Letter. Are we reaching and serving the blind poor?

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Dear Sir

After a career in international banking, I began the study of medicine at age 40 and later established a small family-funded Eye Foundation. I have practised basic surgical ophthalmology in Latin America on a day-to-day basis for the past eleven years. In addition, I have been able to observe and follow the successes and failures of the fifteen projects our Foundation assists in Latin America, Haiti, Africa and Asia.

I am deeply concerned and disturbed by the widespread administrative and organisational failings which lead to unnecessary obstacles being placed in the paths of the blind poor. It appears that we are making enormous technical progress while ignoring the administrative and management skills required to reach the poor more effectively. The following are examples of some of these shortcomings.

1. Failure to ‘triage’ (priority of need and treatment) arriving patients, thereby focusing our limited resources on the more serious, treatable cases.
2. Turning away the blind due to often trivial and petty bureaucratic policies, e.g., registration cards are not available after 8:00a.m.
3. Insistence on useless laboratory and medical examinations for procedures carried out under local anaesthesia.
4. Cancellation of surgeries, often due to insignificantly raised blood pressure, coughing, anxiety and nervousness, lack of co-operation, etc. Almost all of these cases can be completed uneventfully and safely with the use of minor medications along with a small amount of patience and support.
5. Tying up a surgeon’s time and energy with endless, routine clinical examinations.
6. Failing to allocate operating room time, bearing in mind that cataract surgery (and trichiasis procedures in trachoma endemic areas) have greater value and effectiveness in the developing world than all other eye procedures combined.
7. The direct material costs of good quality cataract surgery with IOL are now approximately $15. Ineffective charity programmes routinely charge the poor up to seven or eight times this amount.
8. Keeping uncomplicated post-operative patients more than one to two days, thereby reducing the beds available for new patients.
9. An insistence on large, comfortable US-style hospital beds and accommodation, thereby reducing available ward space. The blind patient is more than happy to spend one or two nights under almost any conditions. His or her real concern and fear is to be sent away untreated due to a lack of available beds.
10. An insistence on unnecessary follow-up. Our own approach in an uncomplicated case is to send the patient who is far from home away with an eye shield and have him return if there is a problem, or if he or she desires to do so. If there is a noticeable loss of vision later, we recommend a return visit for a possible YAG or needle capsulotomy.
11. A frequent lack of empathy and courtesy towards the poor. We don’t really have to make an effort to be accommodating if the patient has no other treatment possibilities.

It is worth noting that virtually none of these factors or attitudes are found in such highly effective, superbly organised hospitals as Aravind (India), CBM-Lahan (Nepal) and SEVA-Lumbini (Nepal).

The blind poor make tremendous sacrifices to reach surgical treatment centres. A significant factor in the success of the above three hospitals is found in the confidence and knowledge of the poor that once these sacrifices are made they will not be turned away untreated.

Thank you for the opportunity to express these impressions and concerns.