requiring intravenous fluids

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Vancouver ends and Africa awaits

Well our time in Vancouver has come to an end and it has been a superb 6 months. I have had an amazing training experience with loads of hands-on surgery and a continual flow of interesting oculoplastic, lacrimal and orbital cases.

This should set me up well to start back as a Consultant in Cardiff but I am under no illusion that this increased responsibility will be an enormous challenge.

We cannot fault Vancouver which has been an incredible place to live, a vibrant, cosmopolitan, family friendly place with unparalleled access to the great outdoors. We arrived in deep snow and left in 30 degree sunshine with a beautiful Spring in between.

So onto Africa and Northern Kenya where I am headed for the Samburu tribe to provide practical help for the people who are blighted by trachoma in the form of surgery, antibiotics and environmental improvement. We are also hoping to do some research on how to better treat this disease.

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Vancouver Graduation

We’ve just had our fellowship graduation which was a great evening enjoyed by all and I’m almost finished in this beautiful city. It was a combined academic and clinical evening recognising the trainees who have passed their final exams, the clinical fellows and the postgraduates completing their higher degrees.

As the sun really starts to shine, the city really springs into life with the beaches packed, the open-air swimming pools open, skis hanging in the garage while the kayaks, mountain bikes and sailing boats come out. Great place to be!

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Working in the Eye Care Centre

I am primarily working with Dr Peter Dolman but also spending some time with Drs Rootman, Buffam and Rossman. They all have offices within the Eye Care Centre which is adjacent to Vancouver General Hospital near the middle of the city, but we also spend some time operating at the Children’s Hospital and the University Hospital.  Apart from becoming proficient with general oculoplastic techniques, there are many weird and wonderful tertiary referral cases from all over Canada and the rest of the world. The schedule is pretty gruelling with long days and emergency cases out of hours but with usually four days a week in the operating theatre there is plenty of hands-on cutting experience. There’s also night skiing less than half an hour from the hospital, which makes up for any long day!

The case load is very similar to any other centre around the world, entropion, ectropion, ptosis etc but we also see some more unusual pathology.  Similarly the emergency cases are comparable to those seen in the UK, Canadians also like to get drunk and punch each other in the eye with beer bottles, although eyelid laceration from a bear’s paw is not so common at home.

Dr Dolman has developed the VISA classification system for thyroid orbitopathy, which is a useful tool in the management of this difficult disease so we see many thyroid patients and regularly perform orbital decompressions both for rehabilitation and optic neuropathy secondary to apical optic nerve compression.  The timing of intervention for these patients is critical and watching how other people treat thyroid patients has been very useful.

Dr Dolman has also championed the non-endoscopic endonasal approach for dacryocystorhinostomy (DCR), which I thought would be very difficult. In fact, the anatomy is well displayed and accessible without an endoscope so that learning the technique has been very satisfying; it also helps that I have a teacher with endless patience. This low-tech approach has excellent results and is fast to perform with minimal instrumentation so I hope it will benefit my patients back in the UK.

Dr Rootman is well known worldwide as an authority on the orbit; he is an excellent teacher and has an encyclopaedic knowledge of all things orbital. Particularly impressive is his management of orbital varices, notoriously difficult to deal with because they are often large with many vascular connections and they bleed heavily. He has developed techniques to image and glue them with the help of the interventional radiologists which makes them much easier to remove.

Working with these internationally recognised people has been an amazing experience. More importantly, they are good teachers and have an excellent bedside manner with their patients. Plenty to think about for the future!

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