Week 1 – “The World Health Organization estimates that over one billion people who need eyeglasses do not have access to them. The vast majority of these people live in developing countries like Kenya where there is barely one optometrist per one million people. Given the high poverty levels, access to eyeglasses is almost non-existent. Lack of proper eyeglasses severely impacts people and their livelihoods by decreasing their productivity at work, limiting or eliminating new opportunities, affecting their quality of life, deteriorating their general health and possibly leading to (preventable) blindness. What solution do you propose to address this problem?”
Capacity Building & Unique Regulatory Environments – possible optometry solutions for the last mile
Sage Herrick | January 26th, 2019 | Ukweli Test Strips
I visited Nicaragua in the summer of 2017 to conduct public health research in six rural communities. My research partner, Pond, and I stayed in San Juan Del Sur. This small city is about 90km from the Costa Rican border, sandwiched between the Pacific ocean and lago Cocibolca. We brought everything we thought we needed for our three-week stay except for a spare pair of glasses.
Pond had a specific prescription for each eye and needed them badly, as we unfortunately discovered. He lost his glasses the same day we were robbed and was unable to see. Getting him a new pair was a two-day expedition to Managua, home of the only optometry office in the entire country. I was impressed with how gracefully Pond handled the situation. He conducted field mapping of our most complicated community successfully without his glasses. Luckily, he had brought his prescription swimming goggles. We spent three days in Mira Valle interviewing people about malaria risk while Pond was wearing his swimming goggles. It juxtaposed us from that farming community in a humorous way.
Despite having insurance and the travel resources to get to the capital city quickly, this experience was a huge hassle and ate up three days of our fieldwork. But it was necessary. I can’t imagine Pond being as effective as he is without the right prescription. He might not be currently pursuing a Ph.D. at Caltech if he didn’t have appropriate access to optometry to show what he can accomplish.
I asked Pond during this ordeal if the lack of optometrists was similar in his home country. He told me that it was the easiest thing to get glasses in Thailand because there was no insurance process. Pond did say this undermined the quality but noted that he’s never seen prices or wait times as he has in the United States. This may be an unfair comparison to draw. The US has a population of 325.7 million versus Thailand’s 69.04 million and has a healthcare system so complex that few politicians have actually read the 1,000+ ACA Bill. The US handles more regulatory approvals than Thailand by virtue of being an extremely wealthy country, but this could be a hidden gem. The huge potential in the developing world can almost be seen as a second chance. LDCs can be a place where we can leapfrog over some inefficient steps and get to a context-specific solution that actually works. I am reminded of the US environmental pollution during the 60s and if that ‘stage’ of development could be skipped in developing countries with appropriate technology then we would be better off. I hope this same logic can apply to the healthcare system, where we skip the inefficiencies of our environment and get straight to the last mile.
It’s vain for a junior in college to pretend she has enough knowledge to propose a solution for optometry shortages in developing countries. Instead, I researched other solutions already being implemented and they largely fall into three categories:
Training & Ethics
Brien Holden Vision Institute
Humanitarian optometry missions should build capacity, not dependency
Optometry in developing countries
The role of optometry in Vision 2020
I pulled several themes from each of these initiatives that are worth mentioning:
“Vision 2020’s major priorities are cataract; trachoma; onchocerciasis; childhood blindness, and refractive error and low vision. These have been selected not only because of the burden of blindness that they represent but, also, because of the feasibility and affordability of interventions to prevent and treat these conditions” (Holden 2002; 15(43): 33–36.) This shows a priority towards the most prominent conditions but what also is feasible.
Handouts do not last – patients have to like wearing their glasses and not get headaches.
Screening for eye problems can lead to screening for more severe cases, which is beneficial for healthcare in general.
Refractive error is the frontline challenge and capacity building is a big part of the answer. “A total of 153 million people (range of uncertainty: 123 million to 184 million) are estimated to be visually impaired from uncorrected refractive errors, of whom eight million are blind.” (WHO 2002).
- Volunteer Optometric Service to Humanity (VOSH) is not an effective humanitarian organization. Cataract surgery is not provided but can be done in 8 minutes.
- Recycled glasses have low success rate
I found it interesting that we don’t need a flashy technology to solve this problem, we just need to empower people in LDCs. This often takes the role of supporting optometry schools and building capacity at the local level. My final recommendation for these initiatives is a market-centered survey of why people would not wear glasses. Something as simple as having a choice in frames or color can give people agency that is often stripped from them in humanitarian settings. The solutions would also benefit from a prescription delivery system because Glaucoma medication must be taken regularly even if patients live in rural communities.
Any solution touches on a deep nerve in many modern debates about access to healthcare in general. Is healthcare a human right? Is it a normal or inferior good? Is a single-payer system superior to an insurance network? There are no easy answers when it comes to access. I believe that healthcare is a basic human right which we should strive towards, but the challenges sometimes look too big in our current neoliberal economic order. Healthcare is treated as a zero-sum game.
I could see arguments against any proposed solutions from a Maslow point of view, which I find hollow usually. Yes, people cannot benefit from eyeglasses if they starve, but everyone can help with something specific. Eyesight does not become unnecessary in the face of food shortages, and to pretend it does is oversimplifying the human condition.
I was pleased to find several solutions for this gap between need and care and I hope it remains sustainable.