Losing sight of the plight
Around 3.8 million Indonesians can’t read this or any other blog because they suffer from curable eye conditions. At least half are cataracts. The goal is to clear the problem by 2020. Yet just 11,000 free cataract operations for the poor were performed last year, mostly funded by overseas and local donors. Duncan Graham reports on an opaque problem.
Foreign doctors are not allowed to work in Indonesia. Permission is sometimes given for overseas specialists to make short training visits to the Republic, but that’s all.
There are only 1179 members of PERDAMI, the Indonesian Ophthalmologists’ Association. That’s a ratio of one eye surgeon to every 203,000 citizens. The World Health Organization recommends one to 20,000.
Blurring the problem is that most eye doctors work in the big cities, and not all are active. Few practise in the regions where the need is greatest.
Cataracts can strike anyone, but the rural poor who toil outside without using sunglasses are most vulnerable.
To get a cataract operation in Indonesia you need to be rich – or very poor and in the right place, like Bali, Medan or Malang. Here your surgery might be conducted by an Indonesian doctor paid by an aid agency or benevolent business. The system seems hit or miss, and that includes the subsidies .
The Indonesian Red Cross has allocated Rp 1 billion (US$104,000) for eye surgery for the poor through hospitals treating 500 patients.
However the Singapore-based A New Vision managed to get 625 operations and training programs run in Sumatra for US$75,000 (Rp 720 million). Effi Jono, the founder of the charity, raised the money from family and friends.
“We were greeted with protests and petitions (from local medical professionals) when we first tried to work in Medan,” said the Indonesian-born accountant.
“Thankfully we were allowed to go in and now have a much better relationship with the ophthalmologists of North Sumatra.
“Not allowing foreign doctors to work is a huge problem. Unless something changes it will take almost 40 years to clear the backlog of cataracts – provided no new cases are detected.”
In 1990 Australian potter turned aid activist John Fawcett raised funds to pioneer lens implant surgery in Bali. Since then his foundation has screened 750,000 people and treated more than 34,000 cataracts.
Malang’s largest private eye clinic employs eight ophthalmologists who also work in the public sector. Klinik Mata Malang charges upwards of Rp 7 million (US$730) per cataract for private patients, but discounts this to Rp 1.5 million (US$156) when altruistic companies sponsor operations for the poor.
“They must have a letter from their local community leader confirming they have no money,” said clinic spokeswoman Dr Seskoati.
“Personally I think we need overseas doctors to enhance our skills because the techniques and technology are changing so fast.”
The clinic’s two operation rooms look more like dentists’ surgeries than hospital theatres. The patient sits in a chair that tilts flat. Local anaesthetic is used and music to sooth. Dr Seskoati prefers the voice of Italian tenor Andrea Bocelli. He’s blind.
The Jakarta Post watched an operation on closed circuit TV conducted by four doctors, including two trainees. Using a powerful microscope the eye was sliced, probed, vacuumed and fitted with a new lens before three stitches were inserted. It took about 30 minutes.
Moments later the patient, second-hand goods dealer Nero, 64, (left, with his wife Luluk Hasana) was slumped on a sofa surrounded by family and friends, his right eye bandaged. His cataract had been growing for 20 years following a poke with a piece of wood.
He felt groggy, but said he was not in pain. The cost was met by a company that makes herbal remedies.
Nero should see clearly soon, but for a few days he won’t be able to pray by kneeling and pressing his head to the ground.
“The days of cataract surgery in hospitals needs to pass,” said John Fawcett (left). “Provided proper sterilization procedures are followed operations don’t require the massive and costly resources of a sophisticated hospital.
“Surgical day centers and mobile clinics are the way to go. A slow but acceptable rate for a surgeon is two cataract operations an hour.”
“I’ve been advocating change but hitting brick walls trying to get an audience with the health policy makers in Jakarta,” said Ms Jono. “The whole public health system is crumbling and it seems the bureaucrats aren’t interested.
“Sometimes I wonder whether we should be putting our money into countries where we’d be more welcome.”
If you blink your way off the street into a Singapore hospital seeking cataract surgery you’ll walk out with clearer vision but a lighter purse. Prices vary, but SGD$ 4000 (Rp 32 million) is average.
The costs are similar in Australasia where insurance companies often pick up the tab.
Yet overseas aid agencies appealing for donors claim just US$25 (Rp 240,000) will restore an Indonesian’s sight.
“That’s the cost of materials, the surgery is extra,” said Mr Fawcett. “If you look at the agencies’ ads closely they say donors can ‘help’ save an eye for US$25. The patient pays nothing, but the real cost is around US$50 for walk-in operations at a big city clinic like the one we have in Surabaya, or double that in isolated areas.”
These figures are skewed because the Fawcett rural clinics are supported by the Indonesian Air Force, which has been flying surgeons and equipment into remote areas at no cost.
It’s a similar situation in Medan where the hospital doesn’t charge for A New Vision’s theater use. Regencies have helped transport patients for free along with the Army, effectively using the military to subsidize treatments. Ms Jono said a general justified his troops’ involvement “because the army had two duties – to defend the nation and to help the poor.”
Even after including all these factors the gap between prices is enormous.
“Doctors like to drive Lexus,” said Ms Jono dryly. “This is a business – charges depend on demand and what the market can bear.”
“Not everyone thinks like that,” commented Dr Anny Sulistyowati (right), head of PERDAMI in the Malang region.
“We operate on the poor for very little. We tour the islands of Eastern Indonesia seeking patients. “I drive a Toyota Alphard.
“I studied for nine years and I’ve been a surgeon for 12. We never think in terms of getting a high return from our training – we’re not traders.”
She rejected allegations that PERDAMI had a quota system for graduates. “The problem is that only 12 universities teach ophthalmology and each takes around six per semester,” she said. “There aren’t enough lecturers or facilities, and few graduates want to be ophthalmologists.” Those that do are often women, attracted by regular hours because most work isn’t emergency.
Dr Sulistyowati said she had no issues with foreign doctors, or local general practitioners doing eye operations provided they were properly trained and registered.
So how can the backlog be cleared and the 2020 goal achieved? Dr Sulistyowati: “This is a very serious problem, but frankly speaking, I don’t know the answer.”
WHO’s Vision 2020 goal: A world in which no-one is needlessly blind
Ratio of ophthalmologists to citizens in Indonesia: 1 / 203,000
WHO recommendation: 1 / 20,000
Number of free cataract operations in 2012: 11,000
Backlog: Close to 2,000,000
(First published in The Jakarta Post 23 January 2013)