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Module 8: The Significant Harm of Worst Practices In Eye Care

As with all health programs, eye care programs must be founded on best practice principles in public health.  The “worst practice” principles that are often employed by some organizations involved with eye care can do significant harm.

Worst Practice: Optometric “Medical Missions”

Providing optometric care solely in the form of presbyopic or refractive correction is counterproductive and can prevent patients from seeking eye care for other ophthalmic conditions. Many NGOs that provide “optometric medical missions” in which they only prescribe eyeglasses during a short-term intervention to populations in developing countries.  A serious misconception behind these types of missions is the idea that providing some care is better than providing none at all. However, “optometric medical missions” can be wasteful, unethical, and harmful, and they often serve as medical tourism or “volunteer vacations.” These short-term interventions typically fail to partner with local eye doctors, thereby undermining the local healthcare system.  Additionally, patients who encounter such optometric medical missions will leave believing they have received a complete ophthalmic exam, no matter how cursory the vision screening, even if they are explicitly told otherwise. If a patient with cataracts, for example, is told that eyeglasses will not correct his sight, but an option for subsidized or free cataract surgery is not provided, the patient will continue to believe that nothing can be done to improve his sight. This visit to the “optometric medical mission” group is often the only time that a patient will seek eye care.

Though few would question the honorable intentions behind these interventions, short-term missions rarely produce tangible, lasting medical benefits.  Rather, they tend to be self-serving, ineffective, and provide only temporary, limited care, without addressing fundamental eye care needs. Further, there is generally no follow-up or quality control; most optometric missions identify their success based on whether a patient smiles upon receipt of the glasses, or whether the team is invited back for a future mission. These are not effective metrics for evaluating success. In the Indian state of Andhra Pradesh, for instance, 25.9% of those surveyed stopped using their eyeglasses because they felt that the prescription was not appropriate; 19.6% of those surveyed did not use their eyeglasses because they had lost them and could not afford to buy a new pair, and 17.9% found the eyeglasses to be uncomfortable. For these reasons and more, follow-up care must be available to all eye care patients, including those receiving glasses.(1)

“It is also important to recognize that while spectacles provide an easy answer to the need for presbyopic correction, the mere handing out of spectacles without an appropriate eye examination biases against quality eye care for everyone regardless of socioeconomic status, sex, or geographic circumstance. Coupling spectacle distribution to meaningful eye care is an important link in the blindness prevention chain from community to hospital. Random spectacle distribution breaks the chain of patient care and is counterproductive.”(2)

Presbyopic treatment should be provided as one facet of complete eye care.(3)

Worst Practice: Eyeglass Distribution By Non-Eye Care Professionals

Allowing medical and non-medical providers to practice beyond their abilities is one of the worst practices in global health.  There are numerous examples of short-term medical missions involving students or other non-eye care professionals dispensing prescription eyeglasses, which is concerning:

Worst Practice: “The trial and error method is the most economic. One simply places all the differing strengths of eyeglasses in an ascending manner on the table and the patient tries each one beginning at the weakest continuing through the strongest until he/she finds the best lens strength for his/her refractive error. Essentially no cost is involved except the cost of the glasses which is $1 - 2 per pair.”(4)

Worst Practice: “Various government and private community health centres offer spectacles, usually donated ‘recycled’ spectacles selected by potential users on a trial and error basis, or handed out by health workers with no training in dispensing.”(5)

Worst Practice: “Attendees learned that medical mission trips aren’t just for professionals. Hospice care, offering free reading glasses and simple counseling are just a few examples of services that do not require much medical skill.”(6)

Some short-term groups bring advanced and expensive equipment, such as an autorefractor, in an attempt to have non-eye care professionals prescribe eyeglasses. Those prescribing the glasses have no background in eye health and cannot identify the difference between refractive error and other eye diseases. Some mission organizers claim to train their volunteers to use advanced optometric equipment, but such training is cursory and cannot qualify non-medical personnel to prescribe eyeglasses. It is important for organizations and NGOs to recognize that it is unethical and harmful for non-eye care professionals to prescribe eyeglasses. A concerning example is demonstrated by a short-term medical mission group:

Worst Practice: "One excellent method of ministry is to provide eyeglasses.  These eyeglasses not only allow the person to read their Bible but to also improve their standard of living.  Unlike providing a supply of medication, these glasses will typically be useful for several years. These teams are prevented from doing their best by a lack of training, professional assistance and proper equipment... [The organization] has assisted by providing numerous training manuals for the non-professional...With over 5 years in development, this program uses advanced optometry principles provided by experienced optometrists and described in textbooks. The intelligence built into this program gives the user the benefit of some of the experience and knowledge of these optometrists.”(7)

Additionally, visiting physicians on short-term medical trips often feel compelled to treat patients outside of their specialties, simply because there is no specialist available, or because the patients are unable to afford the cost of receiving care by the local specialist. In the developed world, internists do not treat children and general surgeons do not prescribe eyeglasses – why should this be different in the developing world? Lowering the standard of medical care for those in developing communities is unprofessional, unsafe, and unethical.

The Harm Caused By Distributing Glasses By Non-Eye Care Professionals

The dispensing of eyeglasses by non-eye care professionals can be problematic and harmful for various reasons.  First, prescribing corrective distance eyeglasses requires refraction by a skilled optometrist or ophthalmologist.  In the Western world, it is illegal for anyone but a licensed professional to prescribe eyeglasses.  Patients provided with the wrong prescription – which is almost always inevitable if non-eye care professionals are distributing glasses without refraction or examination – will experience headaches and discomfort, and will not wear the eyeglasses.  This perpetuates distrust of health providers.  Additionally, there is a common belief among patients that eyeglasses will help any visual problem.  If a patient with cataracts is given glasses, his vision will not improve.  Nevertheless, the patient might believe that he was given glasses to cure his eye ailment; when the glasses do not work, s/he might think that there is no cure for his visual problem, and will likely never seek eye care again.

Worst Practice: Training Community Members To Prescribe Eyeglasses

The patient barriers described earlier are usually insurmountable to impoverished patients living in rural villages, preventing them from receiving eye care by trained professionals.  In an attempt to overcome such barriers, local community members are sometimes trained to prescribe reading glasses.  However, research indicates that those trained solely to prescribe reading glasses may be perceived by those in villages to be licensed eye care professionals.

“There is an indication of relative inaccessibility of hospital eye services to the population. Reasons for this inaccessibility include the consumers' concept of who could provide eye care and their inability to distinguish between the different providers, and their perception of the hospital and its staff.”(8)

Module 3 described the high percentage of patients in developing countries who have never sought eye care and who have never had an eye exam.  When receiving reading glasses from a trained local community member, it can be impossible for a village patient to understand that receiving  reading glasses does not constitute a complete eye exam by an eye care professional.  Even if they receive reading glasses, patients may have a serious but curable condition such as cataracts or pterygium.  The reading glasses will not improve their vision; reading glasses only treat presbyopia.  A complete eye exam, diagnosis, and surgery would be required to improve a cataract patient's vision, and even then, barriers remain, preventing patients from receiving complete eye care from a licensed professional.  Training local community members to prescribe reading glasses only eliminates barriers for correcting presbyopia, and can negatively affect the identification and treatment of other treatable eye diseases. 

If community members are trained to provide any type of eye health service, they must be integrated into a local eye clinic's ongoing outreach programs by eye care professionals at the same location.  The primary role of the community members should be to help reduce the primary barriers to patient care, and their close involvement with local eye clinics can be highly beneficial to the patients.

Worst Practice: “Referrals” to Local Eye Doctors

Short-term medical missions or other organizations that claim to “refer” patients to local eye care professionals must reduce barriers to care.  “Referring” without reducing barriers to care will not enable a patient to access locally available resources.  It is the responsibility of the visiting global health organization to facilitate transportation from remote locations and subsidize cost, as well as maintain data on the number of patients receiving care by the local clinics.  Hundreds of thousands of patients can be referred to an eye doctor, but what actually matters is the number of patients who receive quality care.

Worst Practice: The Dangers of Short-Term “Surgical Safaris”

Of all the worst practices in global eye-care, short-term surgical missions can be considered the worst offenders. Even the best efforts of the most experienced ophthalmic surgical teams cannot overcome the risks of short term surgical missions. Post-surgical monitoring and follow-up care is necessary to prevent infection and to ensure the success of an operation.(9) When visiting doctors do not work with their local counterparts, there is no ophthalmologist to provide follow-up care or to treat infections that may arise after the operating surgeons depart, which is often the day after operating.  For information on the importance of partnering with local doctors, refer to Module 3 of the Unite For Sight Global Health Course (http://www.uniteforsight.org/global-health-course/module3). The ramifications of botched surgeries affect more than just the surgical patients and their families; a single poor surgical outcome can lead an entire village to fear doctors and surgery on a long-term basis.

“The perceived quality of the provided services had a strong influence on uptake. Patients who reported having spoken to someone who had good experiences with the service provider were more likely to avail themselves of the offered cataract surgery.  Conversely, patients who had heard negative aspects about the services provider were not inclined to take up services. Virtually everyone had discussed cataract surgery with relatives or friends.”(10)

The photo below shows a patient who lost all function in his eye due to poor quality surgery provided by a short-term visiting team of surgeons.

Additionally, while a limited number of patients may have received free surgical care by the visiting ophthalmologist - perhaps 50 to 100 during a 1-week visit - the other patients from the region will not have had access to surgical care. Such interventions are thus minimally effective at best, as they do not encourage community members to seek regular eye care, nor do they build local capacity.  Furthermore, patients tend to view Western visitors as superior, which compromises the status of local doctors.(11) Patients may decide to wait until the next time that a Western doctor visits instead of seeking care by the local ophthalmologist. It is often rich patients who take advantage of free surgical care provided by visiting surgeons despite being able to pay, simply because they believe that the visitors provide higher quality surgery.

Large surgical missions of dozens of volunteers often focus heavily on numbers of patients treated instead of quality of care.  Quality of care must always be the paramount focus of any surgical or medical care.  According to The New York Times, Operation Smile, a nonprofit organization that sends surgeons to provide cleft lip and cleft palate surgery, has received criticism for failure to work collaboratively with local surgeons:

“Over five days, Operation Smile volunteers did 188 operations in Rooms 1 through 7; Chinese doctors did 61 operations in Rooms 8 and 9. The results were very different. According to a study done at the hospital, of the 61 operations with Chinese surgeons, only two caused any postoperative problems, in both cases minor bleeding. But over 40 patients under the care of Operation Smile had serious complications, the hospital study reported."(12)

“Last year alone, four children died during or after surgery, adding to at least 12 other patients that the charity acknowledges losing since it began operations in 1982. Repairing a cleft lip or palate in the developed world is rather low risk and deaths are rare. Physicians in China, where Operation Smile has performed many of its operations, have accused the surgeons of 'assembly line' medicine. In Bolivia, a pediatric surgeon branded the organization's practices 'a form of neo-colonialism.'

… 'This is a form of neo-colonialism,' argued Dr. Rosa, who said his hospital had performed about 2,000 of these surgeries. While his hospital would be eager to cooperate with surgeons from the United States, Operation Smile had committed 'surgical safaris against our children,' who are from poor families who are unlikely to complain, he said."(13)

It is equally important for ophthalmic surgery to be of the highest quality.(14)

Local doctors are often left to deal with complications following low quality surgeries, which is both time-consuming and a financial burden to the local clinics. What do local surgeons generally want? Instead of an overwhelming team of 45 visiting doctors, "they would like to see a small team of experts who would teach their Chinese counterparts new techniques. They would also like some help with equipment purchases and financial support to developing a [local] team of Chinese surgeons. They note that the hospital surgeons already perform hundreds of such surgeries a year for paying patients."(15)

While some countries have regulations designed to encourage continuity of care after visiting providers have left, most developing nations do not have the infrastructure to support such regulations.(16) Thus, the burden of ensuring high quality, comprehensive, continued care lies with the foreign medical providers.

Another downside to short-term surgical missions is their wastefulness.

“Burnham's concern is echoed by other critics of medical volunteerism, who charge international volunteers with providing substandard care and squandering millions of dollars that could be put to better use by local authorities. 'I have seen professors from fancy American universities teaching endoscopy skills in Laos to internists who don't have access to an endoscope,' said Dr. Christian Dupuis, a Belgian plastic surgeon who has volunteered in Southeast Asia for two months each year since the 1970s."(17)

It is important to realize that those hit hardest by the dangers of surgical safaris are those who can least afford to correct such damage. 

“The other groups active in the field were service clubs, many of which held eye camps on a commercial basis. The poor, rural cataract patients were the worst affected, as much of the cataract surgery was sub-standard. Most damaging was the absence of post-operative services for the patients operated on in eye camps and many became blind due to post-operative complications. We have treated many eye camp patients like this at our Hospital’s outpatients’ department (OPD). The provision of post-operative care for the patient is not only essential for good service delivery, it must also be viewed as an individual human right. Eye camp organisers generally did not offer proper post-operative care. Why was this the situation?

• People were not properly advised or educated
• They were not aware of their needs
• They were not informed as to how they should maintain their eye health
• People are poor and totally unaware of their rights.”(18)

Worst Practice: Contaminated and Expired Medication

 “Expired drugs (at the time of their arrival) and drugs close to expiry still comprise a large proportion of donations from nongovernmental organizations, corporations, pharmaceutical industries and associations. This practice is defended by a sad assertion that making use of expired, partially degraded drugs is better than having none at all. It obviously raises an ethical issue about the existence of first-hand/first-class drugs and second-hand/lower-class drugs and a disturbing division between the rights and worth of different populations. Some entities seem to find it legitimate to send unusable drugs to nations which are not prepared to dispose of them safely and properly. The recipients receive the drugs as donations and instead are obliged to manage them as waste.”(19)

Global health NGOs and nonprofits rely on donations of health care supplies to facilitate medical care abroad and ease financial burdens. However, not all donations are useful, and contaminated or expired medications can be particularly dangerous.   Unfortunately, well-intentioned but inappropriate donating can “turn developing world hospitals into dumping zones for pharmaceutical junk, sent on the basis of “anything must be better than nothing.”(20)

Such donations are not only wasteful, but potentially dangerous. Expired medications often degrade into toxic substances, and lowered drug efficacy may lead to patients receiving incorrect or ineffective dosages.(21) With regards to ophthalmic surgery, the post-operative use of ineffective expired drugs can lead to infection and the consequent loss of vision.(22) Substandard and contaminated drugs yield the same effects. Particularly with antibiotics, expiration and contamination can not only harm patients, but contribute to the ever-worsening global problem of microbial resistance.(23)

Expiration dates are not the only factor to be considered before donating drugs. Pharmaceuticals that are unfamiliar to local medical providers are useless, as are drugs that have not been properly labeled or stored.

“A World Health Organization audit of Albania in 1999 noted that 50% of donated drugs were inappropriate or useless and would have to be destroyed. Two thirds were due to expire, and one third were identified by brand names unfamiliar to Albanian health workers. In 1991 Pharmaciens Sans Frontières, a charity that sends pharmacists to developing countries, found that only 20% of the 4 million kg of drugs collected from 4000 French pharmacies for international aid programmes could be used. The rest of the drugs had to be burnt in a complicated and costly way to comply with international law.”(24)

“Although the act of donating drugs may seem philanthropic—and often genuinely is—the effects of inappropriate donations or “dumping” can be downright dangerous on the receiving end. When developing countries receive pharmaceuticals or even cosmetics with labels in languages they don’t understand, the results can be disastrous. Without proper labeling, it’s difficult for recipients to tell hemorrhoid cream from toothpaste, lip balm from suppositories.

And when well intentioned but inexperienced parties, such as church or service groups, collect pharmaceuticals and aren’t cognizant of dating, refrigeration, and humidity-control issues, there is plenty of room for error. Even when qualified medical entities are involved, shortcuts sometimes are taken around normal procedures, out of the desperation that results from dire circumstances in the recipient country. And it’s the patients who suffer, as they’re put at risk by expired, inadequate, or inappropriate drugs. Not only do they sometimes receive substances that aren’t right for their symptoms or are dangerous, but the presence of the unsuitable drugs can eliminate the desire to search for better alternatives.”(25) 

Inappropriate pharmaceutical drug dumping has not gone unnoticed by the World Health Organization, which has responded by creating guidelines for proper donations.(26) The core principles of proper donations are:

1. Maximum benefit to the recipient
2. Respect for wishes and authority of the recipient
3. No double standards in quality
4. Effective communication between donor and recipient

The WHO goes on to specify donation protocol, emphasizing that drug must not expire for at least a year after donation; packaging and labeling must be clear, complete and accurate; generic drug names must be included to ensure universality; and all donations must be “based on an expressed need and be relevant to the disease pattern in the recipient country. Drugs should not be sent without prior consent by the recipient.”(27)

Worst Practice: Bringing Unneeded Equipment

Special attention should be paid to the WHO donation guideline regarding expressed need; distant donors are not aware of local needs, and unsolicited donation of any and all medical supplies is costly, wasteful, cumbersome, and rarely helpful.

“Recipient hospitals often cannot use the donations because they do not serve their needs. And worse, unsolicited donations commonly cause additional problems for the recipient hospitals, creating storage problems or necessitating the disposal of medical garbage.”(28)

“Another hospital I visited had received funds specifically donated for the construction of a new wing, even though their greatest need was a rebuilt sewage and electrical system. Had the donor not directed the funds, the hospital could have spent the money much more productively. Large donations may make the donor feel warm and fuzzy, and entitled to decide on the use of the money. Unfortunately, that doesn't always lead to the best use of desperately needed funds. Donors are not always aware of current needs.”(29)

Go To Module 10: The Importance of Doctors Working Together >>

Footnotes

Community Eye Health Online Course

• Table of Contents
• Module 1
• Module 2
• Module 3
• Module 4
• Module 5
• Module 6
• Module 7
• Module 8
• Module 9
• Module 10
• Module 11
• Guidelines For Evaluating Eye Care Work