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Equality in vision care still a long way off

Humanitarian, researcher, and academic Dr Jacqui Ramke gave a lecture at the University of New South Wales as part of the School of Optometry and Vision Science’s Vaegan Seminar series.

She is currently in the UK on a Commonwealth Rutherford Fellowship at the London School of Hygiene & Tropical Medicine. She is also a contributor to the Lancet Global Health Commission on Global Eye Health, is involved in setting the priorities of the Cochrane Eyes and Vision group, and is a Technical Working Group member helping develop the World Health Organization’s (WHO) Package of Comprehensive Eyecare Interventions.

This follows on from her previous work in Indigenous communities throughout the Northern Territory and Timor Leste. She has also spent more than 10 years managing programs for non-governmental eye health organisations across the Asia-Pacific region.

Her research is focused on equity in eye health, particularly in low and middle-income countries and between the sexes. The topic is close to her PhD research, which used epidemiological and health systems research to promote equity in eye health.

The reality

Globally, three out of every four people living with blindness or vision impairment (VI) ‘only’ have cataract or uncorrected refractive error, both treatable conditions. Treatment is affordable, even when those affected reside in low and middle-income countries.

Furthermore, for a whole range of poorly understood reasons, women and other marginalised groups experience barriers to accessing good, and in many cases any, eyecare.

In 2015, most countries, including Australia, agreed to a set of sustainable development goals that aim to ‘leave no one behind’. For that to be achieved in eye health, better evidence is needed on how to improve access to eyecare for everyone. In essence, adequate eyecare is an integral part of universal health coverage, something that has yet to be achieved in most countries.

Although inroads have been made into rates of blindness and VI, population growth rates are outstripping progress. While numbers are currently stagnant, they are expected to deteriorate in the longer-term if further interventions are not forthcoming.

On a global scale, 89% of vision loss is in poorer countries. Almost universally, female eyecare lags behind what is provided to males. This leads to, among other things, lower economic status, reduced independence, reduced societal contribution, and lower social capital. Marital status is used as a proxy for social capital in some studies and, generally, the unmarried are treated inequitably.

Social groupings also often reveal divides in access to eye health care services. For example, 88% of the white Australian population have ready access to cataract services, whereas the figure for indigenous people hovers around 52%.

Research to quantify efforts and outcomes are underway, but according to Ramke more work is still needed. Other problems that are still poorly understood include failure to attend services even when appointments have been made, and long delays before re-appointments. Exactness of appointment and phone access have already been shown to be relevant factors.

Expected standards of treatment exist and the quality of interventions involving cataract surgery is guided by a WHO Quality Framework. Other research was undertaken by the Queen Elizabeth II Trust-funded Community Eye Health Consortium, which was operated from 2014 to 2019. Inequity remains an entrenched problem, and the current figure of 30% for female participation in eye health programmes shows there is still a long way to go.

Interestingly, Ramke gave similar figures (34%) for the percentage of female authors in the prestigious health journal Lancet. The International Agency for the Prevention of Blindness is currently looking at population and authorship representation in major journals and it set up a Gender Equity Working Group in 2018.

By Lewis Williams

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