IN THE SUPREME COURT, STATE OF WYOMING 2014 WY 16 OCTOBER TERM, A.D. 2013 January 28, 2014 MARK S. HICKS, administrator and personal representative of the ESTATE OF JOHNNA R. HICKS, Appellant (Plaintiff) S-13-0107 TUENIS D. ZONDAG, M.D., and CENTRAL WYOMING NEUROSURGERY, LLC, Appellees (Defendants). Appeal from the District Court of Natrona County The Honora
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Submission for the Australian Multilateral assessment
Vision 2020 Australia commends the Australian Government for undertaking a review of its
key multilateral development partners. This submission contends, in line with the Australian
Government’s commitment to blindness prevention and the proven effectiveness of blindness
prevention programming by key multilateral organisations including the World Bank, that
funding for multilateral aid partners should include a focus on supporting blindness
Avoidable blindness and Australia’s leadership role
Blindness and vision impairment is a major global public health problem. The World Health
Organisation estimates that 285 million people are blind or vision impaired. Around 80 per
cent of all vision loss is treatable or preventable, and restoring sight has a major role to play
in achieving the Millennium Development Goals and breaking the poverty cycle in developing
countries. At a global level, the WHO and International Agency for the Prevention of Blindness
have partnered in VISION 2020: The Right to Sight, a global initiative for the elimination of
Australian NGOs have a long history of tackling avoidable blindness in developing countries. In
2007, recognising this expertise and the importance of eliminating avoidable blindness, the
Australian Government announced a $45 million Avoidable Blindness Initiative to tackle
blindness and vision impairment in the Asia Pacific.
Vision 2020 Australia’s Global Consortium — a partnership of nine leading eye health NGOs —
was formed and has partnered with AusAID to implement programs across the Asia Pacific.
The Global Consortium is an important example of partnership, and maximises the different
strengths of its member organisations. Former Parliamentary Secretary for International
Development Assistance the Hon Bob McMullan MP noted that ‘the members of this
Consortium have transformed the lives of tens of thousands of people’, and asserted that the
Global Consortium’s efforts are a ‘key element in the long-term strategy to combat global
poverty, to give people…the chance to achieve their dreams and aspirations.’
In 2010, the Government included blindness prevention as one of the eight key ‘future
challenges’ facing Australia’s aid program, and in 2011 provided a further $21.3 million for
the next phase of the Avoidable Blindness Initiative in East Asia. On top of funding for
programs, the Australian Government has also funded a WHO Blindness Prevention role in
1 This submission is prepared on behalf of the nine members of Vision 2020 Australia’s Global Consortium, including ACFID members CBM Australia, Foresight Australia, The Fred Hollows Foundation and the International Centre for Eyecare Education. 2 http://www.who.int/mediacentre/factsheets/fs282/en/index.html World Bank and WHO — tackling river blindness
Onchocerciasis, or river blindness, affects approximately 42 million people worldwide, with over 99 per cent
of its victims in Sub-Saharan Africa. The disease continues to have major public health impacts and is a key
to development, yet thanks to commitment by multilateral donors including the World Bank and World
Health Organisation, its prevalence and impacts have been dramatically reduced and we are now on the
verge of eliminating this disease.
was launched to combat this public health problem. Weekly aerial
spraying with environmentally safe insecticides helped control the black flies which spread the disease,
thereby reducing transmission. In 1995, a second program, the was established to control the disease in 19 African countries. Through a broad international
partnership and the participation of 115,000 rural communities, APOC and OCP included the donation and
distribution of the drug Mectizan®, to more than 45 million people in Sub-Saharan Africa.
With one annual dose, Mectizan® prevents and alleviates the symptoms of the disease.
Between 1974 and 2002, the OCP improved the lives of millions. Achievements included:
• transmission of the disease-causing parasite was halted in 11 West African countries
• 600,000 cases of blindness were prevented
• 22 million children born in the OCP area are now free from the risk of contracting the disease
• approximately 25 million hectares of arable land — enough to feed an additional 17 million people each
APOC is expanding this success to other parts of Africa, preventing approximately 54,000 cases of blindness each year. OCP operated with an annual cost of less than $1 per protected person and the annual return on investment was approximately 20 percent, primarily attributable to increased agricultural output. The annual cost of APOC operations, taking into account the donation of drugs, is approximately $0.58 per person treated. A preliminary analysis prepared by the World Bank demonstrated that the economic rate of return for the program is 17 per cent for 1996 through 2017. This rate is comparable to World Bank projects in the most productive sectors, including industry, transportation and agriculture. Efforts to eliminate river blindness demonstrate the gains that can be made through partnership, and the variety of positive impacts that improving eye health can have for a population. They also emphasise the catalytic role the Australian Government could have in fighting other key eye conditions in Sub-Saharan Africa, including through funding multilateral initiatives in this area. World Bank — treating cataracts in India
Worldwide, the leading cause of blindness is cataract, which accounts for more than half of global blindness.
In India in the early 1990s, it was estimated that more than 80 percent of blind people, totalling more than
10 million, experienced bilateral cataract, and another 10 million people had cataract in one eye. In 1994,
recognising the problem and the need for enhanced efforts to tackle the condition, the Cataract Blindness
Control Program was commenced in seven states in India where the need was greatest. The program
consisted of introducing a new, more effective surgical technique; shifting from a strategy of providing
treatment in mass camps to one where fixed sites were used; partnering with Aravind Eye Hospital and non
government organisations for service delivery; and improving management and training at all levels.
In the program’s seven years, a total of 15.35 million cataract operations were performed, with dramatic
improvements in the quality of care available. Surgeries using the recommended technique increased from 3
percent before 1994 to about 42 percent between 1999 and 2002. By the end of the program, which included
a major communications component, around 90 percent of the population in the program area were aware of
3 See Centre for Global Development, Controlling Onchocerciasis (River Blindness) in Sub-Saharan Africa, the availability of treatment for cataract blindness. Surgical outcomes has improved substantially, and because of training provided through the program India’s eye health system today is recognised as a leader in the developing world. The total cost of the World Bank funded project was approximately $US136 million, with close to 90 per cent coming from the World Bank. In some settings, costs were as low as $10 per cataract operation, due to the efficiencies of high patient volume and the local production of high-quality artificial lenses. Overall, the WHO has stated that cataract surgery is one of the most cost effective public health interventions available. Scope for future multilateral commitment
Clearly, Australia and multilateral agencies have a track record of tackling blindness prevention in a cost
effective and sustainable manner. With Australia’s annual contribution to the World Bank and other
multilateral agencies set to increase over the coming years, and with a Partnership Framework having
recently been established between Australia and the World Bank, there is substantial scope for Australia to
push for greater commitment to blindness prevention, thereby contributing to Australia’s stated goal of
tackling avoidable blindness in its aid program.
One avenue for this would be through a specific program, like those outlined above. Contributing to the
extension and expansion of APOC offers one such possibility, as it including cataract surgery within the
Results Based Financing programs. Another area where Australia and the World Bank might enhance their
commitment to tackling avoidable blindness would be through efforts to tackle the disease trachoma.
Globally, there are 1.3 million people with blindness caused by the bacterial infection trachoma. 1.8 million
people have impaired vision and an additional 8 million other trachoma-infected people have trichiasis –
painful ingrowing eyelashes. Trachoma is regarded as one of the major neglected tropical diseases, all of
which are common conditions for which effective methods of prevention and treatment exist already but fail
to get through to most people who need them.
In 1998, the WHO Alliance for the Global Elimination of Blinding Trachoma by 2020 (GET 2020) was created
to tackle trachoma, and the Fifty-first World Health Assembly (WHA) in 1998 called upon its member states
to collaborate in the WHO alliance to eliminate the public health impact of trachoma by 2020. At that time,
Pfizer Inc. also committed to donate Zithromax® for the preventative antibiotic program that can help stem
transmission of the disease. In the period since, substantial progress has been made. The value of the WHO-
endorsed SAFE strategy (Surgery– Antibiotics – Facial cleanliness – Environmental improvements) has been
firmly established and continues to be improved by smart innovation; the first countries have reached or are
reaching their intervention goals; and the total burden is shrinking. Despite this progress, a significant
upward push is needed to make the 2020 ambitions come true.
As outlined in the 2020 INsight document prepared by the International Coalition for Trachoma Control, a
relatively modest increase in commitment to tackling trachoma will have a profound difference in levels of
blindness and poverty – across Africa, but also in the Asia Pacific where trachoma still represents a
substantial barrier to development. An Australian Government commitment to the WHO’s efforts in this area
would be inline with the stated priorities of Australia’s aid program and would build upon the existing
strategy and work in a cost effective and tangible way.
The inclusion of eye examinations, appropriate spectacles and referral to other eye health services as a part
of school health programs is another area in which Australia could advocate for or provide funding to
address through multilateral programs. Blindness remains a crucial barrier education in developing countries,
and screening children in schools is an important way of ensuring that vision loss is detected and treated as
4 Baltussen R, Sylla M, Mariotti S, ‘Cataract Surgery: a global and regional cost effectiveness analysis’, Bulletin of the World Health Organisation 2004, 82(5) 5 International Coalition for Trachoma Control, 2020 INsight, July 2011. early as possible. The World Bank’s strategy for mainstreaming school health and nutrition, and responses to HIV/AIDS, in all education programs, offers an example of how vision screening might also be incorporated. Conclusion
The programs in India and Africa outlined above are good examples of cost effective, tangible aid programs
being implemented by Australia’s multilateral partners. They satisfy the stated criteria of the AMA: they
have a demonstrable and sustainable impact on poverty, clearly align with Australia’s aid priorities, offer
value for money and a high rate of return, and exemplify what can be achieved through partnership. Given
the huge challenges that remain in tackling the causes of blindness, and the importance of improving
national health systems to enable countries to address their own eye health needs, greater commitment is
needed by multilateral organisations like the World Bank. With Australia already having come on board as a
major international donor in efforts to tackle avoidable blindness, there is now a real opportunity to provide
funding for blindness prevention activities by multilateral organisations, and to advocate that blindness
prevention should be elevated on the agenda of Australia’s multilateral partners.
Experimental Neurology 192 (2005) 73 – 78Continuous dopaminergic stimulation reduces risk of motor complicationsFrancesco Bibbiania, Lauren C. Costantinib, Raj Patelb, Thomas N. Chasea,*aExperimental Therapeutic Branch, Building 10, Room 5C103, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892-1406, USAbTitan Pharmaceuticals, Inc., South San Francisco, CA