Academy 2019 Orlando Plenary Session
(video transcription provided for reference only, please excuse the typos!)
Introduction: Welcome to the largest event in optometry, academy 2019, Orlando and the third world congress of optometry. Please welcome to the stage the current American academy of optometry president and fellow since 1980, Dr. Barbara Caffery.
Dr. Barbara Caffery: Thank you and good morning. On behalf of the board of directors of the American academy of optometry, I welcome you warmly to the 97th annual meeting of this academy. We are thrilled to be sharing it with the world council of optometry, who have helped us to open our eyes wide and to have a wider field of view on eyes and the global problem of vision.
The academy has been very busy this year. We have hired a new executive director, Mr. Peter Scott, who has with calm and creativity made this meeting happen. We are very grateful to have him. We also did the heavy lifting involved in creating a new strategic plan for this academy. Our vision as you can see – inspiring excellence in eye care is the quintessential purpose of this academy. Our mission is to provide exceptional education, support innovative research and disseminate knowledge to advance optometric practice and improve patient care.
We have also listed our values and made them clear. Lifelong learning, excellence, evidence-based care integrity, collaboration and collegiality. These are what the academy stands for. And we have five strategic pillars which will be our strength in the next years. Education, research, membership, leadership and legacy and partnerships.
This academy believes that there is no better time to be an optometrist than now. As we approach the quintessentially optometric year of 2020 – we must start to understand that the world needs optometry. You are about to hear of the World Health Organization initiative, to eliminate preventable blindness by 2050. One aspect of that is the seemingly simple problem of uncorrected refracted air. It was described to me as follows – we have a clear problem and we have a clear solution. Which is a pair of spectacles. Now we need to connect the dots and it is you and I who have to be those dots. And do not relax for anytime under the illusion that the over 2 billion people who need our care, live elsewhere. They live on your street. They go to school with your children and grandchildren. They are your neighbors and they need our help.
Then there is the epidemic of myopia. Surely, we can all agree that children deserve to be less myopic and we can band together to identify those that need our help. The academy exists to inspire you, to use your excellence, to contribute to the resolution of these problems. This is optometry’s time. Let us change the vision of the world. I would now like to introduce Pete Kollbaum who is the head of our academy’s foundation.
Pete Kollbaum: Good morning everyone and on behalf of the American academy of optometry foundation I welcome you to academy 2019 and to Orlando. For those of you that don’t know us, the foundation plays a crucial role in the support of the academy and the mission of the academy as well as the goals and mission of optometry in general. Every year with the help of many like you, the academy foundation raises money to fund student, resident, practicing clinicians and research awards and specifically over the last 10 years, we have awarded more than 5 million dollars in grants and funds. The slide behind me shows a snippet of the impact that this has had, but the real impact is on individuals these programs have supported and the trickle down of the caring work of these individuals over the years.
The benefit is profound, it’s real, it’s happening in this room, maybe even by those sitting around you. 121 students, clinicians and researchers are here at the meeting because of our grants and foundations funds. Many of you have benefited from our flagship Ezell program over the years and our patients and our colleagues have also benefited as well. All from the research the foundation has helped fund since the inception of the foundation in 1947. Each year we begin with a single goal, to try to be even more impactful. We have some exciting plans for the years ahead, but we need your help. We all have a stake in improving the quality and care of our patients and the potential for all this, all these improvements, starts with the advancement of knowledge that the foundation aims to support.
So today I want to express sincere gratitude to those who have already committed to our mission and to implore those who have not yet, to please consider doing so. To please consider getting involved, supporting the future of optometry and vision science in the future of our academy. Please see me or any of the other foundation board members who are wearing these convenient blue and white tags, please come see us at the foundation booth number 331 at the exhibit hall to learn more. We have all had people help us get to where we are today and it’s now our time to help our future colleagues, our future leaders and the future of our patients. Please consider donating now to the foundation, to your foundation. With that I thank you and I’d like to introduce president elect of the academy, Dr. Tim McMahon.
Dr. Tim McMahon: Welcome to Orlando. As you heard, I’m Tim McMahon, I’m going to be the moderator for this particular session. In this year the academy meeting has a series of firsts. The first of those Dr. Caffery has already alluded to you in that this is the first time in the history of the academy and this is the 97th meeting in the academy that we’ve ever partnered with another organization, in this case the world council of optometry. The world council operates on an international basis for developing optometry and vision care world-wide and this year we’re going to cosponsor their annual meeting which is the third world congress. The first two were – first was in Metagene, Columbia, the second was in Hyderabad, India and the third here in Orlando. Now that gives this particular meeting an international flair. Now coincidentally and positively – another event took place just a couple of weeks ago and that is the World Health Organization based in Geneva Switzerland, released its long-awaited world vision report.
This is a report on the burden of eye and vision care worldwide, and very positively WHO reached out to optometry in developing this particular document. In fact, two of the speakers, our optometrists on the panel, participated in the development of this report and we’re going to be talking about that. They are both members of the board of directors of WCO as well as fellows of the academy. So, our first speaker is actually the person who led the development of this report at WHO and that is Dr. Alarcos Cieza, Spanish born psychologist by training, held a number of important department positions in Europe before going to Geneva and joining WHO. Her department and her role as lead is actually – to produce this particular report to figure that this will be the person to invite to talk to us about it. So, without further ado, I’d like to introduce Dr. Alarcos Cieza who will give us an overview of what’s going on in WHO and introduce the world vision report to you. Dr. Cieza.
Dr. Alarcos Cieza: Thank you so much for the introduction and let me emphasis, what a pleasure it is to be here with all of you today. For the first time I am presenting in front of an audience. The first ever World Health Organization report on vision, and what from a WHO perspective we would like is, that the world report on vision, challenged the eye care sector exactly the same like WHO currently feel challenged. And we also hope that the eye care sector feel the same urgency for action that we at WHO feel. This is our director general from WHO, Dr. Tedros and when presenting the report, he said, we have no choice but take on the challenge and I hope indeed that, that is what it’s coming to you today.
The question that you may ask actually – why feeling challenged and what is all this about urgency? Especially because actually if we look at the content of the world report, we are not providing new information. We have just collected the information that is out there and summarised and presented in a unique way. So, let’s see, the first thing that we present in the report is the universality of eye conditions. We say very clearly, that anyone, when we live long enough, will have an eye condition. And we present this data in the report. We present the data on the number of people with macular degeneration. The number of people with diabetic retinopathy, the number of people with glaucoma and the number of people with trachoma. What we also present is the number of people under estimation of people having myopia and presbyopia around the world.
I always like to put, even if we look at the small eyes, at the 196 million people with age related macular degeneration. I always like to put it in the context of a reference of a country and if you look at the United States – so there are more people with age related macular degeneration around the world, than the half of the US population. And this are the reference – and then when you see numbers like 2.6 billion people with myopia, 1.8 billion people with presbyopia, then you see the dimension of their eye care need. Because actually the significance of these numbers is that they portray the huge need that there is, the huge need of eye care that there is around the world. Because, actually if we look at the numbers, we cannot even add them up because we know that there is overlapping so that in terms of what we can say in – with the available data, is that there are so many people with myopia, so many people with presbyopia, but we cannot say how many people in total around the world have at least one eye condition. So, again, this data portrays the huge need for care. And, this need is suspected to increase due to the population trends, we are living in an aging society and also due to our lifestyles. So, we can expect an increase on the number of people with glaucoma, with cataract, with MND with refractive errors in the years to come.
What we also present in the world report is that actually – and something that we frequently forget, that there are common eye conditions like conjunctivitis, like dry eyes that are the cause or the most common causes for sickened care and that actually they also pose a huge burden in people’s lives and also financial hardship. However, we don’t know much about these conditions. We don’t know much about the epidemiology globally of these conditions and we don’t know much – from the perspective of epidemiological data but also from the service data, we don’t know much. So, considering all of this, there is urgency – not only because this number portrays the large need of care, but also because there is a still large need of data that allows us also to provide a more coherent story. For example, that we can say, how many people at least have at least one vision impairment, or how many people get every year and how often eye conditions that do not cause vision impairment, because these are then the true numbers of need for care.
If we look in the world report at the data that we have presented in terms of vision impairment, we say it very clearly, at least – at least there are 2.2 billion people who have a vision impairment around the world. And again, this number and the significance of this number is because it provides a rough estimation. However, putting the action into at least, because with the system numbers we cannot say more. We know that the number is much larger, but at the end of the day we can only say with confidence that at least 2.2 billion people around the world have a vision impairment with the data we have.
What we also present in the world report and what we can say with the available data is, that at least 1 billion have not received the care they needed and therefore have today a vision impairment or are blind, or are people that still need care. And there are 16 million people around the world that because they didn’t receive the care they needed, they are as I said – have vision impairment or blindness and there are still 65 million people that need a cataract operation and over 800,000 that are in the need of glasses. And again, the urgency here is the need of care, but also that tells us how poor the coverage is around the world. How many people still do not receive the care they need, even if this care is simply a pair of glasses.
And we know, that this is because the lack of access to care, and the lack of access because of many different reasons. Sometimes it’s simply because the care is not available. Does not exist. But that means, in concrete terms – the health professionals do not exist. Or the consumables that are needed to provide the care do not exist, or the glasses that are needed to provide the care do not exist. Sometimes it’s because even if the care exists, it’s not accessible to everyone, because in some rural areas around the world, especially in low income countries, to go there where the care is provided is extremely costly, sometimes bothersome and sometimes impossible. And for many people around the world, care is not affordable. And even – and if potentially difficult to imagine, in a country like the US, even a pair of glasses sometimes is something that is not affordable.
What we also know is that vision impairment is not distributed equally. We know for example, that Andres distance vision impairment is four times higher in low income countries than in high income countries and what we also know is that there are people that are much more risk to experience Andres vision impairment in rural areas, women, older people, people in low income, indigenous population in countries where there are indigenous population, ethnic minorities and also people that have certain types of disabilities. So, when we look at the data on vision impairment, the urgency is because we see that there is a lack of available accessible and affordable eye care services, but also there is still a large need for data. For data again, that allow us not to tell this story only with – at least – and we cannot add these numbers, but really at some point we can tell the whole story of the need for eye care, how many already receive the care they need, and how many still need care.
And, at this point let me do a parenthesis, because you know, in the organization – in the World Health Organization, we talk between the different colleagues from the different programs and if I tell this story to my colleagues from other programs, the question that they ask is – how can this be? How can really this be? Is that true? Are you really sure that that is true? That that is what the data says? How can it be when the eye care sector is such a mature health sector, we have – I have learnt today, so an organization like yours, already 97 years doing great work. So, you can find these kind of examples everywhere in the world. So how can a mature field that have already demonstrated so much in public health, for almost eradicating some conditions or also avoiding blindness in children because of vitamin A deficiency and so on and so forth, how can it be? How can it be that in a field of eye care where there are great epidemiology’s, working and building careers in the eye care sector, how can it be that we still cannot tell the whole story? How can it be in a field where the advocacy is so mature? In few sectors in the health sector, you find really an advocacy from the civil society that is so well coordinated and that is so well organized at the global level. That where there are umbrella organizations that try to communicate in the same way with the same messages, that know how to do the advocacy to bring forward policy [inaudible 24:33] it is really amazing, what you can learn of the advocacy in the eye care sector. So, the question is – how can it be? How can it be in a field, the realities like that, in a field that has embraced technology and innovation, not only for diagnosis but also for the treatment and also for providing services and overcoming barriers. And how can it be – more importantly, being an almost unique health sector. A unique health sector for the kind of interventions that you have, because if you reflect on the interventions that you provided, doesn’t matter whether they promote it, preventive treatment or rehabilitative interventions, what we can say that the eye care interventions that exist, they are not only effective, they are not only cause effective, they are in the eye care sector, the whole range of interventions to address all possible needs. And again, it is in a sector in which you find the most feasible and cause effective interventions. So, how again – how can this be? That there is still so much need for care and so many people that are not covered and we cannot tell the full story.
One – and there are many possible answers to this question, but one that we have found over and over and over again – there is a lack of integration of the eye care sector in other areas of the health sector and this has consequences. Sometimes I even like to present it like – you know, the eye care sector for parts of the government, even from the ministry of health is very often like a black box. Do not know how many people need care, how many receive it. Who provides the care? Do not know much. It is really a black box. And one of the reasons for that is – because it’s not even sometimes really seen as an integral part of the health sector. The services are – somehow, somewhere, by someone provided. What we see is, that still there are services that are provided in parallel, as I said – not integrated, what we sometimes call as in a vertical fashion. What we see is, that there is a huge amount of services that are provided by the private sector, however without any kind of coordination with – for example, the public sector. So, knowledge is not shared. And information is not shared. What we always see is uncoordinated and unregulated workforce and to bring to you an example that is relevant to you, we did collect data in 24 countries. In eight of them, optometry is not recognized as a profession, and do not have an educational requirement. And I would like here to call again for the urgency of action, also after having heard Barbara talk about your vision and mission.
Eye care is not part of the health information system, or the health information system does not collect information of eye care in most of the countries of the world. So, let me put an example of what are the consequences of that – yeah? Or portray it in a way that you can really imagine what happens if there is not integration in a country. Every country has usually a national and strategic plan that goes across different sectors, if the country is a low-income country, then this national strategic plan is a development plan. And, a development plan or strategic plan for each of the different sectors, for labour, for education, also for health, and then in this strategic plan what do you do is you set priorities. You plan what do you want to do as a country. And countries and the ministries of health plan, okay where do they want to see the priorities? It is about HIV aid? It is about maternity and child health. It is about aging. It is about non communicable diseases. What are the priorities that we have in the country to move forward?
The reality is that eye care is very, very often not a part of the health strategic plan and if it is not a part of the health strategic plan, eye care will not be prioritized. The services will be provided somehow, somewhere by someone, but not as part of this strategy. So, we need to advocate, make sure that eye care is part – an integral part of the health strategic plan so that not only it can be prioritized but also integrated. And considered in the planning. In many countries of the world, still eye care is not part of Universal Health Coverage and that has also consequences for those who cannot afford the care they need. And I would like to introduce very briefly the concept of Universal Health Coverage as we present it at WHO. We usually represent Universal Health Coverage as a cube. As a cube that has three dimensions. The first one is – okay what is the population that I need to cover in this country? So, it is to cover the whole population of a country. The other dimension is – what are the services that needs to be covered, who’s cost needs to be covered, and then what are the costs that need to be covered. In an ideal world – then the budget of the health sector is as large as this cube, so that you can cover the whole population with all interventions that are needed, and you can cover all these costs for those interventions so that people do not need to pay out of pocket. The realities however, that the budget is always much, much smaller and then it’s when the negotiations start. And it is when you start to reduce gaps.
The first intention is to try to cover the whole population, cover in all the costs for at least some basic interventions. And once you have that, then you start to add interventions and services in the package, so that as many people as possible get the care they need without having to suffer financial hardship. Still even basic interventions like cataract surgery, or the provision of glasses is not part of those packages of care that are part of Universal Health Coverage. So, there is an urgency for action and there is an urgency for action because we also have a window for opportunity, we have a huge window of opportunity with the sustainable development goals. The sustainable development goals are the agenda that is currently dictating the agenda of international organizations like WHO but also civil society, also governments. And it is a very ambitious agenda because the intention is to make development sustainable over time. So it is about structural changes and in the goal three – about health, that is the one is most important for WHO, the one we work on, there are different targets that we need to achieve up to 2030 and you know, when we talk about these targets of the goal three at WHO, we usually talk about – there are 12+1 targets because the one is Universal Health Coverage, because we know that Universal Health Coverage is the catalyst in countries to achieve the others. So, the intensity with what we work, the momentum that Universal Health Coverage has created is tremendous. And countries have worked into it – so we have – and that is the reason we have a window of opportunity.
We have also a window of opportunity because effective coverage of refractive errors and effective coverage of cataract surgery is being considered as indicators to monitor Universal Health Coverage. Because, at the end of the day, this eye care interventions are so priority ones and so relevant that it – the help of this interventions help and to know how they are providing helps to know how countries are moving towards Universal Health Coverage. So, what we need to provide it – how many people, our denominator, how many people are in need of refractive care, how many of those received the care with the intended gain. So that they see well. And the same for cataract surgery. How many people in total are in need of cataract surgery? How many of those indeed – how many of those we achieved the health care we intend. So, it is not only about coverage, it is about effective coverage. The coverage intended outcome need to be achieved. We have an opportunity, however if we cannot provide the data, we will miss this opportunity. That is the reason why we see urgency for action also in this area. So, what is what the world report recommends? Looking at all of this. And I am sure that no one of you will be surprised when they first recommended – when I tell you that the first recommendation that is mentioned in the world report is – we need to make our care an integral part of Universal Health Coverage.
The second recommendation that we provide in the report is, implement integrated people centre eye care services and the action is on integration. Let me introduce very briefly the definition of integrated people centre eye care. We talk about eye care that are managed and delivered so that people receive a continual of eye care interventions covering promotion, prevention, treatment and rehabilitation. To address the full spectrum of need associated with eye conditions and according to the need that are coordinated at different levels inside of care and beyond the health sector and recognize people as participants and beneficiaries of these services throughout their life course.
And we provide then a specific priorities that countries need to move forward to if they want to implement integrated people centre eye care. The second recommendation that we provide is, promote high quality research. High quality research that at different levels, but also high-quality research that allow us to tell the full story about eye care. And monitor trends and evaluate progress – in 30 years from now we should not be where we are today, compared to 30 years ago, in terms of monitoring the progress that we do.
And, one of the points that I didn’t mention at the beginning, in terms when I was talking about access to health services, access to health services also require the awareness of those who need those services and that cannot be underestimated. That is the reason why there is the fifth recommendation on the world report. So, I don’t know if you feel challenged, I don’t know if you see the urgency for action, I think if I were you, I would feel like that, but I really look forward to hear from you, also to hear what my colleagues what they have to say now, one of them representing your sector and how the sector may receive the world report on vision and then Sandy presenting also how potentially the report will be received in the US. I look forward also to hear from you, don’t hesitate to go to our webpage, download the report, read it and tell to WHO whatever you need to say. Thank you.
Dr. Tim McMahon: Thank you Dr. Cieza. Our second speaker is Professor Kovin Naidoo. South African raised optometry degree of Pennsylvania college for optometry as well as his PhD in public health. Kovin returned to Africa to begin to work on many of the things that have been presented in Dr. Cieza’s report. Eventually becoming part of what is known now as Brien Holden Vision Institute, rising through those ranks to become the head of that organization with Brien Holden’s passing. Recently he left BHVI and has joined Essilor is senior vice president for vision impact and philanthropy based out of Singapore. I asked Kovin to look at this report, which he was an editor of, and present it from an optometrist’s view, looking at the world wide impact of optometry and what that means for us and what that means for patients on a world-wide basis. So please give a warm welcome to professor Kovin Naidoo.
Prof. Kovin Naidoo: Thank you, Tim, and thank you for your leadership in bringing these kind of issues to the centre stage. You know I’ve always felt at the American academy and a lot of the world conferences as the poor cousin. You know, the public health guys have the smallest room with the littlest of people, not in size but in numbers and so it’s great to be here in the main stage and to bring eye care to the centre stage. But I want to preface my presentation by saying- first I am trained like many of you in the US. I have lived like some of you and worked in the developing world and I have seen both sides and my biggest pain about all of the work that we’ve done in the space is the fact that in this world we fail to bring these different things together. As much of the politics and the economy of the modern world, we tend to want to be in different camps. I think the world report was approached and was a pleasure to be on the editorial committee and work with a non-optometrist, non-ophthalmologist for a change, because Alarcos came to the table with a different perspective. She and her team came to the perspective not with the usual approach that these professions they compete, how do you work around the politics – it was about how do we do what is necessary and for once I saw my US training and my upbringing in the developing world and my work in the developing world, come closer together than ever before. And I want to thank you Alarcos on behalf of optometry and those you think like us for what you guys have done through this report, and I’ll explain some of that.
Let me also say, it’s the first time I’m speaking as a corporate person in a meeting which is quite strange for me. I’m employed by Essilor now in the social impact division and I head up the inclusive business and philanthropy section and my key metric and my team’s key metric is the number of people that we reach so we are at very different sections. So I go back to the point about this competition and who is doing what and who is achieving what – when we look at the world report the first question I got was – but these numbers don’t coincide with your myopia paper that you guys did when you were in Brien Holden, it doesn’t coincide with this etc. Let’s understand this – professor Holden and I had a difficulty when we attended our first meeting at the World Health Organization in 1988 – 89 around there. Because the WHO said to us, that their cut off point at that time for vision impairment and blindness was 6-18.
Now you as a clinician know, that a day in a practice, you could have a majority of your patients walking 6-9 and 6-12, and it was difficult to understand. But what they did explain to us – it’s not about who are the people who need services, it’s about who should be prioritized when resources are limited. So again, it is irrelevant for us to start fighting about these numbers, lets understand that the WHO numbers talk about vision impairment and blindness and it talks about how we reach the most vulnerable in our societies and recently you know, when Essilor launched the illuminating poor vision in a generation, what it will take to eliminate uncorrected refractive error by 2050, we speak at a different metric. And that metric is about looking at a number of 2.7 billion people for uncorrected refractive error alone, and it’s based on a 6-9 visual acuity cut off, not a 6-12, because that’s talking more about not a definition of blindness and vision impairment, but talking about who are the people that need services. And the WHO in no way through this report is saying we mustn’t address the needs of the old population. What it is saying is that if you really want to start with governments with limited resources, make sure that this is what they target, the people who cannot function, cannot work, can’t learn because their vision is so bad. So, let’s put that debate to rest because it’s an irrelevant debate. I’m going to address these key points today, look at the global environment for optometry, the enabling environmental. How do we as a profession internalize the report, and the response of optometry, what it should be.
If we are quite frank about what we are faced with today in optometry is that we have a lack of relevance in public health systems across the globe. There is exceptions and the US is one of those exceptions. We are marginalized in most of the world, either consciously by others or unconsciously by our own actions which we rarely talk about. human resources in terms of the number of optometrists, no matter the great work we’ve done and what we claim, we are falling – we have a negative achievement in that. We are falling far behind the population growth across the world. We have pockets of success and a lack of scale, and we are guilty of touting, especially those of us in public health – of touting those pockets of success as a great achievement and which it is, but there are other challenges – which I’ll talk about. When we look at the public health system, we often think of it as a government system, but if you look at the WHO document, it talks about not just eye health, not only health department, it talks about finance, education, social development, it talks about the private sector, it talks about the public sector, and that all constitutes the health system of a country. So private optometry, which is the majority of our profession in the world, developed or developing world, is actually very much a part of the public health system. We know that there’s marginalization, either consciously by ophthalmologists in some countries. Unconsciously by optometrists who will insist that we don’t work with others because it’s a political battle, and then go to governments and say we should be the sole providers of eye care in our country, even though we only serve 10% of the population and hope that that minister is smoking something really good.
There’s orthotics, optical technicians and others who we don’t engage, and you know, a very crude term – one of the political activists in South Africa – we should do everything to bring people into our fold and one of my friends said – its rather you have them inside pissing out than outside pissing in. and I really – it may be crude in its orientation, but it’s actually very relevant in its application to how we approach eye care in the world. We should be looking at whether we can bring our national associations orthoptists [49:05] optical technicians to become part of an optometry fraternity. I’ve seen in countries where these people are called – are invited to ophthalmology conferences, I have seen as part of that fraternity and I integrated into ophthalmological services while we adopted an adversarial approach, particularly in the developing world.
So, we need a new system in the way we see eye care. We know that when it comes to human resources there are limited number of optometrists, there are challenges in producing optometrists, because we need to expand the scope. We need to ensure that what you do here by screening people and treating people for eye disease, it’s done in Africa. In fact, it’s done in my, its needed in my continent more than you need it here, because we have so little ophthalmologists. We have so little eye care. I was involved in an initiative in the Malawi school of optometry many years ago together with sight savers and we trained optometrists and when they were deployed, I got a call from one of the optometrists saying to me, the ophthalmologists are fighting with us – and I said – what the hell. You’ve got 30 ophthalmologists in this country and they’re fighting with you?
And he said – yeah, the ophthalmologist is swearing me because I’m not treating glaucoma, I’m sending it to the hospital and he says he has too much work. That’s a reversal about what you and I think.
So, if we think about people and eye care, we can achieve more than we can as a profession than we think we can do through an adversarial approach. There’s a maladministration – distribution of our optometrists. We know that we aggregate to the cities, we know people will go to universities, find it difficult to go to rural communities where – like the partnerships and the opportunities you may get in private practice do not exist, and that’s a huge challenge for our people, and we can’t force optometrists to go to these areas when you and I are not living in those areas. We can encourage them. So we need to then say, if that’s the reality of our world – I was in a meeting in Kenya soon after I joined Essilor, and the Kenyan optometrists were opposing the training of some rural practitioners, and then I sent everyone out of the room and I said, optometrists to optometrists, would you ever go and work in those areas? The guy said – no Kovin. And they were honest, and then I said okay – so let’s develop a system where we can integrate what’s happening in those rural areas into optometry and work to build a system that you are finally involved in that system and have influence and even control the times, rather than opposing services to your people in rural areas, and I’m glad to announce that we came up with an agreement that now looks at how we can increase access to services in Kenya without us fighting each other and bringing all those cadres under the banner of optometry.
The scope of training is valuable. I hated Andy Gurwood, those of you who knew him, and Pennsylvania college of optometry. That bloody guy knocked the window after 15 minutes and expected me to have the drops in the patient’s eyes and ready to go into the waiting room and wait for dilation. He would just bang that window, and it was only when I went back to Africa, I realized how valuable it was to have an Andy Gurwood over your shoulder when you’re training as an optometrist in the US. Because – when I set up an eye clinic [inaudible 52:23] hospital in KwaZulu Natal the first day I had a 100 patients and Andy was over my shoulder every minute of that day. Because I could work through those patients. So, scope can be valuable, but it’s also the expertise that we have in the US for example that is a huge public health benefit to the rest of the world, if we can export that in a very value and relevant way, and not in a way that looks at – can we sell education to these people. Optometry institutions here can make a difference by taking these lessons of how you have come up with systems to train people that insures that in 15 minutes you can have somebody ready to go and sit in a waiting room, and you’ve done IOP’s, you’ve done everything possible. By the way I still can do it in 15 minutes.
So, we have a global environment for optometry where we know that we have pockets of success, we have good demonstration in our ability to contribute, but we have a lack of scale and you know, when I made a career shift, some of the people said – for many other reasons but one of the reasons was that I wanted to be in an environment where we talked scale. Not – this is my model, do the same power point presentation over and over all over the world and claim that we are doing great work. After a while it becomes about job retention rather than serving people. So, we all need civil society, private sector, education, WHO, everyone needs a rethink about these things that we are doing. Are they reaching large number of people in our world?
Our colleagues in malaria, HIV have showed that. We in South Africa were bearing tons of people because of HIV. It was when people came together and achieved scale in HIV and got Bill Gates to then take notes of them and George Bush who invested a lot in HIV programs in Africa, we saw lives being saved across the board on our continent. I saw physically the number of invitations that I had for funerals decrease, because that’s how big a difference some of these things made. So, scale is important. Yes, we can have demonstrations modeled, but we can’t live and continue with demonstration models all our life. We have a small but active group of NGOs’, educational VAO, etc. doing amazing work, but we need to grow the sector. And we know that where we’re having the most success isn’t the developed world. You are the central primary eye healthcare individuals in your healthcare system here. In other countries it’s not the same. Optometrists are not the first point of contract except in the developed world, and even rural areas, even if a nurse is the first point of contact, the optometrists are not the second point of contact. So, what we’re dealing with the deficit that is beyond even your – many of your understandings because unless you’ve seen it – because quite frankly you’ve been very successful here. But we have an opportunity, an enabling environment where uncorrected refractive error is the leading cause of blindness – is the second leading cause of blindness in our world and uncorrected refractive error is the leading cause of vision impairment. If we address these, we will move the needle on health care like efforts around trachoma, river blindness, HIV, malaria, tuberculosis – all those sectors have been able to do this by moving the needle, but we have an opportunity to change the numbers that Alarcos presented on eye care. Like no other profession in the world, because look at what uncorrected refractive error impacts are and look at who manages and leads that sector throughout our world.
Myopia has changed the space. I remember when the first time the statisticians brought the myopia results to me when we were publishing this paper, to say that by 2050 half of world’s population will be myopic. I was just shocked, but first I thought that they were just stupid. To be honest I thought we should change the team, but I then realized that it was such a brilliant team that went and did an analysis that looked at the numbers like nobody else had done before, and yes, 50% of the world’s population will be short sighted. That is in your hands and my hands. Myopia is a game changer. It covers all aspects of eye care. It’s about research, it’s about clinical services with myopia control, it is about public health ensuring that there’s access, because we know that Jeff and other people will tell you, you’ve got to get to that kid quickly right, and so access is important. The quicker they get the prescription, the more we can control the myopia growth. And then we know that time outdoors is proving to be a major driver of preventing myopia and we know that that’s a great health promotion strategy to talk to parents, talk to the broader community etc. and we know that governments like in Taiwan etc. are responding, are instituting laws that now people must spend, children must have two hours outdoors, lunch break etc. and we know that its creating a new advocacy option to place optometry on the centre stage of eye care. Not just for the sake of it, but for us to make a difference to our world.
Diabetes is growing at an alarming rate and in fact by 2050 when you look at the numbers diabetes is tracking myopia. So, in the modern world there is going to be two major public health issues that are going to dominate our life, myopia and diabetes. Myopia is firmly in our hands, diabetes impacts our patients – and I’m not going to give you that lecture, in significant ways and it’s going to add to the blindness and vision impairment data, unless we ensure that the scope of care that you provide, is the scope of the care that every poor person in the world is getting access to. That dilated fundus exam, that monitoring on a regular basis. That drub intervention that ensures that it is affordable and you don’t take a drug that comes in a 2 liter and packaged in a small container and becomes very expensive. That’s the world we live in. so, diabetes is going to be a great opportunity for us as well. We know that school eye health has been elevated on the agenda. It has taken us into the education department. It has given us an opportunity to talk about development in broad ways, it impacts on the sustainable development goals. These were agendas that optometry was not there ever before, but school eye health is growing at a fantastic rate. In terms of the focus on school eye health across the world. And you may think it’s a problem elsewhere – in my current role, one of the biggest budgets Essilor spends is to sport school eye health programs and support OD’s to do programs in the US for children who cannot afford eye care, whose parents cannot afford eye care, and I know many of you are part of that program. So, this is an agenda that is what the world report is talking about and you, and I are involved in it at the moment.
The report talks about eye care in a much broader way. I was also involved in the global action plan development, but there we spoke about in a very mechanistic way and it was necessary at that time. How many cataracts? How many refractive errors and how we deal with it? When we got to the – as part of the editorial committee, when we got to the first briefing meeting in Geneva we were told, think the system, think eye health, this differently. And this is a great opportunity because now it includes all of the services we provide.
So, the global action plan recognized optometry for the first time not as an ally to healthcare profession. Just before it was published – Bob Shepell and myself and professor Holden were in Geneva, fighting with WHO to say, take us out of the allied health professional box and put us as a separate box, and that was the level it was. Now it’s no more a question about where optometry sits. Spoken enough about refractive error, and you know how big an opportunity. It’s linked to education, particularly through myopia is a big opportunity. We need to talk about systems and we know that the private sector is part of the systems. We need to look at how we fit into the system. We’re doing some work in China, now where we are focusing on county level. So we have linked the county hospital with the eye partner in a small town, with the village doctor and in each county we’re looking at how government comes in, private sector comes in, education comes in, how other aspects of Chinese society comes in, and we are going county by county to make each county uncorrected refractive error free and believe me, if we achieve anything, it’s not going to be because of one company’s efforts, it’s going to be because of the systems approach that is being adopted. And now with other NGO’s and other non-profits are coming into China, I am saying to them, adopt a county, put your banner on it, do it yourself but don’t try and start something that’s a small project that just wants to be different, let’s look at how we can move the needle on eye care in the world, and that’s what the world report talks about.
The shift from macular disease to ocular morbidity takes things like dry eye etc. and places them firmly on the centre stage. It says that when you plan for eye care, we need to think about human resources not just for refractive error, not just about myopia, but about eye healthcare practitioners providing care on a regular basis in a continuous way. This is a great opportunity for optometry. Nobody is better located to this and again, nobody is better located to support the world than optometrist in the developed world, particularly UK and the US who are doing this every day and can actually influence the training, the approach clinical management guidelines etc. of course adapted appropriately. I have spoken about human resource development. In the report that Essilor released, we talk about 600,000 full refraction service points, either optometrists or others. For that to happen we need to think differently, and I just want to give you an example of what I mean by that.
So we can’t get people to rural areas, so we are training people who are linked to an optometrist work under the supervision of an optometrist, linked through telly optometry and the optometrist observes the exam, gets the information sent, even can get scans sent to them and then signs off and provides a prescription. This allows optometry to get to the deep rural parts of countries across the world, particularly we’re piloting this in India, Kenya and other parts and in China, and I have gone and visited these projects and seen how we can make a difference. We cannot argue against this, I’m just coming from Mexico two days ago, where an organization called Salud [inaudible 01:03:56] as a group of neurologists sitting in a room and are managing the whole access to scanning and women getting access to mammograms across the rural communities, by ensuring that tele medicine is utilized and more recently I think it was in optometric management. To my delight I opened an email and it spoke about – it was about an article on tele optometry in the US.
So technology doesn’t have to be our enemy, it can be an opportunity if we think differently about it and we’re even considering using an Uber type of system that when the technician gets a patient they put it out and the panel of optometrists in India will be able to – one of them chooses it, observes it, takes responsibility and it allows optometrists to then set up practices in small rural towns which are not economically viable on their own but together with having a group of technicians that work under them, they suddenly got a viable business providing affordable care in communities. And just because of time to tell you on awareness and promotion, you may have heard about the global myopia awareness coalition that’s being led and driven from here in the US, I was working on that and now industry has come on board and we have raised enough funds to get agencies on board to develop a health promotion strategy. Myopia needs to be dealt with from all angles and talking to our patients, we’ve got to stop thinking about treating patients in the US when it comes to myopia, we’ve got to think about managing patients. And how we become every part of their life. What parents do? How often they bring their children? What children wear? How we treat them? All of that has to change. I’ve spoken about advocacy and policy change. Technology – when we’re linking people up through apps etc., we are driving technology and creating the data. When we publish the paper in 2019, in the beginning of the year when we show that 244 billion dollars in loss productivity occurs due to myopia, it became a big advocacy tool and I still get people asking for that and utilizing that.
And, we’ve covered this, we need to look at technology, leadership of optometry, it is our time, lets step up and lead, entrepreneurship as well as public health, we need to work with each other, we need to not see them as them and us and we need a health team and I’ve said many times in my presentation what the US can do – so in terms of the report we need an active participation of national and international level and I want to challenge the world council of optometry to lead to ensure – and we have Scott Mandel the president and we have the president elect here, to ensure that every national association drives an agenda around the world report on vision and in particular on myopia. Optometry should view the report as an opportunity and not a challenge. Education institutions should review their outputs in relation to the needs of the country, both in the developing and developed world and the role that the US can play in supporting global action and I’ve spoken about it already and in this respect I want to end by saying that – I initiated our children’s vision campaign in my previous role and its one of the quickest decisions professor Holden took, it took him 30 seconds to agree that we can go ahead with it, but it was an initiative that brought together a whole lot of people and allowed us to reach tons of children. But in order to institutionalize it going forward became a challenge because obviously it was a campaign. And I’m glad to announce that having a discussion, myself and Hasan Minto who have been working on this project, having a discussion with John Flanigan from Berkeley led to this, and this just shows what can come out of this country as well. The Berkeley children’s vision institute will be launched as a global initiative to ensure that every child, everywhere across the world who needs an eye exam and a pair of glasses, is supported to get it through a partnership approach. We will mobilize resources through this, bring in advocacy, education, research etc. and I think John he’s quite clear, that this initiative needs every institution in the US. So, if you want to leave this place and say what can I do in relation to the world report, talk to John. Thank you.
Dr. Tim McMahon: Thank you Kovin. Our third speaker for the morning is professor Sandra Block. Sandy is on the faculty of Illinois college for Optometry, did her D degree and then her masters at UIC which is my institution. Sandy has a passion for public health, primarily for disadvantaged inner-city children and youth but also has a very prominent international interest in delivering eye and vision care. Including special interest in special Olympics both within United States and internationally. Sandy was a contributor to this report as well and I asked her to focus on the optometric perspective for north America, which is as Kovin pointed out, we are the most developed with regards to healthcare systems in the world, so how does this report deal with optometry in North America? Please welcome Dr. Sandra Block.
Dr. Sandra Block: So, Tim thank you very much for that introduction and for bringing this session to the academy. I think it really has a significant impact on us right now and listening to the discussions – Alarcos you’ve been a great leader in bringing the world report from idea to reality and Kovin your networking and your insight and your passion continue to amaze me. it’s amazing you get any sleep at all during the day or night, I’m just always amazed by how much you accomplish. And, over the next 20 minutes, what I want to do is kind of bring what they’ve talked about to North America, we need to think about it from our perspective cause things are a little different here than they are outside, so I have nothing to disclose, and I want you to understand that the purpose of this report is really to look at – ensuring that our future eye care is keeping our population seeing well long into their future generations. So, let’s look at a couple of things and I’m going to go through a few of these slides rather quickly cause you’ve actually seen some of them already.
This slide just reminds you that the impact of visual impairment is far greater than we had ever thought about or ever envisioned to talk about and I want you to remember that, with the 2.2 billion that they’re talking about, a majority of them are something that we can actually do to either prevent or reduce the impact of. So, keep that in mind as we move forward. The world report on vision has some very key messages that we need to think about. the Universal Health Coverage that you’ve heard about, we need to think about models that do a much better job of integrating eye care into the healthcare system. We also need to think about how we can address the increasing demand as the number of people who are visually impaired and blind increases, we need to know how much better we can do in addressing the needs of those populations. One of the challenges we’ve had and as having said on [inaudible 01:11:22] report that was released in 2016, surveillance in the United States for sure is not at a level that we needed it at, and here the world report on vision is talking about even having a better number that we can report on or talk about or demonstrate improved outcomes.
We also know that our population is changing. The ageing population is going to change the demand for eye care services as well as not only what kinds of problems they are doing, but how are we going to treat them. And we need to think about the financing piece and I’m going to show you a few things here that I think really impact on how we as a high-income country address health care system. But the question always is, when the health organization comes out with a report, does it really affect us as a high-income country? Typically, we look at it as assisting low- and middle-income countries to address basic healthcare needs. The fact is we always think very egocentrically. We talk about – things are little different here, we have different barriers, we have different challenges and we also have different successes. But the reality is, we do need to think about where we fit into the big picture. US and Canada have tried over the years to really address some of the healthcare issues and as much as I’d like to talk about both of them together, the reality is, they’ve looked at things from very different paths.
You’ve heard about the sustainable development goals. Outside of the United States and Canada, they really focus on the STG’s and almost everything they’re doing. We know that as Alarcos talked about, our purposes really are localised to the STG number 3. Universal Health Coverage, and even more specifically we talk about ensuring that everybody has access to eye care. Without it affecting them financially. Think about our patients with macular degeneration and the cost factor associated with the appropriate treatment. Certainly, that is something we as a high-income country need to do a better job in assessing. But there’s other STG’s that we need to think about, and while we don’t talk about them in much detail when we talk about health, they certainly do effect things like poverty. People who can’t see well, can’t make sufficient amount of money to support themselves often times and certainly education is impacted if they’re not seeing well, and I chose those two as the top two, because I think they are the easiest to understand the relationship. But there are others. If you look at the 17 STg’s you’ll see we fit into a lot of places along the way.
So, in North America where do we stand? Certainly, Canada and the United States have followed different paths. Canada is much more focused on a socialised type of design of healthcare delivery. Well, we know there are private entities out there. Interestingly enough I just read an article looking at what we call the United States and its designed as a more complex system, its referred to as a multi payer system with elements of a single payer, socialised medicine and a self-payer model, certainly something you cannot categorise in any one form or the other. And there are some people who believe some of our government systems is more of a socialised model but that’s not really true. We hear in Washington that there are number of different thoughts about creating more of a focused socialised model, but we’ve not done a very good job in coming out with an answer to our problem. The fact is we in the United States have a significant increase in the cost of healthcare systems and we need to do a better job. This slide just shows the increasing cost but more important is looking at it from a more global level.
In 2008, the United States spent 15% of the GDP on healthcare. In 2017 it increased to 17%. And for those of you who like a more visual presentation here are the 11 high income countries and the one at the top is United States. Everybody else is clustered together showing a very low, slow increase in the cost of healthcare. We need to think about a better way of dressing that. So, that is currently one of our challenges. What is that high cost from? A multitude of things. Obviously, we have an ageing population, but think about your practices. You have lots of high technology in those practices and you need to be able to pay for them, and we do those high technology pieces is because we do a better job at diagnosing and treating our patients. It’s the best way of delivering eye care services, but its costly. We also have a situation in the United States where it’s very difficult for patients to actually access appropriate primary care. Now I’m not talking about eye care, I’m talking about general primary care. There’s lots of confusion associated with the delivery of care and we really need to do a better job in addressing those with social determinants, low income – those who work in lo paying jobs, those who are specific races and ethnicities. So, we need to think about how we can do a better job in accessing services down to them. The reality is, we are looking at the need to change the way we do things for universal health coverage, but this is not a new concept. It’s a concept that was talked about on a global level in 1978, we have just knocked on a job to address the problem. It is considered a human right. It’s the moral and ethical way of dealing with things.
So, what are we going to do – when we think about universal healthcare, what are the benefits about it? Certainly, earlier detection is a much better way of treating people. Improved monitoring of compliance allows us to ensure people follow our suggestions or recommendations to treating their problems. Focusing on the patient more so and their interest in quality of life, and that yields better outcomes in the long run, and most importantly there is the cost saving associated with doing a better job. Detecting it early. Preventing that disease from either taking over the patient or leading to significant visual impairment or blindness. We need to look at how we can get a better return on investment.
One of the things I looked at is, how can we do it differently and historically optometry started out in private practices or group practices or working in corporate entities. In the last half of the last century we saw more optometrists being associated in hospital situations or health organizations. But, were they integrated or were they working side by side? It’s a very different model and I think what we need to do is look at how we do a better job, cause we’re not doing a very good job of Universal Health Coverage.
The thing that I wanted to bring – and I’m going to go through it relatively quickly, is a framework that was created in John Hopkin’s lab where they were working on people with visual impairment in the elderly population. They came in with a framework that was not addressing the eye care provider, it was addressing the primary care provider. The gerontologist, the individual who deals with the health of the ageing population. We do know that the older adults are the fastest growing age group and those are the ones with the most significant number of visual impairments and blindness.
If you look at the trajectory of that blue line, that is the increase in visual impairment from the year 2015 to the year 2050. It is a significant increase in vision problems and for those of you who like numbers, take a look at this table. On the left side you’ll see the three decades 60 – 69, 70 – 79, and those 80 and over and I want you to focus on the last column over to the right, which is the total amount of visual impairment, and look at the difference or increase in the percentage of vision impairment that these folks are going to demonstrate. The earlier group sadly enough I fit into that earlier group but I’m getting closer to the next one, its only 1.2%. that next group is 3.8% but the last group, those 80 and over, that largest growing population in the United States has a prevalence of vision impairment of over 20%. That is an amazing amount of individuals.
In addition, there are other changes that we need to look at with the ageing population. There is an association with visual impairment and cognitive decline. We are going to see as people age, you will notice that as their vision starts to decrease, their cognition will as well and that was supported by a study done out of the Salisbury eye study, and if you look at this study, they showed the relation between that decrease in visual acuity and cognitive decline.
The next piece that is really very interesting with this age group is the fact that as people get older they have multiple chronic conditions and this ultimate geriatric syndrome was presented by Heather Whitson who is a gerontologist and she talked about the fact that 2/3rd of Medicare population have at least 2 chronic conditions and a quarter of them have five chronic conditions. The things that we worry about is, the more chronic conditions you have, the more likely you are going to be hospitalised or have additional complications, disabilities or actually be institutionalised or early death. So, we know there’s lots of core morbidities that are associated with the ageing population, we found that with vision impairment its more likely that you will see people become more depressed. You will see more of an association with a hearing impairment. You will see the cognitive impairment that this study just demonstrated, and the fact is you’ll see more mobility issues and balance. This morning I saw on the news that our past president Jimmy Carter fell in his home and broke his hip. We worry about these things all the time. The fact also is, we are very aware of all the vision problems that this ageing population has. If you look at this list and you look at the top reasons for vision impairment and blindness worldwide, it’s the same. It’s the same things. It’s the cataracts. It’s the glaucoma. We need to do a better job of identifying these diseases early. Either slowing or stopping the progression.
The piece that we haven’t done a very good job with is the last piece. We have an ageing population; we have an increasing prevalence of vision problems and many of them we don’t have the answers for. We need to be able to ensure that we allow this population to age gracefully. We want them to be able to be independent. We need to look at the vision, low vision rehabilitative services in order to engage them as a part of the community and not isolate or marginalise them. The sooner we do this the better it is for the individual and then you’ll see those other common problems that are core morbidities hopefully slowing the progression. The thing that this group came out with is there was a conceptual model that they felt was really important. They felt that the physicians that are treating this population have a true gap in understanding what the consequences of visual impairment were. So, they thought that we really needed to look at how the best way is of dealing with this population and they looked at the multiple functions that individual domains provided and they looked at the risk that were associated with them. And I want to show you first the slide that they suggested that – what we need to do is to educate the healthcare providers better about what visual impairment, whether its decrease in acuity and that’s treatable and some other problems that they should be able to identify or be able to refer, but they looked at this as a model of what they need to do. They believed very strongly that visual impairments lead to different types of problems for the individual who is in their chair. They looked at impacts on physical functioning, cognitive functioning as well as social and psychological functioning. I don’t think that surprises any of us here in the room that a visual impairment will affect all of these three things. The reality is, if there is a decrease in those functional areas, you are going to see significant health outcomes. It’s going to affect the individual, it will affect their family, you’ll see an increase in the disabilities and not just the visual disability but other disabilities. You will see those multiple chronic conditions coming alive and being more of an issue for them and you’re going to see significant increase in mortality if these are unaddressed. But if you look at the framework, the way it’s designed is, if you address some of those personal factors and the environmental factors and the common risk factors, feeding in and have this closed loop – if we do a better job in identifying a visual impairment we can have a more positive impact on their functional status and better healthcare outcomes. So, I think that ageing combined with visual impairment certainly is one of our biggest challenges to address, since we know that many of those causes of visual impairment and blindness certainly are associated with ageing. We could see better addressing, the increase in falls that we see in the poor mobility, we can see better mental health outcomes, we can see better independence rather than the loss of independence as they move forward. So, the fact is, I’ve just focused on one population, but Universal Health Coverage is a birth to death concept. Do we believe that having a Universal Health Coverage should really focus on all the populations and the answer is – yes. You heard Kovin talk about the children – so we all know, the earlier you identify a vision problem in a child, the more likely that the outcomes will be better. Talk about amblyopia, myopia, each of those will impact the academic performance of a child as well as if vision problems are not identified early on, often times quality of life could be effected because they may not be able to get the jobs that they were able to – they could have potentially gotten if they had appropriate education and were successful in the academic environment. We also know that there’s other vulnerable populations out there, certainly the one that’s closest to my heart is the population with intellectual disability.
But there’s other disabilities that need to be just. There’s also those people who live in rural communities. We need to look at the poor, we need to look at the indigent. We in the United States and Canada are high income countries, but that doesn’t mean everybody has the resources. I bring this picture back that Alarcos brought and I’m not going to go through the description but remember this blue box is the way we deliver care. We need to do a better job. We need to expand the services to all. We need to invest more appropriately. We need to reduce the amount of money we spend on healthcare but do a better job at it and ensure that everybody has appropriate access. We do know that there’s an increase in demand that’s going to happen. The changing definition of visual impairment is overwhelming. The first time I heard it I said – how are we going to be able to address it? We know the magnitude of myopia is growing, Kovin just talked and reinforced that. We need to do a better job in identifying the true magnitude of the vision problem in the United States and Canada and we need to move away from the siloed services that we’ve done to a true continuum of care from birth to death, or diapers to depends, whatever way you want to do it. The fact is, we’ve done a great job in collecting data, but is it the right data? The Nasem [inaudible 01:28:02] report talked about in 2016 the United States needs to do a better job. The CDC has started to work on that, but there’s a long way to go. If you noticed on this website that I copied, they talk about the Iris registry, where is the registry from optometry? We do have one, I don’t know that it’s as comprehensive as I’d like, but we need to do a better job in getting the surveillance all the way through the United States and ensure both optometry and ophthalmology is contributing to the data that is out there.
The last piece I wanted to talk about is the issue related to electronic health records. The next step on the meaningful use, is really interoperability. That will hopefully help to improve our surveillance, but we also need to know that there are large gaps in the distribution of optometry. We know that over the United States, 24% of the counties have no eye care services. No optometry, no ophthalmology. We need to do a better job. There’s lots of new schools that are opening, but is that addressing the need? Does this lead us to think about how we can address those deficits? In the October issue of the nation’s health, there was an interesting article from the dental group. They talked about the change in the demographics of the dentists that were out there and they said, there were 30% female dentists in 2016. It’s an interesting perspective considering as we all look at the schools, the majority of our classes are now women. But there were a couple of points that I wanted to really focus in on. The fact is, they looked at the women in dentistry and they found that the women were younger, the women were more diverse than the men were. They had a higher proportion of black, Hispanic and foreign trained individuals. In addition, the women were more likely to serve the needs of children, patients with public insurance and more of the individuals we refer to the vulnerable population, but they were more likely employees of others and they work part time in many cases.
So, the gaps are very similar in optometry, I think we need to look at what the demographics are of the future profession and with that I want to remind you of those key messages – we have a long way to go. I like the idea of integrating technology and telehealth and artificial intelligence in trying to answer some of those questions, but I think over the next few days you’ll hear lots of things about that, the question is – do we just listen or are we going to take some action? So, I’d like to thank you very much for listening and I look forward to you all doing great things.