NORWICH, United Kingdom — The health system in Sudan is fragile with many families having inadequate access to health facilities. Roughly 30% of the population lives further than a 30-minute commute to the nearest health facility, according to UNICEF. In an interview with The Borgen Project, consultant ophthalmologist, Mr. Porooshani, discusses a medical expedition that he led to Kassala State in Eastern Sudan in February 2023. During his time there, Mr. Porooshani provided ophthalmic health care in Sudan in the form of clinic services and surgeries along with the education of local medical students and health care professionals.
Tell us more about your recent trip to Kassala State, Sudan.
“I was invited by a Sudanese doctor’s group, which is a U.K.-Sudan alliance. They acquired a visa for me, arranged my permit to practice medicine and told me to bring what I think is necessary. I was accompanied by a colleague of mine with a lot more experience in such visits as well as a trainee ophthalmologist from Khartoum (the capital of Sudan). So, we had a small team.
I took with me about three suitcases of materials, either disposable materials or surgical materials or eye drops. I also took with me teaching material as we were going to be both teaching and training doctors and seeing patients in clinics. I also took a number of low-cost, solar-powered ophthalmoscopes to teach the students to use. I thought that if I was able to teach the medical students to use it, that would be a step forward.
I also had instruments I was able to use in the clinics. But I have to say that the situation in terms of what we found in the clinics and surgical aspects of the work was obviously very different from what I’m used to.”
In Kassala State, roughly 1.8 million people rely on the medical services of Kassala Teaching Hospital, UNOPS reported in 2022.
How did the provision of ophthalmic health care in Sudan compare to the U.K.?
“The university hospital, which was the teaching hospital, in the center of town and the only free for all hospital, was in a dire state. Simple hygienic facilities for patients or for staff weren’t available. There were shortages of almost everything at any point, both from staff to equipment and disposables. They had to reuse disposable gloves between cases. Sometimes they had to share material between patients, which is why they screen patients for HIV, hepatitis B and hepatitis C before taking them to theatre, as they knew they were going to share some of the more valuable materials.
The government health care sector was deprived and neglected, but there was certainly no shortage of patients. On the other hand, much better medical facilities existed in the private sector but patients had to fund themselves to access them.”
In the most rural areas of Sudan, health care provision can drop to as low as one hospital per 400,000 people. In these areas, non-governmental organizations are the main providers of health services, according to a World Health Organization document published in 2009.
With the support of the WHO, the hospital in Kassala is able to provide urgent treatment to patients free of charge. However, if the patient requires care beyond the first 24 hours after admission, families must find a way to pay for these services.
What did this mean for people who need ophthalmic health care in Sudan?
“Research has been conducted on the burden of cataracts in East Sudan — about 7% of people who are older than 50 [years]are blind and 50% of that is due to cataracts. So, cataract surgery is an effective intervention if you want to [reduce]blindness in low- and middle-income countries. Giving the gift of sight back to those people through a small surgery.
The research also shows that the main burden for people not accessing cataract surgery is unaffordability. So the vast majority of the population can’t afford the cataract surgery. They become unable to work and unable to feed themselves, and their dependents. Especially in rural areas with fewer facilities than in the major towns and cities.”
The U.N. identified Kassala to be in a state of economic crisis in 2020. The economic crisis gives rise to a multitude of problems within the health care system. “More than 400,000 people suffer crisis levels of food insecurity and many cannot afford to buy the medicines they need when they fall ill,” the U.N. reported.
In rural communities, only 13% of the population has access to safe and clean water, which proliferates outbreaks of diseases such as dengue fever and cholera.
“The growth of the private health service was directly linked to the poor service provision in the government sector. The government facilities were unable to attract staff or expertise to even use equipment that was donated to them.
For example, laser machines for the treatment of diabetic retinopathy were donated a few years back but had not been used. When we were there, we cleaned them up and started using them, but this obviously isn’t a long-term solution. They need to encourage or employ ophthalmologists from the private sector to run this service for them.”
As part of a 25-year plan, the Sudanese government is working to reform the health care system in Sudan by 2027. The plan aims to reduce the disease burden and develop and retain human resources.
The ophthalmoscope that you mentioned earlier is a really interesting innovation. Could you elaborate on that?
“The ArcLight ophthalmoscope is made by a group at Saint Andrews University. I was able to buy my own for £60 and I donated another £60 and was gifted six to take with me. The unit in Saint Andrews also sells them in bulk, so you can buy them for maybe £8 per device if you buy 25 or more of them. The average [traditional]ophthalmoscope is £200.
The ArcLight has got two ends, one you can use to see the back of the eye and the other to see the front of the eye. It also has a connector so it can become an otoscope [visualizes the ear canal]as well. I just hung it around my neck because it’s charged by the sun. I taught a group of medical students how to use it and donated to them.
I would consider projects like the development of ArcLight a solution. A small step but very effective.”
The ArcLight is a portable ophthalmoscope, ideal for low-resource settings. The solar-powered charging capability means that a few hours in the sun can power the device for between one and seven days, making it an ideal tool for advancing ophthalmic health care in Sudan.
What impact did the teaching aspect of the trip have on the local medical students?
“I had feedback from the medical students that they enjoyed the teachings and my interactions with them. And I enjoyed my time with the medical students. I’m still in contact with them and they send me questions they have about ophthalmology. One thing to say is that they all had a mobile phone device and loved using it. So, it is a very well-connected country.”
Do you have any plans for similar work in the future?
“Yes. The answer is definitely yes [but]with a completely different worldview this time. I would work on building better communication with the local people and local health workers. I am sure I will both learn from them and teach them a few things.
In my view, all patients deserve to be treated with dignity and respect regardless of their citizenship, financial strength, religion, et cetera. It is something we can all globally achieve — the question is how? And I have been thinking about it.
I left Sudan but Sudan hasn’t left me.”
– Jess Steward