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Volume 35, Number 5September/October 1984

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An Eye on Vision

Written by Arthur Clark
Photographed by Mohammed S. Alshabeeb
Additional photographs by Wayne Imbrescia

Boasting four-wheel drive vans instead of camels and computers rather than saddlebags, and carrying a team of 43 dedicated professionals, a one-of-a-kind, 15-vehicle "caravan" rolled out of Riyadh early this year on a 9,600-kilometer journey (5,965 miles) that wound through villages, encampments and cities throughout Saudi Arabia on a mission of mercy: the groundwork for an upcoming kingdomwide campaign against sight-destroying illnesses.

The caravan - dispatched from the new King Khalid Eye Specialist Hospital (KKESH) in Riyadh on February 11 - returned some 15 weeks later packed with enough data, some experts think, to eradicate blindness in the kingdom.

From the start, the survey team had set their sights high. Doctors teamed up with ophthalmic technicians, nurses and microcomputer-toting "registrar-interpreters" - to interview and examine 16,800 Saudis, including 2,500 Bedouins, in their cross-country effort. And even before data analysis got under way at KKESH late in May, they had begun to revise some eye-health myths and had made some still unannounced discoveries: that the contact-virus trachoma, which can cause blindness if untreated, is not nearly as prevalent as expected and is "disappearing as an entire disease," and that the Bedouins, thought by medical men to be bothered most by eye problems among the country's population sectors, have better, not worse, eye health than counterparts in villages and cities.

The KKESH survey was designed to determine how much visual loss and blindness there were throughout the kingdom - and what the causes are - said coordinator Dennis Ross-Degnan of the Maryland-based International Eye Foundation (IEF) which assisted the joint Saudi Ministry of Health-KKESH project. But in addition to survey work, said the Harvard-trained scientist, ophthalmologists also examined and treated individuals who asked for advice about eye problems along the caravan's routes - even effecting some "instant cures." The survey was also developed to trace the incidence of sight loss in particular geographic and demographic sectors in the country, and to establish ways of providing, in the field, fast clinical and microbiological assessment of the intensity of communicable eye disease.

Such comprehensive surveys are recommended by the World Health Organization (WHO) for countrywide programs to prevent blindness - and are one more example of the kingdom's systematic efforts to provide modern health care from border to border.

The survey was meant to "sample areas, not people," said Ross-Degnan at the survey's conclusion. Though that might sound like an odd formula for covering a country like Saudi Arabia, it most decidedly was not. Routed through all five of the kingdom's major geographical regions (excluding, of course, the population-sparse "Empty Quarter"), the team made 16 main stops, fanning out in groups to randomly selected households, where they took down medical histories, measured visual acuity and then gave complete eye examinations - in some cases with instant diagnoses.

The expedition "covered the length and breadth of the kingdom... from Jiddah on the Red Sea to Dammam on the Gulf, all along the border in the north, to Abha and Jaizan in the south," as Ross-Degnan described it. This was no small achievement for a caravan that included eight vans towing six-person sleeping trailers, a mobile pharmacy and a water truck and two refrigerator trucks, plus a flatbed truck for carrying gear and a pickup truck used by mechanics.

KKESH served as the survey's staging base. Named after the late King Khalid, the facility was opened as a referral center in December 1982 and officially inaugurated by King Fahd in November last year. With a 44-doctor staff, including 30 ophthalmologists, 12 camera-equipped operating rooms, a cornea eye bank and 263 beds, KKESH is described by Medical Director Dr. David Paton as "unequivocally the largest modern eye hospital in the world." Quite simply, it is the centerpiece of the kingdom's eye-health strategy.

The survey was the first major project of the eye center's research department whose director, Dr. Khalid Tabbara, worked with Ross-Degnan to design the eye-inspection program. KKESH Deputy Medical Director Dr. Ihsan Badr, who has served as head of the ophthalmology department at King Sa'ud University in Riyadh, was instrumental in implementing the survey. Both Paton and Tabbara are at KKESH on leave from medical faculties in the United States: Paton from Houston's Baylor College of Medicine and Tabbara from the University of California, San Francisco, Procter Foundation.

"We're able to offer the top of the line in respect to eye-disease treatment," said Paton this spring as he adjusted a TV in his office so that the picture from a nearby operating room zeroed in - via microscope - on a cataract operation. "I don't think there is any other developing country that can make that statement."

Already, the eye center has had wide impact. "In the past, hundreds and hundreds of Saudis were sent to Europe and the United States for eye care at high cost... and there was not always adequate follow-up here," said Paton, noting that Saudis qualify for free eye care from the government. "Now, no more go out for eye care at government expense unless there is a decision from here. And that hasn't happened yet."

In a sketch of the eye survey prepared at its outset, Ross-Degnan attributed many of the eye ailments that do develop in the kingdom to such regional factors as "the lack of availability of water, the harsh glare of the desert sun, the high level of atmospheric dust and, until recently, the lack of easy access to either curative or preventive medical care." He added in the post-survey interview, "as a rule of thumb, 60 to 70 percent of blindness that results is preventable. We'll be able to make a big dent in that in a short time if we're able to concentrate on the population where the high risks exist."

Ross-Degnan's claim will be quickly tested. According to Paton, KKESH plans to start "appointing and rotating staff in remote areas" as soon as the analysis of survey data has pinpointed the "high-risk" areas, and after eye-care facilities are measured kingdom wide. In addition, the eye center was to have started an ophthalmology residency program this September in cooperation with King Sa'ud University. "Within a decade we should be able to produce all of the ophthalmologists we need in the kingdom," said the medical director. "What is needed are super diagnosticians, super surgical technicians and people skilled in the area of preventive medicine. We're developing our program to play to the strengths we need."

Interlinked to the teaching program and coupled to the eye-disease survey is hospital research. Research will be "most relevant to the kinds of eye problems in the kingdom - problem-based clinical research," said Paton, though in fact dramatic results from the survey have already outrun implementation of KKESH plans.

Ahmed Tuwaijri, a 28-year-old University of Chicago graduate from Riyadh who served as eye survey administrator, put his finger on one key reason why. "In the field," he said, "people would know you could cure their eyes." And though survey team members weren't there to dispense service, according to original plans, they found out early on that their aid could come in handy. As a result, they set "office hours" every morning from 6:30 to 8:30 to examine walk-in patients.

One of those patients was a 45-year-old man whose sight in one eye was nearly gone. The diagnosis: a membrane crossed the pupil of the eye, constricting it and severely reducing vision. The examining doctor studied the problem and then effected what must have seemed like a miracle.

"The doctor put a lot of dilating medicine in the eye and the patient sat down and waited," said Ross-Degnan. "Then the membrane broke. It was like an instant cure."

Five ophthalmologists, six ophthalmic technicians, six nurses and eight registrar-interpreters were with the survey team at any one time. Doctors from KKESH, the ministry of health and the IEF participated in the survey. Professional staff got one week off after five on the job and three of the five ophthalmologists were rotated in and out of the field, making for a total survey census of 82.

Demonstrating faith in the team's ability to treat eye maladies, individuals would sometimes walk long distances to the camp. In one such case in the Bishah area in the southwest, a patient's illness was diagnosed as glaucoma, a disease in which increased pressure on the eyeball results in progressive loss of sight. Referred to KKESH, the man was given a lift into Bishah 100 kilometers away (62 miles) to get the papers required to travel free to and from treatment at the eye center. "It was an acute case," recalled Ross-Degnan. "He had already lost some vision. He would have been blind if he'd waited Longer".

In all, more than 150 people were referred to KKESH for complicated surgery, said the coordinator, and in one case, round-trip air fare and a $60-a-day stipend were provided for one family member to accompany a patient.

As to the unexpected discovery that the Bedouin population had a lower incidence of eye disease than either village or city dwellers, Ross-Degnan ventured a couple of theories he thought might explain the situation. One was "survival of the fittest in the desert," resulting in a population with stronger eyes over generations. The second was based on what he viewed as a healthy lifestyle: "The Bedouins are less crowded than people in more urban settings, and hygiene is less of a problem; they have a healthy diet and are an overall healthy people."

The survey also showed that the once-prevalent disease trachoma is not the menace it used to be. An illness that strikes in conditions of crowding, poor hygiene and poor sanitation, "trachoma does still occur and is still a problem, but not the overwhelming problem people thought it would be," Ross-Degnan said. "It's really disappearing ... due to the nation's development and clean water supplies."

To reach such conclusions, the survey targeted households headed by Saudis in 20 regions throughout the kingdom. Survey administrators picked 50-household segments for coverage in each of three demographic zones in each region: cities with populations between 10,000 and 30,000, towns of 1,000 to 10,000 populations, and communities of less than 1,000 persons. Eleven cities with more than 30,000 residents were also included, but survey leaders, judging that cities of that size seemed similar throughout in factors indicating eye disease, did not subdivide them. The two largest cities - Jiddah and Riyadh - were allotted three 50-household segments each, Makkah (Mecca) two and the remainder one apiece.

Lists of residents, starting with the head of the house, in the randomly selected household segments were drawn up, and from a base of 220 names in each segment, the survey team worked through the list trying to derive a statistically true reading of eye illness and blindness in the overall population.

The survey was modified in two areas. In non-metropolitan regions of the Eastern Province, the kingdom's oil-producing heartland, "there were not that many people relative to other areas," explained Ross-Degnan. "Thus we had to over-compensate on the sample."

The Bedouins also proved to be a special case. "There was no conceivable way without considerable expense and time to get any true probability sample of the Bedouins," said the coordinator. "There was no way of defining the areas they lived in." So the survey team examined every Bedouin encountered.

"We'd go out into the desert with guides who could tell us where Bedouin encampments were and just stop at a group of tents and examine everybody we could find," said Ross-Degnan. "We always approached the Bedouins with someone from the local community whom they knew. The Bedouins are fabulous people, extremely traditional and very hospitable and courteous. Many times they would kill a goat or sheep and cook rice and just share their hospitality."

Indeed, the survey seemed to have had as profound an effect on some of the team members as it did on the Saudis they met on the road.

"Actually, I could tell you every inch of this country now," said Tuwaijri, the young administrator who was the team's main go-between with local authorities. "But I had never seen and never would have seen most of the territory we covered without the survey."

High points of his trip, he said, were to spend "days and days in the field, to live with the Bedouins, to eat with the people. To walk into hundreds of houses. To see different traditions from those in my home Central Province, the Najd. It gave me a unique opportunity to know my people. People would see you for 30 minutes, invite you for dinner, butcher a lamb for you... and talk to you as if they knew you for years and years."

Notably, the survey was the first of its kind ever done using minicomputers in the field to speed accurate data collection. By using them, the leaders in the field cut survey time by months.

For Saudi Arabia the high point of the great caravan was its precious cargo: the hope of clear vision.

Arthur Clark is an Aramco World writer stationed in Dhahran.

This article appeared on pages 8-15 of the September/October 1984 print edition of Saudi Aramco World.


Check the Public Affairs Digital Image Archive for September/October 1984 images.