Improving vision and livelihoods: How reading glasses can help workers

• Over 10 million people in Bangladesh have been tested for presbyopia, with 2 million receiving glasses—63% of them women.
• A 32% increase in income for users of reading glasses, proves the economic benefits of affordable eyewear.

A few weeks ago, I visited a large, modern, state-of-the-art RMG factory in Gazipur. Hosted by VisionSpring, a US-based non-profit promoting reading glasses for the elderly population and working men and women, the event marked the launch of a new programme aimed at testing the eyesight of all its 7,000+ workers for presbyopia and prescribing 'reading glasses' where needed. 

Presbyopia, a common condition affecting people aged 40 years and over, causes difficulty in clearly seeing nearby objects. It is estimated that around 520 million people worldwide suffer from this condition. It reduces productivity and often leads to mental distress. The global economic loss due to presbyopia is estimated at $400 billion annually. A simple, safe, and cost-effective solution to this is 'reading glasses'.

My introduction to this technology (reading glasses) took place about two decades ago when Jordan Kassalow, the founder of VisionSpring, first told me about it. Jordan and I were on a panel on health entrepreneurship at the Council on Foreign Relations (CFR) in New York. 

Hearing about this 700-year-old technology reminded me of the many Aarong artisans who struggled with precision work due to eyesight problems, reducing their income-generating capacity, with some even losing their jobs. While consulting an ophthalmologist could solve these issues, many could not afford such services. 

Many were also unaware that they did not even need a specialist like an ophthalmologist to resolve them. In many countries, such eyesight problems are easily managed by optometrists, a distinct group of professionally trained experts. Optometrists examine eyes for refractive errors (myopia, hyperopia, and presbyopia) and prescribe glasses, whereas ophthalmologists handle more complex eye issues and perform surgeries. 

In Bangladesh, the role of optometrists is performed by ophthalmologists, which is a misuse of their time and expertise.

While talking to Jordan, I thought about the thousands of BRAC Community Health Workers (CHWs). Could this group of paraprofessionals be effectively utilised to conduct eye screenings and prescribe glasses in rural Bangladesh? Upon my return, we initiated a pilot project in Narsingdi, followed by another in Manikganj, to explore the potential of using CHWs for this task, supported by VisionSpring. 

With encouraging results, there was no turning back. Over the years, BRAC has trained 25,000 CHWs for the screenings. The resultant numbers are astounding. Over ten million men and women have been tested, and reading glasses have been provided to over two million of them (63% women). 

Sixty-five per cent received them for the first time in their lives. A study using the RCT (randomised controlled trial) methodology found an increase in income among glass users by 32%. A real-life example: Azad Ali, a tailor in Manikganj, upon receiving the glasses, commented on his new tool, "These glasses are like my lifeline. I could not do my job without them."

This simple and safe technology allows individuals to find the right glasses from a selection of different strengths. As mentioned, optometry is an independent profession in most Global North countries. 

Many public and private universities in neighbouring countries like India have introduced undergraduate and postgraduate educational programmes in optometry. In Bangladesh, some organisations, including Islamia Hospital and the Bangladesh National Society for the Blind (BNSB), offer a one-year diploma programme for Mid-Level Ophthalmic Professionals (MLOPs). 

Graduates of these programmes are mostly employed by ophthalmologists in their private chambers as administrative assistants. The Institute of Community Ophthalmology at the Chattagram Eye Infirmary and Training Complex is the only institution offering graduate education in optometry. 

A Bachelor of Science in Optometry (B-Optom) was introduced in 2010, followed by a Master's programme in 2019. Every year, 12 to 15 students enrol in the B-Optom and four in the Master's programme.

According to the World Health Organization, there are over a million visually impaired people in Bangladesh, a significant number of whom remain untreated. The government has plans to post one ophthalmologist in every upazila, but this is unlikely to materialise soon given the short supply and the reluctance of medical doctors to work at the upazila level. A solution is to adopt the optometry model. 

Promoting and scaling up the training of optometrists through public and private universities, alongside the government creating new positions for optometrists at the upazila level, would go a long way in making an essential primary healthcare service accessible to the majority of the population.

With a population of over 180 million, Bangladesh is estimated to have about 700 optometrists (mostly with one-year MLOP qualifications), all of whom work for private clinics and NGO programmes. Compare this with the United States and India, for example, and it becomes evident how dire the eyecare situation is in Bangladesh. 

There is indeed a crisis that receives little or no attention. With a population of 330 million (twice that of Bangladesh), the USA has over 41,000 optometrists, while India, with a population of 1.4 billion, has 49,000 optometrists. 

Bangladesh is clearly lagging far behind. Unfortunately, optometrists are not even recognised by the government as part of the health workforce.

Returning to VisionSpring's initiative of making reading glasses available at affordable prices, the organisation has also implemented new projects in addition to supporting BRAC's community-based initiative. 

It is working with several major RMG factories to get their workers tested for refractive errors. It was impressive to observe how the operation was being organised and implemented in the Gazipur factory with the support of the factory owners. 

Further support from management in providing glasses free of charge to workers who need them would go a long way in making them accessible to all. Implementing significant policy changes at the national level would make the goal of eliminating avoidable blindness a success, ultimately contributing to poverty reduction in the country. 

Such policy interventions should include, among others, recognising optometry as a profession, expanding educational programmes at the university level, and creating new opportunities for optometry graduates within the government's primary healthcare services. 

The July uprising and the promised reforms have created an opportunity to make a lasting impact on the way eyecare is managed at the grassroots level.

Sketch: TBS

Mushtaque Chowdhury, Public health expert