Last Sunday, I touched down in Chengdu, capital of Sichuan province (home of the hottest food in China), to join a team from the Dean McGee Eye Institute (DMEI) planning to launch a blindness prevention program in Sichuan province. The team consists of two senior ophthalmologists who have established close connections to two major hospital systems in Chengdu; a business team of undergraduates from Oklahoma University working on an effective and sustainable prevention model; a group of senior residents and practicing doctors to provide clinical guidance; and one very capable Harvard MPH grad who’s helping to bring everything together.
Being with new faces brings fresh perspectives on an old problem. And my experiences and conversations in just these last few days have led me to reflect a lot on what I saw last summer, and what I’ve read in the literature, to slowly bring into focus the immensely complex picture of blindness in China.
Based on 2002 estimates, the number blind in China was around 5 million, or 18% of the world’s blind, with cataract cause approximately half. By 2008, the backlog of cataract alone in China had reached an astonishing 7.8 million. The bulk of the burden of cataracts in China lies in its rural regions, which makes the county hospital the most logical level from which to tackle the problem. However, through discussions and reflections in the last two days, there are two major bottlenecks I can identify which bar us from eliminating the backlog of cataracts in China.
First is a question of capacity. From experiences in Guangdong last summer, the ophthalmic department of one county hospital consisted of two overworked surgeons who not only had to do surgeries but also hold outpatient hours, conduct screening in remote places, and write patient charts (which were “the most time consuming of all”, as they often remarked). Their hospital hovered around 500 surgeries a year. As we discovered today, even a highly proficient county doc (15-min cataract extractions!) in a well-off hospital with assistants writing all of the patient charts could only reach 1000 surgeries per year. Based on current estimates, to eliminate the backlog of cataracts in Sichuan by 2020 would require each hospital to complete 3000 surgeries a year. At least.
Sometimes the capacity problem is one of better equipment. Sometimes it’s the fact that ophthalmic residents can graduate in China without ever having done a surgery independently.
Second, and I think more importantly, is the question of patient demand. The only way to make cataract surgery affordable AND profitable is to tap into the vast patient demand and achieve high volumes. There’s an interesting contradiction that I’ve been trying to reconcile since my experiences last summer. If you look at prevalence studies, they consistently indicate that the burden of cataracts is there. Yet county hospitals continue to struggle when it comes to boosting surgery volume. County docs will tell you that most patients are aware of the disease and the services, and that cost is the major limiting factor holding them back. Yet epidemiological studies note that cost isn’t a significant factor, while knowledge and awareness are more often the stumbling blocks.
The thing is, county docs are likely only seeing those patients who have self-presented to the hospital for treatment. Prevalence studies instead rely on a method of recruitment that minimizes bias—door to door enumeration.
I don’t think we’re digging deep enough. Even with current screening efforts, we may be only getting patients who are already quite knowledgeable about eye health and turn up for a quick ticket to the hospital. Patient recruitment is often a black box to us, the effectiveness of which hinges upon a hospital’s relationship with local organizations who assist in finding potential patients. I think we need to get closer to the grassroots—something that’s often a little scary in the top-down driven culture of China. And perhaps equally frightening to a society based in theory upon socialist principles, I think we need better marketing.
(Will post pictures once I steal them from friends’ cameras.)