Rebeca Villalobos has developed a participatory system of eyecare that enables Costa Ricans of all classes to access affordable medical services ranging from basic vision tests to sophisticated surgical procedures.
The New Idea
Rebeca's innovative Little Windows of Light program trains schoolchildren as community-wide promoters of proper vision care. In schools around rural Costa Rica, children eagerly line up to shout out the figures they read from an eyesight exam chart posted at the front of their classrooms, while a classmate attentively records and explains each student's results. This groundbreaking program reflects one dimension of Rebeca's large-scale effort to reverse the trend toward preventable blindness in her native Costa Rica.
Rebeca's work is centered on the notion that blindness is not strictly a health problem. Like deafness and dental decay, vision loss is a social problem that requires involvement from a range of community actors for diagnosis, treatment, and prevention. Undaunted by the shortage of optometry professionals and resources, she is working with doctors, nurses, medical students, teachers, suppliers, and even children to incorporate responsible eyecare into the fabric of everyday life.
By reconceptualizing the field of eyecare, Rebeca is ensuring the affordability of vision care for even the poorest citizens of Costa Rica. Her plan for large-scale diagnosis, low-cost glasses, and high-volume, cost-efficient specialty clinics will help detect and correct vision and health problems on a massive scale. Rebeca plans on adapting her model of participatory vision treatment to other health fields, including hearing and dental care, where citizen-based initiatives and community partnerships could substantially reduce the incidence of preventable illness in Costa Rica and around Latin America.
In poor communities throughout Latin America, most citizens, adults and children alike, have never had their vision tested. The eyesight examination chart traditionally used in developed countries is an unfamiliar novelty in many places. Adults with deteriorating eyesight and more severe ocular problems, like cataracts, are commonly left to stumble along toward preventable blindness, typically jeopardizing the income-generating activities with which they support their families. Children with even slight vision problems are often misdiagnosed by their teachers as learning disabled and then placed in special needs classrooms.
In communities where medical attention is already limited, local doctors and nurses are often untrained to detect basic ocular problems. The Ministry of Health does not include ocular care within its primary scope of services. Specialists are few and far between. Costa Rica has a total of only 70 ophthalmologists in the whole country, 75 percent of whom are located in the capital city of San José. Moreover, most of these doctors practice privately and their services cost much more than even a middle-class Costa Rican can afford. Demand for the ophthalmologists working within the Costa Rican social security system is so great that appointments must be made up to a year in advance. People living below the poverty line cannot afford the luxury of glasses or ocular surgery, even when they have been afforded basic vision testing.
The ocular care dynamic is similar, if not worse, in other Central American countries and extends to the fields of hearing and dental care where low- and middle-income patients face a shortage of available options and where trained professionals are not equipped to handle the demand.
Under the auspices of the Association of Medical Services for the Common Good (ASEMBIS), the organization she founded in 1991, Rebecca has developed a range of programs that aim to ensure the accessibility of affordable vision care. She began by training a corps of health promoters, mostly graduate students, to travel to schools, senior citizen centers, and social security clinics throughout Costa Rica to detect vision problems, prescribe treatment, and send the most severe cases for surgery at the low-cost clinic she set up in the outskirts of San José.
The clinic comprises a paid staff of five ophthalmologists and five optometrists who treat an average of 300 patients each day and conduct roughly 120 surgeries a month. The incentive for the doctors, who would otherwise be lured into private practice, are the opportunities both to perform many surgeries, which they enjoy, and to receive access to the latest technology. Patients are asked to pay a small fee for services. Given the high volume of patients, the institution is able to maintain itself financially with this modest fee. A new clinic is under construction that will allow doctors to conduct the more-sophisticated optical surgeries that they cannot perform at the current facility.
Faced with a lack of ocular specialists, Rebeca focuses much of her attention on providing other medical professionals and social actors with the knowledge and skills required to dispense basic vision care in poor communities. In partnership with a prestigious national university, her team of ophthalmologists leads training for medical doctors and students in detection, referral, and treatment of standard ocular defects. Similar workshops are held for primary care assistants who often have more contact with patients than the actual doctors and who commonly perform initial diagnoses.
At the center of her efforts to broaden this national eyecare network is the Little Windows of Light program, which engages third through fifth grade schoolchildren in the vision screening process. These so-called Vision Guardians, who are selected based on their academic performance and conduct, are taught about the importance of vision care and are trained to give basic eye exams to other students and their families. After the entire student body has been tested, an optometrist and three assistants provide inexpensive glasses that Rebeca has secured by attending ophthalmologist conferences. Once the students have been given the glasses of their choice, the Vision Guardians work to counter the childhood stigma often associated with wearing glasses, and they make sure their classmates wear their glasses every day.
Thanks to a partnership agreement with the Costa Rican Ministry of Education, over 800 Vision Guardians have been trained in some 80 primary schools nationwide. They have performed eye exams for nearly 62,000 children. With support from the German Christoffel Blindenmission Foundation, Rebeca's program has begun to expand to other Latin American countries. She has already trained staff of organizations in Mexico, El Salvador, Honduras, and Panama to implement similar programs. In March 2001, Rebeca hosted a regional event aimed at promoting low-cost vision care throughout Latin America.
Building on the tremendous success of Little Windows, Rebeca has begun to develop a similar program to address hearing and dental care. She envisions training schoolchildren, medical doctors, and other community health leaders to perform hearing tests, and she can utilize a similar strategy to promote good oral hygiene. Through citizen-based initiatives and healthcare partnerships, Rebeca will expand her model to help curb the expansion of preventable illnesses in poor communities throughout Latin America.
Rebeca began working with the Good Will Caravan at 19 as a means of financing her studies in psychology at the University of Costa Rica. However, she never imagined that she would one day become an international leader in the promotion of affordable vision care. She was first exposed to the lack of proper vision care and the inefficiencies of the eyecare industry when she traveled to underserved communities as secretary for the Caravan's ophthalmology department. The Caravan's treatment of vision problems mostly involved the arbitrary distribution of used glasses, a system that compelled Rebeca to start thinking of new, more effective methods.
Several years later, Rebeca won a scholarship to study Administration and Planning of Social Projects at the School for International Training (SIT) in Brattleboro, Vermont. For her final SIT project, she called upon her experience with the Caravan to develop a plan for a low-cost ophthalmology clinic. Impressed by the proposal, the Caravan gave her the funding to bring her proposal to fruition. Just as she was getting started, however, the Caravan shifted institutional priorities, and Rebeca chose to branch out on her own. Dedicated to promoting affordable vision care throughout Costa Rica, she and a group of colleagues launched ASEMBIS with the financial support of the Christoffel Blindenmission Foundation in Germany.
Ten years after founding ASEMBIS, Rebeca continues to serve as its executive director. To help develop the technical skills needed to move her work forward, she studied Community Ocular Health at the Santander Ophthalmology Foundation in Colombia and is currently finishing a degree in optometry from the Latin University of Costa Rica. Her focus on school testing came as a result of a recent visit to Israel where she saw students fully engaged in their ophthalmologic examinations. She realized the potential to build directly on children's natural enthusiasm and intelligence and developed the Little Windows project, a true innovation in low-cost vision testing and treatment. Rebeca has proven herself a tireless leader in advancing eyecare awareness, and she is excited by the challenges that await her as she begins to apply her methods to other health sectors.