Off the Beaten Track: Kevin Waltz

What are the most remote locations you’ve worked in?

The group I work with is focused on Central American locations, primarily Honduras, with some work being done in El Salvador. I have about ten facilities and groups that I work with at any given time. The most comprehensive of those is the project in Western Honduras, in Santa Rosa de Copan. It is a large group of buildings, which is going to be a dedicated eye center – very much needed in the area, where around a million people require ophthalmic care. Local ophthalmologists are providing the building and the land, and the charity – through cash and equipment donations – are taking care of all the necessary machinery and supplies. Local ophthalmologists are being trained in modern surgical techniques.

How has ophthalmic outreach changed in the last couple of decades?

In the past, ophthalmologists would mostly travel to a certain location and follow the American marine model: go self-contained, hit the ground running, operate, then fold everything and take it back home. These days projects try to follow a model of supporting local doctors, transferring skills or improving existing skillsets, and using the equipment available at a specific location, which provides a much stronger benefit over time – although that is not always possible. The ultimate goal is to set up a facility that can function independently long-term. A great example of this is the Himalayan Cataract Project.

If I go to a remote setting and perform surgeries myself, I might be able to do a few dozen in a year, broken up over several visits, but if local professionals learn the techniques and have the technology available, they can do so much more – and there are several thousand people waiting for their procedures.

It usually takes between five and ten years to set up a facility in a remote location. Modern equipment is often completely different from what local ophthalmologists originally trained on, and it takes time to adjust to a different microscope, a new set of instruments, or a new phaco machine. Local doctors are often experts in traditional cataract surgery, and they can easily take a person from being blind from cataracts to 20/100 vision, time and again, which in itself is amazing, and makes both doctors and patients happy. But if they can learn how to improve these outcomes and give 20/30 or even 20/20 vision to cataract patients, that’s on a whole different level. Each intervention should maximize benefits to patients, even if it requires a mindset change and learning some new skills.

Once set up, how often do you visit these facilities?

Collectively, we visit projects regularly – three or four times a year – and try to connect locals with industry or institutional partners, so that they have a steady supply of equipment. We also help organize events, inviting speakers from various locations, and initiating networking. For the last six years, we have hosted an annual Honduras interest group meeting during the AAO, where doctors from Honduras, other Central American countries, and the US come together. At the last meeting, in Chicago in 2018, we had 64 attendees. I realized some years ago that many people are working in these locations, but they didn’t communicate with each other; my goal has been to provide an opportunity for people to get together and learn from each other.

What is the most striking aspect of working in places with limited access to care?

I see many children with cataracts – and, in remote settings this can be a lethal disease, as children with severe cataracts might not be able to take care of themselves. We try to prioritize these cases and perform phacoemulsification to control the incision and the optical outcome. There are some difficult decisions to be made: a child’s cataract surgery is very time consuming, it takes a lot of resources, so you could probably operate on three or four adults in the time it takes to operate on a child. But the potential outcome and quality of life is usually so much greater for a child.

What skills have you learned from your time in Central America?

I have certainly learned to be less wasteful – right down to the little things: if you can use one tissue, why use two? Perhaps I don’t need to fill a whole syringe with medication, if I’m only going to use half of it? They seem like such small changes, but it means using half the amount over a long period of time, and it all adds up. I have certainly been more respectful of the resources and the environment, and I think it’s an important aspect of being a doctor. 

What impact do you think these projects – and the volunteers behind them – have on the remote locations?

It’s an enormous impact – and in more ways than we usually consider. There are now so many charities working with developing countries, that airlines open new connections! This makes a difference to other people’s lives – they are able to see their families and friends more often. Volunteers can make a big difference to local providers – they buy food, stay in local accommodation. Governments impose taxes on international flights, and get a certain amount of money from each person entering the country. If I remember correctly, just in Honduras this amounts to $20-40 million a year in tax revenue from foreign charity workers – a huge economic benefit to the system, on top of the important work and skill transfer that volunteers provide. However, it is extremely important to make sure that all the work that is done is balanced with the existing infrastructure. You should never provide free care in places where local care already functions well – this undermines local professionals, who can’t compete with volunteers working free of charge – you wouldn’t stand for it if someone came to where you live and work, and offered their services for free. Doing so has the potential to destroy the existing medical economy, and has an impact on patients, who sometimes delay accessing care for years, waiting for volunteers to arrive. Of course, it’s a different situation if the area is so remote that there is no care available there at all, but if you can help a local doctor make a living, at the same time helping the population access the best care possible, it is an amazing result, and it makes the whole healthcare ecosystem stronger.