Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid. An honest look at controversial topics in the field. I’m Gary Wörtz.

Globally, 285 million people are visually impaired. Thirty-nine million are blind, and 246 million have low vision. About 90% of visually impaired people live in developing countries where cataracts remain the leading cause of blindness, but perhaps the most alarming statistic: 80% of all visual impairment can be prevented or cured.

This episode of Ophthalmology off the Grid is different. Today I want to share really an eye-opening look at the scale and impact of global blindness and really explore the ongoing efforts to combat this devastating issue.

Gary: First, I speak with Dr. Cathleen McCabe about her dedication to medical mission work and the effect this experience has had on her both personally and professionally.

Cathleen McCabe, MD: “This is something that I think for myself has really enriched my life and allowed me to provide a positive impact on the world.”

Gary: Later, I talk to Shira Shafir, the Director of Social Innovation and Impact at TOMS, the company that pioneered the “buy one, give one” business model, first with shoes and now with eyewear.

Shira Shafir, PhD: “Our eyewear team works really hard to produce both sunglasses and optical frames that people want to buy, but with everything that they do, they understand that when someone makes a decision to buy that pair of frames, that another person around the world—in 13 countries, in fact—is going to have their sight restored.”

Gary: Listen in. It’s going to be a great episode.

Speaker 2: Ophthalmology off the Grid is supported by Ilevro from Alcon.

Gary: Today, I have Cathleen McCabe with me, and Cathleen is a friend and has been so for a number of years. We’ve seen each other at conferences, and I always enjoy getting Cathleen’s perspectives. She always has such a positive attitude about what’s going on in her world, what’s going on in our industry, and I recently saw that she was in Africa doing cataract surgery for those in need. Cathleen, with that being said, I would love for you to just tell your story to hear about what’s going on in the world of charity cataract surgery and maybe just how you got involved and got started in this. So, with that being said, let’s hear how your experience was.

Cathleen: Right. Great. It’s wonderful speaking with you, Gary, and right back at you how I’ve enjoyed our conversations at meetings and throughout the years, but this is something really near and dear to my heart. It’s just something I’ve been passionate about pretty much since I entered medicine even, not just ophthalmology but trying to provide better care when we can to patients who are just unable to gain access to adequate medical care or there just isn’t anything available in their area or resources are limited. This is something that I think for myself has really enriched my life and allowed me to provide a positive impact in the world.

And then the second thing that I really have enjoyed about it is involving my family.
Pretty much since we even started doing any medical missions, I’ve involved my children, and, as you know, Gary, I know you have a big family and I have five children, and the first time we took a medical mission with my children was to Belize. I spent a month there doing a general medical clinic in my internship actually. We took my two oldest, they were 5 and 7, my two oldest girls, and they actually spent time in the local school while I was in the clinic there, and I think the really wonderful thing about that is that it gives your children a new perspective on the world and their place in it, so I’ve been really blessed to be able to involve my family.

Gary: That is so cool. We’re friends on Facebook, and I actually saw, I think I saw maybe that you guys were flying halfway around the world recently, and I saw a picture of you and your husband and I think it was your older kids maybe that was in the picture, and I just thought that was so cool that you are paying forward all of the things that you find to be important in life and in medicine and your kids get to actually see you in action. I come home from work and I’m just Dad at home, and no one really, they kind of know what I do, but they don’t ever really get to see the impact of taking care of patients.

We don’t have a ton of patients who get led in by the hand and are totally blind from cataracts, but Cathleen, I had a patient just a couple weeks ago who literally was light perception, both eyes with projection and when he came back in for his postop visit after he even did his first eye, let alone his second eye, just the joy that he was able to share with me, with all of our staff … he was thanking me for what I did but I think what he did for me, it just so reinvigorated that love and that passion for why I decided to become a cataract surgeon and an eye doctor. I love to help people. I love to impact people. There’s just nothing that beats that experience.

Cathleen: Absolutely. What we do changes people’s lives. I just saw a patient today, bilateral hand motions with cataracts here. But I saw this patient a couple years ago, and she came in with her daughter who was a single parent of a very young child, preschool child, and we did her cataract surgery, white cataract bilateral. We did one eye surgery, and the patient was happy but the daughter came in for the evaluation after her first eye and she was just crying and saying what a difference it had made in her life because she used to have to get up early, feed her mom, bathe her mom, get her child to preschool, go to her job, come back, repeat everything for both of these two people she was taking care of, her child and her mom, and that was her life, and then as soon as her mom had her first eye surgery, her mom now was able to not only take care of herself, but to help her with her toddler.

It was just like her life had totally changed, and she was so grateful. So, it’s not just our patients, but it’s their families and their caregivers and all the extended people that have to help them when they’re not able to function with visual impairment. That same thing happens just multiplied for patients in other countries that just don’t have any access or any real pull of changing that situation once they become blinded with cataracts. It’s just mind-boggling when you think about it that the leading cause of blindness in the world today is still cataracts because we know cataracts are something just completely curable, and, to me, it’s hard to grasp what that’s like in another country where you just don’t have any ability to solve that problem.

Gary: Isn’t it ironic, Cathleen, that in the United States, ophthalmologists are actually kind of competing with each other for market share, like we want more cataracts. There’s just not enough for us to take care of or at least sometimes you can kind of get that sense of maybe competition between high volume places and then you think, I’m looking at some statistics of 18 million people around the world are needlessly blind from cataracts and are awaiting care.

Cathleen: In other countries it’s exactly the opposite. You were right, the irony of it in that other countries it’s just that it’s not the patients that are at a minimum or that are at a shortage, it’s the providers and just not having any providers or so few providers that the need is so enormously greater that anything can be provided for. It’s weird. We have that situation that’s just so diametrically opposed to really what the majority of the world experiences.

Gary: It’s kind of interesting. You said this is something that’s really been in your DNA and something that’s been very important to you. My father was a medical missionary internationally for a number of years. He and my mother traveled the world. He’s an internist, and so he shared with me growing up and when I was in medical school, that’s when he was actually doing a lot of the international stuff. He said it’s really frustrating. We can take care of patients so long as we have the supply of medicine when we’re there but when we leave and the medicine runs out, these patients with, for example diabetes or hypertension, seizures, etc. They go right back to where they were, and we really haven’t made as much of an impact. With cataract surgery, it really is the one-stop shop.

It’s the 10 minute procedure that provides a lifetime of vision and it really is dramatic in terms of when you look at value per effort. I don’t think there’s a more valuable procedure in probably anywhere but especially in the developing world for patients who are maybe in their early 50’s or early 60’s and like you said, it’s not just about them. It’s not just about their lack of dignity and their lack of independence. They become a burden on their family and it’s a real issue in the developing world for depression, for a burden on the family, and these patients are hopeless.

Cathleen: Just like you said, that first mission I told you about in Belize, that was a general medical mission and that was really impactful to me, and the fact, exactly what you said, we would have patients come in with hypertension or diabetes or some chronic disease and we might have a little bit of donated medicine there but we didn’t have enough to really sustain the patient or to do a meaningful thing over many years. And you’re right, cataract surgery is this thing that we can do that just changes somebody’s life kind of overnight, and even if we only treat one eye, if that’s all we can do in that instance, it’s just life-changing for that person.

Like I said, that’s been really a passion of mine and just seeing my children be a part of that and work really, really hard while they’re on a mission and then take away that sense of satisfaction that they’ve helped somebody. Even though I don’t have any children going into medicine as a matter of fact, but my son and one daughter went on this recent Kenya trip that we just got back from, and they both have been on multiple medical missions, mostly to the recurrent mission that we do in St. Vincent and the Grenadines. I remember when my son Max, who is 22 now, the first time he went on it as a teenager, it was our family vacation time and he said halfway through it after working these 10-hour days in the heat, just helping patients all day long, he said something to me. He said, “Mom, this is the best vacation we’ve ever been on,” and I thought, “Oh.” It’s those little tiny moments of parenthood when you go, “Oh. We did something right.”

Gary: You’re doing something really right, Cathleen. Not surprising at all. That’s so refreshing to hear. Tell me a little bit about your specific the mission or the place you went and if there are surgeons out there who are looking to make an impact and looking to give back. What are the opportunities that you know about or what are some things that people should be looking for to really make that big impact in a way that’s going to maybe be sustainable?

Cathleen: There’s all kinds of getting involved. So, for me, I started out in going to a mission that was organized partly by the Lions Club in Indiana where I was practicing. It was in Honduras. There are missions that I’ve done through SEE, Surgical Eye Expeditions. There are missions that you can do through MMI, Medical Mission International. This trip that I go on to St. Vincent is through another organization called Mobile Medical Ministry Hospital. But the bottom line is there are many, many different organizations that you can easily plug into and become involved in that are overseas and will either allow you an opportunity to do phacoemulsification or extra caps but if that’s a big leap, if that’s something that’s a little bit scary to do to begin with, there are plenty of mission-type experiences either in your local community, for instance, we have an organization that comes in here called Remote Area Medical which I think is a nationwide organization bringing this type of care, free care, to underserved patients even in our own communities, so that’s a way of sort of getting your toe wet in this type of service.

That would be a great way to start. They’re very well organized, and you can get plugged into something that might be a little bit more locally occurring for you, or you can even go to other mission opportunities that are in the United States but not local. So there are lots of ways of getting involved that way. I think one of the biggest fears that people have is just is it going to be … it’s a different microscope, it’s a different set of equipment, you have to have a little bit of that entrepreneurial MacGyver spirit. You don’t have the things you’re used to or you think you had more of something and you don’t have it or a piece of equipment isn’t working the way it should be so there is a degree of flexibility that’s necessary but the good new is that when you’re done with the experience, I’ve almost always seen that I’ve picked up a trick or two or had to develop a new way of looking at things that normally assist me later in taking care of unexpected things with my own patients.

I think it’s a great way to grow as a surgeon and give back at the same time and meet new people that have new ways of doing things and new ways of looking at things as well so the other people in your team, for instance, often teach me something that I didn’t know about, a new way of solving a problem or making good use of limited equipment and limited supplies that I have never really thought of before.

Gary: They say that necessity is the mother of invention, and when we’re sitting in our cozy operating rooms with all of our favorite tools, we don’t get put into that position where we have to think creatively, and it sounds like you’re out there, you’re doing something that’s super important and at the same time you’re coming back with new skills, new ideas, a fresh way to look at a problem that maybe you’ve never looked at before. Not only that, you’re dramatically impacting the quality of life of the people that you’re touching, and I assume that when you come back, you probably come back with a renewed sense of purpose and a renewed sense of joy in what you do on a day-to-day basis. From my standpoint, I don’t think there’s a downside to this, and I’m just so thrilled to hear what your experience has been and really just want to encourage all the surgeons that are out there that may be listening to this.

Let’s do something about this. We can make a difference. I know that sounds really cliché, so pardon that, but we are the people that at the end of our careers, we’re going to look back and think about either those patients who were 20/20 and blurry and drove us crazy or we’re going to think about the patients that we impacted like this, and I certainly want to have a whole lot more positive memories of patients that I maybe took care of that would otherwise would not have been able to get care rather than driving myself crazy with the 20/20 unhappy’s. Is that a fair assessment?

Cathleen: I think that’s definitely a fair assessment. You think back, and when you have those frustrating days like that, one of the things that I’ve invariably seen is the patients in greatest need are the most grateful, the most stoic, the most understanding, and patient of any of our patients. So it’s just a delight to go in and see a problem, fix it, and have any of the regulatory things we need to think about or paperwork or insurance or all the parts of practice that you find so frustrating that have nothing to do with patient care. It’s just whittled down to a patient in need. You have a gift to give them or a talent or a solution for their problem, and that’s what you do. You fix the problem, and you move on to the next problem and fix that too.

It’s very rewarding, and the second thing is when you get back, invariably I am so grateful for every little convenience I have here. It lets me see all of that in a new light, so the small things that used to be a bother I think, “Well those are small in comparison to the many, many blessings that we have that allow us to take really great care of our patients.”

Gary: That’s right. One of my favorite sayings is, “To whom much has been given, much is required,” and I think if we’re ophthalmologists in the United States, we fall squarely into the much-has-been-given category, and so I think we do have a responsibility whether it’s locally, we do that in our own clinic once a year. We take care of the people who don’t have insurance and can’t get care, and honestly it’s all of our staff’s favorite day of the year. Or if it’s internationally, like what you’ve done.

Cathleen, you are an inspiration in so many ways, and I really, really mean that and really thank you for the leadership that you have displayed both on the standard ophthalmology side of things here in the US but also on this issue. I really look up to you and thank you for all that you’ve one for our profession and for the folks in Florida and Indiana and now I guess around the world. With all that being said Cathleen, thank you so much for sharing your experience and coming on tonight.

Cathleen: All of those kind words right back at you, Gary. I just admire you as well, and it’s been a pleasure to speak with you, and I hope we have a chance to see each other in a meeting and chat soon.

Gary: That sounds awesome.

During its one-to-one business model, TOMS has donated 60 million pairs of shoes to children in need. What you may not know, though, is that the company also has a sight-giving program. TOMS eyewear purchases provide people in need with a full eye exam by a trained medical professional. Each patient then receives the treatment he or she needs. Here’s Shira Shafir on TOMS’ commitment to restoring sight and improving lives.

Hello, this is Dr. Gary Wörtz, and today we have with us Dr. Shira Shafir, and she is the Director of Social Innovation and Impact at TOMS. Shira, I just want to say thank you so much for taking a little bit of your time and talking to me and talking to the rest of the ophthalmic community about the great work that TOMS is doing not only by giving shoes to those who need shoes around the world but actually restoring sight and helping with preventable blindness around the world. When I heard about this program that started quite some time ago, it really warmed my heart because, as an ophthalmologist, clearly that’s what I love to do is helping people who can’t see, and I love the corporate culture that TOMS has. With that being said, I just want to say thank you for coming, and let’s talk a little bit about what’s going on at TOMS these days.

Shira Shafir, PhD: Absolutely. It’s my pleasure to be here and share a little bit about all the things that we’re trying to do at TOMS.

Gary: That’s awesome. As we were talking a little bit earlier, I understand that you have a background in epidemiology and were a former professor at UCLA and really trying to understand and research trachoma, cataracts, refractive error and then started working on really seeing what kind of impact one-for-one giving was having through TOMS. So, tell us a little bit about that story about how you were working in epidemiology and started working with TOMS and then eventually transitioned to really being directly involved with TOMS.

Shafir: As you mentioned, I was a professor at the UCLA in School of Public Health and School of Medicine, where I still hold an appointment, and I had a student who graduated and took a position here in the giving department at TOMS and reached out and asked if I could help understand some of the impact that TOMS was having with the giving program. So, when a child received a pair of shoes or when a cataract surgery was performed, what was the impact on the individual, what was the impact on the community? I began having some conversations about how the company could measure that impact, and those conversations became a little bit more frequent, and then about 3 years ago, I started here full time, and now my job has become broader. So not only do I look at the impact retrospectively, but also continue to look prospectively at how we can increase the impact we’re having.

I also work on managing all of our non-shoe-giving programs, so everything that really is medical in nature, so our sight-giving program, our safe birth program, our safe water, and then also bullying prevention response, so a really tremendously impactful portfolio of work and also an exciting opportunity.

Gary: It’s really interesting. We all, I think, when we’re younger or going through college or having aspirations of changing the world, sometimes real life gets in the way or trying to hold down a 9-to-5 job or finding ways to pay your rent or pay your bills gets in the way, and I just find it just incredible what Blake Mycoskie has been able to do with keeping that dream of not only forming a fantastic company with great products that really are fantastic and stand alone, but really the why behind all that really seems to be solving or potentially providing sustainable solutions to solvable problems. Tell me a little bit about the corporate culture inside of TOMS that perhaps is so unique in that they’re a company that’s making great products but really that focus almost becomes secondary with the primary focus being on really impacting the world. Tell me how that works in a corporate culture.

Shira: At our core, we really do believe we are in business to improve lives, and that is what fuels everything that we do. So our eyewear team works really hard to produce both sunglasses and optical frames that people want to buy, but with everything that they do, they understand that when someone makes a decision to buy that pair of frames, that another person around the world—in 13 countries, in fact—is going to have their sight restored, whether that’s through a sight-saving surgery, whether that’s through a medical treatment, or whether that’s through the provision of a pair of prescription frames. And so, fundamentally, we are in business to improve lives, and it’s really an innovative way of approaching business.

Gary: I think it makes it so easy for people who are consumers and looking for products to want to do business with TOMS or a company like TOMS, and as we had spoken earlier, we both are fans of Simon Sinek and his whole It Starts With Why TED Talk, and I think if there’s one company on the planet that it’s really obvious why you all exist, TOMS would really be in and that’s so evident. Walk us through a little bit about how this sight restoration program works. We’ve talked a little bit about the partner organizations you work with, the countries that you work in. Give us a little bit of a rundown of the logistics of how it actually goes together.

Shira: When someone makes a decision to purchase a pair of TOMS frames, and originally when we started we only had sunglasses but last year we were really excited to launch optical frames, so for those of your listeners who now have the opportunity to purchase optical frames for their patients as well, we think that’s a tremendously exciting opportunity. When the patient makes a decision or the customer makes a decision to purchase those frames, we then make the match, and so we allocate what we talk about as ones between all of our sight-giving partners and all of our sight-giving partners are members of the IAPB, and they all operate under a sustainable eye care model.

What they will do as eye care professionals, all of whom themselves are ophthalmologists or optometrists, is they will make the decision after performing a comprehensive eye exam what is the best way to help restore sight to that individual, and so they essentially have one of three choices. They can help restore sight by providing a sight-saving surgery, and the vast majority of the time that will be a cataract surgery but in some situations that may be, for example, surgery for trichiasis. They may help restore sight by providing the appropriate prescription glasses, or they may help restore sight by providing medical treatment.

One of the things we’re most excited about is, first of all, we’ve helped to do that over 400,000 times, as you’ve mentioned, and second of all, over 40% of the sight-saving services that we have provided to this point have been surgical services, and that’s pretty tremendous because there are other industries, there are other competitors who are also helping to restore sight, but the fact that we’ve allocated over 40% to surgical services we know is tremendously impactful.

Gary: That cannot be understated. Just a little bit of my background, my father’s an internist, and they were medical missionaries in Kazakhstan and throughout the world and what was interesting just being an outside observer and actually going at times and helping with that, internal medicine is a great field but you know it’s not a one-time intervention that provides a long-term cure. It’s really an ongoing medical risk management. The great thing about cataract surgery, as we all know, is it’s really a one-time intervention that provides potentially a lifetime cure, and it’s low-cost and high-impact, and, as an ophthalmologist, obviously I’m a little bit biased, but I think in terms of impact-per-dollar, I don’t know if there’s a better thing to invest in than cataract surgery for those who have preventable blindness.

One other thing that I was sort of reading on your website and doing a little bit of research, I didn’t realize that two-thirds of the people around the world who have preventable blindness are women, and you all really work heavily to try to provide cataract surgery and other services, particularly to women to try to neutralize that gender gap. Is that true? Could you speak a little bit about that?

Shira: Absolutely. As you mentioned, two-thirds of those who are preventably blind around the world are women, and there are a number of reasons for that, but one of the biggest reasons is that in a number of communities, particularly those in the developing world, they just don’t prioritize providing services to women in their communities. And so we have asked our partners to preferentially provide service to preventably blind women, and so one of the things we’ve seen is that well over 50% of the services by gender that have been provided to this point have been provided to women, and so that’s something that we are really particularly proud of because we know that there are a huge number of downstream effects when you are able to help restore sight to a woman in a community.

For example, you can see that there are effects, such as their daughters no longer have to be removed from school if the mother can once again see, and so now you’re essentially providing service for two people by helping to restore sight to a mother or to an older woman in the community. So, we’re incredibly proud that our partners have preferentially provided sight-restoring services to women.

Gary: That provides such a generational impact where you’re breaking that cycle potentially of decreased opportunity for younger women. I just love everything you all are doing, and it reminds me that no matter what I’m doing, there’s always a way to give back if you look for it, if you find it, and it’s such a rare thing to see that being modeled so clearly by a company that’s a for-profit, or a company for example and I’m really just super impressed. Will you give me a little bit more guidance on maybe some of the ways ophthalmologists may be able to help either with TOMS or potentially with the partner organizations that you work with?

I’m sure a number of people who will be hearing this would be interested in giving back and doing potential cataract missions. A lot of ophthalmologists I know do that already. We do that in our practice locally for people who cannot pay for cataract surgery through a once-a-year program in our community, but for folks who are looking to also go out and give some of their time, could you give us a little bit of information about your partner organizations and perhaps how to get involved if you have any information on that?

Shira: Absolutely. With our sight-giving model, one of the things that’s most important to us is that our partner organizations are, first of all, holistic; they’re high-quality, they’re sustainable; they’re job-creating. But the last thing about them is that they have to be local, and it’s really important to understand the eye care needs of the community. They have to be individuals who are local members of the community and that they are a local presence, and so as you mentioned with your experience with your parents, you have to have someone who is a member of the community and, particularly as we’re seeing with the increase in diabetic retinopathy and glaucoma, we want to have someone who is there in order to monitor the health care needs of the community in a very sustainable and ongoing way. So we’ve chosen to work with eye care organizations who are permanent members of the community who can care for the eye care needs of the community members on an ongoing basis.

But we also recognize that there is another model, and that’s to come in and be able to provide for cataract services and cataract surgery, and that’s where I think a number of your listeners could come in and help to be able to provide for kind of a bolus of cataract services, and there are a number of really excellent organizations like Sightsavers and Orbis who do work in this way and I think your listeners would have a tremendous impact on a community if they were able to come in. For your listeners who are interested in learning more about the sustainable eye care model, I do encourage them to go to seva.org, or if they’re really interested in traveling a little bit farther, one of our partners, the Aravind Eye Care Organization in Madurai, India, is really the exemplar and the model of how this has been developed.

One of the things that they might find really interesting that’s quite different from the way that surgery is performed here in the United States is, fundamentally, they believe in high-quality but high-volume surgery, and so very often they’ll have up to four patients in the operating theater at any given time, and so that would be something really fascinating and different to see for some of your listeners.

Gary: Absolutely, and there are a number of ophthalmologists internationally and locally that I know that have gone and have seen the small-incision manual cataract techniques that are just quite incredible without even phacoemulsification. They’re able to do just amazing work through extra caps.

Listen, I really just want to say once again, Shira, thank you so much for giving me a little bit of your time. I feel like sometimes people don’t get recognized or companies don’t get recognized that are really just doing the right thing for the right reasons, and I really appreciate the work that TOMS is doing, not only with giving shoes to the needy but also helping save people from preventable blindness. So, once again, just thank you so much, and if there’s anything that I can do to help in the future, don’t hesitate to reach out.

Shira: Thanks very much. It was an absolute pleasure to speak with you.

Gary: In many areas, access to eye care is incredibly limited. I encourage our listeners to consider how they can join Dr. McCabe and companies like TOMS in their efforts to serve the many individuals in need worldwide. After all, as ophthalmologists, our commitment is to provide the gift of sight whenever and wherever possible. This has been Ophthalmology Off the Grid. Thanks for listening.

Speaker 2: Ophthalmology off the Grid is supported by Ilevro from Alcon.