Aeesha NJ Malik is a consultant ophthalmic surgeon at the International Centre for Eye Health based at the London School of Hygiene and Medicine (LSHTM). She is on a mission to improve the eye care of children across the globe, working alongside agencies like the UNICEF and WHO. It mainly includes training primary healthcare workers in eye care for children and improving eyecare services for premature babies. Currently, she is leading a project in Tanzania and it is part of a global programme of a few UN agencies.
Excerpts from an interview:
You are leading a global network to prevent premature babies from going blind from Retinopathy of Prematurity (ROP) in Africa and Asia. Is India a part of it?
Yes, India is included but as a mentor to many of the African and other Asian countries. India has several centres of excellence with doctors with a lot of experience in dealing with ROP, while it also has its own problems on dealing with ROP. This means that Indian doctors have both the expertise and experience required to train doctors in Africa and other low-income countries and this is what they have been doing. This is a great example of how we work – often we use South-South partnerships (of developing countries) to go where the expertise is. Also doctors from other developing countries often have a greater understanding of the challenges faced by their colleagues around the world, rather than those from high-income countries.
In another programme, a colleague has been working in India with policy makers and experts to improve regional programmes and develop national guidelines. The situation in India is that in public and rural hospitals there is still much to be done in terms of improving neonatal care and ROP care - and these are linked. The lower the standard of neonatal care the more the numbers of children with ROP. One of the main reasons that there is so little ROP in the UK and the US is that the standards of neonatal care are very high there and several preventative measures are taken. So our team is working in India to improve ROP care nationally as well.
(ROP is an eye disease that can afflict premature babies.)
What is the current project you have taken up in Tanzania?
The project in Tanzania involves training primary healthcare workers in eye care for children. This is part of a WHO/UNICEF global programme which is implemented in over 100 countries. This programme currently trains child health workers on how to deal with all the main childhood illnesses, but not eye conditions. What we have done in Tanzania is develop a training module on eye care which can be used to train the child health workers and this is part of the WHO/UNICEF programme. This is the first time this has been done.
I work at the LSHTM but we have worked with the Ministry of Health (MoH) in Tanzania to develop the programme and they have ownership of the module and will be the ones using it for training. Our next step is to get evidence from Tanzania on the impact of the work. We have already started discussions with WHO to include this in their global childhood programmes.
What is the kind of childcare policy that you would suggest for a country like India?
That is a significant question! I can only answer in terms of eye care for children. I strongly believe eye care for children needs to be part of child health programmes. It is very important that primary health workers are trained in screening and recognising eye diseases as these are the health workers who will see the children first.
Early diagnosis is absolutely vital in children because if they present late, they may never be able to see properly even if they are treated. This is because early childhood is a critical period in the development of vision - and a child needs to be able to see in order for its vision develop normally. Primary health workers must be able to screen and diagnose the most basic and important eye conditions and then know where to send the children for specialist help. There needs to be support for children and families at every step with a lot of clear information and communication in their local language, otherwise many poorer families may not bring their children to hospitals due to lack of money or mistaken beliefs.
When looking at comprehensive eye care for children then every level from primary care, secondary care to tertiary/specialist care needs to be addressed for there to be an effective health system which prevents children going avoidably blind.
In a country like India where atrocities against children are on the rise, do you believe they have a direct link with child health?
This is a very tragic state of affairs. Of course, this has huge impact on children's emotional, mental and physical health and development. Any kind of trauma in childhood has a long-lasting effect on that child and people around him or her. It is one of the greatest human wrongs to commit atrocities against children who are one of the most vulnerable groups in our society, and we must do all we can to protect them in every way.
What is the Tanzanian model of integrating eye care into the child health programme?
In 1995 WHO and UNICEF jointly launched the global programme - the Integrated Management of Childhood Illness (IMCI) - which later expanded to include neonates and was renamed (IMNCI). This is now established in over 100 countries and a recent review by WHO pointed to its success while advocating further integration with other child programmes. This is a modular programme which includes ears but does not include eyes. We decided to develop an eye module and a training programme which could be included and use them to train primary child health workers. This process began in May 2017 in Tanzania when we first formed a steering committee with the Tanzanian MoH, WHO, UNICEF and active NGOs in the country.
We started in Tanzania since a local ophthalmology leader had been working with our team since 2007, having done both a pilot study and formative research on child eye health care. When we presented our local research results and our aims, the MoH was immediately very supportive. They had considered this previously, but this time the timing was right with the expansion of their IMCI services and training.
Importantly, countries have some local control with what they can include in their IMCI programmes and how they can adapt them. The MoH agreed to work with us to develop the module and pilot test it. Thus over the last year we have been working together and pilot tested the module earlier this year in real-life conditions during a routine MoH training.
We have faced a number of challenges with funding when we changed to testing in real-life conditions, working to the MoH schedule and also when we had to produce more training materials such as videos which we initially had not anticipated. However, all these efforts became worthwhile when the MoH agreed to include our module after the national IMCI review meeting in May 2018.
From now on all IMNCI training which is done in Tanzania will include eye care. Since May this year, 1,700 staff delivering IMNCI have, or are being trained in 6 districts in 3 regions across Tanzania. According to MoH data these child health workers will see on average 5,800,000 children per year, who will now benefit from prevention and treatment of eye conditions.
Potentially, 246,500 children with eye problems will directly benefit annually from diagnosis and treatment, of which potentially 4,930 children with serious eye problems will be detected early enough to be treated.
How successful was the programme in Tanzania so that it could be adopted globally?
We have successfully developed the module with the Tanzanian MoH and they have successfully included it in their programme nationally. They now have ownership and responsibility for delivering this programme across the whole country. They have already successfully trained approximately 2,000 primary healthcare workers. Therefore, we know that it is practically possible and can be adopted globally right now. However, since this is the first time this is being done we are planning to do a more detailed evaluation to look at the impact it is having on eye care for children.
What motivated you to take to the field of child health and work in low-income countries?
Since I was a child myself I wanted to work in low-income countries and with children. I was born and brought up in a small village in Scotland where we were one of the few immigrant families. I always had a sense of the difference in opportunities for children depending on where they happen to be born in the world. This was confirmed when I went to medical school and started working in medical projects all over the world.
During medical school I volunteered in medical projects in remote areas in Pakistan, the Amazon in Venezuela and Brazil, Tanzania, and Thailand. I saw first hand there how children were living and the lack of healthcare. In a remote area of rural Venezuela I saw how a child was living in a basic hut with no sanitation or electricity. We would travel to their villages and set up makeshift clinics under trees in the centre of the village where we would weigh the children and give vaccinations.
Any child developing serious eye problem like cataract would have little chance in a place like that. Immediately after my stay in Venezuela I went to the central Amazon basin in Brazil and saw for the first time the WHO/UNICEF programme, which I am currently working on, in action. I saw how it was transforming care for children in these rural and remote areas and it made a big impact on me to see both the problems and the difference a good solution can make. Ever since then I knew I would work in child health in low-income countries.
As an expert in public health, what according to you is an ideal society for healthy child healthcare?
I think one that addresses all aspects of childcare covering everything from educating and empowering parents and children, to screening, prevention, and excellent hospital services with equal access. Good nutrition, immunisations and hygiene have transformed high-income countries and these are still some of the highest impact interventions for child health. However, you also need modern neonatal care with high-quality equipment and the latest evidence-based interventions. All these aspects of child healthcare are very different but all these have an important part to play in ensuring all children have the best possible vision and prevent avoidable blindness.
Could you please elaborate on your work? Where could you see unexpected positive changes by the locals?
I always work with local doctors, nurses, policymakers as well as parents and children. Healthcare can only improve when the local staff and patients take its ownership and are responsible for the programme.
I have been really impressed by the changes noticed in Tanzania. We have been working with its Health Ministry from the beginning and they were extremely positive about including eye care. They arranged the design of the module and training and launched it nationally. This was totally unexpected but very welcome! We hope all other countries will embrace it in the way they (Tanzania) have.
How optimistic are you in making the low-income countries a healthy land for children? And why?
I am always very optimistic as we have the knowledge of what is needed and many interventions are basic and easy to do. I believe and have seen that people do have the will to change and it is incredible what can be achieved when we work together for the common goal to improve eye health for children. I am reminded of the saying: “Never doubt that a small group of committed individuals can change the world, indeed it is the only thing that has”.
Dr Malik would like to thank her funders for these projects, BCPB, CBM and the Queen Elizabeth Diamond Jubilee Trust. She is currently looking for further funding and partners in continuing and expanding her work. Please follow and contact her through:
Insta: @globaleyedoc
Twitter: @aeeshamalik
Email: aeesha.malik@lshtm.ac.uk