Sight-seeing in the Solomon Islands

To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program.

The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”.

Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs.

The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara.

Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams.

Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner.

Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.