My medical school ophthalmology elective to Southern Africa was cancelled during COVID. Three years later, as an F3 doctor, I decided to make it happen anyway, volunteering at the rural eye clinic where I had originally planned my elective. This article is a guide on how to arrange and make the most of an elective in a low-income country. The challenges are greater, but the rewards are often profound.

Why Choose a Low-Income Country?

Electives in resource-rich countries like Australia or the USA offer structure and advanced research and technology. By contrast, electives in low-resource settings offer hands-on experience, exposure to ample patients, and fascinating pathology.

The ophthalmic disease burden differs dramatically between the UK and sub-Saharan Africa. In England, there are about 25 consultant ophthalmologists per million people (1). Across sub-Saharan Africa, the average is ten times lower at 2.5 ophthalmologists per million (2). In South Africa, about 600 consultant ophthalmologists serve a population of 60 million, and most work in private or urban settings (3). Public hospitals, especially in rural areas, depend on small teams or visiting specialists.

While the NHS struggles with over 600,000 patients on ophthalmology waiting lists (4), South African patients may never be able to access eye care at all (5). Cataract remains the leading cause of blindness, affecting an estimated 170,000 people (6)—a sad reality for a highly treatable condition. Trachoma is the most common cause of preventable blindness worldwide, and although South Africa has relatively better care compared to the rest of Africa, certain regions such as the Transvaal still see trachoma as the leading cause of preventable blindness (7). It is a worrying trend in the 21st century that a country like South Africa continues to carry a burden traditionally associated with the developing world.

Working in such an environment teaches you to rely less on investigations and more on examination skills, teamwork, and clinical knowledge. You quickly appreciate both the ingenuity required to deliver high-quality care with limited resources and the privilege of working within the NHS.

Preparing for Your Placement

1. Finding the Right Placement

• Start early—ideally 9–12 months ahead.
• Contact mission hospitals, NGOs, or university-linked eye clinics. University global health offices or social media communities like Ophthalmology Electives on Facebook can be invaluable.
• I found my hospital on a list of previous elective destinations sent out by my university (UCL).

When you email, include:

• A concise CV highlighting ophthalmology experience and your level of training.
• Specific learning goals (e.g., learning slit-lamp exams, observing or assisting in theatre).
• Proposed dates and duration.

Clarify whether you’ll be observing, assisting, or participating in outreach, and confirm accommodation and transport logistics early. Most centres host many medical student electives and know what to expect. It is normal for them to charge a small fee, which can be an important income stream for many clinics.

2. Medical and Safety Preparation

Before you go:

• Vaccinations & prophylaxis: See a travel clinic early. Malaria prophylaxis is essential in most regions.
• HIV PrEP: Consider pre-exposure prophylaxis in sub-Saharan Africa, particularly if you will be performing exposure-prone procedures and are at risk of needlestick injuries. It is not essential, and none of the local healthcare staff I met used it.
• Insurance: Secure comprehensive medical and travel cover. Student indemnity (e.g., MIPS, MDU) often includes elective work.
• Accommodation: Safety is very important, and you should aim to stay in a secure compound. Speak to your supervisor about where previous elective students have stayed and follow their advice. I lived on the consultant’s farm—it was both beautiful and safe.
• Documentation: Carry a letter of good standing, vaccination records (if required), medical school transcripts, and proof of insurance. And do not forget your passport!

3. What to Pack

• Lightweight scrubs, sturdy shoes, and personal eye protection (PPE).
• Stethoscope.
• Eye equipment:
  • Ophthalmoscope (if you have one)
  • Pen torch for pupil examination
  • Snellen chart (physical or an app)
• A reusable water bottle and torch.
• A basic medical kit: mosquito repellent, loperamide, painkillers, plasters, and rehydration salts.
• Sun protection: sunscreen, wide-brimmed hat, loose long-sleeved clothing, and sunglasses.
• Ophthalmology resources: books like the Oxford Handbook of Clinical Ophthalmology or Kanski’s Clinical Ophthalmology provide an excellent grounding for both UK conditions and tropical diseases you may encounter abroad. Online resources such as EyeWiki are also helpful.
• Optional but valuable: a driving licence. Safe, independent travel can make a huge difference. If you do not have one, team up with another student who does.

4. Learn Before You Go

Arrive prepared to contribute from day one:

• Brush up on examination techniques. For example, this useful article on using an ophthalmoscope:
  https://mindthebleep.com/how-to-use-an-ophthalmoscope/
• Review cataract surgery principles, intraocular lenses, and common/tropical conditions such as cataracts, keratoconus, trachoma, and pterygium.
• Consider shadowing a theatre list in the UK to familiarise yourself with theatre etiquette, infection control, and basic surgical workflow.

Immersing Yourself in the Experience

Clinical Exposure: Learning by Doing

Under supervision, I practised slit-lamp exams, observed theatre lists, and reviewed patients in outpatient clinics. During an outreach trip, our consultant performed over 15 cataract surgeries a day, operating with great speed and precision. Each day brought lessons in efficiency, clinical reasoning, and improvisation. With limited access to investigations, diagnoses relied heavily on history and examination.

The Kalahari Cataract Outreach

A highlight was joining a mobile outreach to the Kalahari Desert. I flew in the cockpit of a tiny propeller plane with the surgical team. Over four days, scores of patients were screened and operated on—many had been blind for years due to lack of access to a cataract surgeon. Watching sight restored, sometimes for people who had travelled hundreds of kilometres, was humbling. I was deeply impressed by the local staff, who worked tirelessly in difficult circumstances. If possible, ask your elective centre whether any outreach events are scheduled during your stay.

Beyond Medicine: Logistics and Leadership

Arriving in rural South Africa felt like being dropped into another world. One of my first tasks was counting money and collecting a vehicle. Initially disorienting, I soon found these responsibilities surprisingly rewarding.

Volunteering in a low-resource country means doing a bit of everything. These experiences teach adaptability, leadership, and respect for the unseen systems that keep healthcare functioning—often managed out of sight in the NHS. I was extremely impressed by the hard work and dedication of the local healthcare providers.

Getting the Most Out of It

• Be proactive: Don’t wait to be invited—ask for opportunities, feedback, and supervision.
• Keep a logbook: Record surgical cases and clinics attended. It supports learning and enhances your portfolio.
• Be culturally aware: Respect local customs and hierarchies.
• Network meaningfully: Connect with local clinicians and visiting teams; future collaborations often begin here.
• Make time for rest: Use days off to explore and relax. Southern Africa has world-class food, festivals, hikes, and safaris.

The Benefits: Professional and Personal

1. Clinical Growth

Resource limitations sharpen clinical judgement and examination skills. The exposure is broad and hands-on—ideal preparation for F1 and beyond.

2. Renewed Perspective on the NHS

Working where equipment and staff are scarce reminded me that our challenges—waiting lists, workload, bureaucracy—are enviable compared to genuine scarcity. An important point to remember when working in the NHS.

3. Confidence and Resilience

From navigating rural roads to auditing clinic supplies, every day required initiative. That confidence translates directly into better teamwork and problem-solving back home.

4. Inspiration for Global Ophthalmology

Seeing preventable blindness up close can profoundly shape your career path and emphasises the importance of improving global healthcare. I was inspired by the local doctors and healthcare providers.

Safety, Ethics, and Sustainability

• Supervision is vital: Never exceed your competency.
• Avoid “voluntourism”: Aim to give back through teaching, research, and genuine clinical commitment.
• Prioritise wellbeing: Dehydration, fatigue, and isolation can creep up quickly—look after yourself.

Final Reflections: Why It’s Worth It

A low-income country elective isn’t easy. It’s administratively demanding, occasionally uncomfortable, and always unpredictable. But it is also unforgettable. If you approach it with humility, curiosity, and initiative, it will change your understanding of medicine—and perhaps your career. I was inspired to pursue ophthalmology; perhaps the same could happen to you.

Essential Takeaways

• Start early: Apply 9–12 months ahead.
• Prepare properly: Vaccinations, insurance, and clear supervision plans.
• Pack smart: Scrubs, PPE, and sturdy shoes are invaluable.
• Be proactive: Learn actively, get stuck in, reflect often.
• Stay humble: You’re there to learn, not to lead.
• Enjoy it: The challenges are real, and so are the rewards.

References

1. The Royal College of Ophthalmologists. Workforce Census 2023. London: RCOphth; 2024.
2. Dean WH, Buchan JC, Gichuhi S, Faal H, Mpyet C, Resnikoff S, Gordon I, Matende I, Samuel A, Visser L, Burton MJ. Ophthalmology training in sub-Saharan Africa: a scoping review. Eye (Lond). 2021 Apr;35(4):1066–1083. doi:10.1038/s41433-020-01335-7. Epub 2020 Dec 15. PMID:33323984; PMCID:PMC8115070.
3. Willie MM. Eye care services and benefits paid by medical schemes in South Africa. Afr Vision Eye Health. 2023;82(1):a756. https://doi.org/10.4102/aveh.v82i1.756
4. NHS England. Consultant-led Referral-to-Treatment Waiting-Times Data 2023. London: NHS England; 2023.
5. Lilian RR, Railton J, Schaftenaar E, Mabitsi M, Grobbelaar CJ, Khosa NS, Maluleke BH, Struthers HE, McIntyre JA, Peters RPH. Strengthening primary eye care in South Africa: an assessment of services and prospective evaluation of a health systems support package. PLoS One. 2018 May 14;13(5):e0197432. doi:10.1371/journal.pone.0197432. PMID:29758069; PMCID:PMC5951550.
6. Kluever H. National-level outreach: South African Bureau for the Prevention of Blindness. Community Eye Health. 2006 Jun;19(58):27–28. PMID:17491727; PMCID:PMC1705636.
7. Ballard RC, Fehler HG, Fotheringham P, Sutter EE, Treharne JD. Trachoma in South Africa. Soc Sci Med. 1983;17(22):1755-65. doi: 10.1016/0277-9536(83)90388-x. PMID: 6648595.

Article written by Finian O’Malley (SHO) and reviewed by John Marler (Ophthalmology SpR)