2020 IPEP CONFERENCE
Welcome to IPEP Conference 2020! In these extraordinary times, we have organised the conference to be held online. The theme this year is: "Communication", which covers two very relevant topics - Telehealth and First Nations Health. There are two parts to this conference:
Part 1 - Recorded videos, podcasts, and transcripts of insightful interviews conducted with experts and professors working and researching in Telehealth and/or First Nations Health which are available to you from Monday 14 Sept to Thursday 8 Oct (AEST).
Part 2 - A live Zoom session on Thursday 8 Oct, 7:30-9:30pm (AEST) to delve deeper into case studies with some of these experts.
Please head over to this link to register - https://forms.gle/djdp5gUGjzDre6wv8
If you have any questions, please email us: firstname.lastname@example.org
PROFESSOR HUGH TAYLOR
Hugh is a Melbourne Laureate Professor and the Harold Mitchell Chair of Indigenous Eye Health at the University of Melbourne. From 1990-2007 he was the Professor of Ophthalmology at the University of Melbourne and the Founding Director of the Centre for Eye Research Australia. Prior to that, he was a Professor of Ophthalmology at the Johns Hopkins University in Baltimore with joint appointments in Epidemiology and International Health.He is currently working to close the gap for vision by eliminating trachoma and providing equity in eye care for Indigenous Australians. He has written 30 books and reports and more than 700 scientific papers. He has received multiple international awards and prizes. In 2001, he was made a Companion in the Order of Australia.He has been President of the International Council of Ophthalmology, Vice President of the International Agency for the Prevention of Blindness and Chairman of Vision 2020 Australia. He has served a number of international bodies including the World Health Organization.
Indigenous Health: First Nations Eye Health [Video Transcript]
Presenter: Professor Hugh R. Taylor AC, Harold Mitchell Chair of Indigenous Eye Health & Melbourne School of Population and Global Health
Hello there! My name is Hugh Taylor and I am delighted to be talking to the Interprofessional Education and Practice Health Students’ Network and I will be talking now about First Nations Eye Health. I am sorry that this is a video presentation, rather than an in person presentation but given where we are now, of course it is understandable.
I want to talk about First Nations Eye Health and the work we have been doing. To start off with, I want to acknowledge that we are all meeting and working on Aboriginal and Torres Strait Islander land that has been looked after and cared for by the traditional custodians for 2000 generations, and whose ownership has not been ceded. I also want to pay my respects to the elders’ past, present and emerging and to any aboriginal or Strait Islanders people who are listening to this meeting.
I was born and educated in Melbourne. When I finished my Ophthalmology training in Melbourne, I spent a year or so working as the Assistant Director of the National Trachea and Eye Health Program where we examined our First Nations people right across the country. Now this gave me a strong interest in the issues around the provision of eye care to such an under-served and needy deserving group.
In 2008, we started a small group in the Melbourne School of Population and Global Health to look at what we could do to address issues around indigenous eye health, where we had a mixture of funding from trusted foundations, private donors and government. We are committed to provide equity in eye care for all indigenous Australians. We have a small group working on Trachoma and another group working on diabetes and providing regional care and a group on communications and coordinating our activities.
I want to talk about the Vision of Fist Nations Australians. First of all, I want to talk about the good vision I have. The is around vision loss and trachoma and in the work we are doing about closing the gap for vision using our roadmap. But it is important to recognize that Eye Health, as with other health status, are really dependent on so many other factors, whether they are biophysical, individual factors, societal factors and systemic factors. We are looking at complicated issues, there is not a single one-step-fix-all solution to any of these problems.
The Australian census in 2016 showed nearly 800,000 First Nations people living across the country. The projections are there is now almost 900,000 and by 2025, it is expected to be 1 million people. What is important is that the age distribution is quite different for indigenous and non-indigenous Australians. Over a third of Aboriginal and Torres Strait Island people are less than 15 years old whereas less than 20%, only 1 in 6, of the non indigenous people are less than 15 years old. The other thing that is very important is that over 75% of the Aboriginal and Torres Strait Islander people live in the towns and cities. Only about 20% live in remote or very remote areas.
Now some work I did in the 70s showed that Aboriginal people have the world’s best vision. This is an aboriginal woman in Western Australia who holds the world record vision, as far as I know. She can see 6/1.5 with each eye. There she is reading that chart under the umbrella, at which is 12m away. That means, she can read at 6 meters, but normal people have to walk up to 1.5 meters length, about 1.5 arms’ length, to be able to read. And while we call normal vision as 6/6 vision, Aboriginal and Torres Strait Islander people, this is aboriginal people where studies were done, half the adults have 6/2.4 or better. Less than a third of European males or females could do that. Aboriginal and Torres Strait Islander people actually start off with much better vision than what we define as “normal”.
In 2008, we did a National Indigenous Eye Health Survey and we confirmed the fact that vision loss was much less common in First Nation’s children, with not only good vision but much less inherited problems of squint or other eye conditions. But for the adults, those over the age of 40 had 6 times more blindness than mainstream Australians and nearly 3 times as much vision loss. Overall, 94% of this vision impairment and vision loss was avoidable, it was unnecessary or preventable, they could be treated. Over a third of the people never had an eye exam.
Now we know the main cause of vision loss and we know what to do about it. For Cataract, we need to provide access to cataract surgery. For diabetes, one needs regular eye exams every year and in treatment for diabetic retinopathy with injections or laser treatment. For refractive error, we just need to provide the right glasses. And for Trachoma, as we will talk about, one could use the WHO SAFE strategy to eliminate Trachoma.
What’s more, most of this vision loss can literally be fixed overnight. If you give somebody a pair of glasses, they will see right away. And if we do cataract surgery, they will see the next day. So, we can really address this and show what needs to be done.
Moreover, vision loss caused 11% of the health gap and the amount of vision loss will double over a 20 year period, from 2010 to 2030, if we left things the way they were. Clearly, heart disease was the number one cause of the health gap, followed by diabetes. But vision loss was essentially, equals to trauma and ahead of alcoholism and stroke. So, we could essentially eliminate 11% of the health gap by providing good eye care.
What was also striking was the unmet need for eye care in Fitzroy, where I live, is the same as it is in Fitzory Crossing in the Kimberley. In Fitzroy Crossing, clearly, we need to get more optometrists, ophthalmologists and eye services. But the Victorian Aboriginal Health Service in Fitzroy is less than a mile from the Royal Victorian Eye and Ear Hospital, the largest eye hospital in the Southern hemisphere. All we needed to do is to get people to go back and forth across Victoria parade, to be able to provide proper eye care.
Now we are very interested in trying to provide equity in eye care and equity in eye health. In order to do this, we need to take a health systems approach and make sure it was evidence-based. This is really based in primary care with extensive community engagement. But because we are linking the primary care services and HOs at the community level, one needs to look at building multi-sector, multi-level and multi-strategy. Because one has to link in primary care, various visiting eye specialists’ services of optometry and ophthalmology and hospitals. One has to coordinate things on a regional level, at the jurisdiction level and at the national level. The multi-strategy designed is really to make sure people do what is needed to do for eye care, such as make sure everyone with diabetes gets an eye exam every year. But how they do that may be very different, depending on the locally availability and needs. Some might be done through an optometrist, ophthalmologist, a GP or health worker with a camera using telehealth, lots of different ways as long as it is done. Most importantly, these services have to be culturally safe and appropriate and that is where the community consultation and engagement is so important to have proper community design. Once again, one has to look at monitoring and evaluating things to keep some accountability.
We looked at the patient journey or the pathway of care and said it was like a leaky pipe, where they are multiple leaks. The patient might have an eye problem and might go to whatever eye health service or GP - be referred to an optometrist and sit on the waiting list, be referred to an ophthalmologist and sit on the waiting list, maybe for cataract surgery for a long time and there were multiple leaks. And if you only fix 1 or 2 leaks, the pipe will still be leaking. We came up with 42 leaks or issues that needed to be addressed. And these recommendations form the roadmap to close the gap for vision that was built around this community engagement and cultural safety, linking the aboriginal community health services with the regional provision of eye care and using a multi-layered approach.
And in the regional implementation, the stakeholder partnership, was self-defined regions to define an area with a hospital where cataract surgery could be done to act as a hub. There are 64 of these self-defined regions across the country. Within each region, we developed a stakeholder collaboration with the HOs, optometrist, ophthalmologist, hospitals, PHNs and the any other people involved. This group of people would identify what are the population-based needs of that particular region and what are the shortfalls in the current services. Together they will develop the regional directory and referral protocols for someone who might need a pair of glasses, cataract surgery or whatever. Together with the support of the local coordination and case management, we made sure people don’t fall through the cracks. They will also monitor the regional performance and data collection for oversight. Currently, there are about 59 of these regional groups that are established or being established in the 64 regions across the country.
One of the areas we particularly focused on is on the need for eye care for people with diabetes. 37% of indigenous adults have diabetes, a rate 5 times higher than adults in the mainstream. Everyone with diabetes are at risk of going blind. But up to 98% of this blindness can be prevented by timely examination or treatment. But once vision is lost, it cannot be restored. Someone who is blind from diabetes cannot manage their drugs or blood sugars, can’t check their feet and can’t even get themselves to the doctor. So, it really is very damaging for people with these complex chronic diseases.
We have done a lot on focusing on trying to improve eye care for people with diabetes in primary care. People with diabetes form nearly ¾ of indigenous adults who needed eye exam each year and many of them may need to be referred for diabetic retinopathy, with changes in the back of the eye. Some may need cataract surgery while others may need glasses. So, we need to build referral pathways for referral for retinopathy but also for surgery and glasses. And these latitudes will be exactly the same pathways that people who don’t have diabetes will use. In many ways, focusing on diabetes is a way for implementing eye care for all. Part of the work is to be involved in getting new Medicare item number for
retinal photography and the Commonwealth has now provided retinal cameras and over 150 aboriginal health services across the country. There has also been a lot of work done on health promotion and education.
We’ve developed an extensive list of materials that are working very closely with communities. Many of these are community designs and community-owned to alert people to the need for regular eye exams. But also, to help the staff and HOs to know what are the steps they need to go through the eye examination for diabetes or healthy adult check, as well as learning to rate diabetic retinopathy.
I now want to switch to Trachoma. This is a blinding eye infection that starts in little children and ends up causing blindness in middle aged and older adults. Australia is the only developed country to still have Trachoma. In 2009, the Australia government committed to eliminate Trachoma by 2020.
This is the data that came out about a month or so ago by the World Health Organization showing the distribution of Trachoma where it is still mainly a problem in African countries. But also, in some South Asian countries and some countries in Latin America. There are also 13 countries that eliminated Trachoma, including Cambodia, China, Iran, Ghana, Laos, Mexico and Morocco, Nepal and Oman. So, there is a lot of progress to be made and Australia really needs to working hard to make sure we reach that elimination target.
Now Trachoma, as I said, is a blinding eye infection. A single episode of infection will give a little bit of follicular conjunctivitis, as you see in this top left-hand photograph of these little lumps of follicles underneath the eyelid. With a single episode of infection, that will settle down without any problems. With a child or individual repeatedly infected, each episode of infection becomes more intense inflammation. The more intense the inflammation is, the longer it goes on, the more scarring is caused, as you can see here with these extensive scarring. As with scars anywhere on the body, scars underneath the eyelid will contract and they will turn and pull the eyelashes in and rub on the eye and cause blindness.
Every child with a dirty face is a health hazard and at risk of spreading Trachoma infection. And a child or individual needs about 150 episodes of infection to have enough scarring and damage to cause blindness. Because the infection is in the eye, the infected eye secretions and the tears drain through the nose, the infected nose secretions gets spreads from one child’s face to another. Transmission is stopped by keeping every face clean. So, our message for the community is “Clean faces, strong eyes”. We have to stop this frequent transmission and retransmission of infection from one kid with a grubby face to another.
We have developed a series of health-promotion messages and building on the WHO SAFE strategy. SAFE stands for surgery to correct the in-turned eye lashes, the end stage of the disease. The use of antibiotics to reduce the levels of infection. The antibiotics are usually given once a year to everybody in a family or community. The F for facial cleanliness to keep every child’s face clean and the E is for environmental improvement - to improve hygiene so the kids can actually wash. Now SAFE is the wrong order from a public health perspective, it should be EFAS, putting environmental first and surgery last. But EFAS isn’t as good an acronym as SAFE. We built on these and built it further. We’ve got Milpa the trachoma iguana who is the mascot for Trachoma and “Clean faces and strong eyes”. He comes out in community events, football events and so forth. He is adorned on posters and murals and even on interactive water trails for fun events. We have also built into a more comprehensive hygiene message to stop germs, including blowing your nose, washing your hands with soap and washing your face. Of course, you can’t wash your face without washing your hands. Brushing your teeth, having a shower and not sharing towels.
It is also important to remember that even if people know about these issues about clean faces, they have to have access to safe and functional washing facilities. So often, the bathrooms and wash facilities in houses and schools are terrible. And so, we have worked on to trying to improve the appearance and maintenance and developed things like safe bathroom checklists to help people in identifying repair and maintenance. Good hygiene not only reduces trachoma, it also will reduce Otitis media, respiratory infections, gastro infections and skin infections, particularly scabies that leads onto heart disease, glomerulonephritis and kidney failure. And of course, in the pandemic time of Covid-19, good hygiene is a really important message, with the hand washing and safe coughing and blowing.
Overall, we have been making quite good progress of Trachoma in Australia. The number of communities where Trachoma is still a problem has reduced dramatically, going from something like 205 communities that were at risk in 2008 when the prevalence was 21%. Now there are about 50 to 53 communities where Trachoma is a risk and the prevalence now is about 4.5%. As you can see the rates have somewhat plateaued and there is still a lot more work to do, particularly focusing on the “Clean faces” and safe bathrooms, which is really the need for proper maintenance in houses and schools, so that children can wash their faces.
Broadly, overall, with the roadmap altogether, we are also making good progress. Of the 42 recommendations, the first step has been done on every one of those. 21 of these have been fully implemented. This is the annual update we released at the end of last year and we’re working on starting the 2020 update. We are actually some real progress.
With that, we have shown that the rate of blindness has been reduced by about half. Now that is not acceptable, being 3 times more than mainstream but it has been reduced from being 6 times, so that is really good progress. We’ve increased the number of eye exams by more than 3-fold and increased the number of people having diabetic exams or cataract surgery, both of those have more than doubled. There is some good progress is being made but there is still more work to do.
I started off mentioning how eye care is a complex and healthcare is complex, health status is complex with many of these interacting facets. And this is the same information given around in a different way. It shows the complex systemic, societal, individual, biophysical factors that interact on health status.
In this slide, I’ve marked all the different factors that directly relates to vision loss and blindness. Again, you can see that there is not one simple thing to fix, but one needs to address these multiple issues. Which is why this health systems approach we have taken with the roadmap to close the gap through vision is so important and successful.
In summary, indigenous Australians and first nations Australians still have unnecessary blindness and vision loss. There is a real vision gap still. But there is much we can do to address this, as has been set up by the Roadmap and we have made some really good
progress. The gap for blindness has been halved. Not only that, but also what our fundamental work is doing is showing how to link primary care and aboriginal community controlled health services with visiting specialist services. What will work for eyes is the same health systems approach and also help develop the other specialist services like ear, hearts, lungs or kidneys. In conclusion, we can close the gap through vision and we can bring equity in eye health.
Thank you very much for listening and for your attention.