American Medical Student Reports on Eye Care in Armenia


Dana Hornbeak Describes
Amazing Work by American And Armenian Eye Doctors
LOS ANGELES — What can the rest of us learn when a top American scholar visits the Armenian EyeCare Project? Plenty! Dana Hornbeak is a medical student specializing in ophthalmology who volunteered to spend time in Armenia. The attached story describes what she saw as an official medical observer. Written by Hornbeak, herself, this story details many of the dramas and medical miracles she’s been witnessing on a daily basis through her work with the Armenian EyeCare Project.
Hornbeak has been working at the side of Armenian and US physicians while they care for patients. As an official observer of the Armenian EyeCare Project, she has been watching and learning at all of the AECP’s facilities, which include the Mobile Eye Hospital, Education Center, Diagnostic Center and five specialty vision-care clinics.
Medical Observers are pre-med students, medical students or interns who are offered opportunities to visit Armenia to learn and observe, to help the people and to see the country at the same time. Medical Observerships run two to four weeks or longer in length. Volunteers pay their own expenses for airfare, lodging and food. This program draws the best and brightest ophthalmology students. Dana Hornbeak’s report paints a clear picture of the program and the people in Armenia who are benefiting from the EyeCare Project.
Hornbeak received a Fulbright Fellowship in 2008-09 from the US State Department for ophthalmology research and an ambassadorship in Singapore. Now she is focusing on Armenia as a medical observer at the side of Armenian and US physicians as they care for patients.
Medicine is a calling, according to Hornbeak. She follows her principles by endeavoring to give back to the community through volunteer work. She says, “A good doctor should have compassion, a strong work ethic, integrity, level-headedness, humility and a desire to learn.”
Founded in 1992 by Dr. Roger Ohanesian, the AECP’s mission is to eliminate preventable blindness and to provide sight-saving care to the people of Armenia. The AECP’s catchment area extends throughout the country, something that few health-related networks have been able to accomplish. The Armenian EyeCare Project works alongside and completely integrated with local physicians, nurses and health leaders. Donor dollars enable the Mobile Eye Hospital to travel countrywide each year caring for close to 50,000 Armenians at no cost to them. In 2008, and again in 2009, the project provided more than 40,000 eye examinations; nearly 7,500 prescriptions and eyeglasses; and 1,200 surgeries. In addition, the staff of the project sees 60,000 in their five specialty clinics each year with ophthalmologists trained in the United States under EyeCare Project Fellowships, do extensive work in medical education and training, and have clinics found only in Armenia — a Low Vision Clinic, an Eye Bank and a specialty Clinic for Infant Ophthalmology.

Notes from the Field: The Armenian EyeCare Project
By Dana Hornbeak

Malayan Ophthalmologic Center: Yerevan, Armenia, February 2010. I see Grigor’s calloused, weathered hands before his eyes: farmer’s hands, as stoic and tough as he is. His eyes are a bewitching clear hazel — a cross between Middle Eastern and European — manifesting the hundreds of years of cultural mixing that typify this crossroads. I wonder what those eyes have seen in the past turbulent decades.
Smiling through gapped teeth and wrinkled dimples, he hands a small white paper to the ophthalmologist and sits down for a refraction reading. I glance at the slip: The label “Armenian EyeCare Project” (AECP) stands out amidst the Armenian characters. I learn that Grigor is from a rural village several hours north of Yerevan, and was seen by one of the AECP’s regional eye screenings. Diagnosed with a dense cataract, he came to the Malayan Ophthalmologic Center (MOC) for surgery — all paid for by the Armenian EyeCare Project. He now returns for a post-operative checkup — excellent outcome, no complications — and will return to his farm tomorrow. For Grigor, as for countless other patients, his “Armenian brothers in America” are restoring his vision. Restored vision in turn means restored livelihood, as all farm, factory, and household activities rely on adequate eyesight.
There are very few safety nets here. For many patients, the Armenian Diaspora in the US and organizations like the Armenian EyeCare Project are their primary opportunities to receive health care. Armenia is a country of striking socioeconomic contrasts. The national income has returned to what it was in Soviet days (still low compared to most developed nations), but now income is dramatically uneven. Wealth is almost entirely privately owned, usually by a select few powerful businessmen, or “oligarchs.” Meanwhile, the vast majority of citizens live day-to-day, the government is poor, water systems are unreliable, and medical facilities — if available at all — are not up to par with the US or Europe.
Even in the capital city of Yerevan, the wealthiest part of Armenia, wide tree-lined boulevards belie a second reality in the side streets: dilapidated Soviet buildings, exposed electrical wires, rusted metal doorways and balconies, pot-holed dirt alleys, and small corrugated tin-roof shacks. Elite designer clothes and upscale cars juxtapose with the grim prospects of the working-class clerks handing them their groceries. It is a stark and humbling disparity.
Due to poverty, isolation of countryside villages, or both, patients often present to AECP screenings or to the Malayan Ophthalmologic Center with advanced disease. My first day in the admitting and triage clinic, for example, included a fulminant case of preseptal cellulitis, a 15-year-old boy with untreated low vision since a penetrating eye injury at age six, and a cataract visible from across the room — the most severe cataract I have ever seen. As Ohanesian says, “In the US there are cataracts, but here there are cataracts.” These patients come to the Malayan Ophthalmologic Center because it is considered the leader in ophthalmologic care in the country — a rank largely due to the partnership with the Armenian EyeCare Project, including donated equipment and professional collaboration.
In rural regions, it is much more difficult to obtain eye care. Most families are subsistence farmers in the countryside or in remote villages, eking out a living by working the land. In rural factory and mining towns, unemployment and poverty have led an entire generation to emigrate to Yerevan or overseas. These families usually do not have access to medical care, much less ophthalmologic care. Even if they have money for an eye checkup, there are usually no ophthalmologic specialists in their region, and only rudimentary surgical facilities. The AECP’s Mobile Eye Hospital comes here: to the most remote, under-resourced areas, and to the individuals who would otherwise have no opportunity to regain their lost eyesight.
My month and a half in Yerevan are both clinically and organizationally interesting. Clinically, as a fourth-year Duke medical student soon to start my ophthalmology residency at the University of Pennsylvania, it is a fantastic educational opportunity: learning from experienced Armenian ophthalmologists, seeing complex ocular pathologies, and practicing examination skills. Organizationally, it has been a case-study of the Armenian EyeCare Project, drawing on my background of a Master of Public Health (MPH) and undergraduate Honors Thesis. For my undergraduate thesis, I analyzed the organizational structure of a health care-related NGO in the Peruvian Amazon. The result of my two months of field research – identification of several key factors for organizational success – now gives me a framework for evaluating the Armenian EyeCare Project.
Despite the cultural differences and 10,000-plus miles separating them, many of the markers of the Amazon NGO’s success are visible in the AECP. These include strong collaboration with local professionals, a committed core leadership group, positive relations with the local community, sustainable education programs, responsiveness to changing health needs and provision of necessary equipment. To these, the Project has added research, which promotes long-term academic involvement with the local medical university.
The project provides immediate eye care through year-round rural eye screenings and Mobile Eye Hospital surgeries. The project also builds the capacity of the Malayan Ophthalmologic Center by supplying much-needed diagnostic and surgical equipment. Indeed, the majority of the center’s equipment has been supplied by AECP and bears the AECP label.
Focused on “teaching a man to fish” in addition to providing immediate assistance, the project invests in the future through patient education and physician training. Throughout the year, AECP-funded doctors travel to rural regions of Armenia for several weeks at a time. There they do eye screenings for children and adults; run educational programs with local ophthalmologists and primary care physicians, including giving them a helpful 200-page “Essentials of Ophthalmology” manual; educate patients with a host of informative brochures; and assist patients in reaching regional surgical centers.
For complex pathologies that cannot be treated locally, the Armenian EyeCare Project funds patients’ surgery at the Malayan Ophthalmologic Center. Finally, all patient visits are recorded in a database, allowing for valuable research on ocular disease prevalence and treatment outcomes.
The Armenian EyeCare Project is well-known and well-liked by the local community, both in Yerevan and in rural Armenia. For instance, the US Embassy in Yerevan uses it as an example of how the US Diaspora is giving back to Armenia, currently displaying a photo of the Armenian EyeCare Project on its front gate. “Even in rural regions,” notes an MOC ophthalmologist, “every ophthalmologist in Armenia knows about the Project.” Unlike many American or European NGOs elsewhere which have engendered competition among local partners, the Armenian EyeCare Project works alongside — completely integrated with — local physicians, nurses and health leaders. As a result, its scope extends throughout the country, something that few health-related networks have been able to accomplish. It is no surprise, then, that I first found out about the US Diaspora from an Armenian in Yerevan. I have lived my entire life in California, but it wasn’t until coming to Yerevan that I understood the significance of the Diaspora in California and the US “Oh, you are from California? As in, Glendale? Yes, we know America: many of our Armenian brothers and sisters are there.”
A worldwide Armenian “family” isn’t far from the truth. If people make a nation, the majority of “Armenia” actually lives outside its borders: more than eight million, as compared to some 3.2 million within Armenia. Organizations like the Armenian EyeCare Project help to unite this territorially diverse group, successfully blurring the lines between Armenian and Armenian-American. Indeed, judging from Grigor’s smile and newly-restored vision, national boundaries just don’t seem to apply.

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