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PEOPLE living in developing world countries aren't the only ones who have trouble accessing eye care. The homeless living in downtown Vancouver , Canada have unexpectedly high rates of eye disease and also face numerous barriers to care, according to David Maberley, MD. He spoke at the annual meeting of the Canadian Ophthalmological Society, where he presented research showing that the Vancouver homeless are not only under-serviced, but have multiple health and vision problems, even in a system where many services are publicly funded. Dr. Maberley spends part of his time working at the Vancouver Native Health Society (VNHS), a health unit that take all-comers on East Hasting's Street in Vancouver's east side, Canada's poorest neighbourhood. The downtown east side has a high concentration of transients, sex trade workers and drug addicts. He helped launch an ophthalmology service there in April 2000. Getting ophthalmological care to this population can open the door for these people to having other medical problems addressed. Eye exams don't have the social stigma other conditions may have and ophthalmologists can encourage people to get additional care. Vision problems often accompany other conditions, such as HIV, syphilis, physical abuse or addiction. He cited statistics showing that homelessness in Canada increases the risk of early death by nine times in men and 31 times for women. The risk is half that in the US , and it is believed that the Canadian social safety net lightens the risk, though it is still significant. Ophthalmology was added to VNHS because several changes had adversely affected eye care delivery in the community. For one, St. Paul 's Hospital, traditionally the medical centre that cared for the downtown population is in a neighbourhood that has become increasingly "gentrified" over the last decade. Homeless and under-housed people had to move further away, meaning specialty care was less accessible. "In addition, in British Columbia we have had de-insuring of routine eye exams and so a lot of the patients that we provide care for were not showing up at ophthalmic clinics. They couldn't afford them," Dr. Maberley said. A research project was launched to clarify the actual need for ophthalmological care in the community, whether care was being delivered in an appropriate and culturally sensitive manner (a significant portion of the population is aboriginal), to determine the prevalence of eye disease in the community, and look at barriers to care. A total of 226 people who went into the clinic for general medical care agreed to have an eye exam and fill out a questionnaire. Participants had an average age of 46 years, had not had an eye exam for eight to ten years, and had an average presenting acuity of 20/60. Vision loss was quite significant, higher than researchers anticipated: 17% had unilateral visual acuity below 20/50 in one eye, and 22% had visual acuity below this level both eyes. Altogether, almost 40% of the population had some degree of vision loss, he said. A total of 13% were legally blind in one eye, while 4% were bilaterally blind having less than 20/200 in both eyes. The main causes of poor vision were uncorrected refractive error with vision less than 20/50, cataracts, retinal emboli and diabetic retinopathy. There is a paucity of Canadian national data on blindness, so the findings were compared to population data from the UK . The rate of blindness among Vancouver 's homeless is 10 times higher than what it is in the general community – similar to some developing world countries. Of the people going into the VNHS, 47% lived in rooming houses, 11% in emergency shelters and 12% outside on the street. Only 31% of people could be considered to be adequately housed, he said.Income was a big predictor of poor eyesight. A total of 45% of people were on welfare, and another 40% were on disability. Some 60% had not completed high school. Barriers to getting eye care included transportation woes, the delisting of eye exams, and difficulties because of other health and social problems such as mental illness, addiction and poverty. Working with the homeless is a good learning experience for ophthalmologist and residents in training, Dr Maberly emphasised. David Yorston, MD, who has done extensive work in developing countries delivering specialty and basic eye care, said he was impressed by the project in downtown Vancouver . "This is a reminder that not everyone who lives in poverty is in a third world country," he added. David Maberley, MD, |
