MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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22 EW International May 2013 International outlook Battle-scarred nation East Timor now battles eye disease by Matt Young EyeWorld Contributing Writer Phones, water, and roads may not work, but eyecare initiatives do A popular internet meme makes fun of "first world problems" in prosperous countries. The sad truth is that real problems and challenges are faced every day in developing parts of the world. In this month's "International outlook," contributing writer Matt Young highlights the challenges of providing the most basic of eyecare in the newly sovereign nation of Timor-Leste. The exceptional efforts of international agencies such as The Fred Hollows Foundation New Zealand and the personal efforts of dedicated individuals like Laura Cleary are helping to shape the future of a nation by addressing the needs of its citizens. Their work is inspiring and reminds us of the vast unmet need that still exists. John A. Vukich, MD, international editor C alling Timor-Leste, or East Timor, is like calling every other nation with one main difference: After dialing the country code, you pray. That's because there's often no getting through with any reasonable connection to many phones in Timor-Leste. "Telco Systems here is … developing," said Laura Cleary, former program manager, The Fred Hollows Foundation New Zealand, via a Skype chat after a series of failed phone call attempts. Ms. Cleary, who lives in TimorLeste, had few illusions about what she was in for when arriving in 2008 in the middle of the rainy season. Assassination attempts on the president and prime minister occurred days before her first visit. This was a country recovering from a recent history of illegal executions and starvation deaths of tens if not hundreds of thousands of people in a scenario compared to the killings of the Khmer Rouge. "I lived in Nepal for a while in my early 20s, and Timor-Leste has a similar smell—people cooking with wood fires, cars with poor exhausts burning diesel, and rotting rubbish," Ms. Cleary said. "Sometimes living here can be challenging. The power goes off regularly. The water supply is infrequent. The postal system is pretty non-existent. Most people don't have bank accounts. And the roads are very, very bad. But I think people here are aware of the bad things that come with conflict and are trying to work together to build peace." Following decades of struggle against Indonesian occupation, Timor-Leste became the first new sovereign nation of the 21st century on May 20, 2002. While its development struggles continue, one silver lining has been its eyecare initiatives, which have had some success. "Although Vision 2020 [World Health Organization's Vision 2020: The Right to Sight initiative] advocates periodic reassessment of vision loss prevalence and causes to monitor national eyecare programs, Timor-Leste is unusual in achieving this," according to a report published in April 2012 in Ophthalmic Epidemiology. "With an initial NEHS [National Eye Health Strategy] based on the 2005 [cross-sectional eye health] survey, and data from the 2010 investigation available to inform a subsequent iteration, a cycle of evidence-based care has been initiated." The report, authored by Jacqueline Ramke, of The Fred Hollows Foundation New Zealand, found that prevalence of low vision had fallen. A significant cataract backlog remains, and measures are being implemented to address that. Ms. Clearly explained that there were studies conducted in 2005 and 2010, known as the Rapid Assessment of Avoidable Blindness (RAAB), which give a "snapshot of the status of eye health in a given country." "I think it's commendable that Timor-Leste has done two RAABs already," she said. "In countries with similar poverty levels, you'd be unlikely to see even one RAAB having been conducted—particularly in countries with the kind of low infrastructure base you find in TimorLeste." The difficulty, she explained, involves getting a large enough sample size to create an accurate snapshot. "It's really hard to travel to remote areas, and with no clinics in those areas you'd need to take your diagnostic equipment with you." That requires resources—big cars and a lot of staff trying to pinpoint data and follow up with people who have no fixed addresses or telephones. Somehow, Timor-Leste managed to do this. "The government would have provided approval for the study and then assisted the researchers as they traveled around Timor-Leste," she said. "There is a definite commitment by many people in TimorLeste to work hard for positive continued on page 24

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