Monday 13th August (Part 1)
An early start this morning, to drive to the Narsingdhi Lions Hospital. This is a comprehensive eye-care (CES) project, with two partners working together - the hospital and ABC (Assistance for Blind Children) who provide the community based rehabilitation (CBR) and education aspects. The CBR workers acted as outreach workers for the hospital, finding and following up patients as well as providing rehabilitation services.

We visited a number of beneficiaries, starting with a primary school where there were three blind children. The teacher had been trained to support blind children, and in addition there was a visually impaired CBR worker who acted rather like an itinerant teacher, focusing on helping the children with Braille.

We went on to meet Shariar Immon, a beneficiary of the Childhood Cataract Campaign, who could now read clearly and was attending school, Mr Shadek Mia, who had started a grocery shop since receiving CBR training, and Mr Iman Ali, who had a tea stall, and whose cataract operation had meant he could return to running it himself.

As always, it was good to meet people who directly benefit from the work our partners do, and to see that we do, indeed, transform lives.

ABC were involved with the setting up of local (pan) disability committees in line with the 2001 Disability Act. They were also setting up self help groups of visually impaired people and their families, both to support one another and to advocate for their rights with the government.

Sunday 12th August (Part 2)

We visited the Resource Centre, where they have a range of low vision devices and training aids before driving to the BNSB Sirajganj base eye hospital. Sirajganj is in the north west of Bangladesh, a 3 hour drive from Dhaka. This meant we drove through some of the most badly hit flooded areas, and for much of the time it was like driving along a dyke across a massive lake. People were living in makeshift shacks by the side of the road, alongside their livestock.

We went to open a paediatric out patients department wing of the base eye hospital. It was a spacious modern wing, with bright murals and furniture. We toured the area then the rest of the hospital, which was full of cataract patients. I met my first children who were part of the
Bangadesh Childhood Cataract Campaign – five children ranging from six months old to about five years. All had bilateral cataracts, and some had been operated on the previous day. Although I have been with Sightsavers for more than two years now, it still moves me to meet a totally blind child, knowing that tomorrow that child will see for the first time.

The hospital, together with a number of associated sub centres in two other districts, performed over 13,000 cataract surgeries in 2006. The doctors I spoke to believed they could do twice as many if they were able to mobilise the patients, and they had plans to open a number of Vision Centres to help achieve this (small centres in more remote areas where they can screen people).

It was clearly an efficient operation, and Prof Matin, the President, was keen to do more. He was very scathing about government hospitals – saying the staff had the ‘wrong attitude’.

Our return journey to Dhaka was rather protracted as part of one of the roads had collapsed due to the floodwaters, causing a serious traffic bottleneck.

Sunday 12th August (Part 1)

This morning we set off to visit CDD (Centre for Disability in Development), a community based rehabilitation (CBR), education and low vision partner. CDD provide all the special needs training for both education and CBR in Bangladesh, and are funded by Sightsavers to provide training in the visual impairment aspects of CBR for CBR workers. In addition to providing training, CDD provide many of the Braille books for schools, and offer a low vision service.

The quality was very high, although all the training was provided in Dhaka, which meant CBR workers and teachers had to travel from all over Bangladesh. The CBR course was three months long, which must lead to recruitment issues. They are hoping to open two new centres in other parts of the country soon. I was pleased to hear that several of the trainers at the centre, and a number of CBR workers, were blind.

There is no concept of an itinerant teacher (trained to identify and give special assistance to blind and low vision pupils) in Bangladesh – they train class teachers and resource teachers (who provide expertise for all pupils with special needs at a single school). There is a standardised Bangladeshi version of Braille, but children are taught English Braille first as apparently this is easier, before moving on to Bangla Braille. There is an increasing demand for Braille texts, which is putting a strain on CDD who rely on a single heavy duty Braille printer.

Saturday 11th August (Part 5)

We have recently started a pilot programme with a new organisation of blind people – BVIPS. This is a group of blind graduates who are starting up, as the only other organisation of (rather than for) the blind is apparently non active.

The office is clearly very active in advocacy, but there was one area which stood out for me – their work with NFOWD (see later) and the electoral commission in promoting the voting rights of visually impaired people. They had been successful in improving the process to allow visually impaired people to have a sighted guide of their own choice to vote with them (although they had to be of the same gender as Bangladesh segregates its voting stations). I wondered whether we have done any similar work elsewhere, and thought this sort of advocacy ought to be fundable from the Department for International Development etc. This will all have to be repeated for the next set of elections due in 2008.

This evening we held a dinner at a local restaurant for a range of partners, government officials, donors and other agencies. This was a great opportunity to meet a number of partners ahead of visits later in the week.

Saturday 11th August (Part 4)

Back at the office our attention turned to social inclusion and advocacy work. Our community based rehabilitation (CBR) in Bangladesh is as much an outreach, case finding project for cataracts as it is a CBR project. Over the last four years it has identified nearly 50,000 cataract patients compared to 7,000 persons needing rehabilitation services. CBR workers are also used to ensure follow up – a great example of real comprehensive eye-care services (CES) in action. (Sightsavers promotes a model of comprehensive eye-care services, whereby a community is served with ALL aspects of eye-care in their entirety)

I asked whether the restriction on only being able to support visual impairment rather than other disabilities proved to be a problem, but this did not seem to be the case. At the moment we had a cross referral system with other INGOs for other disabilities, although it was acknowledged that this wasn’t working as well as it might. We did not have any evidence concerning the proportion of blind people who had other disabilities, but CDD expressed the view that children with multiple disabilities would generally not survive infancy.

The office was keen to do more on education, which they regarded as the priority should more funds become available.

Saturday 11th August (Part 3)

We went from the school to one of the slum areas where the people served by this project live, and walked through. The smell is probably the aspect which will stay with me – the sweet smell of rotting rubbish, which languished in huge mountains all around, the foetid stench of sewage and the acrid smell of woodsmoke all mingled. It was very muddy underfoot and the dark bamboo homes were crammed tightly together and had been damaged by the floods. People paid 500 takas (£5) a month rent for a tiny one room shack to the private owner of the land, who could sweep them away at any time if a better development opportunity arose. These people lived hand to mouth – most were unemployed. Many of the children were near naked with skin problems and as there were no latrines (although there were fresh water standpipes) it was likely that diarrhoea would be a major issue, particularly as they walked through floodwaters to reach the slum area. I have to say that the poverty I witnessed here was more depressing than anything I have seen in rural areas.

Saturday 11th August (Part 2)

I did not know whether to be proud or appalled that Sightsavers funds 50% of all cataract operations in Bangladesh, and 100% of all low vision services. The Cataract Surgical Rate (CSR) needed to deal with the current backlog and incidence rate is between 2,400 and 3,000 per million people per year, compared to around 1,000 being achieved at the moment

Attention turned to the Bangladesh Childhood Cataract Campaign, where it was very pleasing to see that we are well on target for this year. I was quite surprised at the age profile of the children treated – only 25% were under 5, and more than 25% were between eleven and fifteen. Apparently some sight is restored even for this older group, which I had not appreciated.

At this stage we took a break from the office to visit an outreach camp for the Dhaka Urban eyecare project. This was held in a school near a number of the slum areas. Patients came to the school for examination, and if they were found to have cataract they were checked for hypertension, diabetes and any problems with tear ducts then those who could demonstrate they were poor were transported directly to the hospital for the operation, free of charge.

In the half day before our visit they had identified twenty patients, including a 30 year old woman with bilateral cataracts whom I met. She had had problems for a couple of years and was tremendously excited at the prospect of recovering her sight.

Saturday 11th August (Part 1)

This morning began with a briefing at the Country Office

Blindness in Bangladesh is overwhelmingly caused by cataract – the recent national blindness survey showed 80%.This seems to be a much higher proportion than anywhere else I have visited. There is a considerable amount of refractive error (people who require glasses) and low vision – this often overlaps with cataract. Diabetic retinopathy (blindness caused by diabetes) and glaucoma are clearly problems which will become significant in the future, but at the moment cataract dominates.

As always seems to be the case, the ophthalmologists are concentrated in the urban areas whilst 80% of the need is mainly in rural areas. Around half the ophthalmologists are in government hospitals and half in NGO hospitals (a small no in private hospitals), but 86% if cataracts are performed in NGO hospitals and only 10% in government ones. This rather shocking statistic is caused by a number of factors, including lack of training, lacking of mid level eyecare personnel and lack of equipment. Wherever we went during the trip, people were dismissive of the possibility of the government hospitals ever functioning properly. Nonetheless, it is my view that we should not be deterred from our long term goal of developing the government sector, not just the NGO sector.

It is particularly concerning to hear that the government has set aside £300k to spend on eyecare, yet it cannot seem to do this because of lack of management. This is despite having a Vision 2020 committee led by the Director General of Health, a separate directorate for eyecare and a National Eyecare Plan. Clearly a priority needs to be providing support to enable them to spend this budget properly (and keeping up the pressure them to do so).

Friday 10 August

This was essentially a rest day (Friday and Saturday are the weekend in Bangladesh), with the opportunity to read the briefing notes provided by the Country Office. I was very pleased to have the chance to meet some of Nazma’s family who generously entertained me that afternoon.

Thursday 9 August

Nazma (Nazma Kabir is Regional Director for South Asia and the Caribbean) and I flew on Emirates from Gatwick Airport. (On airmails donated by Emirates, a company who provide corporate support to Sightsavers.) The journey was uneventful and we arrived after a short connection at Dubai with all luggage intact just one hour late.

Visiting Bangladesh

9 – 17 August 2007

This was a particularly difficult time to visit Bangladesh, as it was in the grip of the worst floods for a decade. Although I had seen newspaper pictures in the UK, this doesn’t really compare with seeing the problem directly. Our partners work had been disrupted, particularly in the north of the country, and my programme had to be significantly curtailed due to travel problems. This was a pity, but on the other hand I think it is important that I visit places during difficult conditions, not just when things are at their best, so I can appreciate the challenges under which our people work.

The key objectives of the trip were:

• To meet the staff of the Bangladesh Country office, discuss current and future programme plans and to brief them on the status of the Strategic Review.
  

• To meet a number of key partners, both long standing and new, and perform a couple of inaugurations of new centres.
  


• To meet government officials and advocate for Vision 2020 and social inclusion for blind people
  


• To meet a range of beneficiaries.

Summary

This represented the culmination of years of work, by those in the Gambia and the Regional Office. It also would never have come to fruition without the early contact made by Sir Graham Burton, and we are very grateful for that.

This was the biggest project (in financial terms) that Sightsavers has ever carried out, and I believe we can be very proud of the result. It is a hospital and training centre of the highest standard. The training centre in particular will make a massive impact on West Africa (and potentially beyond), where the shortage of trained personnel is so acute. My heartfelt thanks go to all those at the Country Office (and to all the partners and suppliers) who made it possible.

We have clearly impressed the Sheikh Zayed foundation, which we hope will enable us to build a very strong funding partnership with them into the future. They have seen many building projects across Africa, and we must have done well to impress them so much.

I personally enjoyed this trip a great deal – visiting the hospital itself, but also seeing my first trichiasis operation. As ever though, meeting our overseas staff, and seeing how hard they work and the difficulties they face (in this case bureaucratic as much as anything else), remains the highlight for me.

Thanks once again and well done, Jerreh and the team. (Dr Jerreh Sanyang, The Gambia Country Representative)

19th – 20th February

The 19th was declared a public holiday as it was Independence Day, so for me it was a chance to catch up on email and to relax. On 20th I left for London, and whilst the plane was more or less on time (well positively punctual for West Africa), my bag was the very last one to arrive from a completely full Airbus of people, so I didn’t arrive home till the small hours. Tired but satisfied.

Sunday 18th February

The foundation visited a village today and were able to view a trichiasis operation and talk to members of the community. We had lunch after, and they said they had found this both fascinating and shocking. Dr Hussein, their medical advisor couldn’t get over the fact that surgery was performed next to a hut. The foundation left early that evening, but not before telling us that they were extremely impressed with everything they had seen.

Saturday 17th February

This morning Sightsavers personnel attended the Ministers meeting to ratify the resolution needed to secure ongoing management of the Centre, while the foundation visited the hospital privately. This gave them the opportunity to talk to the Director of the Centre, consultants, nurses, students and patients, and generally to look at whatever they wanted without us shepherding them. They said they really appreciated this, and I believe it dramatically increased the levels of trust between us.

Early that evening we all visited State House, where the President was having a reception. This time the President did reveal himself, and there was an opportunity for the foundation (and for us) to meet with him, albeit briefly.

Friday 16th February Part 2

The Inauguration began at around 5:30, and was attended by the Vice President, and representatives of all the Health for Peace countries, as well as some ambassadors (eg the American ambassador but not the British High Commissioner). There were many speeches, including from Simon Bush, (West Africa Regional Director) from me and from the foundation, then the Vice President and the foundation jointly cut the ribbon and declared the centre open. Everyone trooped through the various buildings, and I was very pleased to see that all the final touches were in place. It looked absolutely stupendous, everyone was very impressed.

After some African dancing (which I was bullied to take part in!), the foundation retired, and we went on to a Gala Dinner – which started at 11pm.

Friday 16th February Part 1

We began the day with a courtesy visit to the Minister of Health, and met his permanent secretary. The MoH didn’t appear at a single meeting or function the whole of the time I was there, causing some offence to others (eg the Minister of Health from Sierra Leone) who had made the effort to come. It was also very peculiar as he was barely mentioned. The Minister for Education stood in for him, but there was no apology made. The President is currently on a rather bizarre campaign saying that he can cure AIDS and asthma via a new herbal concoction, so perhaps the MOH was involved in this.

The Sheikh Zayed Foundation arrived around lunchtime, having travelled via Ethiopia and Nigeria. A long and exhausting trip from Abu Dhabi.

15th February part 2

We went on to a secondary eye unit in another village, where they performed cataract operations. I was very pleased to see that they all had mosquito nets – something that isn’t universal in the places I have visited. I met the patients, and discovered that none of them had been cataract blind for more than a few months. Talking to the doctors here, it became clear that The Gambia has now cleared its backlog, and is treating incidence only. A great achievement. Recent surveys have shown that the prevalence of blindness here has reduced from 0.7% to 0.4%.

However, they see an increasing number of people coming over from Senegal, and even more from Guinea Bissau, and it is clear that the problems there (particularly in Guinea Bissau) are much more severe. It is therefore excellent that we will be starting programmes there this year, and that the Sheikh Zayed Regional Eye Care Centre (SZREC) covers all these countries.

We then visited a primary centre, to talk to a Community Eye-care Nurse, and then on to a school to meet a teacher who was also one of the ‘Friends of the Eye’, who move among the community raising awareness of eye-care and encouraging people to get treatment.

Overall it was a great visit, particularly since the Office were fully occupied managing the myriad of guests arriving (or trying to arrive) for the Inauguration.

15th February part 1

Today I had the tremendous experience of witnessing my first

trichiasis surgery. Momodou (project officer) took Hannah and me out to one of the villages, where an ophthalmic nurse performed the operation on a very nervous, but very brave elderly man. His wife had had the operation the previous week, and despite having suffered the complication of a granuloma (inflammation around the stitches which is easy to remove), had persuaded her husband to have the treatment.

The operation looks very much like battlefield surgery, although it is clearly done professionally and with proper attention to maintaining a sterile environment. It is also quite bloody to watch the nurse pull back the eyelid and slice through the inner lid, then cut deeply to release the adhesions. Not something to watch after lunch, but I found it absolutely riveting.

Tuesday 13th February part 2

We left Jerreh at the site, with his mobile glued to his ear, dealing with a vast myriad of administrative nightmares, and Dr Hannah Faal (West Africa Regional Eye Care Consultant) took me to the Royal Victoria Hospital, which had been the home of eye care in The Gambia for many years (she herself worked there). The comparison was very stark – two rooms and a veranda, plus a theatre.

We went back to the office and I held a surgery with the staff. Issues raised included the perennial of forecasting, which was perceived as very time consuming and rigid. It was felt that it was actually less rather than more flexible than the old budgeting system. It is clear that a re-launch and explanation of the forecasting approach, together with some tools to help people use it, is desperately needed, as this complaint comes up time and time again on my trips.

I was also asked about my views on user fees, and on why Sightsavers always rented offices overseas rather than building their own.

Tuesday 13th February part 1

I arrived late in the afternoon, and successfully transferred to the hotel, together with luggage. I believe I was one of the few who was able to fly direct from one airport to Banjul without any stopovers, connections, delays, or cancellations (Air Senegal chose these days to go on strike). Talking to Jerreh (Dr Jerreh Sanyang Country Representative) over the course of this trip really brought it home to me how difficult it is to travel in West Africa.

Firstly we visited the hospital to check that everything was ready for the inauguration. My first thoughts were how great the hospital looked. It is very well designed in comparison to many I have seen. There did however seem to be a plethora of remaining tasks – the contractors were repainting the entire inside of the various buildings, and were also attending to a few cracks (not structural!!). There was furniture and equipment to unpack, and some paving to be laid. The landscaping looked good, although sadly we had been forced to burn off some of the elephant grass at the edge of the site as the President’s security had been concerned about snipers. Apparently this also reduced the risk of future fires so wasn’t all bad.

My Trip to The Gambia

The objectives of the visit were as follows:

• To visit and inaugurate the new Sheikh Zayed Regional Eyecare Centre.
• To meet and build relationships with the Sheikh Zayed Foundation, with a view to encouraging a long term funding relationship.
• To visit some of the programme work in the Gambia (a limited amount though due to the administrative challenges with which the Country Office were grappling).To support the ongoing advocacy initiatives, particularly around the Health for Peace Initiative (HFPI).
• To meet the Country Office staff of The Gambia – who will also be supporting Senegal and Guinea Bissau programmes from this year onwards.

Originally it was intended that I would visit Senegal, to see the impact of the HFPI work there, and to meet those involved with our planned project in Louga (funded by Anglo American). However, the President of The Gambia’s office announced that the Inauguration should move from 18th to 16th at very short notice, and this made a visit to Senegal impossible. It also threw a significant spanner into the best laid plans of the Country Office and many visitors!

Note on Health for Peace Initiative
This is an initiative between a number of West African countries (initially Senegal, The Gambia, Guinea Conakry and Guinea Bissau, recently extended to include Sierra Leone and Liberia), where they have agreed to cooperate on health matters to help preserve peace in the sub region. Each country is spearheading one or two aspects of health (eg HIV/Aids, immunisation, malaria), and The Gambia has chosen eye-care.

Overall Impressions

This was an absolutely fascinating trip, and something of an emotional rollercoaster. I will never forget it. Here are a few of the thoughts I am currently left with:

• The dedication of many of our overseas staff is not to be underestimated. Staff in Sierra Leone stayed with us through the war and worked in unspeakable conditions, and Verda is now having to cope with very difficult situations and extremely harsh conditions. They all have my deep gratitude and utmost respect.
• Working in post conflict environments is extremely hard, and we need to think very carefully about whether it is the best use of our resources. When a society is so badly broken down eye-care is absolutely not top of anyone’s list, and it is really difficult to make progress. On the other hand, the people in such a situation are in great need, and the visually impaired are particularly vulnerable. A difficult call.
• River blindness is a persistent disease, and if we become complacent because the apparent burden globally has reduced then it will simply come back with a vengeance.
• The Neglected Tropical Diseases initiative is gathering momentum, and we need to think carefully about how to deal with it.
• Sierra Leone is a programme which is definitely up and coming, with a particularly strong Oncho (river blindness) Coordinator leading great progress in this area. Let us hope our application to Irish Aid is successful so we can build the eye unit in Kenema. (It was!)
• HR development is the key problem in both countries. This is a problem all over Africa, but the added complication of post conflict conditions makes it a really huge stumbling block.

Wednesday 15th November Part 2

Our last visit was to the Christian Association of the Blind (CAB). There are five different associations in Liberia, which causes problems – two are officially recognised by the African Union of the Blind. CAB generally seemed pretty on the ball, and it was clear that Dr Kota, the Director, would be an excellent advocate and a good community based rehabilitation partner. The only wrinkle is that CAB are building their own School for the Blind in Monrovia with money from the World Bank. I asked why they didn’t just support the existing school, and it was clear that there was a situation rather like that with Sierra Leone Association for the Blind (SLAB) in Sierra Leone, where they would prefer to manage schools themselves, even if they say they support the Ministry of Education.

After a quick clean up at the hotel, we left for the airport and I had an uneventful trip home via Senegal and Brussels.

Wednesday 15th November Part 1

Verda (Sightsavers Country Representative for Liberia) and I went out to Malama to visit a river blindness endemic community, and see how Mectizan® distribution was working in the field. The distribution is managed from a health clinic sponsored by World Vision.

The last distribution had been a bit haphazard as no census had been conducted first, but this is something that will be remedied next time. There is a very large catchment area, and problems finding enough volunteers in each village to distribute the drugs, (CDDs). There were a range of issues – low literacy rates and resentment that CDDs weren’t paid being two key ones. We found a few anomalies in the registers, in particular there were cases where children under five were being treated. The view was that height was taken as the overriding factor rather than age, as claims of age were often incorrect. The CDDs we met were very unhappy about not being paid, particularly as they said that the community didn’t believe this to be true.

Verda and I went to a local village and called an impromptu meeting to try to address this. We explained the situation, and I stressed that there was no money to spare to pay CDDs either from the government or from Sightsavers, but that many communities chose to show gratitude to CDDs either in kind or by exempting them from other community labour. The clan chief in the village was not very supportive (‘if they volunteer they should just get on with it’), and it became clear that unless local community leaders are really bought in and understand that the programme is supposed to be community led rather than government led, this problem will persist.

Tuesday 14th November Part 2

After JFK we had a second meeting with Dr Amegoshie, at the hotel. We learned that the Dr is also a General Surgeon at Harper, where he is called on to operate in emergencies, and is the County Health Officer, which brings a significant administrative burden. These, together with a range of practical problems, were leading to the low cataract surgical rate.

We identified a few blocks, such as failure to order drugs in good time, resulting in them running out, and transportation problems. We still sensed though that a significant problem was Dr Amegoshie simply feeling isolated and overwhelmed. We offered help from the ophthalmologist /cataract surgeons in Sierra Leone to set up and run an eye camp in March next year. I was very pleased that the doctor embraced this offer with relief – there was no question of any ego getting in the way.

1. This evening was our last as a travelling group, as we were all going our separate ways the next day. The key priorities for Verda were agreed to be
   Get tough on the ‘skippers’ – as tough as you need to be
2. Push the ministry forward on hiring the Programme Manager, to ensure we have a good person driving things into the future.
3. Make sure the Sierra Leone liaison happens, and provide as much support as possible to Dr Amegoshie to make it a success
4. Make sure the school screening happens

Tuesday 14th November Part 1

We began the day with a visit to the Deputy Minister of Health where I met Dr Guize, the National Eyecare Coordinator. He spoke a lot about the problems of lack of equipment nationwide. The Deputy Minister also spoke about setting up a national secretariat for recruitment, which should help with the issue of ‘skipping’, (see post of Monday 13th) and about the need to de-centralise river blindness control to the districts and ensure it became more integrated with eye-care.

Following this meeting, we were very privileged to be given an audience with the President, Dr Ellen Johnson Sirleaf. We had a very positive meeting with her – not just an introduction. She too was very keen on our focus on the south east, and offered to help in any way she could, particularly with the problem of keeping trained people in the country.

We went from the President to visit JFK hospital – the main referral hospital in Monrovia. The eye clinic here is run by Dr Guize. He was right in saying that there was very little equipment there. The ground floor building was reasonably spacious, with enough consulting rooms, and there were several nurses. Half of the eye clinic was occupied by Chinese opthalmologists, although they had gone for the day and padlocked all their rooms, so we could not see what equipment they had. Dr Guize said he was able to use their operating theatre once a week.

Monday 13th November Part 2

We are planning to rebuild the eye unit in Harper (hopefully with UN Mission in Liberia funding, although we must submit the plans for this to them as a matter of great urgency), but it was clear that staffing would be a huge challenge.

All of us were feeling pretty depressed at this stage, and once our flight was formally cancelled we went to see Verda’s office at the National Drugs Service. Our depression was further exacerbated as Alex, the Finance Officer, had just received an eviction letter saying we had to leave our current office space by the end of the year. (We have since received some good news – the Ministry of Health have offered us some much better office space).

We went on to visit the Minister of Health, and I was impressed by their openness and eagerness to address the issues.

Sightsavers has offered funding to support the eye-care secretariat, in the form of a full time Programme Manager. The Minister was keen that this post should be openly advertised with the salary clearly set out in the advert, rather than having someone appointed via patronage. We agreed to help them organise this. He was very keen on our proposal to become tougher with ‘skippers’, and said the Ministry itself was planning to take a similar line. I felt reassured that the Minister and his staff had the right mindset and were honest and reliable.

Today amply demonstrated the difficulty of trying to operate in a post conflict country.

Monday 13th November Part 1

We woke this morning to no water. Given everything I had seen it did not feel appropriate to complain to the hotel. I did however regret my decision of the day before to put my only source of water – a large bottle – into the fridge. It woke me up I guess…

The intention today was to fly to Harper, on the South East corner of Liberia, where we are supporting an eye clinic. UN Mission in Liberia (UNMIL) have free helicopter flights to Harper which Non-Government Organizations can use. Unfortunately the weather was not in our favour, and we waited in vain the whole morning at the heliport. We were joined by Dr Amegashie, the ophthalmologist (and general surgeon) at the clinic and had something of an ad hoc meeting in the departure area.

It was a pretty depressing story. Dr Amegashie had only managed to do three cataract operations in October, and the biggest problem was staff. We had trained several nurses, most of whom had ‘skipped’ after training. One had simply not returned from Ghana. The cataract surgeon who was supposed to be there was also no longer working. We asked Dr Amegashie if he could suggest anyone else to train, and the answer was ‘no’.

It was clear that we need to be much tougher in enforcing the bond for people we train (we are entitled to recover all costs from the individuals if they don’t return immediately after training). We have never done this before, and now we must be prepared to see it right through to court action if necessary. Otherwise the problem of ‘skipping’ will persist.

Sunday 12th November

We had lunch today at Verda’s house, with a range of people from other International Non-Government Organizations (INGOs). Save the Children, Africare, World Vision and the EC were all there. We spent most of the afternoon discussing some of Liberia’s problems, and the full horror began to sink in. Here are some statistics/facts:

1. 75% of women are thought to have been raped over the last few years.
2. Unemployment is currently running at 85%.
3. A whole generation has not been educated, and many are child ex combatants, who have essentially gone feral.
4. Many women and girls (and boys?) are now reduced to selling their bodies to get food (a handful of Liberian dollars depending on the ‘riskiness’ of the practice on offer)There are around 26 doctors for the whole country of 3.5 million people.
5. Life expectancy is 39 for men and 41 for women.
6. Currently around 30 – 40% of children are not enrolled in school, and teachers earn $20 a month. As a result, there are few teachers, and around 40% of them hadn’t even finished high school.
7. Around 24% of people have access to clean water and only 5% to sanitation
8. An estimated 24% of children do not live to see their fifth birthday.
   

These are very sobering facts, and it made me quite concerned as to how we could get the government to give any priority to eye-care, when there were so many other problems to deal with. Having said that, the plight of the visually impaired here is particularly acute, and they need strong advocates.

Saturday 11th November Part 2

We visited the Liberian School for the Blind on our way to the hotel. This was a deeply depressing place – the buildings were fairly new, but there was absolutely nothing inside them as far as I could see. The children sat on benches around the walls and all looked depressed and hopeless. We donated four Braillers and two globes – the school only had one brailler and this was only used by the teachers. None of the children had been screened to check whether they just had refractive error – it was agreed that Verda would arrange for this to be done as soon as possible.

We then drove on to Monrovia, and I had my first sight of how badly Liberia has been damaged by the 14 years of war. The only way I can describe it is to say that everything is broken, and all the buildings are burnt. There is rubble and rubbish everywhere, and every few miles there is a UN Mission in Liberia (UNMIL) checkpoint. Many buildings are empty and occupied by squatters. The atmosphere on the streets is a mixture of despair and menace – very different from Sierra Leone which has a feeling of recovery. We stayed at the Mamba Point hotel, where the local US Marines were having a birthday party that night. It seemed utterly incongruous to see all these people in dress uniforms and gaudy frocks with a huge cake.

Saturday 11th November Part 1

Today we drove to Liberia. The first hour was fine, on tarmac roads, but after that the road was unmade and got worse as it went on. There had been heavy rain in the night which added to the problems, and it took us five hours from the end of the tarmac to the Liberian border, even though the distance was about the same.

We met Verda Tarpeh, Sightsavers Country Representative for Liberia, at the border, and crossed without too much difficulty (about two hours). Verda was called upon to shout at the customs people as there was some discrepancy between the chassis number of the Sierra Leone vehicle and that shown on the paperwork. Apparently shouting is the only way here, although I sense it wouldn’t have worked quite as well if I had done it….

Friday 10th November

We drove to Kenema to see the small clinic there, and to view the site of the proposed new unit (which we now know will receive Irish Aid funding). The hospital staff here said that river blindness was actually a bigger problem than cataracts in this district. They also had a major problem with Lassa fever. Their Ophthalmic nurses and Cataract Surgeon had been trained in The Gambia – apparently this had been a good course.

We met their river blindness focal person who had begun his community awareness work and started training the CDDs (volunteers trained in each village to distribute the drugs, as opposed to the old system using health workers).
He was waiting to hear when he would get his Mectizan® – apparently this is the last area to be treated.

We drove then back to Bo for a fairly early night.

Thursday 9th November

We began the morning by visiting the Eye department at the Bo government hospital, and met Mr Sandy who runs the clinic. There is a lot of river blindness in the area – this is second only to cataract as a cause of blindness here. They typically perform 40 cataract operations a month, although at busy times after a camp (there are two free camps a year) this can rise to as much as 40 in a day. The optical centre seemed to be very well run.

After the hospital we went to Paul’s School for the Blind. This had recently had new buildings and was apparently in a much better state than when Sightsavers had last visited. The children seemed pretty lively, and this is one of the schools to which we will roll out the Inclusive Education Programme pilot if it works well at Milton Margai.

After lunch we drove out to Bumpeh to meet a number of people who had benefited from the Community Based Rehabilitation project (partnered with Sierra Leone Association for the Blind - SLAB). All had been trained in some kind of handicraft – such as weaving, hammock making, and these were being encouraged to train others.

Wednesday 8th November

We drove out to Moyamba to visit a village in an area where river blindness was prevalent. Almost all the rivers in Sierra Leone are infested with the black fly, and it is very noticeable that there are no villages anywhere near the river banks. When driving over the rivers, somehow the beauty of the landscape took on a sinister hue, when you realise the menace associated with the waters.

The last part of the journey was undertaken by canoe, and we were welcomed by drums and singing. We went into the local schoolroom for a village meeting, to discuss concerns that the people had. The first three rows of the audience were mainly blind from river blindness, and I was shocked at how young some of them were (women in their twenties). However it was gratifying to learn that everyone knew about Mectizan®. People wanted to know why we couldn’t spray to get rid of the fly – the biting still caused great irritation. They also wanted to know what to do about a nearby village where a number of people were refusing to take the medication, as they understood the need for full community coverage. The biggest issue, as in most places we went, was that the volunteers (CDDs) wanted to be paid - but we explained that given the scale of the distribution, this was unaffordable by the government (or Sightsavers), and that it was the responsibility of the community to show gratitude in other ways. This will become a much bigger issue with the integration of Neglected Tropical Diseases.

River blindness seems a strange disease – at this village there were many blind people, yet we visited others equally near a river infested with river blindness where there were hardly any.

Tuesday 7th November Part 2

After this we moved on to visit the Minister for Education. The main topic discussed was the Education policy, as we are keen to ensure that children with special needs are not forgotten. The Minister assured us that this was not the case, but we are still worried as we have not seen the redrafted version of the new policy. We took the Minister through our IEP, stressing that the initial work with Milton Margai was a pilot, and that we intended to roll this out to the other schools for blind children.

We then visited Milton Margai – you may have seen this school featured on breakfast television as it is twinned with a school in Kent which had some media coverage last year. A great deal of work had been done over the last year or two to spruce up the buildings. The children all seemed very cheerful and lively (a real contrast to those we met later at the school for blind children in Liberia), and in general it was a place of optimism. I asked the headmaster whether there were many children with multiple disabilities – apparently not. His view of why not was pretty stark – they will probably have been abandoned and left to die….

Tuesday 7th November Part 1

We began the day with a meeting with Graine O’Neill at Irish Aid who seemed very supportive, and had just been asked for comments on our proposal regarding the Kenema eye unit. Fingers crossed! (Since this trip we have discovered that we have been successful in winning this – thank you Irish Aid!)

We then visited the British High Commissioner, Sarah Mackintosh, and put forward the possibility of the Commission funding a pilot integrated education project (IEP), with the Milton Margai School, (a special school for blind children) where we will provide equipment for the children leaving the school and going on to secondary education. Unfortunately it is unlikely that they will be able to fund this as she said they had already provided a lot of funding to the school. However, she was certainly a supporter, and could be a useful contact into the future.

Monday 6th November Part 2

Next we toured the Connaught Eye clinic, directly below the office, and it seemed to me that they are clearly achieving a lot without the sort of equipment I saw on my trip to India.

One of the biggest frustrations in Sierra Leone is around training, there is no ophthalmic nursing course, and the nurses all go to The Gambia. Before the war it was a centre of excellence. There are high hopes that the nurses college will reopen and it has moved from the Ministry of Health to the Ministry of Education recently.

After the Connaught Clinic we went to meet Mr Kabakeh Noah, who is the Community Based Rehabilitation (CBR) Programme Manager, and a member of Sierra Leone Association of the Blind (SLAB). He is totally blind himself. Sightsavers has a major project with SLAB, part funded by Comic Relief. A major advantage is that SLAB is the single, accredited organisation of the blind in Sierra Leone (unlike in Liberia where there are several competing organisations).

We paid a joint visit to the Minister of Social Welfare, Gender and Children’s Affairs. There is a Disability Bill in draft, which the Minister believed could be put before Parliament before the end of the year. This seemed pretty optimistic to me, particularly given the number of other bills (eg Domestic Violence, Child Protection) that the Ministry were trying to get through. SLAB was essentially behind the bill, but felt that there had been inadequate consultation.

We then went on to a courtesy visit with the Deputy Minister of Health (the Minister was in Geneva for the vote on the new Director General of the World Health Organization).

We spent the afternoon at the SLAB training centre, where they were teaching skills such as baking, soap making, sewing and tie dying. SLAB membership is growing, and there is clear demand for more training centres outside Freetown.

A couple of e-newstories from Zambia:

http://english.people.com.cn

http://www.upi.com/AfricaMonitoring/

Monday 6th November Part 1

Our first visit was to the onchocerciasis coordinator, Dr Koroma. The oncho (river blindness) programme in Sierra Leone
had been disrupted for 12 years due to the conflict. There had been some administrative problems in 2005, so 2006 is the first year for some time that there has been a distribution. The evidence gathered is that the disease has returned with a vengeance – if anything it is worse and more widespread than before the war.

The lesson here is clear – we must not be tempted to think that because river blindness has dropped to 0.8% of world blindness we can now stop supporting Mectizan® distribution. If we do this the scourge will return.

Treatment for river blindness relies on treating as many people as possible to stop transmission. It is not the case that someone who is treated is protected – they are only protected if the vast majority of the people nearby have been treated too. This is why we have issues around border areas – a village can be re-infected if we don’t treat the next village across the border.

Next year Sierra Leone will be combining river blindness and
lymphatic filariasis treatments. (confusingly in many places river blindness is referred to as ‘filaria’). This is the beginning of the major push by the World Health Organization (WHO) for the integration of treatments of a wide range of so called ‘neglected tropical diseases’ or NTDs. They are starting with lymphatic filariasis and river blindness as the drug treatments are closely related.

After the visit to Dr Koroma I met with the Country Office staff. What an incredibly warm welcome! I was very touched. We had a brief meeting to give me some of the history of the office, which had remained open all through the war. People had slept at the office on mattresses, in rat infested conditions. It really brought home to me how much some of our overseas staff are prepared to sacrifice for Sightsavers.

Travelling to Sierra Leone and Liberia

The purpose of this trip was to meet some of our partners in Sierra Leone and Liberia and gain an understanding of the issues faced, to meet a number of beneficiaries (with a particular focus on onchocerciasis), to gain an appreciation of the difficulties of working in post-conflict countries, and to compare Liberia (where the conflict is more recent) with Sierra Leone (where there has been some time to rebuild) as well as to meet the staff at the Country offices.

I left on the evening of 5th November on a flight to Freetown via Brussels, arriving in the evening. The journey was uneventful, and I arrived together with my luggage around half an hour earlier than expected!

An interesting peice in the Gambian Observer about the Integrated Education Programme in The Gambia: http://www.observer.gm/enews/index.php?option=com_content&task=view&id=7436&Itemid=33

An interesting article about education in Uganda:

http://www.reliefweb.int/rw/RWB.NSF/db900SID/DHRV-6YG53P?OpenDocument

Thursday 31st August – Part 1

We went to Mulago hospital, to visit the main national referral hospital. The most obvious problem was that the unit was badly organised from a use of space perspective. The rooms were badly laid out, and full of filing cabinets, yet the corridors were vast and under utilised. Half of the eye unit was on one side of the hospital, and half on the other, so it was difficult to optimise the position without taking a holistic view of the whole hospital.

Mulago was rather a depressing place – the wards were very large, with rows of patients like a military hospital. The eye unit operating theatre was of a much lower standard than at Mengo, and whilst they also had access to the main theatre, they didn’t use it because it was too far from the wards, and they would also have to move equipment each time.

That said, the hospital’s main ophthalmologist was clearly a very dedicated man, and we learned that they work closely with Mengo, and have some specialised lasers enabling them to do more advanced work than Mengo. We didn’t see this – it was in yet another part of the hospital. It was clear that the hospital as a whole needed replanning – I couldn’t believe that it was only the eye unit that was so disjointed.

Wednesday 30TH August – Part 3

Finally we visited the Jinja Ophthalmological Clinical Officer (OCO) training school, led by the legendary Dr Binta. He gave us a great presentation marred only by a terrific thunderstorm which blew in the windows and half the building. A chunk of this went in my eye – at least I was in the right place!

The school has trained 161 OCOs over a number of years, and of these only 12 are no longer in practice. 3 have left the country, 1 became visually impaired and couldn’t continue, and the rest have died. This is a pretty good record. All OCOs are registered nurses with at least 2 years of experience, and the course lasts a year. Apparently it is getting harder to recruit people, and they have now started to offer courses for Ophthalmological Assistants, who are less qualified and the course lasts 3 months. We met a number of OCOs trained by Dr Binta in the hospitals we visited, and they were all extremely complimentary about the training.

The training included information on refraction and low vision. One issue was over cadres – at the moment there were no low vision cadres in government, and there was also confusion over refractionists / optomotrists. Another issue was that the government was keen that at least 60% of students should be private and fee paying. At present there were next to none, and it was clear that Dr Binta preferred it that way.

Dr Binta is clearly a highly respected man who had achieved a great deal for sustainable eyecare in Uganda.

We travelled back to Kampala – not quite such a beautiful place as the source of the Nile.