What are the unintended consequences of outreach projects, and how can they be avoided?
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‘Mission’ model vs. training and engaging local physicians
I do not like, and have never participated in, programs in which outside physicians come in with a team to cure lucky cataract patients in a low-resource country without engaging the local physicians.
This has been described as a “mission” model. To be clear, these interventions do transform many lives in places where no other care is available, but some have argued that these short-term outreaches have little long-term effect on overall blindness in a country. Perhaps, but they do restore sight to many people who would have otherwise died blind. The people they cure are no longer a statistic; they are 100% able to see, and their lives are restored. However, this type of program has the potential to create problems. There can be complications that either cannot be handled locally after the team leaves or require extensive effort and cost to local doctors. Mission trips can dissuade patients from seeking care locally or impair the cost recovery and sustainability of local ophthalmologists. It can perpetuate visual impairment if it leads to patients waiting for Western doctors to return and provide free care.
In the last 20 years, ophthalmic services have spread to almost every country. At the least, future mission trips should seek to partner with local physicians, teach and leave resources so work can continue after they leave.
Our program, HCP Cureblindness (formerly Himalayan Cataract Project, www.cureblindness.org), began doing high-volume cataract outreaches in Nepal in the early 1990s. The program was started and led by Nepali ophthalmologist Sanduk Ruit. We developed techniques and protocols that enable us to provide high-quality cataract surgery to more than 1,000 people in a week with four or five operating microscopes and an excellent team. We utilize these large programs as a teaching resource. Senior residents often perform 50 to 100 cases under supervision in a single week. Even the poorest of the poor recognize quality. Done well, these outreaches not only improve quality of care but also spread the word that a person does not need to remain blind. This leads other patients to seek care. In conjunction with the cataracts, we screen for all eye diseases and refer to hospitals when appropriate.
Since 2006, we have spread our methods of teaching and eye care development in Asia and brought our system to sub-Saharan Africa. These high-volume training cataract outreaches provide great training opportunities for residents and young physicians as well as support staff and incredible joy to communities. Our program has provided more than 1 million cataract surgeries over the past 28 years but more importantly has trained and supported local doctors who have done millions more.
Geoffrey Tabin, MD, is co-founder and chairman of the Himalayan Cataract Project, now HCP Cureblindness, and a professor of ophthalmology and global medicine at Stanford University.
Unsustainable technology vs. focus on local eye care
Despite good intentions, global outreach projects can undermine the sustainability of the local eye care systems and local providers, not allowing them to grow.
In many situations, the patients will be waiting for us, “the American doctor who does surgery for free,” instead of consulting the local ophthalmologist. This creates unfair competition, with local doctors resenting us rather than developing the trust that is necessary to team up and cooperate toward the common goal of eliminating reversible blindness. Instead of using and supporting care that may be already in place, by continuing in these types of mission trips, we may set a precedent that cannot be followed by local providers, making patients dependent on foreign care.
Often during our short-term trips, many times we bring donated IOLs, medications and surgical equipment. In countries that are manufacturing their own products, this may take away from the local economy with local companies that may be manufacturing and selling these products, not allowing them to further build their own capacity. In India or Nepal, for instance, IOLs are manufactured at a fraction of the price compared with the U.S. or Europe. If visiting doctors would have kept bringing donated lenses that normally cost hundreds of dollars, there would have never grown a local economic incentive to develop a sustainable and affordable IOL locally. Whenever possible, we should purchase and use local products to support the local economy and help promote local economic growth. This way, we are not only helping those in need but also supporting the local economy.
When we provide donated equipment, we should also carefully consider how useful and sustainable this equipment is in a specific environment. I have traveled to many countries where I saw the most up-to-date equipment sitting in a corner of the hospital unused because either the surgeon had not been properly trained on how to use it or there was no ability to service the equipment, many times because the medical engineers had not been trained on it or no representative for that donated equipment’s company was available in the country to service.
Overall, I believe we can be more involved in helping develop local eye care systems. Questions to consider: Are surgeons trained to perform phaco? Do local hospitals have the supplies, equipment or even regular electric supply to support phaco and other machines? What medical equipment can we provide that can be locally maintained and serviced? Based on this, we can also decide what kind of training we should provide for local surgeons. Manual small-incision cataract surgery is often a more sustainable procedure than phaco and helps with training of whichever technique is more applicable. We should look at the surgical outcomes of the local surgeons and then focus on what needs to be improved, providing education on specific techniques or assistance with recognizing and managing potential complications. We can also assist with continuing medical education; instead of us traveling to other countries, we can bring those local surgeons to our country for further training through a mini-fellowship or mini-observership to learn a specific surgical technique, and then we could travel to their country in a more supervisory role when they perform these newly learned surgical techniques on their own patients.
Soroosh Behshad, MD, MPH, is an associate professor at the University of California, Irvine.
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