It took just 15 minutes for the surgeon to restore Katrina Makatees’s quality of life. “I almost fell asleep in there!” the 82-year-old jokes, while the surgeon who has just removed her cataract turns to the next patient at a public hospital in Upington in South Africa’s Northern Cape province.
Medical charities have organised an “eye clinic week” in the town and patients fill every seat along the corridors. For some here, this might be a chance to regain their sight. For others it might mean at least a diagnosis even if they cannot be cured.
South Africa’s last census on disabilities, conducted in 2011, found that 11% of the population had “seeing difficulties”, with more than 700,000 people saying they had severe problems.
Numbers are predicted to swell in the coming years, due in part to an ageing population and changes in lifestyle driving a diabetes epidemic and a surge of related eye complications. These will be non-communicable diseases of the back of the eye: diabetic retinopathy, glaucoma and macular degeneration. Rates of these are high and rising.
Cataracts – a clouding of the eye lens – are easily treated with surgery. Yet it remains the leading cause of blindness in low and middle-income countries. In total, the World Health Organization (WHO) estimates that 2.2 billion people have impaired vision and, for at least 1 billion of these, it could be prevented or treated. In Northern Cape, South Africa’s largest province, only one public hospital offers the routine operation.
“Many patients are dying blind while on the waiting list,” says Dr Jonathan Pons, who runs an eye clinic in neighbouring Eswatini, (formerly Swaziland) and flies to Upington three times a year to conduct surgeries as part of an outreach project by the charity Kalahari Wings.
Despite having an eye-surgery theatre, Upington hospital does not have a regular ophthalmologist. Helped by volunteer health workers and local nurses, Pons operates on almost 100 people on his four-day visits. Not everyone will have their sight restored.
“Today we had a patient, Johannes,” says Pons. “A healthcare practitioner sent him to the hospital for the surgery which was going to cure everything, who thought this would be the answer. But when I examined him, he didn’t have a cataract. There are other causes of blindness. Especially in young people, young Africans, we have a very high incidence of severe glaucoma, much higher than in other parts of the world.”
“In South Africa in particular people are ageing against expectations as HIV has been managed well, and in general [globally] living conditions are improving and people are living longer. And at the same time non-communicable diseases like diabetes, hypertension are on the rise. So those two factors account for a lot of the blindness and eye conditions: one would be cataract and the other would be diabetic retina problems. It has been difficult for the universities to react and to train enough specialists to meet this need. And to recruit them for the public health system, not for private health.”
“It was like a haze before my eyes,” Makatees says about when her eyesight started to decline rapidly in December. “I used to bake my own bread, sew, read, fill in crosswords … But the cataract took everything away from me.”
Private clinics were unaffordable: operating on one eye costs at least 25,000 rand (£1,000) – 10 times her monthly state pension. Makatees says she felt increasingly isolated at her home on a rocky hill on the outskirts of Springbok, a town nearly 250 miles (400km) from Upington.
She was referred, along with 20 other people with eye problems from the town, earlier this year by an optometrist, Tharien Schoeman, with the operation paid for through Schoeman’s charity Caring4Sight.
Otherwise Makatees’s name would have been added to the 3,000-plus waiting list for surgery at Kimberley hospital in the provincial capital, almost 500 miles from Springbok – the hospital has one eye surgeon.
“The Northern Cape is a rural province, and we struggle to attract specialists to come work in the public sector,” says Dr Esmé Olivier, chief executive of Kimberley hospital. Due to a shortage of trained nurses, only half of the clinic’s theatre capacity can be used. “It is a human resource crisis,” she says.
Her hospital is focused on the rising problem numbers of NCD eye conditions.
“We need to deal with all the other ophthalmic diseases: all our retinal problems, diabetic diseases of the eyes, glaucoma … So our numbers for cataract surgeries are very low in our facility, because we need to deal with secondary and tertiary care<” says Olivier.
“The majority of our patients come in at a late stage for glaucoma or diabetic eye disease. Our services out there are not optimal, the lack of optometrists to pick up these high pressures in the eye is definitely a concern in our province. Either they get diagnosed late, or because of lack of funds, transport with the distances of the Northern Cape,” she says.
“We are always worried (the numbers) are going to get worse.”
In 2000, South Africa joined the WHO’s programme to eliminate avoidable blindness globally within 20 years. But it has not managed to meet just its recommended annual cataract surgery rate of 2,000 operations for every one million people and, since 2019, no new national eye-care coordinator has been appointed. Covid only added to the backlogs.
Schoeman adds: “People have no hope of reaching the top of the list. I have 270 people on my own list in Springbok, and it grows every day.”
The next morning at Upington hospital, the corridors echo with joyous exclamations as patients remove their eye patches. “I can read again,” exclaims Makatees, squinting at her medical file.
Before a row of astonished bystanders, most of them her neighbours, Cecilia Bock, 39, stands up and walks down the corridor. Bock had entered the hospital clinging to her mother’s arm. She had had poor eyesight since she was 16 and became fully blind last year.
The post-operative assessments show she should now have at least one metre of vision. “She’s walking,” whisper the onlookers, as silent tears stream down her face.
The eyesight of Johannes Cloete, a 38-year-old from Springbok, began to fail last year and he had to stop work. He was hoping to have cataract surgery but the tests show his eyesight is failing because he has glaucoma.
This degenerative condition is particularly prevalent and aggressive among people of African descent. “If it had been picked up 10 years ago, he would have had treatment or surgery.
“But he is now at the end stage, the nerve is completely destroyed. It is not treatable,” says Pons. Eye drops can only delay “inevitable blindness”.
“His case speaks to the challenges of providing primary healthcare to such a dispersed population,” says the surgeon. “People fall through the cracks in these remote places.”
Schoeman adds: “It feels like we all failed him. Why does someone actually have to go blind from a preventable illness? It shouldn’t happen, not in this day and age.”
Cloete sits on his mattress on the hospital floor, staring straight ahead. In a few hours, he will board his bus for the long journey back home, with only a bottle of eye drops.
As he hears the rejoicing in the corridor, he puts a brave face on the devastating news he has received: “Last night, I dreamed I could see again. It was beautiful.”
