Are globalization, standardization and connectivity contributing to eye care equity?
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Tangible progress has been made
The global spread of science communication, the dissemination of best practices, monitoring of outcomes and the connectivity provided by network technologies offer immense opportunities for making high-quality and affordable eye care available to more people around the world.
During my years in Nepal, I witnessed an amazing improvement in eye care. Immense changes began when Dr. Sanduk Ruit returned from a 2-year fellowship in Australia. He brought back a higher standard of cataract surgery and also established a world-class IOL factory that transformed the quality of and access to cataract surgery. Next, superb young colleagues, Govinda Paudyal, Rohit Saiju and Suman Thapa went to Australia to train in retina, oculoplasty and glaucoma. They brought back to Nepal world class subspecialty skills and the concept of excellence leading to a world-class residency training program. This, combined with attention to quality ophthalmic nurse and paramedical eye care worker training, led to a profound transformation. Nepal is now the only large low-income country that has reversed its rate of blindness.
For areas that are even more left behind, such as Africa, fellowships in Nepal and India, including Dr. Rao’s LV Prasad Eye Institute, are currently playing a similar role. These South-to-South partnerships through which talented young African doctors are able to receive world-class training, are starting to raise the quality in several African countries. A rising tide lifts all boats. Doctors return full of inspiration with the confidence that if quality care can be delivered in Nepal and India, African people will be able to do equally well. Gullapalli Rao trained as a cornea surgeon in the U.S. and returned to India to raise the standard of corneal surgery in India. When high-quality, life-changing outcomes are offered, patients will walk miles from their villages to actively seek care rather than having to be found and recruited for care. Quality drives demand.
Telemedicine is another game-changer. Africa, in particular, made a big sudden jump from no communication to cell phones and internet connectivity. There, as in other parts of the world such as Nepal and India, telehealth is vastly improving health care access in rural communities.
A third aspect that is leading transformation is the availability of high-quality, low-cost medications, IOLs, phaco machines, autorefractors, OCT devices, operating microscopes and everything needed to provide great care. Several manufacturers are working in this direction, making advanced technologies available in underprivileged areas at affordable costs.
According to the WHO’s latest World Report on Vision, $14 billion are needed to eliminate all needless blindness from cataracts and low vision from refractive error. It is a travesty that for lack of money we still have 17 million people who are needlessly blind, especially as America continues to spend trillions of dollars on its military. However, sooner or later, the world will realize that blindness is the low hanging fruit of global health. The process is happening, and funding is slowly improving along with improved communication, education and dedication to quality outcomes. We are making progress. I do foresee a world where no one is needlessly blind.
Geoffrey Tabin, MD, is co-founder and chairman of the Himalayan Cataract Project and a professor of ophthalmology and global medicine at Stanford University.
Still largely confined to a privileged few
While globalization and standardization have improved the quality of care and quality of education, the fruits of these are largely confined to the populations of developed countries and the privileged classes in developing countries.
Both “quality” and “equity” remain elusive to the less privileged populations of the world. In practical terms, equity in eye care has a long way to go. The chronic issues of availability, affordability and accessibility remain major issues for large segments of the population. Where these are addressed, it is not equitable, as quite often the care is suboptimal in quality. In developing countries, the majority of people are still living in rural areas, and delivery of health care to these rural populations is often minimal and suboptimal. Poor infrastructure, poor training and poor systems contribute to this pernicious problem.
At the LV Prasad Eye Institute, our vision has been “reconciling excellence with equity.” Equity encompasses all aspects: economic, social, gender and geographic. To ensure the practice of these founding values, our pyramidal model of eye care delivery was developed to encompass all levels from primary to advanced tertiary without compromise. Permanent facilities with good quality infrastructure, appropriately trained personnel for that level of care and operating systems were put in place. Our primary care vision center model reaches out to the tribal and remote rural areas, the people with no or poor access to quality eye care. This has achieved equity of all areas in a significant manner. The strategy of providing these entry points in neglected geographic areas with commitment to these communities focused on finite populations ensured quality and significant gender equity. This model, in our experience, addresses many issues plaguing proper eye care delivery in developing countries. But the road ahead is still long.
Gullapalli N. Rao, MD, is founder and chair of LV Prasad Eye Institute, Hyderabad, Andhra Pradesh, India.