Brisbane ophthalmologist Dr Graham Hay-Smith shares his experience aboard the Africa Mercy in Madagascar, highlighting the transformative impact of cataract surgery and the importance of volunteering.
I was recently privileged to leave my comfortable practice in Brisbane and spend a couple of weeks aboard the Africa Mercy in Madagascar. Madagascar is one of the world’s poorest countries, with extremely limited healthcare. There are thought to be fewer than 25 ophthalmologists serving a population of around 30 million – roughly equivalent to the combined populations of Australia and New Zealand. By comparison, our two countries have more than 1,200 ophthalmologists – almost 50 times as many.
During my time on the ship, I had the opportunity to dust off some well-known but rusty skills, performing cataract and pterygium surgery on patients who were in desperate need of care. My aim in sharing this experience is to highlight the opportunities for doctors, optometrists, nurses, and willing volunteers to contribute, and to encourage colleagues to support health systems in countries that lack the resources we often take for granted.
Life aboard a floating hospital
The Africa Mercy is a large converted Danish rail ferry – originally designed to roll trains on and off – completely refitted as a five-theatre hospital ship. It includes an ICU, PACU, and general wards for around 80 patients. Outpatient facilities are limited on board, so most outpatient work (including the work of optometrists) is conducted dockside in special tents set up in a warehouse, with the staff eating and sleeping on board. The ship is home to volunteers delivering high-quality clinical care to some of the world’s poorest patients.
When I was on board, there were around 400 individuals from 46 nations, including more than 50 from Australia and New Zealand, which made it easy to feel at home. The ship also has a small international school for long-term crew and their families, allowing volunteers to serve for extended periods.
Getting to the ship was no small feat. Few flights serve Antananarivo, Madagascar’s capital, and none are direct from Australia. Roads are challenging, and the 350km trip to the port of Toamasina can take 12 to 14 hours, so domestic flights are often the better option – though still not much faster.
Upon arrival, I was immediately welcomed by the ophthalmology team. As a surgeon, I was assigned a single cabin – utilitarian but comfortable, and certainly preferable to some of the bunks I’ve known (and I’ve slept in a few, having served in the Army).
I usually started my day with a run around the port or town, often accompanied by other crew members, such as David from Dumfriesshire, the ship’s GP who I had flown in with. My clinical day started with a 7:30am team meeting, and by 8:30am, surgery was underway after a quick assessment of the morning patients with a handheld slit-lamp.
The ophthalmic theatre has two operating beds and a single Alcon microscope that swings between the two beds. Anaesthetic blocks were performed by the surgeon. After a few attempts at peribulbar blocks, I reverted to retrobulbar, which provides the akinesia and anaesthesia needed for a 6.5–7mm scleral wound.
All cataract surgery was MSICS – Manual Small Incision Cataract Surgery – a technique particularly suited to low-resource settings. On the ship, we used only a single crescent knife for the scleral tunnel dispensing even with the #15 scalpel. I am fortunate to have trained during a time when some consultants had not yet converted to phacoemulsification. My old-school ECCE training under Mr Whitelock and Senior Registrar Mr Aoroa at St Bartholomew’s in central London came in handy, as did my prior experience in Ghana, where I performed MSICS during research work in the late 00’s when the technique was still relatively new.
I am grateful to Dr Elie Abbey from Togo, who was the other ophthalmologist on board and he helped me brush off the cobwebs as my rusty MSICS surgical cogs started to turn again. He is a high-volume MSICS surgeon and perfoms little phaco – the opposite to me. He offered tips that saved both time and resources – for example how to hold the crescent blade to reliably incise the sclera without my fingers blocking the view. I hope one day to return the favour, sharing my experience as a high-volume phaco surgeon.
By around 4pm, the day was done, leaving time to head to the deck for fresh air and daylight – essential for jet-lagged retinae. On some evenings, seminars were held for volunteers. I attended talks on delivering care in highly challenging environments, including the Red Cross Hospital in Gaza and war-torn South Sudan.
Weekends allow for excursions off the ship. I explored the somewhat bizarre French colonial-era Pangalanes Canal, spent a night in Palmarium, and took a nocturnal boat trip to see the long-fingered Aye-Aye lemur – a moment worthy of David Attenborough himself.
At the end of my two weeks there was a moving dockside service, where patients from the previous month’s surgery returned to give thanks for their restored vision. The palpable impact of these ‘good works’ was crystal clear and deeply rewarding.
Challenges, rewards, and reflection
MSICS presents a challenge for Western-trained phaco surgeons. Many steps differ from phacoemulsification, and gaining competence – and maintaining it – is a real challenge for surgeons who predominantly work with modern techniques. My Oertli machine in Brisbane safely emulsifies even very dense lenses, leaving relatively minimal endothelial trauma. For most of my patients in Australia, the trauma of MSICS is not justified.
I found returning to MSICS was humbling but also helpful to me as a surgeon. Even after thousands of cataract operations, I felt a bit like a registrar again in my 50s. RANZCO recognises these challenges and now organises MSICS training events, often with the support of colleagues from the Indian subcontinent and elsewhere.
The need for Mercy Ships’ services is evident in the patients. During my visit, we celebrated the 1,000th cataract surgery performed on this particular Madagascar service. I estimate that over 80% of the patients I operated on could see only hand movements in their better eye prior to surgery. The transformation after MSICS is immediate and life-changing.
Mercy Ships’ work goes beyond surgery. It brings hope, education, and cross-cultural engagement to communities that rarely see advanced medical care. The ships offer a model of healthcare delivery that combines skill, resourcefulness, and compassion – all made possible through donations from around the world and time given by volunteers.
My time on the Africa Mercy was deeply rewarding. I returned home eager to do more, reminded that even small contributions collectively make a meaningful difference. Every health professional has the ability to put ‘a drop in the bucket’ to support those far worse off than ourselves.
For me, volunteering offered more than just the chance to provide surgery. It was an opportunity to travel, experience new cultures, meet remarkable people, and work alongside colleagues in ways I seldom do in Australia. For example I seldom have the opportunity to work with other disciplines in reconstructive oculo-plastics any more. I relished the challenges of revisiting old techniques, and returned a more competent and well-rounded ophthalmologist as a result.
I hope other eyecare professionals will consider carving out time from busy schedules to support initiatives like Mercy Ships. The rewards – for both patients and volunteers – are profound, and the lessons learned will stay with you for a lifetime.
Those keen to know more about Mercy Ships can go to the website: https://mercyships.org.au/volunteer.
