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Lessons from 2020 for equity in global eye health

by Dr Matire Harwood & Dr William Cunningham

With so much that occurred across the world in 2020, some people might have missed that last year marked the culmination of a global initiative for the elimination of avoidable blindness, VISION 2020: The Right to Sight, preceded by the publication of a WHO World Report on Vision1 and the 73rd World Health Assembly resolution on integrated people-centred eye care. The Lancet Global Health Commission on Global Eye Health reports on these events, focusing on outcomes from VISION 2020.2 We thank the commissioners for the opportunity to introduce this substantial body of work, and applaud their constant advocacy, research achievements, and comprehensive recommendations for future efforts to improve global eye health.

As eye and health equity experts, we read the findings from this Commission as pessimistic optimists. Our pessimism arises in response to the inequities described throughout the report. Inequities are defined as differences in health that are not only avoidable but also unfair and unjust.3 Inequities also “entail a failure to avoid or overcome inequalities that infringe on fairness and human rights norms” including the right to enjoy life and participate with family, in the community, nation, and the world in meaningful ways.4 The Commission reports on multiple breaches in human rights across all levels of eye health. In summary, people’s rights to sight are undermined because of: (1) differential access or exposure to the determinants of eye health including wealth or poverty, education, and discrimination (on the basis of gender, ethnicity, Indigeneity, age, and social status); (2) differential access to eye health care; (3) differences in the quality of care received (unequal treatment); and (4) differential access to participation in the eye workforce (as governors, funders, policy makers, clinicians, and researchers).

Frustratingly, political inaction, deliberate or not, is a major barrier to addressing many of these issues. When considering other major health issues in 2020 (eg, COVID-19, Black Lives Matter, climate change), flawed political decisions suggest that some leaders have “a pessimistic vision of humanity itself, which is reduced to a racial and economic expression of biological survival”.5

Therefore, similar to the campaigning eye surgeon Fred Hollows, we need to counter such thinking as “optimist[s], always, that the world can be a better place”.6 Optimism and equity will succeed in the right circumstances. In Aotearoa (New Zealand), leaders from science, health, and politics came together in 2020 to manage COVID-19. The process, lauded internationally for its results,7 is not perfect and continues to evolve in regard to equity.8 Yet values such as courage, kindness, and teamwork, underpinned by optimism, were key.7

Although Aotearoa set an outstanding example of the management of COVID-19, the country still experiences eye health inequities. Indigenous people, including Māori and Pasifika, have higher rates of uncorrected refractive error, keratoconus, untreated cataract, and diabetic retinopathy.9 Aotearoa is also afflicted by universal eye health issues including the absence of Indigenous workforce representation, complex barriers to health care, and scarce research that specifically examines equitable eye care. Fortunately, Aotearoa now has various groups such as the Royal Australian and New Zealand College of Ophthalmology, Kapo Māori (support group for Māori with vision and hearing loss), Fred Hollows Foundation New Zealand, and The Blind Foundation of New Zealand, which are all committed to improving eye health equity in the country. We draw upon our core values of courage, kindness, and teamwork, and are thankful for the work on this Commission to help guide our efforts. Similar values are threaded throughout the Commission. We read of eye health workers safeguarding the rights of people; developing and delivering services within communities; growing the evidence base to inform better eye care; and resisting notions that eye care is a luxury and eye health is a privilege. Articles cited in the Commission reflect the work that occurs despite unenthusiastic political environments. Such outstanding leadership has resulted in the age-standardised global prevalence of blindness falling by 28% in the past 30 years.2 Major infectious diseases causing blindness have also declined significantly since the 1990s, and will be potentially eradicated by 2030. This news is exciting and inspiring.

It is crucial that we build on this work to address inequities. Eye health care and research, which is people-centred, Indigenous-led, tackles the intergenerational wider determinants,1 and has a culturally safe workforce10 will not only achieve equity but also has the potential to benefit all, contribute to the global Sustainable Developmental Goals,2 and, as Fred Hollows aspired, make the world a better place.

Whāia te iti kahurangi, ki te tūohu koe me he maunga teitei (Pursue that which is precious, and do not be deterred by anything less than a lofty mountain). We conclude with this Māori proverb about optimism, courage, and passion. We commend the Commission for their sustained optimism to scale the imposing inequities and political inertia; the courage to seek transformative change; and the love they have for people who deserve better. We challenge the courageous, the loving, and the pessimistic optimists to join them.

By Dr Matire Harwood, Associate Professor, Department of General Practice and Primary Care, Faculty of Medical and Health Sciences, University of Auckland, and Dr William Cunningham, Cataract & Retinal Surgeon, Eye Institute, New Zealand

First published 16th February 2021:


  1. World report on vision. 2019. item/world-report-on-vision (accessed Jan 17, 2021).
  2. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health 2021; published online Feb 16.
  3. Ministry of Health. Achieving equity in health outcomes—summary of a discovery process. 2019. achieving-equity-health-outcomes-summary-discovery-process (accessed Jan 18, 2021).
  4. Health systems: equity. 2019. topics/equity/en/ (accessed Jan 17, 2021).
  5. Michelsen N, de Orellana P. Pessimism and the alt-right: knowledge, power, race and time. In: Stevens T, Michelsen N, eds. Pessimism in international relations. Palgrave Macmillan, Cham: 2019.– 3-030–21780–8_8 (accessed Jan 17, 2021).
  6. The Fred Hollows Foundation. 15 of Fred Hollows’ most inspiring quotes. 2018. (accessed Jan 17, 2021).
  7. Cousins S. New Zealand eliminates COVID-19. Lancet 2020; 395:
  8. Jefferies S, French N, Gilkison C, et al. COVID-19 in New Zealand and the impact of the national response: a descriptive epidemiological study. Lancet Public Health 2020; 5: e612–23.
  9. Māori and Pasifika eye health. 2020. community-engagement/maori-and-pacifica-eye-health/ (accessed Jan 17, 2021).
  10. Freundlich S, Connell C, McGhee C, Cunningham W, Bedggood A, Poole P. Enhancing Māori and Pasifika graduate interest in ophthalmology surgical training in New Zealand/Aotearoa: barriers and opportunities. Clin Exp Ophthalmol 2020; 48: 739–748.