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Cataract blindness in India
Community-bespoke doctoring SIR-Your March 12 editorial casts more shadow than light on the notion of medical undergraduate community-based teaching. We would defend the broad definition of such teaching, as used in the Association for the Study of Medical Education (ASME) report.’ We suggest that you confuse the issue with inappropriate use of the term community medicine which has an established meaning more to do with learning about the community than learning in the community. Further, the suggestion that what you go on to describe as ambulatory teaching may overcome logistical difficulties may be true from the hospital perspective, but placing large numbers of students in extramural sites is a complex exercise and is demanding of resources in terms of time, space, personnel, and funds. The implications of community-based undergraduate medical education have been explored by Illife,2 and although we endorse the sentiments of enhanced learning in the community, his cautionary notes should be heeded. In the past, hospitals were seen as the natural environment for the training of future doctors. Their role remains central, but changing care structures now demand some shift of focus as has been reiterated in the recent General Medical Council recommendations on undergraduate medical education.3 The community can be seen as a resource in which hospitals, general practice, teaching departments, and others converge to meet the needs of students. However, this will not happen until medical educationalists, curriculum planners, and those responsible for allocation of funding realise its potential and resource its development. Until then the laudable aims of community-based teaching will remain academic. Surinder Singh, Joe Rosenthal Department of General Practice and Primary Care, Royal Free Hospital School of Medicine, London NW3 2PF, UK
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McCrorie P, Lefford F, Perrin F. Medical undergraduate community based teaching: a survey for ASME on current and proposed teaching in the community and in general practice in UK universities. Association for the Study of Medical Education occasional publication no 3. London: ASME, 1993. Illife S. All that is solid melts into air-the implications of community based undergraduate education. Br J Gen Pract 1992; 42: 390-93. General Medical Council. Tomorrow’s doctors: recommendations on undergraduate medical education. London: GMC, 1993.
Cataract blindness in India SIR-There are 12 million blind people in India and cataract for 81% of blindness.1 At present, the 84 million Indian people with blindness due to cataract constitute half of the world totaJ.1 Between 22 and 38 million new cases are estimated to arise each year in India.1.2 At two large annual eye camps held in Beas, Punjab, India, a total of 10 720 patients attending for cataract surgery were examined by 32 ophthalmologists. The criterion for blindness was visual acuity of 3/60 or less in the better eye.3 Of 10 720 patients aged 41-96 years, 4218 (39 % ) were blind-3102 (74%) (1939 women and 1163 men) had bilateral cataract and 1116 had cataract in one eye. In these 1116 patients, 418 (10%) had corneal disease, 344 (8%) glaucoma, 52 (1%) complications of intraocular lens, and 302 (7%) phthisis bulbi and miscellaneous in the contralateral eye. Patients were asked why they had not sought surgery earlier. 598 (19%) had no transport, 501 (16%) were unaware of the operation, 417 (13%) were satisfied with their vision, 398 (13%) could not spare time from their work, 312 (10%) could not afford to travel, 318 (10%) were afraid of surgery, 247 (8%) were waiting for cataract to mature, 268 (9%) had no facilities for surgery, and 43 (1 38%) did not know that cataract was curable. Patients need to be made aware that cataract can be operated on at an early stage with intraocular lens implantation. Mobile eye camps are needed to provide cataract surgery free of charge in all areas. In this study 63% of people with blindness due to cataract were women. In India men are the main wage earners and are considered as the priority for health care. Social environment is regarded as an important factor in awareness and the decision to seek surgery for cataract.4 Patients in developing countries are faced not only with the difficulties of accessibility and cost of eye care facilities but also availability of technology acceptable to their culture.5 Apart from the lack of ophthalmic specialists, which seems a key factor, we are faced with the need to convince patients that they will indeed benefit from surgery. We need not only to increase the number of ophthalmologists but also to identify the real obstacles and pay more attention to the delivery of appropriate services.5 accounts
I thank all their help.
Jagat Ram Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
Program for control of Blindness in India. Report of national workshop. Director General Health Services: New Delhi, Ministry of Health and Family Welfare, Nirman Bhawan, 1989: 1-55. 2 Minassian DC, Mehra V. 3·8 million blinded by cataract each year: projection from the first epidemiological study of increase of cataract blindness in India. Br J Ophthalmol 1990; 74: 341-43. 3 Available data on blindness (update 1987). Geneva: World Health 1
SiR-You are to be congratulated on your editorial on medical education. You emphasise the importance of refocusing undergraduate medical education to equip doctors with core skills-notably an understanding of people, the ability to communicate sensitively with patients with various problems and backgrounds, and the ability to make clinical decisions on the basis of high quality
reasoning. We strongly support your view that merely moving education out of hospitals is not in itself enough and what is required is teaching by multiprofessional primary care teams who can demonstrate the principles of sociology, communication theory, and psychology in their day-to-day care of patients who are living in their homes and in community institutions. It is good to see you underlining the importance of the family, but the only effective way of teaching this is to show students the impact of illness on the person and on the family, by those who care for whole family groups simultaneously. Denis Pereira Gray, Russell Steel, Keiran Sweeney, Philip Evans Institute of General Practice, Exeter EX2 5DW, UK
1228
Postgraduate
Medical School, Barrack Road
ophthalmologists, doctors, paramedics, and social workers for
4
5
National
Organization (WHO/pbl/87.14). 1987: 23. Brilliant GE, Lepkowski JM, Zurita B, Thulsiraj MBA. Social determinants of cataract surgery utilization in South India. Arch Ophthalmol 1991; 109: 584-89. Sommer A. Organizing to prevent third world blindness. Am J Ophthalmol 1989; 107: 444-46.
Dwindling donor aid for health programmes in developing countries SIR-In her Feb 12 commentary LaFond correctly points out the increasing difficulties faced by aid agencies investing in health in poor countries and draws attention to the confused and frequently inadequate responses of donors to the continuing shortcomings of health care delivery systems. There is a second dimension, however, to this issue, which
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McCrorie P, Lefford F, Perrin F. Medical undergraduate community based teaching: a survey for ASME on current and proposed teaching in the community and in general practice in UK universities. Association for the Study of Medical Education occasional publication no 3. London: ASME, 1993. Illife S. All that is solid melts into air-the implications of community based undergraduate education. Br J Gen Pract 1992; 42: 390-93. General Medical Council. Tomorrow’s doctors: recommendations on undergraduate medical education. London: GMC, 1993.
Cataract blindness in India SIR-There are 12 million blind people in India and cataract for 81% of blindness.1 At present, the 84 million Indian people with blindness due to cataract constitute half of the world totaJ.1 Between 22 and 38 million new cases are estimated to arise each year in India.1.2 At two large annual eye camps held in Beas, Punjab, India, a total of 10 720 patients attending for cataract surgery were examined by 32 ophthalmologists. The criterion for blindness was visual acuity of 3/60 or less in the better eye.3 Of 10 720 patients aged 41-96 years, 4218 (39 % ) were blind-3102 (74%) (1939 women and 1163 men) had bilateral cataract and 1116 had cataract in one eye. In these 1116 patients, 418 (10%) had corneal disease, 344 (8%) glaucoma, 52 (1%) complications of intraocular lens, and 302 (7%) phthisis bulbi and miscellaneous in the contralateral eye. Patients were asked why they had not sought surgery earlier. 598 (19%) had no transport, 501 (16%) were unaware of the operation, 417 (13%) were satisfied with their vision, 398 (13%) could not spare time from their work, 312 (10%) could not afford to travel, 318 (10%) were afraid of surgery, 247 (8%) were waiting for cataract to mature, 268 (9%) had no facilities for surgery, and 43 (1 38%) did not know that cataract was curable. Patients need to be made aware that cataract can be operated on at an early stage with intraocular lens implantation. Mobile eye camps are needed to provide cataract surgery free of charge in all areas. In this study 63% of people with blindness due to cataract were women. In India men are the main wage earners and are considered as the priority for health care. Social environment is regarded as an important factor in awareness and the decision to seek surgery for cataract.4 Patients in developing countries are faced not only with the difficulties of accessibility and cost of eye care facilities but also availability of technology acceptable to their culture.5 Apart from the lack of ophthalmic specialists, which seems a key factor, we are faced with the need to convince patients that they will indeed benefit from surgery. We need not only to increase the number of ophthalmologists but also to identify the real obstacles and pay more attention to the delivery of appropriate services.5 accounts
I thank all their help.
Jagat Ram Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
Program for control of Blindness in India. Report of national workshop. Director General Health Services: New Delhi, Ministry of Health and Family Welfare, Nirman Bhawan, 1989: 1-55. 2 Minassian DC, Mehra V. 3·8 million blinded by cataract each year: projection from the first epidemiological study of increase of cataract blindness in India. Br J Ophthalmol 1990; 74: 341-43. 3 Available data on blindness (update 1987). Geneva: World Health 1
SiR-You are to be congratulated on your editorial on medical education. You emphasise the importance of refocusing undergraduate medical education to equip doctors with core skills-notably an understanding of people, the ability to communicate sensitively with patients with various problems and backgrounds, and the ability to make clinical decisions on the basis of high quality
reasoning. We strongly support your view that merely moving education out of hospitals is not in itself enough and what is required is teaching by multiprofessional primary care teams who can demonstrate the principles of sociology, communication theory, and psychology in their day-to-day care of patients who are living in their homes and in community institutions. It is good to see you underlining the importance of the family, but the only effective way of teaching this is to show students the impact of illness on the person and on the family, by those who care for whole family groups simultaneously. Denis Pereira Gray, Russell Steel, Keiran Sweeney, Philip Evans Institute of General Practice, Exeter EX2 5DW, UK
1228
Postgraduate
Medical School, Barrack Road
ophthalmologists, doctors, paramedics, and social workers for
4
5
National
Organization (WHO/pbl/87.14). 1987: 23. Brilliant GE, Lepkowski JM, Zurita B, Thulsiraj MBA. Social determinants of cataract surgery utilization in South India. Arch Ophthalmol 1991; 109: 584-89. Sommer A. Organizing to prevent third world blindness. Am J Ophthalmol 1989; 107: 444-46.
Dwindling donor aid for health programmes in developing countries SIR-In her Feb 12 commentary LaFond correctly points out the increasing difficulties faced by aid agencies investing in health in poor countries and draws attention to the confused and frequently inadequate responses of donors to the continuing shortcomings of health care delivery systems. There is a second dimension, however, to this issue, which