Glaucoma, a treatable but irreversible disease, is stealing vision at high rates in Sub-Saharan Africa.
Karim Damji, the Royal Alexandra Hospital Foundation Research Chair in Ophthalmology, recognized something needed to be done and he created a program to train the first generation of glaucoma subspecialists in Sub-Saharan Africa and empower local health care professionals to prevent glaucoma-related vision loss.
The journey to Africa
Damji is Chief of Ophthalmology at the Eye Institute of Alberta and chair of the Department of Ophthalmology in the Faculty of Medicine & Dentistry. He has always been passionate about developing better care models for underserved populations, whether that be in rural or remote areas in Canada or overseas. He was drawn to Edmonton from Ottawa a decade ago because of the University of Alberta’s emphasis on global citizenship and the support provided for people to do global health work, made possible by donors to the Royal Alexandra Hospital Foundation.
After spending some of his childhood in East Africa, he developed an affinity for that part of the world. As it turns out, Africa has a great need for Damji’s passion and expertise.
Glaucoma is a leading cause of irreversible blindness in Sub-Saharan Africa, affecting 4 to 8 per cent of the population aged 40 years or more. Damji is a glaucoma specialist and has been practicing for over 20 years.
Despite the prevalence of the disease, Sub-Saharan Africa has very few ophthalmologists and limited resources available to detect and prevent glaucoma. Damji sought to address this problem, but rather than organizing a short-lived outreach program, he was determined to empower the community, build capacity in local health care professionals and create lasting change.
“My feeling is that it’s better to work in partnership and introduce professional development in a mutually beneficial way,” said Damji. “As a Canadian I feel blessed to have a great education so I wanted to share what I know. As you share, you also learn. I am learning much more than I am giving.”
Stopping glaucoma in its tracks
STOP Glaucoma started a decade ago in partnership with the Aga Khan University and the University of Nairobi in Kenya and Addis Ababa University, Jimma University and Gondar University in Ethiopia. They later began working with colleagues in Tanzania at Kilimanjaro Christian Medical Centre and Muhimbili University of Health and Allied Sciences.
The program aims to develop glaucoma leaders to build capacity on the ground.
“I felt that it was a natural fit for academic institutions to work together. This way the people we are training are not only excellent clinicians who can take on problems, but also have the ability to have a ripple effect on their training programs, faculties and colleagues,” said Damji.
In Sub-Saharan Africa, about 90 per cent of people with glaucoma are unaware they have it. Unfortunately, patients often realize when it is too late and they are losing vision rapidly.
In an area with so few ophthalmologists, it was not practical to have them go everywhere, so Damji piloted a tele-glaucoma model. Tele-glaucoma uses electronic technology to detect and manage patients with or at risk of glaucoma. Medical information is transferred electronically between practitioners on the ground, from one site to another, and with the patient and glaucoma specialists. A Grand Challenges Canada grant enabled them to pilot tele-glaucoma to improve detection in Ethiopia and Kenya.
Once the disease is diagnosed, the management of glaucoma also poses unique challenges.
“It’s a lifelong disease like diabetes. We knew a lot of people wouldn’t be able to afford medications, so we focused on building capacity for laser and incisional surgeries,” said Damji. “Through civil society partners we have been able to donate laser machines to do selective laser trabeculoplasty (SLT) which is effective to lower pressure in the eye. I first started using this technology in 1998 and I’m pleased to see it has since been adopted globally.”
The ‘sandwich’ training program, which is an element of the STOP Glaucoma program, developed by Damji and colleagues takes about 18 months for fellows to complete. It involves rotations in Edmonton and the fellow’s home country coupled with investment by organizations to help create an enabling environment for glaucoma care at their home institution. There have been three trainees from Ethiopia and Kenya in the past five years, and a new fellow from Ethiopia will start at the U of A in January 2018. Similar program models have been adopted by other universities in Canada and the U.S.
“In Canada we are fortunate because trainees can get a license for hands-on training,” said Damji. “We have an advantage over the U.S. and Europe where trainees largely observe. Our international fellows benefit by learning more about glaucoma management, how a different health system functions and also acquire leadership training.”
Ophthalmology team from UAlberta with residents from Addis Ababa University following a teaching symposium.
Changing lives across the world
STOP Glaucoma has widely expanded training, prevention and treatment incrementally within partner institutions and their surrounding communities.
“I was in Ethiopia recently and after 10 years of investment there, I don’t feel I’m needed any more from a clinical perspective,” said Damji. “The clinicians are so good, I’m redundant. They’re doing such good work. When I go there, I learn techniques from them. My mentees have now become my mentors and this is deeply gratifying.”
Vision loss from glaucoma is currently irreversible. The disease can progress over decades, or in some cases over a few years. In Canada the disease is often caught early through regular visits to an ophthalmologist or optometrist. Access to these services in Africa is limited since there are so few eye care professionals. Often when people seek care for glaucoma, they are already blind in one eye.
Damji now sees his key role as helping the institutions partner with organizations to obtain funding and continue to grow.
“Part of the reason we were able to get this program started is through the generosity of the Royal Alexandra Hospital Foundation that helped fund the first fellows,” said Damji.
The network of experts in Africa connected through STOP Glaucoma continues to meet and consult with each other on difficult cases. They have recently developed glaucoma guidelines relevant to Sub-Saharan Africa. The young leaders and their universities now want to develop their own regional fellowship programs in glaucoma, and Damji continues to support them in this endeavour.
The program is not just changing lives in Africa; it is having a huge impact on U of A trainees. Ophthalmology resident Sourabh Arora traveled to Africa in 2014 as part of the project.
“I learned a lot professionally and personally that I would have never been exposed to otherwise. I learned a lot about life,” said Arora. “I was immersed in their unique cultures.”
Arora said the experience also made him look at how we treat patients in Canada and how we can streamline care better to reduce costs.
“They provide such excellent patient-centered care, with far fewer resources,” said Arora. “We brought that mentality back to North America by trying to provide care in more cost-effective ways.”
Karim Damji was recently recognized for his contributions to global health by his alma mater, the University of British Columbia. Damji will be presented with the 2017 Global Citizenship Award
at their annual Achievement Awards in November.