Report 4.1 :: Guyana


3 October 2009

Guyana is located in the North Eastern corner of the South American continent (directly beneath Venezuela). It has one of the largest populations of the English speaking Caribbean nations (approximately 800,000 people). It is included in the Caribbean category, despite having no coastline that borders the Caribbean Sea, on account of its inclusion in the old British Empire.

I was in Guyana as a volunteer with the International Centre for Eyecare Education (ICEE), an international non-government organisation (NGO), who had organised for me to do some work with a local NGO, the Caribbean Council for the Blind: Eye Care Guyana (ECG).

ECG was established, not too many years ago, in order to facilitate the improvement of eye services within Guyana. They serve both those with reversible and irreversible eye sight problems, which explains their motto: ‘Giving the gift of sight, while creating opportunities for those whose sight cannot be restored’. Anybody can be seen by one of their eye specialists for free; and any glasses that are dispensed as a result are made available at a fraction of the cost charged by the private practices around town (mostly staffed by untrained practitioners who have inherited the family business).

In order to help achieve its objectives, and those of the Vision 2020 campaign in the Caribbean, Eyecare Guyana has established a one year training program that is producing refractionists (or ‘opticians’). A second year has recently been added to the first. I was in Guyana for a fortnight to assist the teaching faculty of the school, or so I thought.

School was out when I was in Guyana, so I didn’t get to attend or deliver any classes. The year long training program had recently finished, and the third set of graduands (five in total, all from Guyana) were being ‘released into the wild’; And students from the two previous graduating classes were to be returning to participate in the second year classes in a few weeks time. As such, I was assigned the task of travelling with the graduating students to their new places of employment so as to help them settle into professional life.


Week 1 :: Bartica

I spent the first week in Bartica, a regional town accessible only by boat, which has no resident eye specialist. The student I was travelling with indicated before we got started that her preference was to have me seeing patients rather than supervising her activities. I therefore found myself practicing rather than tutoring in the temporary outreach clinic set up in an area hungry for eye care.

And when I say hungry, I mean ravenous. The waiting room was full to overflowing when we arrived for our first day of work. I was thankful that it was not my job to sort out the order in which all those gathered were going to be seen. It wasn’t possible for us to leave the consultation room once we were inside because of the crowd that was crushed up against the doorway. We worked out the maximum number of patients we thought we would be able to see each day, and then booked up the full week (we had three and a half days of examining time) with the people who had presented that first morning.

Because we didn’t have a third vision chart at our disposable, I found myself needing to measure the patients’ habitual vision for the first time ever in an outreach clinic. For a day and a half I had very little success direct patients around the eye chart (despite having a first language in common with nearly all of them). It wasn’t until I asked how the local practitioner ask her patients to read the chart that I realised I needed to ‘turn down the grammar’ in order to secure better responses; Asking patients “up to which line from the bottom you able to see & call,” felt altogether wrong as the words left my mouth, but it had a far higher success rate at getting people to start with the smallest line they could read rather than starting at the top of the chart (every time I asked them to read the chart).

This change alone didn’t amend all the trouble I was having. After trying three different ways of asking one particular young boy to read the chart, I stopped (a little frustrated) to ask him what was wrong? He explained that he couldn’t pronounce the word at the top of the chart, or any of the ‘words’ beneath it. The top line was H O Z R C, he did much better after I explained that the lines were not actually words and that he just needed to call out each letter one at a time. That experience made me aware of how much we take for granted that our patients in developed settings are familiar enough with the vision testing process to save us from the need to explain every little part of every little procedure. In Bartica, where many people were having their first ever eye exam, I also had trouble getting patients to choose the better of two lenses in the subjective refraction.

For the first time in my professional life I was examining patients without a retinoscope (because there was not one available for the trip); I have since taken a vow to never let it happen again. Refracting patients without a retinoscope is like starting the process in total darkness and hoping the patient will produce the necessary light to find the right way out. I didn’t fully appreciate just how much of my expertise is wrapped up in my use of that particular instrument. At one point I found myself using the correction lenses on the ophthalmoscope to try and establish the magnitude of the myopia in a child who was too young to give good responses in a subjective refraction (which really didn’t work well). A slightly more successful improvisation technique was using the pinhole after establishing the best spherical correction to work out if a search for an astigmatism was necessary. Finally, I can confirm that practicing in such settings is a fast way to get a lot better at direct ophthalmoscopy.

We saw about 250 patients that week (mostly women and girls) split pretty evenly between the graduating student and myself. The student was very confident in her own abilities. I didn’t have a lot of time to closely observe her practice, but she did correctly diagnose a toxo scar at a macular. She proved herself to be every bit as capable as me in an outreach clinic.

We made referrals for the usual suspects, cataract, glaucoma, and pterygium. Those that needed the attention of an ophthalmologist were given a referral letter and encouraged to take the boat to the Georgetown Public Hospital, where two ophthalmologists practice. On the whole we saw less pathology than I expected to turn up.

The spectacles that were dispensed were all brand new. ECG has moved past the stage of trying to utilise donated spectacles. We had a small supply of ready made reading glasses, magnifiers and walking canes (one of the vision rehabilitation officers was also working with us). We were also able to order prescription glasses to be produced in the ECG optical lab. They have a flat rate for prescription glasses, single vision or bifocals, with the restriction that the bifocals could only be ordered with a spherical distance prescription. Patients who required, or just wanted, astigmatic bifocals or photochromic lenses, were told that they needed to see a private practitioner in Georgetown. The most enjoyable part of this first week for me was the novelty of telling people how much their glasses were going to cost them, as the inexpensive option was a thousand dollars (which just happens to be my favourite number) due to the weakness of the Guyanese currency (one Guyanese dollar is worth less than one New Zealand cent). Prescription glasses for adults were $10,000, and for children, $6,500. While these prices sound ridiculously high, they are actually very affordable and a much cheaper than what the same glasses are sold for in private practice.

Though I can’t claim that this week represents my best work, because of the abovementioned difficulties, a good number of appreciative people were attended to and helped with their ocular complaints. I slept very well that following weekend.


Week 2 :: Georgetown / Suddie

In the second week I was visiting recent graduates in established clinics. The plan was to observe their practice and offer advice and assistance (where welcome, some were certainly more open to being coached than others). I visited the clinic in the main hospital in Georgetown, and another across the nearby river at the West Demerara Hospital. Despite giving patients staggered appointment times at these clinics, they all turn up at 8am on the day of their appointment and wait (somewhat patiently) for their turn to arrive.

I also travelled, again by speedboat, out to the small rural village of Suddie, where I worked alongside another recent graduate for a couple of days who was in the later stages of her first pregnancy. In addition to offering her a little advice I was also able to provide cover for her while she attended medical appointments and had her final ultrasound. It was at this clinic that I saw a lady with profound vision loss, both eyes having less than 20/200 vision, one eye suffering from a scarred cornea and the other from advanced posterior capsule opacification. I was stunned to learn that the public hospital’s YAG laser had been broken for a long time and was not likely to be fixed or replaced any time soon. This poor lady, who cannot afford to see a private practicing ophthalmologist, therefore has no access to the laser she needs to improve her vision. Fortunately there are plans a foot to send all patients to see the local Cuban eye team who are better staffed and equipped than the local public hospital; she should get the treatment she needs there.

On the whole I thought the students were quite competent. The one year training program is certainly producing refractionists who are capable of dispensing spectacles and who are confident in their own abilities. At times they could be described as being ‘over-confident’, especially when giving advice on conditions they don’t have the equipment or expertise to properly investigate. They can hardly be blamed though, spending the second week observing the behaviour of their patients confirmed my suspicions of the week before: Guyanese people rarely present complaining of visual blur. More than half the presenting complaints are of tearing, itching, headaches, and most often of all – burning! (I never did get to the bottom of what they were actually referring to with this well used word, even though I asked all the practitioners I met what they thought it meant, it seems to be an umbrella term used for any type of pain, strain or discomfort.) The sun and the heat usually get a mention in the presenting complaint also; and yet almost nobody uses sunglasses! So the graduands are being asked to solve problems beyond their scope of expertise more often than not; and their patients also need to be excused for not understanding the differences between different types of eye specialists, especially those in rural settings that have no easy access to anyone but a refractionist.

The other observation that was confirmed as accurate in the second week was that nine out of every ten patients are female. I’m sure that’s not because the men’s eyes in Guyana are ten times more resistant to refractive error & disease as the ladies who they live alongside.

In the spirit of preventative medicine, Guyana would benefit greatly from public health campaigns aimed at the benefits of wearing sunglasses and the need for men to have regular eye exams.


Concluding Comments

I was surprised that the school wasn’t better equipped. As the flagship of the Vision 2020 drive in the Caribbean (the third most impoverished region in the world) I expected it to be the recipient of much support, which in turn would mean an abundance of good quality equipment to be used in the training of the future eye specialists of the Caribbean nations. The director of ECG did explain to me that the shortage of equipment is partially explained by the success of the teaching program to date. In that, as they have sent their graduates out to establish clinics in rural settings (usually hospitals), they have had to send the equipment with them which was formally being using in the school. Even so, one of the charts in these rural clinics was so worn and tardy that I was not able to the 20/20 line binocularly, when normally I can see 20/15 or more with each eye alone. I hope that as the school expands, the funding that has been promised for the equipment it requires to train its students is forthcoming.

On that expansionist note, ECG currently has a proposal before the local university to begin a four year optometry degree in late 2010. The proposal is in the latter stages of the approval process. The plan is to include an exit point at the two year mark for those who want to be refractionists rather than optometrists. The prospectus has been based on the better degree level courses in the United Kingdom, and that of a similar school in Malawi. Once the proposal is formally approved, ECG will require the services of at least two more optometrists to establish the school and teach the courses. These teaching and administrative positions represent a wonderful opportunity to be involved in what is effectively developmental work, establishing a high quality educational program for the training of key eye specialist. Not only will this work bless Guyana, it will also benefit all the Caribbean nations from which it will draw students.


Next Stop

Final Stop: Nicaragua