The Answer Is Clear

I read your recent article "20/20 in the Classroom" [Idea, Fall] and realized that the research was not 20/20. I have discussed this issue many times during my 39 years as a public school teacher.

The issue is not a total lack of vision care—most poor families have access to such care through schools, clinics, Medicaid, and other social welfare programs. The problem is that students don't wear their glasses. I have contacted hundreds of parents about their children's vision. They have all said that glasses were purchased or given to them, but the child repeatedly lost them (probably on purpose), refused to take them to school, or would not consistently wear them. Children, especially those who already have low self-confidence, often don't wear glasses because others bully them, and our society does not present glasses as fashionable or cool.

The answer? Schools need to require that students wear their glasses at school. Schools mandate certain attire, behavior, and vaccinations. Why can't they do the same for glasses so that students can learn at their best? Up-to-date vision test results could be part of students' records for teachers to use. Students could be suspended if they don't wear their needed glasses (school nurses can see if contacts are being worn), just as they are suspended for not having necessary vaccines. Parents would then have support for getting their kids to wear glasses or contacts in the classroom.

Shirley Little, Ed '76 (MEd)

Annapolis, Maryland

Cost/Benefit of Care

Greg Rienzi's perceptive review, "A Global Rx" [Forefront, Fall], of Randall M. Packard's excellent 2016 tome, A History of Global Health, cites two initiatives discussed by Packard "that global health might want to emulate."
The first is Paul Farmer's Partners in Health; the second is Raj and Mabelle Arole's Comprehensive Rural Health Project in Jamkhed, India. Rienzi implies that one reason they might deserve emulation is their sustainability, though, according to Packard, "Partners in Health 
is perhaps not a model that is applicable everywhere because it requires a lot of resources."

The Jamkhed project, which was inspired by what the Aroles learned from Carl Taylor while at Johns Hopkins, is a primary care system fitted to meet the needs of poor people in rural Maharashtra State: community-based, low-cost basic curative and preventive care, delivered not by doctors but by paraprofessionals comfortable living and working away from hospitals and specialty clinics.

The 1978 Alma Ata International Conference on Primary Health Care, largely designed by Taylor and Halfdan Mahler, the World Health Organization director-general at that time, envisioned such care for everyone, but especially for those lacking any care: "rural and remote populations, slum dwellers and nomads." In his book, Packard explains that the vision laid out at Alma Ata failed for many reasons but most importantly because it was seen as visionary—too ambitious, too expensive, and too slow—and because a "lack of statistical evidence limited the ability of programs to convince donors that primary health care was more cost-effective than selective interventions."

These assessments need to be re-examined. Global malaria eradication was overall a protracted, high-cost failure. Smallpox eradication was successful, but its impact on mortality was negligible. Taylor questioned the cost/benefit of a polio eradication campaign as opposed to the construction of primary care systems, while Packard, decades after Alma Ata, quotes WHO Director-General Margaret Chan, in response to news of a potentially effective Ebola vaccine: "There is no replacement for very strong and good, resilient health systems with the capability for surveillance."
Packard references the late Johns Hopkins Professor Richard Morrow's elegant model illustrating the relatively low costs of primary care for the many vs. expensive tertiary care for the few. (It is important to note that women's education is perhaps the most powerful social determinant of health and should therefore be incorporated into any primary care system.)

As a doctoral student at Johns Hopkins, I was able to show that the annual cost per child of the Under-Fives' Clinic—the primary care system for young children created by David Morley and Margaret Woodland in rural Nigeria in 1955—was $4.43 in 1967 dollars, and that after 11 years it had achieved immunization coverage of more than 90 percent, eliminated malnutrition, and cut deaths in half for children ages 0 to 5. 

Why these remarkable results have been so neglected puzzles me; this deficit is one of the few to be found in A History of Global Health, but it is important as the debate regarding the benefits of disease-specific interventions versus the building of sustainable primary care for all becomes ever more relevant. 

Nicholas Cunningham, Med '55, HS '69, SPH '77 (DrPH)

Springfield Center, New York

Dark Side of Fun

The summer "Fun Issue" of Johns Hopkins Magazine was a nice change of pace for easing into the summer reading season. However, "fun" sometimes has a dark side, i.e., the butt of a joke, the object of a bully, or the destruction of a crowd raising hell (having fun). What you may have been reaching for is the concept of joy. Indeed, you frequently expanded on fun events in the issue by using the words "enjoy" or "enjoyable."

In this regard, the interview with Marin Alsop on the response of audiences to an outstanding musical performance is more a sense of joy than fun, and the response of the musicians to the audience's reaction also inclines more toward joy than fun. Alsop's interview calls to mind a personal experience of mine. I returned to Baltimore from the war in 1946. I met a young lady, and on our first date we attended a Baltimore Symphony Orchestra concert. The music director was Reginald Stewart, and the featured performance was Beethoven's Seventh Symphony. Like the audience described by Alsop when the Seventh Symphony was first played 200 years ago, Nancy and I were carried away by the second movement. From then, it became "our song." (Not many couples can say, "Our song is Beethoven's Seventh Symphony.")

Since Nancy's death, I am filled more with a sense of gratitude than sadness. But I can say that being alone is neither fun nor enjoyable. Nevertheless, I enjoyed your summer issue. Keep up the good work.

Paul Hessemer, Engr '49

New Holland, Pennsylvania

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