Optometry (2008) 79, 464-471
Volunteer-based vision nongovernmental organizations and VISION 2020 Matthew Gordon Pearce, O.D., M.P.H. An-Najah National University Faculty of Optometry, Nablus, West Bank, Palestine. KEYWORDS Public health; Voluntary workers; Delivery of health care; Nongovernmental organizations; World Health Organization; Vision 2020; Volunteer eye care
Abstract BACKGROUND: The World Health Organization and the International Agency for the Prevention of Blindness developed the global initiative, VISION 2020, with the goal of eliminating avoidable blindness by 2020. An unknown number of volunteer-based organizations conduct short-term vision camps as a means of eliminating blindness in developing countries. METHODS: VISION 2020 strategies are reviewed and volunteer organizations’ understanding of VISION 2020 and methods of service delivery are considered through survey results. RESULTS: From the surveys it is apparent that volunteer organizations are not aware of the VISION 2020 initiative and do not conduct their projects and programs in a way that is supported by VISION 2020. CONCLUSION: Volunteer organizations have the skills, resources, and enthusiasm to make an impact on the burden of visual impairment. They do not, however, follow strategies accepted as most appropriate by the larger global eye health care community. Volunteer organizations are encouraged to reprioritize the work they do and change the methods they use. Optometry 2008;79:464-471
Visual impairment is an often overlooked public health problem. It is estimated that 7 million new cases of blindness occur annually, creating a net increase of 1 million to 2 million blind each year.1 The prevalence of low vision is estimated to be compounding at a rate of 5% per year.2 It is estimated that 314 million people in the world are visually impaired—with 45 million of them blind.3,a Of these, 153 million are visually impaired because of uncorrected distance refractive error, and millions more are affected by uncorrected presbyopia.3,4
Corresponding author: Matthew Gordon Pearce, O.D., M.P.H., 230 E. Ponce de Leon Ave., #115, Decatur, Georgia 30030. E-mail:
[email protected] a The World Health Organization defines low vision as visual acuity of less then 6/18, but equal to or better than 3/60, or visual field loss to less than 20 degrees in the better eye with best possible correction. Blindness is visual acuity of less than 3/60 or visual field loss to less than 10 degrees in the better eye with best possible correction.3
Refractive error was overlooked previously in prevalence data because of the definition of visual impairment.5 Visual impairment is defined using best-corrected visual acuity.6 Recently, there has been a shift to measure the prevalence of blindness and low vision with entering visual acuities. This reflects the vision that individuals use in their day-to-day activities.7 It shows whether individuals are going through life with functional visual impairments caused by uncorrected or undercorrected refractive errors.5-8 If visual impairment was defined using entering visual acuity, refractive error would be the second leading cause of blindness and one of the most common causes of low vision in many parts of the world.6 More than two thirds of blindness is avoidable,1,9 whether is it preventable with cost-effective interventions or reversible.1 Developing countries share an unequal burden of visual impairment, with prevalence rates 10 to 40 times greater than those in developed countries10 and contain a full 90% of the world’s visually impaired population.11
1529-1839/08/$ -see front matter © 2008 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2007.10.016
Matthew Gordon Pearce
Public Health
There are 3 main reasons for the high prevalence of avoidable visual impairment: 1) Global disparity and inequity in the availability of eye care services12,13 2) Economic barriers to eye care services14 3) Lack of knowledge in relation to the importance of eye care services15
VISION 2020 To address the global burden of visual impairment, the World Health Organization (WHO) and the International Agency for the Prevention of Blindness (IAPB), a group of 46 international nongovernmental organizations (NGOs) working in blindness prevention, launched a global initiative called VISION 2020 in February 1999. The goal of VISION 2020 is to eliminate avoidable blindness by the year 2020 via 3 major objectives: 1. To raise awareness of the causes of avoidable blindness and their treatment among key audiences. 2. To identify what resources are needed to increase prevention and treatment programs available. 3. To facilitate the planning by national programs of the 3 core strategies.16
Strategies The initiative outlines 3 core strategies necessary for the elimination of avoidable blindness (see Table 1): 1. Disease control: facilitate the implementation of specific programs to control the major causes of preventable blindness (cataract, trachoma, onchocerciasis, childhood blindness, and refractive error). 2. Human resource development: support the training of eye care personnel. 3. Infrastructure and technology development: improve infrastructure and technology, thereby allowing eye care to be more accessible.16 VISION 2020 is an international framework for planning at the national level and implementation at the local or district level. Nations are to develop their own specific plan
465 using VISION 2020 as a template. A primary health care approach to blindness prevention is encouraged.16 Even before the development of the VISION 2020 initiative, optometrists and ophthalmologists from industrialized countries recognized that there were availability and economic barriers to eye health care in many developing countries. To address these barriers, they founded volunteer-based, nongovernmental vision organizations (referred to in this report as volunteer organizations) with the objective of providing eye health care to populations that otherwise would have no access. These volunteer organizations claim they have a “responsibility to share [their] skills”17 and feel that they have great potential to take the lead in combating the noncommunicable preventable causes of blindness.18 Traditionally, these organizations travel to communities for short-term vision camps. These camps can range from the provision of refractive care to nonsurgical and surgical treatment of ocular disease. IAPB member organizations have also been active in the development of visual impairment prevention and treatment projects and programs. They are not identical in their objectives, membership, or organizational structures, but the overall objective, to decrease the burden of avoidable blindness, is common among all of the organizations.
Purpose No literature was found that attempts to list the number and types of organizations working on visual impairment prevention and treatment in developing countries. It is not known if volunteer organizations make use of the strategies outlined in VISION 2020. The aim of this study is to attempt to determine volunteer organizations’ understanding of VISION 2020 and the appropriateness of their interventions when considered from a public health standpoint. It also provides indicators, developed from a public health viewpoint, against which volunteer organizations can be judged and concludes with recommendations for volunteer organizations.
Methods Table 1
Core VISION 2020 strategies
1. Disease control a. Focus on 5 priority diseases i. Cataract ii. Trachoma iii. Onchocerciasis iv. Childhood blindness v. Refractive error 2. Human resource development 3. Infrastructure and technology development
This study was granted institutional review board (IRB) approval by the Emory University IRB. Because of the absence of literature in relation to volunteer organizations, a Web search was conducted to identify volunteer organizations active in global eye health care. Organizations that use volunteers in their projects and programs and expressed a desire to aid in the elimination of avoidable blindness in developing countries were included. A 46-question survey was developed, modeled after surveys evaluating medical supply donations and donators.19,20 Key areas of questioning included the organiza-
466 Table 2
Optometry, Vol 79, No 8, August 2008 Demographics and objectives of the respondent voluntary organizations
Organization
Age of organization (yr)
Number of members
EyeCare WeCare Foundation
5
8
Global Health Cares
3
3
The New England College of Optometry Student VOSH Voluntarios de Santa Cruz
⬎20
20-25
6
400
VOSH California
?
50
VOSH Colorado
?
8
VOSH Indiana
33
100
VOSH Michigan
24
200
VOSH Minnesota VOSH New England Council of Optometry
30 15
100 75
VOSH Northwest
?
60
VOSH Ohio
?
30
15
30
VOSH Wisconsin
tion’s objectives, understanding of VISION 2020, project and program logistics, and geographic areas of work. Surveys were sent via e-mail to 51 volunteer organizations. Of these 51 organizations, 8 e-mail addresses were no longer functioning, and no other e-mail address for these organizations was found. Three e-mails, over a span of 4 weeks, were sent to the remaining organizations to encourage response. Returned surveys were evaluated qualitatively and quantitatively (frequencies).
Results At the end of 4 weeks, 13 surveys were returned (30% of valid e-mail addresses; see Table 2). Of the volunteer organizations that responded to the survey, 7 (54%) stated a familiarity with VISION 2020 (Global Health Cares, New England College of Optometry Student Volunteer Optometric Services to Humanity [VOSH], VOSH Indiana, VOSH Michigan, VOSH Minnesota, VOSH New England Council of Optometry, VOSH Ohio); however, only 5 of those 7 organizations indicated that they took steps to familiarize their membership about the global initiative (Global Health Cares, VOSH Indiana, VOSH Michigan, VOSH New England Council of Optometry, VOSH Ohio), and only 2 (15%
Objectives To provide free vision services to the rural poor in developing countries To bring improved health care and health care infrastructure to developing nations around the world To provide eye care to underserved populations in developing countries To provide free exams and give prescription eyeglasses to the needy in developing countries free of charge To provide free eye care to indigent populations in third world countries To provide free health care and glasses to the underprivileged To provide eye care to people in third world countries To treat eye diseases and dispense eyewear to impoverished individuals worldwide To provide free eye care to third world countries To provide free eye care services and solutions (glasses/meds/education) to needy populations around the world To provide eye care to those that cannot afford or is unattainable To provide vision care to people who do not have access to vision or cannot afford it To provide eye care and eyewear to third world countries
of total) could list the 5 priority eye diseases of VISION 2020 (New England College of Optometry Student VOSH, VOSH Ohio). When presented with a list of the core strategies as outlined in VISION 2020, 3 organizations (Global Health Cares, EyeCare WeCare and VOSH NECO) stated that they were active in all aspects of VISION 2020. VOSH Michigan indicated it was active in disease control. The rest indicated that they were not active in any of the 3 core strategies or were unable to answer because of a lack of familiarity with the initiative (see Table 3). None of the surveyed organizations were active in a VISION 2020 national program, nor could they state if the countries they were working in had developed a VISION 2020 national program.
Work with priority diseases The first strategy encouraged by VISION 2020 is disease control, which is focused on 5 priority diseases. Three organizations (VOSH Indiana, VOSH Michigan, and EyeCare WeCare) indicated that they provide care for those visually impaired from cataract; VOSH California and VOSH Ohio refer cataract patients to a local surgeon. VOSH NECO purports to treat all ocular conditions.
Matthew Gordon Pearce Table 3
Public Health
467
VISION 2020 core strategies being addressed by the organization
Organization EyeCare WeCare Foundation Global Health Cares The New England College of Optometry Student VOSH Voluntarios de Santa Cruz VOSH California VOSH Colorado VOSH Indiana VOSH Michigan VOSH Minnesota VOSH New England Council of Optometry VOSH Northwest VOSH Ohio VOSH Wisconsin
Disease control
Human resources development
Infrastructure and appropriate technology development
X X
X X
X X
X X X X X X X
X
Percent of distributed spectacles that are recycled
Organization EyeCare WeCare Foundation Global Health Cares The New England College of Optometry Student VOSH Voluntarios de Santa Cruz VOSH California VOSH Colorado VOSH Indiana VOSH Michigan VOSH Minnesota VOSH New England Council of Optometry VOSH Northwest VOSH Ohio VOSH Wisconsin
Percent of distributed spectacles that are recycled 100 N/A 75 75 0 98 95 90 99 5-10 80-90 50 95
Unsure
X
All organizations bring topical medications with them to treat various cases of conjunctivitis and keratitis. Many also bring glaucoma medications and lubricating eye drops. These medications are distributed to those who need them until the supply is exhausted. Seven of the surveyed organizations indicate that there is a system in place to refer patients requiring further care. This often involves providing a list of the names of those requiring referral to the host organization. It is then the responsibility of the host organization to make the appropriate contacts and referrals. VOSH California provides patients who need further care with the name, phone number, and address of a local ophthalmologist. None of the organizations indicated that they treat trachoma specifically, although most provide treatment for infections of which trachoma, presumably, is one. Trachomainduced trichiasis and onchocerciasis are not specifically addressed by any of these groups. Childhood blindness is not addressed specifically by any of these groups aside from treating refractive error in children (all).
Table 4
None
X X X X
All organizations surveyed, except Global Health Cares, treat refractive error, and 11 of the 12 remaining organizations use recycled spectacles to some extent. VOSH California is the only organization that indicated it uses new spectacles for all of its patients. VOSH NECO gives out recycled spectacles only 5% to 10% of the time. The rest of the organizations use recycled spectacles from 50% to 100% of the time, with the majority using recycled spectacles in excess of 75% of the time (see Table 4).
Human resource development The second strategy encouraged by VISION 2020 is to develop human resources. Two surveyed organizations specifically work in the area of human resource development (Global Health Cares and EyeCare WeCare), and 6 other organizations have worked alongside local practitioners (ranging from optometrists and ophthalmologists to general physicians, opticians, and optometry students) in some of their vision camps. VOSH Ohio, VOSH NECO, VOSH Indiana, VOSH Michigan, and EyeCare WeCare have trained local practitioners during some of their vision camps. VOSH Ohio has worked with local optometry students. VOSH NECO has provided basic education and training on what ocular conditions need referral for surgery and the treatment of ocular emergencies. VOSH Indiana has trained a local physician to do post– cataract surgery follow-ups. VOSH Michigan has trained local general practitioners in the use of an automated refraction device and basic spectacle dispensing as well as the treatment of ocular infections. EyeCare WeCare has trained local Filipino ophthalmologists to do surgery.
Infrastructure development The third VISION 2020 strategy is to develop an eye care infrastructure to promote sustainable eye health care. Despite the difficulties of infrastructure development, 6 of the surveyed organizations (46%) have developed permanent
468 Table 5
Optometry, Vol 79, No 8, August 2008 Volunteer organizations’ partner organizations
Organization
Public or private organizations*
Global committees/ groups/associations†
EyeCare WeCare Foundation Global Health Cares The New England College of Optometry Student VOSH Voluntarios de Santa Cruz VOSH California VOSH Colorado VOSH Indiana VOSH Michigan VOSH Minnesota VOSH New England Council of Optometry VOSH Northwest
Kiwanis Clubs Nicaragua Ministry of Health, Rotary Clubs Local NGOs or governmental organizations
None None VOSH NECO, VOSH/International
Lions Clubs, Rotary Clubs, Local host organizations Lions Clubs, Rotary Clubs, Other VOSH chapters Lions Clubs, Rotary Clubs, Kiwanis Clubs VOSH Honduras Lions Clubs, Rotary Clubs None Nicaragua Ministry of Health, Rotary Clubs
VOSH/International FUDEM None VOSH/International SEE, VISION 2020 None VOSH/International
Any organization willing to sponsor a mission is considered Lions Clubs, Rotary Clubs, Church groups Lions Clubs, Rotary International, Church organizations
VOSH/International
VOSH Ohio VOSH Wisconsin
VOSH/International VOSH/International
* These organizations were listed in response to the question: Does the organization work with any other organizations either public or private? † These organizations were listed in response to the question: Does the organization work within any larger global committees/groups/or associations?
clinics. Most are staffed by local health practitioners, but the provision of eye health care is often dependent on the presence of volunteers. VOSH Indiana in Honduras and VOSH California in El Salvador have developed permanent eye health care clinics that are open 6 days per week, year round. VOSH Michigan has also developed a permanent clinic in Honduras that is open 2 days a month. Many organizations leave their remaining recycled spectacles and medications behind after a vision camp.
Partnerships VOSH/International (the parent group for the VOSH chapters surveyed) partners with other organizations, such as the World Council of Optometry and Lions clubs, but strives to maintain independence, stating it “should create its own light, rather than pale in the shadow of others.”21 None of the volunteer organizations surveyed work in conjunction with the organizations on the VISION 2020 taskforce; however, they work alongside service organizations in North America and in the countries being visited. These organizations include Lions, Kiwanis, and Rotary clubs. These clubs often are the source of recycled spectacles and act as the host organizations within the developing country. Other organizations that partner with the surveyed organizations include church groups and regional NGOs within a country (see Table 5).
Conducting research The volunteer organizations surveyed do not publish in peer-reviewed journals. Program evaluation has only been
done by VOSH California and was not available for analysis.
Advocating for eye care The volunteer-based organizations surveyed did not indicate that they work on advocacy issues.
Discussion The 51 organizations identified are a small sample of volunteer organizations active in the treatment and prevention of visual impairment. In addition to the small sample, the poor survey response rate makes extrapolation to all volunteer vision organizations active in the developing world impossible. The above results are important because there has been no previous data published on volunteer organizations’ understanding of VISION 2020. Experience indicates that most volunteer organizations use similar methods to those of the respondents. Personal communication with other researchers has also revealed that volunteer organizations have been reluctant to respond to surveys in the past, thereby limiting a broad understanding of their methods, goals, and understanding of VISION 2020. These results will serve to frame the discussion of volunteer organizations’ work in vision care in the developing world. Further study on their methods and results is encouraged. Responding organizations are predominantly VOSH/ International affiliates. This could be because VOSH chapters tend to be very active and dedicated to the elimination of avoidable blindness and are, therefore, more likely to respond to a survey. In addition, they have a strong presence
Matthew Gordon Pearce
Public Health
on the Internet, making it more likely that they can be contacted more easily than other less active, smaller volunteer organizations. It is important to note that each VOSH chapter is independent of the others. One of the goals of VISION 2020 is to have all nations and organizations concerned with blindness and low vision act in a coordinated effort on the same set of strategies. It is, therefore, important that all visual impairment prevention organizations be familiar with VISION 2020. The respondent organizations, while expressing familiarity, were unable to outline the basics of the initiative, such as naming the priority diseases and indicating in which of the 3 core strategies they were active. This indicates that the message of VISION 2020 has not been heard by the volunteer organizations or that they have chosen not to work within the VISION 2020 framework. The idea that vision camps do not aid in reaching the larger goal of developing access to local, sustainable vision care is appropriate. Yorston22 notes that the work of volunteer NGOs often takes place outside of national VISION 2020 programs. Berger and Nnadozie23 point out that vision camps help only those served but do little to enhance local capacity. The respondent organizations work outside of national VISION 2020 programs as they are unable to indicate if the countries they work in have developed national VISION 2020 strategies. Furthermore, they do not make the enhancement of local capacity a priority. Yorston22 encourages these organizations to not only continue working toward blindness and low vision prevention but to change the way they work, becoming involved in the development of national programs and services,22 whereas Berger and Nnadozie23 encourage the volunteer organizations to partner with educational institutions and work with or establish new national blindness prevention committees. The public health philosophy encouraged here, and echoed in VISION 2020, recommends a shift from an “approach of ‘do unto communities’ to do ‘with communities.’”24 Despite not being able to name the 5 priority eye diseases in VISION 2020, the volunteer organizations work predominantly with the 2 largest causes of preventable blindness: refractive error and cataracts. With regard to refractive error, the majority of organizations use recycled spectacles as treatment. Although the use of recycled spectacles has been a long-used strategy, it is discouraged by the WHO Refractive Error Working Group (REWG), and no study was found that supports its utility or benefit for patients. The WHO REWG describes the collection and distribution of used spectacles as a well-intentioned but not a cost-effective strategy. They raise quality control concerns, as well as concerns with patients not receiving spectacles that are correct for their refractive error. Importantly, the REWG points out that the use of recycled spectacles is not helpful in the development of a sustainable refractive error eye care system because it creates a dependence on outside sources.25
469
Indicators As communities and nations realize the importance of eye health care, they are presented with choices as to how they can offer these services to their populations. Communities should be assured that if a volunteer organization provides eye services, the long-term eye care interests of the community are protected. The following indicators were developed by looking at the VISION 2020 strategies. They can be used to evaluate the strategies used by volunteer organizations. If the organization meets these indicators positively, it is safe to assume that the organization will provide a service that will do more than meet an immediate need; it will also encourage the development of a sustainable eye health care system for the community and nation.
1. The volunteer organization follows the National VISION 2020 Plan The organization should have the core strategies and ideals of VISION 2020 as its guiding principals. The organization will be known by the VISION 2020 national program and will actively work with it to design and implement culturally and nationally appropriate strategies for the prevention and treatment of visually impairing conditions. Human resource and infrastructure development strategies must be complementary to disease treatment strategies. Disease treatment must concentrate on at least 1 of the 5 priority diseases that are of epidemiologic importance in the community and any other diseases of importance as decided by the national VISION 2020 program.
2. The volunteer organization cooperates with other blindness prevention organizations The volunteer organization should work with other established vision impairment organizations working in the same country or community. They should cooperate and share information important to the prevention and treatment of visual impairment. A willingness to combine resources when appropriate is encouraged. Uncoordinated public health interventions do not put scarce resources to the best use because duplication of efforts may occur.
3. The volunteer organization conducts needs assessment In coordination with the national VISION 2020 plan, the volunteer organization should conduct (or consult to) epidemiologic research to determine what causes of preventable blindness are of local importance. They should also determine what barriers to care exist in the community before beginning projects and programs.
470
4. The volunteer organization monitors and evaluates its projects and programs Most volunteer organizations currently judge their success subjectively. If the majority of the recipients of their care smile, or if the team is invited back for a future visit, the vision camp is deemed successful.26-28 Only 2 objective evaluations of volunteer organization efforts were identified from the last 20 years.29,30 Monitoring and evaluation must be an integral part of the volunteer organization’s projects and programs. Results of evaluations should be disseminated widely. If monitoring and evaluation finds that certain strategies are not working, the organization should be willing to adapt them to more appropriate strategies.
5. The volunteer organization seeks community involvement Input should be sought as to what the community thinks are important issues in the prevention of visual impairment. For example, questions such as “does the community desire rehabilitation services?,” “is refractive error correction acceptable?,” “if not, why not?” should be asked.
6. The volunteer organization educates community members The volunteer organization should place importance on the education of the community. This education can be delegated to trained local people, but a core aspect of the organization’s work should be the education of the public. Education should include such things as the importance of seeking eye care, the availability of eye care, who to seek it from, and the appropriate use of spectacles and ocular medications. Some of this education may take place during the provision of care but should also occur through social marketing schemes, public broadcasts, posters, and community eye health education meetings.
Optometry, Vol 79, No 8, August 2008 health care system in the country of interest and to determine if a new cadre of eye health care professionals needs to be created or if, with appropriate training, new responsibilities can be delegated to existing health care workers. This will require input from the national VISION 2020 program.
8. The volunteer organization does not use recycled spectacles or expired medications The organization should not use recycled spectacles or expired medications. The WHO has clear guidelines on the appropriate use of donated medications, and these guidelines must be followed by the organizations working in the prevention of visual impairment.31
9. The volunteer organization supports local eye health care providers Volunteer organizations should work with local eye care providers, improving their education, providing updated equipment, and ensuring that the work of the volunteer organization does not interfere with the viability of local opticians, optometrists, or ophthalmologists. Care must be taken to involve any local professional in the projects and programs being implemented within the practitioner’s catchment area.
10. The volunteer organization places importance on sustainability The volunteer organization should have as its primary goal the creation of a sustainable local eye care system. These organizations should look at themselves as short-term stopgap measures. Their job is to assist nations and communities in meeting eye health care needs while helping develop local human resources and infrastructure that will allow for a long-term sustainable eye care system.
7. The volunteer organization participates in the development of a cadre of mid-level practitioners
Recommendations
Members of the volunteer organizations are encouraged to band together to form a cadre of educators and to provide resources for the creation of education facilities. This is an entirely different strategy for these organizations and requires them to accept a new responsibility. It is important to create sustainable primary eye health care systems in developing countries, and this is not possible without educated eye health care professionals to perform refractions, diagnose and treat basic ocular diseases, and refer more complex cases to secondary or tertiary care centers. The creation of a new cadre of middle-tier eye health care professionals should be approached with great caution. It is important to understand the current logistics of the
It is interesting that despite decades of encouragement from the WHO and various optometric professionals for volunteer organizations to change their priorities,23,25,32,33 their strategies have remained virtually unchanged for blindness and low vision treatment and prevention. With the adoption of VISION 2020 as the guiding document for blindness prevention, now is the time for a dramatic shift in the work of volunteer organizations. If the above indicators are the minimum requirements for a volunteer organization to be considered acceptable for global work in the prevention and treatment of low vision and blindness, the limited survey results become alarming as many volunteer organizations are not meeting minimum requirements. The following recommendations will allow volunteer
Matthew Gordon Pearce
Public Health
organizations to add greater value to the global visual impairment prevention community. Volunteer organizations should: 1. Strongly consider reprioritizing the work they do from direct care to developing human resources and infrastructure. 2. Determine the local burden and causes of visual impairment. 3. Help in the training of mid-level eye health care practitioners. 4. Help provide professional and community education. 5. Form public and private partnerships at all levels. 6. Discontinue the use of recycled spectacles and expired medications. 7. Aid in the creation of a sustainable spectacle distribution network. 8. Evaluate their outcomes.
Conclusion The larger “prevention of visual impairment” community has decided that VISION 2020 is the overarching document that should guide the world’s efforts in preventing and treating visual impairment. WHO, multinational organizations, and nations are using VISION 2020 as their guiding framework. For volunteer organizations to be a part of the solution to global visual impairment, they must join the community of organizations and nations who accept the strategies of treating 5 priority diseases along with developing human resources and infrastructure as the best method for decreasing the burden of preventable blindness and low vision. The new role for a volunteer organization should be to provide education and training, to supply technology if able, and to provide care during the infancy of the eye care system in coordination with the national VISION 2020 program. This would put the skills of these organizations to the best use in the development of sustainable eye care systems in developing countries.
References 1. Waddell KM. Eliminating global avoidable blindness. Journal of the Royal College of Physicians of London 1999;33(6):568-73. 2. Sommer A. Global health, global vision. Arch Ophthalmol 2004;122: 911-2. 3. WHO. Global initiative for the elimination of avoidable blindness: action plan 2006-2011. World Health Organization; 2007. 4. ICEE. Durban declaration on refractive error and service development. World Congress on Refractive Error and Service Development. Durban, South Africa; 2007. 5. Taylor HR, Keeffe JE. World blindness: a 21st century perspective. Br J Ophthalmol 2001;85:261-6.
471 6. Dandona R, Dandona L. Refractive error blindness. Bull World Health Org 2001;79(3):237-43. 7. Taylor HR. Refractive errors: magnitude of the need. J Commun Eye Health 2000;13(33):1-2. 8. Munoz B, West SK. Blindness and visual impairment in the Americas and the Caribbean. Br J Opthalmol 2002;86:498-504. 9. Cetin E, Yaman A, Berk AT. Etiology of childhood blindness in Izmir, Turkey. Eur J Ophthalmol 2004;14:531-7. 10. Tabbara KF. Blindness in the Eastern Mediterranean countries. Br J Opthalmol 2001;85:771-5. 11. WHO, IAPB. State of the world’s sight: VISION 2020: the Right to Sight: 1999-2005. 2005. 12. WHO. Magnitude and causes of visual impairment: World Health Organization. [Fact Sheet No. 282] November 2004; Available at: http://www.who.int/mediacentre/factsheets/fs282/en/print.html. Last accessed February 13, 2006. 13. Pararajasegaram R. The challenge of escalating avoidable blindness: a call for action. Natl Med J India 2001;14(6):324-6. 14. Dandona R, Dandona L. Review of findings of the Andhra Pradesh Eye Disease Study: policy implications for eye-care services. Indian J Ophthalmol 2001;49(4):215-34. 15. Nirmalan PK, Katz J, Robin AL, et al. Utilisation of eye care services in rural south India: the Aravind Comprehensive Eye Survey. Br J Ophthalmol 2004;88:1237-41. 16. WHO. Global initiative for the elimination of avoidable blindness. WHO/PBL/9761, 1997. 17. Kime TQ, Holmes GB, McQuarrie CW, et al. International eye/vision care: the United States responsibility. J Am Optom Assoc 1984;55(9): 647-51. 18. Keefe JE, Konyama K, Taylor HR. Vision impairment in the Pacific region. Br J Opthalmol 2002;86:605-10. 19. Coyle D. Benefit or burden?: recipient thoughts and concerns of donated medical supplies and equipment in the developing world. Atlanta: Emory University; 2003. 20. Golding L. Donating medical supplies and equipment: being good at doing good. Atlanta: Emory University; 2003. 21. Rose SB. VOSH revisited. J Am Optom Assoc 1984;55(9):671-4. 22. Yorston D. National Prevention of Blindness Programmes. Community Eye Health 2000;13(36):51-2. 23. Berger IB, Nnadozie J. Onchocerciasis and other eye problems in developing countries: a challenge for optometrists. J Am Optom Assoc 1993;64:699-702. 24. Holden BA, Sulaiman S, Knox K. The challenge of providing spectacles in the developing world. J Comm Eye Health 2000;13(33):9-10. 25. WHO. Elimination of avoidable visual disability due to refractive errors: World Health Organization. Geneva; 2000. Report No.: WHO/ PBL/00.79. 26. VOSH. VOSH history. Available at: http://www.vosh.org/documents/ history2.pdf. Last accessed March 21, 2006. 27. Holbrook D, Fors LA. Student volunteer optometric services to humanity. J Am Optom Assoc 1978;49(2):155-7. 28. Hayes P. Student optometric service to Haiti. J Am Optom Assoc 1978;49(2):187-9. 29. Johnson B, Yolton RL. The effectiveness of optometric aid to Fiji, South Pacific. J Am Optom Assoc 1986;57(6):436-9. 30. Leasher JL. Evaluation of an emergency visual health program. Oral Scientific Presentation at the UNESCO First International Congress for Development of Visual Health June 2003; Barcelona, Spain. 31. WHO. Guidelines for drug donations. WHO/EDM/PAR/994. 1999. 32. Yolton RL. Public Health Presentations at the 1987 Meeting of the American Academy of Optometry. Am J Optom Physiol Opt 1988; 65(6):512-4. 33. Leasher JL. Give in favor of developing countries all the time not just when disaster strikes. Optometry 2005;76(10):559-61.
