• From Goat-Based Pricing to Eye Injury Radio Dramas: How an Ophthalmologist Tackled Improving Eye Health in Pakistan

    Monitoring markets is not unusual for ophthalmologists who invest in stocks, but for Timothy Kietzman, MD, it was the local goat market he tracked with the greatest interest. That was because he and his colleagues in Gilgit, Pakistan — where Dr. Kietzman practiced for nearly a decade — had decided to price their cataract surgeries according to the value of a goat. How they wound up tracking goat sales in the remote, high-altitude region near Pakistan’s border with China is a story of determination, adventure and sacrifice, a story more than worthy of a recipient of the Academy’s 2012 Outstanding Humanitarian Service Award.

    In the beginning. Dr. Kietzman got his start in ophthalmology early, scrubbing in as a sixth grader to join his father in the Nigerian clinic where he worked as a missionary doctor. “I was always a dad’s boy,” Dr. Kietzman says. And by high school, all that tagging around had persuaded him that he, too, wanted to be a doctor.

    Dr. Kietzman examining a patient in Gilgit, Pakistan.
    Dr. Kietzman examining a patient in Gilgit, Pakistan.

    Despite discouragement from some college mentors who doubted Dr. Kietzman’s aptitude for medicine, he was admitted to Loyola Medical School after doing his undergraduate degree at Wheaton College. Because attending Loyola meant “go[ing] into debt with time or money,” Dr. Kietzman enrolled in a U.S. Army program that would pay for his studies but oblige him to give them four years after he finished schooling. Since Dr. Kietzman’s future wife was also studying to be a physician, she joined the program, too.

    A taste of what’s to come. By 1990, both had finished their residencies and Dr. Kietzman had finished one of his four required years. Then Saddam Hussein invaded Kuwait and Dr. Kietzman was sent to Saudi Arabia for nearly three months. He left behind his young family and some of the recommended uniforms — opting to take fewer clothes so he’d have room to pack the Academy’s Basic and Clinical Science Course books in his duffel bag.

    It was one of the first real adventures in Dr. Kietzman’s career as an ophthalmologist, but he hoped for greater things in the future. As Christians, he and his wife both hoped and expected that God would someday call them to use their skills and training somewhere overseas. “We had no idea what this adventure would be, but we definitely wanted it,” he said.

    When Dr. Kietzman’s father went back to Nigeria in 1994 to be honored for his work there, Tim accompanied him, thinking the trip might clarify God’s calling on his own life. Knowing the culture and language as well as he did, might he not be called to carry on his father’s legacy there? Instead, he found himself jarred and unsettled by everything from the frequent requests for bribes on the road to certain troubling practices at the hospital. “I had romanticized my childhood,” he said. And the country had, of course, changed from the place where he grew up.

    The next chapter. So, after returning home to Texas, where he and his family then lived, Dr. Kietzman ultimately took a job with a “cataract cowboy” in Georgia. Though he worked there seven years and considered buying into the practice, something kept him from that commitment. “I never felt settled,” he said.

    Eventually, the Kietzmans decided to register with Interserve USA, an organization that matches people willing to go overseas with businesses and nonprofits that need different kinds of professional workers.

    Three months later, Interserve presented the Kietzmans with three opportunities: Kabul, Afghanistan; Upper Mongolia; and Gilgit, Pakistan. When the Kietzmans began to look more closely at the last option, they discovered that a former college classmate of Tim’s had started an eye hospital in Gilgit in 1994.

    Dr. Kietzman examining a patient in Gilgit, Pakistan.
    Dr. Kietzman examining a patient in Gilgit, Pakistan.

    Though the Kietzmans had never heard of Gilgit before, they discovered it was within a few hours’ drive of some of the world’s tallest mountains. And despite the region’s remoteness, more than a million people were scattered throughout the mile-high valleys northwest of India’s Kashmir region. According to a government survey, 2 percent of these people were cataract blind. And because their outdoor work exposed them to long hours of the strong UV rays that characterize high altitude, cataract blindness developed much earlier here than in other populations.

    In short, “it turned out to be a perfect playground for an ophthalmologist like me,” Dr. Kietzman said. After raising money for equipment, the family moved to Pakistan in early 2000.

    They hadn’t been there long when Dr. Kietzman treated the first of what would be many open-globe injuries. Over six years, he treated more than 300, most of which were caused by such things as wood chips or stone fragments, walking into thorns (a popular means of keeping goats off fences) and blast injuries.

    Effecting change. “Pakistan was a Libertarian’s paradise,” Dr. Kietzman said. Given the region’s instability — “violence was always there, sort of smoldering under the surface” — it was a setting where the “strongest wins,” Dr. Kietzman said. To protect themselves and their property, people built stone walls.

    Dr. Kietzman with a cataract patient. Note the stone wall behind them, typical of Gilgit construction."
    Dr. Kietzman with a cataract patient. Note the stone wall behind them, typical of Gilgit construction."

    Dynamite was readily available and commonly used to split the stone for these and other building projects. And despite the prevalence of blast-related eye injuries, there was a cultural resistance to wearing eye protection. Not only did Dr. Kietzman observe a “fatalistic” mindset among his patients with open-globe injuries, wearing glasses was stigmatized.

    “I found myself yelling at my patients,” Dr. Kietzman said. After his wife challenged this response, he began to think how he might prevent injuries. First he tried to warn unsafe workers as he drove by, but that had little effect. Then he tried buying cheap sunglasses, but he would later find them scratched, broken or abandoned.

    After three years, he decided to write an educational drama, modeled on the TV dramas popular with his patients and neighbors. After studying the stories closely, Dr. Kietzman wrote a short radio play about a man who ignores several warnings and proceeds to injure his eyes while chopping wood.

    “We made it funny … cartooned up the characters,” Dr. Kietzman said. After getting his script translated into three different local languages, he recorded the drama, using his laptop to create sound effects.

    Although local Pakistani radio stations did not usually play public service announcements the way U.S. stations do, Dr. Kietzman and some of his contacts persuaded the Gilgit station to air his drama. It finally seemed to change risky behavior. During his last four years in Gilgit, Dr. Kietzman said he saw a significant reduction in open-globe injuries at the hospital.

    Taking a toll. Despite these achievements in his work, however, life in Pakistan was proving difficult for the family. In August 2002, terrorists attacked the hill-station boarding school near Islamabad where the Kietzmans had sent their sons. Six Pakistani staff were killed. When all of the students were immediately relocated to Thailand for the year, Dr. Kietzman’s wife Laurel accompanied their boys.

    A year later, she returned to Pakistan and homeschooled them for a year, as she had done during their time in Georgia. When the school returned to its newly fortified grounds in 2004, however, Laurel became increasingly involved in helping the staff. By 2007, she was needed on a nearly full-time basis, helping with classes, serving as the school “nurse” and even as a house parent. Because Islamabad was 20 hours’ drive south of Gilgit, this imposed yet another long season of separation from her husband.

    When Dr. Kietzman began to deal with depression from the strain on their marriage, he told the hospital he could only work for them until June 2010. His family returned to the United States permanently in August of that year, after their third son graduated from high school. However, due to the hospital’s struggle to find a replacement, Dr. Kietzman stayed on until November 2011.

    “It’s like a frog in hot water,” he said of the gradually increasing strain on their marriage. Had they seen the final result in the beginning, they would have chosen differently. But because the pressure increased slowly, they kept accommodating to each new challenge.

    Serving the future. Yet as it became apparent they would not stay in Pakistan forever — as he first thought — Dr. Kietzman increasingly focused on ensuring the eye hospital’s sustainability. He trained an ophthalmology resident for five years, and worked closely with several technicians until they could competently triage cases and treat common, basic conditions. And he and his colleagues developed the hospital’s goat-based pricing for cataract surgery, drawing on lessons others had learned decades before in India. 

    Though that country had once boasted numerous charity-run hospitals, Dr. Kietzman said only those based on a fee-for-service model made it into the 20th century. “If they totally relied on donated money to continue, they eventually died,” he said. 

    The challenge in Gilgit was establishing a reasonable fee in the face of “raging” inflation. As the doctors wrestled with what people could afford, they realized that goats were a commonly held asset. And at least once a year, every family would sacrifice a goat for the religious holiday Eid. To monitor inflation and make sure their fees were price appropriately, the doctors decided to follow the price of goats. 

    “If the family wasn’t willing to sacrifice a goat for their grandmother’s vision, they probably weren’t able to afford the surgery and might need some help,” Dr. Kietzman explained. Thanks to this model, Gilgit Eye Hospital was 70 percent sustainable when he left Pakistan for good.

    Today, Dr. Kietzman is a few months into a neuro-ophthalmology fellowship, having persuaded Northwestern University’s department chair Nicholas J. Volpe, MD, to take him on as a fellow. After the fellowship, he plans to join the Wheaton Eye Clinic. Meanwhile, his wife has built up her hours in ER medicine, and they’re getting used to living together again. He also received one of the Academy’s two Outstanding Humanitarian Service Awards at the 2012 Joint Meeting in Chicago.

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    About the author: Christi A. Foist is the managing editor for YO Info and the Web and member communications editor for the Academy’s website.