“Our experience with the traditional ‘screening model’ in which low level eye care workers identify patients with visual impairment and refer them on for more definitive care is that very few patients follow that advice. Furthermore, because their diagnostic skills are limited, these health workers may turn away all but the most advanced cataract patients and refer irreversibly blind patients for surgery, resulting in inconvenience and disappointment.”
This excerpt, taken from a 2005 article reviewing experience from two rural cataract surgery programs in east Africa, resonates with me as I ruminate over the news that our new group of local volunteers just returned from the second implementation of SEER Project, exactly one year after we had launched it for the first time. Two key differences about this year’s project. First, although my generous funding through Swarthmore’s Lang Center had expired with my graduation, we were able to secure funding from Google through their Fifth Annual Social Entrepreneurship Competition. Second, for a number of reasons, I was unable to return to China this summer, and was limited to coordinating via email and skype–which meant that all of the on-the-ground preparation and implementation was carried out by the local volunteer team and driven by one especially dedicated and amazing returning team member. Bravo to their efforts.
Now that they’ve returned from the internet black hole that is rural China, I’m looking forward to hearing details of their trip–mostly about the successes they had, but also about the challenges they faced. And if past experience is any indicator of the present state of affairs, I’m willing to bet certain challenges intrinsic to a Village Health Worker-driven screening model will remain, which brings me back to the opening excerpt of this post:
1. Only a minority of patients will follow the screening advice. It’s usually bad taste to cite oneself, but since it’s the only published figure from the region I could find: it appears that only about 30% of patients referred for cataract surgery ultimately show up at the hospital–and that’s for screenings done by ophthalmologists, who have more credibility than VHWs.
2. Not all of the patient referrals will be accurate. It’s an unavoidable reality when personnel shortages require you to train VHWs with little understanding of the myriad eye diseases that can make a cataract patient “unfit for surgery”. Based on numbers from last year, about half of the patients referred by VHWs were not deemed eligible for surgery, either because the cataract was not “mature” enough yet for the doctors to feel comfortable operating, or because another eye condition (like diabetic retinopathy) had already done significant permanent damage to the retina, making removal of the cataract pointless.
These challenges can be incrementally reduced by improving the quality of training, clarifying criteria for referral, exploring innovative ways to build trust between VHWs and villagers, etc. I’m hoping that the successful completion of this year’s program, led and implemented by local volunteers, represents a promising first step toward more opportunities to do all of the above in the future. But above all, the SEER program was never designed to replace the ophthalmologist-led outreach screening sessions, only supplement it. Unfortunately, with the end of the funding for the pilot outreach program that was started back in 2010, we’re already starting to hear from some of the hospital directors that they plan to stop carrying out screenings.
Which would be a real shame, considering that they haven’t yet reached what I believe to be their full potential, exemplified by the extensive programs by hospitals such as Aravind and Sankara Nethralaya in India, which can reach surgical volumes of 300-400 patients. A day. And while I still remember hospital directors from two years ago telling me that the India model will never work in China because China is “different”, I think the difference begins in the attitudes held by those with the power to do something about it. “Clinicians are part of the teams in the field and at the hospitals, but they are not expected to run the programmes,” writes the article about the two east African programs. It was the same in India, where they had entire staff and project managers dedicated to reaching out to community partners and working to make sure every day on the calendar was filled with patients ready for surgery. In China, it’s done by already-overworked (and undercompensated) doctors, doctors who were probably the first to advocate for putting the screening programs on the chopping block.
The sense that I get is that the hospitals in China dipped their toe into the waters of community eye care, were skeptical of the initial results, and jumped right back on land. Unlocking the full potential of outreach screening programs would require going the whole nine yards: hiring specific program management staff, clearly defining separation of responsibilities, setting up regularly scheduled screenings (instead of doing it “when patients run out”, as is currently done), and fostering a network of community partners with direct access to the patients who can play a counseling and follow-up role–VHWs, for example. We’re currently working on writing up an analysis of focus group research exploring ways to improve the success of a rural cataract surgery program. No spoilers here, but I’ll just mention that while the surgeons are still the most important part of any cataract surgery program, much more attention will need to be focused on the role of hospital management and non-physician personnel.