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More than 50% of the thinking part of the human brain is dedicated to processing visual information. We are, in a word, visual beings. And yet around the world, our vision is getting worse — and we’re not quite sure why. Abdul talks about the life-changing impact of correcting vision. Then he speaks with Sarah Zhang, staff writer at The Atlantic, about what we know about the growing burden of nearsightedness.

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Dr. Abdul El-Sayed, narrating: COVID cases are up 15% in the UK, suggesting that a fall wave in the US could follow. Monkeypox cases are declining across the country and there’s been a possible breakthrough in Alzheimer’s treatment with a new drug showing a 27% reduction in patient decline. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Today we’re talking about the increasing burden of myopia or nearsightedness around the world. We’ll explore its causes and its implications. But first, I want to tell you about the single most fulfilling moment as a public health practitioner. I was giving a guest lecture to a class of first year undergrads at the University of Michigan. I was talking about some of the work my team and I did when I was serving as the city of Detroit’s health director. After the lecture, a young woman waited behind until after every question was asked. She took off her glasses and said, I wore these, especially for your lecture today. They were translucent, red with sparkles, and the lenses were uncommonly large. They were a look you probably wouldn’t find on the otherwise fashionably dressed college student. Tell me, why did you wear those? I asked. Well, because I got these glasses at my school about five years ago. The first time I got a pair of glasses, the first time anybody told me I needed glasses. Before I got them I wasn’t a very good student. After I got them, I realized that it wasn’t that I wasn’t smart. It was that I just couldn’t see very well. I wore them because you gave them to me. I hadn’t actually given her that pair of glasses, but my team at the Detroit Health Department had. See, we were tasked with rebuilding a health department basically from scratch. The city had made the disastrous decision to shut down the Health Department in 2012 as bankruptcy was looming. They wanted to cut as much of the city budget as they could, along with Human Services and a series of other programs. The Health Department budget was zeroed out and all of its programs were privatized into a series of nonprofits. Bringing the department back meant rebuilding all those programs, but it also meant asking what a city health department should look like in the 21st century, what it should do and how it should engage with the public health challenges of our time. That also meant tailoring our approach to the challenges Detroit uniquely faced. You remember being in elementary school when you’d have to line up once or twice a year and look into a machine that had a bunch of E’s facing every which way. That was vision screening. It’s something that health departments do around the country. It was one of the programs that had come back to the health department while I was there. And one day I was reviewing the data and I found that 30% of our kids who had had a vision deficit, had had one last year, meaning they’d spent an entire year with uncorrected vision. They had never gotten the glasses they needed. The downstream consequences are staggering. You can’t see what’s happening on the blackboard? You can’t learn what’s happening on the blackboard. If you’re not seeing or learning, you’re probably going to find other ways to entertain yourself. A vicious spiral sets in. Kids are labeled as, quote unquote, “bad” when the real problem is that they just can’t see. It’s way worse if you’re Black or Brown and stereotypes about who’s a bad kid already work against you, it’s even worse if you’re in a crowded, underfunded classroom where you can’t get the kind of individualized attention that could identify your challenges and solve them. We wanted to do our part to fix that, so we set out to build a program to provide every child a free pair of glasses within two weeks of a vision test. We worked with the national nonprofit called Vision to Learn. We had to raise nearly half a million dollars to build what basically amounted to a mobile optometrist office. That mobile office would follow our vision screening team around, and any child who had had deficits would then go under the bus to get their eyes tested. But this is the part where bureaucracy usually gets in the way. In order to coordinate all that, we had to get standing permission from parents to get a child’s vision tested. First, we had to work with both the Detroit School District and the network of charter schools in the city to make sure that the permission slip was included in the packet that got sent to every parent at the beginning of the school year. Second, though, we had to work with the state and the federal government to bill for the services we were providing so the program could remain sustainable. We rolled our program out on a crisp fall morning at an elementary school in Detroit. I remember putting the first pair of glasses on a little boy in kindergarten, watching his eyes light up under those glasses as he looked around and saw the details he’d long been missing in his classmates faces. I had thought that that was the most fulfilling moment in my time as a public health commissioner. But then the young woman I told you about with the red sparkle glasses told me what she was studying. I’m doing a public health major, and I want to work on asthma issues in southwest Detroit, where I grew up. Southwest is Michigan’s most polluted community, a place that’s bombarded by industrial pollutants from nearby factories and forced to breathe the exhaust of idling trucks as they wait on the bridge to Canada. I’m working with the city and the state to regulate truck exhaust, she said. The cycle continues, I thought. Today, millions of kids live with uncorrected myopia or nearsightedness. And the problem? Well, it’s getting worse. Myopia can, of course, be corrected after the fact with glasses or contacts. But stopping it from developing in the first place is much tougher to do. And in a world where kids are playing outside less and looking at screens more, it’s becoming far more common. I recently came upon a great piece in The Atlantic by our guest today, Sarah Zhang, exploring the rise in myopia, why it’s happening, and what we can do about it. And it brought home just how much bigger the challenge is, even beyond Detroit, but globally. She joined me to talk about it. Here is my conversation with Sarah Zhang: 

Dr. Abdul El-Sayed: Okay. Um. Can you introduce yourself for the tape? 

Sarah Zhang: Uh. My name is Sarah Zhang and I’m a staff writer with The Atlantic.

Dr. Abdul El-Sayed: Sarah, thank you so much for taking the time to chat with us today. You’ve written a really compelling piece about an issue that is uh near and dear to my heart. I want to ask you, you know, what got you interested in the rates of myopia, particularly in children? 

Sarah Zhang: Uh. Well, it’s also near and dear to my heart. Um. Since we’re talking on Zoom, you can see that I am wearing glasses and I’ve had glasses since I was maybe, oh, ten years old. And I had that experience of going to the eye doctor every year um until maybe until I was 22 or 23. And every year my eyes were getting worse and worse, and my parents would kind of groan and be like, Oh, no, we have to get you new glasses again. And so um I think just like, you know, growing up and being around uh sort of like an intensive academic environment, I just knew I just felt like almost everyone around me had glasses. And I think there was a point where I realized huh it’s actually kind of more unusual. My default assumption is if someone’s not wearing glasses, they are probably wearing contacts. Um. It’s like somewhat almost unusual to have perfect vision rather than to have um than to be nearsighted. And so I have just kind of been interested in this um phenomenon for a while. You know, there’s sort of been some really interesting and kind of really forgive the adjective, eye popping numbers out of Asia where up to 90% of kids are nearsighted. Um. These are teenagers who are graduating from from university or high school and would actually, what really motivated me to write this and to like write it now is that we’re actually at the cusp of um all of these new treatments that are supposed to slow nearsightedness in kids becoming really widely available in the U.S. So we can, we can talk about that later. But I just found that to be like such an interesting paradigm shift in how we think about myopia and or nearsightedness. 

Dr. Abdul El-Sayed: Yeah, I actually want to step back. Um. You said that you were first diagnosed when you were ten. How how did you know that you uh ultimately would go on to need glasses? What was that experience like? 

Sarah Zhang: Uh. I think a very common story. I um couldn’t read the [laugh] the blackboard anymore. Um. You know, like at first I would try to sit in the back of the classroom and then I had to move to the front of the classroom. And eventually even the front of the classroom was being challenging. And I think eventually my parents realized I wasn’t just totally obtuse and couldn’t read the board, or my teachers realized this and in fact that I actually just could not see. Um. So I think this is probably a pretty typical experience for for most kids. I mean, I, I think I was around, around third grade when I got or fourth grade when I first got glasses. And it was just like a complete change. It feels like the world reappeared in front of my eyes. I hadn’t realized, because it’s such a gradual process, I hadn’t realized um how much vision I had lost. And, you know, I think this is an anecdote I’ve heard a lot. It’s like you suddenly realized you can see the individual leaves on trees again um, because when your eyesight is going bad, you like sort of slowly deteriorate and then all of a sudden it like snaps back into focus. And it really does feel like kind of miraculous that a thousand years ago, if I had eyesight as bad as I do now, I’d probably be like pretty useless in anything in life. Um. It is like truly amazing that like, we’ve made what should be or could be like a really debilitating disability like essentially for the most part, a minor inconvenience. 

Dr. Abdul El-Sayed: Was it a teacher who first recognized that you were having trouble, or was it you who first realized you’re like, I just can’t see the blackboard and there’s got to be something wrong here? 

Sarah Zhang: Oh, God, I honestly don’t remember. I do remember that we used to have, like, eye screenings in school every year, and so maybe it was caught through that. But I honestly don’t remember. I’ve been in glasses for so long that, like, I don’t really remember a life without glasses if I’m going to be totally honest. Um. I know some people like find it really annoying to have something in front of their face or like annoying to like, you know, when you have glasses like it’s clear in front of you but still blurry around you. But it’s, I’m so used to it that, like, looking at my face without glasses seems strange to me. 

Dr. Abdul El-Sayed: Hmm. I ask because, you know, the experience is just so ubiquitous for people who either need glasses and don’t have them or people who’ve had glasses their whole lives. It’s just almost a baked in function of who you are, which speaks to just how critical our ability to see really is. I mean, and you think about our ability to process information. There’s more of our brain that is built around processing visual information than built around processing any other part of our uh experience of of our sensory experience. And so, you know, it is just such a um foundational aspect of of what we are, not even who we are, but of what we are uh as human beings. I’m um one of those, those odd bookworms who never needed glasses um and I– 

Sarah Zhang: Congratulations. 

Dr. Abdul El-Sayed: Uh. Yeah. Thank you. I was I was um you know, it’s always sort of one of those things where it’s like I felt like I never really fit in because I didn’t have them. Uh. And I feel like people who wear glasses look so smart. [laughing]

Sarah Zhang: You know, it’s funny, I, I sort of assume like kids don’t want glasses, but I was talking to like one particular optometrist in New York City and he was like in New York the kids want glasses because they want to look smarter. And I was like, Oh, wow. [laughing] What does that say about us? 

Dr. Abdul El-Sayed: I had the also the, I don’t know, fortunate or unfortunate circumstance of being like the the one um kid who is usually in uh accelerated classes who also played a lot of sports. Right. So I had this sort of like dichotomy of like, what am I and where do I fit in? Uh. And I feel like if I had a pair of glasses I could put on in class, I might um I might, I might pass for a smart kid. But the but that was my circumstance. But also, I, I very much appreciate that it’s a deep level of privilege to not have um eye issues. And so many people uh have to build a life around that. Um. And for so many other people who don’t have access to those glasses or those correctives, the factor of not having uh perfect eyesight is a truly an impediment and a disability. And so I want to sort of put this in historical context because um that’s sort of the context within which you wrote your piece, which I really appreciated. So take us back about 25 years. Um. I’m going to, I’m going to say, you know, 25 years to when I was a kid, I feel like we were probably both um kids at that point. How big was the problem then and how big is the problem now? 

Sarah Zhang: Yeah, so it’s actually something that’s been going on for decades, even more than 20 years. Um. So if you uh even back in the sixties and seventies, there were these sort of really interesting studies coming out of Alaska, out of sort of like the northernmost um settlement in Alaska, where uh there used to be like virtually zero myopia among the population, the indigenous population there, and then the span of a generation. It just kind of like shot up um as uh the population started going to school, sort of [?] living adjusting to a modern lifestyle. And this was sort of like really interesting to eye doctors at the time, but kind of thought of as like a local phenomenon or like maybe they were just measuring wrong or something like that. But around like 20 or 30 years ago, um sort of like Asia really awakened to this problem of nearsightedness. So as I was saying, there are some just like really truly like dramatic numbers of how many kids by their late teens are nearsighted. So this is especially true in East Asia um and Southeast Asia. So around that time, um there’s also still a lot of skepticism that this is a real phenomenon. Again, you have like, eye doctors arguing. Are they just measuring the wrong things? Or like, is there just this sort of bias the way the data is being collected? Um. Or maybe this is like a this is a genetic thing and this is like only happening in Asians. But over time it’s been pretty clear that this is far more widespread and it’s probably happening all over the world. So in the U.S. we don’t really have great national data yet, but between the seventies and the 2000s, the early 2000s, when like the last national survey was done, the number of people who are nearsighted um sort of went somewhere from around a quarter to 42%. And so there’s there’s reason to think it’s probably even higher now, just anecdotally, you know, eye doctors keep telling me like they’re seeing more kids younger needing glasses. So I wish we had like better data on exactly what the scale of the problem is. But um I think at this point, you know, what was originally thought, it was like, oh, maybe a weird fluke in the data or like maybe happening in certain populations. It’s recognized that it is something that is actually much more global and universal. 

Dr. Abdul El-Sayed: You name checked a couple of different regions, but um is it a regional issue? Are we finding that some regions, whether in the country or in the world, are having a higher jump than other regions? 

Sarah Zhang: Um. That’s a really good question. So there’s sort of some broad patterns. Um. Certainly, as I said, like it was first noticed in Asia where the jump was really high. And part of that um may in fact have to do with, with their, we can get into like later causes of this, but like they’re really intensive educational system and how much um time kids devote to school work and homework. There’s also just data giving going back to, you know, the early like 20th century that it’s more common in kids in cities than in rural areas or like more common in sort of like more rigorous um city schools than in like rural schools where kids might actually spend less time in school. Um. So there are these, these sort of like broad trends. Um. We, we don’t have like mo– and like nowadays. Like, I can’t tell you what it is between like Iowa and New York, but um I think there’s sort of like a there’s sort of like a broad sense that this is like a the biggest problem in cities. 

[AD BREAK] 

Dr. Abdul El-Sayed: The pandemic has had a major impact on the health of children in a lot of ways, whether uh it’s, you know, COVID itself or um it is the anxiety and depression uh that came with the pandemic. Do we have any sense of whether or not the the pandemic might have accelerated this or slowed it down? 

Sarah Zhang: Yeah, this this came up a lot in my conversation with eye doctors. So there is some data coming out of um, for example, China now that suggests that kid’s eyes did like get worse more quickly during the pandemic than um during usual time. So, of course, China also had like lockdowns that were way more intense than we have had, we had in the West. Um. So you you expect to see a bigger effect um. We don’t have any data in the US yet, but just anecdotally I’ve had eye doctors say that they’ve seen kids prescriptions jumped more than they would expect in a year or two, um which is maybe related to, uh you know, Zoom school or like, you know, pandemic school closures. Sort of all at the level of anecdote right now. But I think in a few years time, it’ll be a little bit more clear. 

Dr. Abdul El-Sayed: Mmm. So that would suggest that kids who already had myopia, their myopia got worse in the context of the pandemic. You know, it’s interesting, right? Because your point is a good one. We don’t collect systemic data that we can compare across uh place or across time, which makes measuring this a function of a whole lot of anecdote that then we try and piece together. So thinking through it, you’ve already alluded to a couple of potential uh causes. And generally the way our bodies work is, is, you know, use it or lose it. So, you know, we know that um the whole point of of exercising, lifting weights is that you want to give your musculature some positive uh stimulus such that it maintains or grows. Um. Similarly with our eyes, right, um our ability to see things is a function of basically how much we look. [laugh] Um. And some of the the hypotheses that you’ve offered here have a lot to do with what students persistently look at. Right. So, you know, rigorous schools or intense um study, meaning we’re sitting here looking and reading at sheets of paper or screens that that might bias our eyes toward being able to see things um that are close rather than seeing things that are far. What are ophthalmologists and and optometrists positing about why we think that myopia is on the rise right now? 

Sarah Zhang: Yeah. So the answer to this question both seems like really, really intuitive and it’s actually surprisingly controversial when you go down to the the details and try to figure out exactly what is wrong. So so, you know, as you’ve said, you know, is there like a certain element of like use it or lose it, right? So it seems pretty clear that there’s something in our modern lifestyles that is causing our eyes to become myopic. You know, these huge jumps and increases in myopia in a generation or two. It can’t be genetic, right? Like our genes are just, like not changing that fast. Our DNA is not changing that fast for this to be explained by um genetic jumps. And so. Um. Right, that that suggests that there’s some massive change in behavior. And if we just look around like obviously we’re spending more time on screens, spending more time looking at things that are close to our face. And so there’s this one school of thought that this uh rise in myopia is caused by what is just called near work. So that literally is just looking at things that are close to your face, whether that’s a book, TV, computer, phones usually these days. And it’s is, as you say, like your your eyes, especially like a kid’s growing eye, um they kind of just get used to the fact that they’re only looking at things close, close to their eyes. So uh it’s just sort of doesn’t uh doesn’t know that it needs to grow to to accommodate clear distance vision. What’s sort of tricky about this hypothesis, which is like very intuitive, is that when you actually try to add up how much time kids spend on near work and there’s actually doesn’t seem to be a correlation between more hours of near work and worse eyesight. Um. And there are various explanations for this. Like, maybe people are just not really tracking correctly what they’re doing. Maybe, you know, this stuff is like hard to measure. But there is another hypothesis that what’s the problem is not actually the fact that we are looking at things close to our face. The problem is that we’re spending the time indoors and even on this school of thought, there’s actually like two competing ideas of like why indoors is bad, right? So one is that um when you’re outdoors, you are naturally just seeing things that are far away. Um. So your eye, like, you know, when you look out into the distance that is just like way further than even if you’re looking out like um in like a really large room. Um the other actually has to do with sunlight. So it’s just way more uh way brighter outdoors. So indoors, even in a fairly bright room, uh the brightness is something like in the thousands of lux, a unit of brightness that people use. Um. Outside even on a cloudy day when it’s snowing, you’re going to get like tens of thousands of Lux. So it is just your eyes just get way more light outdoors. And there’s maybe there’s a thought that maybe this somehow changes the chemical pathway of like how your eye grows. So, you know, there’s a lot of like controversy and debate over the details of this. But sort of the upshot was kind of the same right. Like if you’re spending more time indoors looking at screens, you’re spending less time outdoors. So the sort of like what to do, [?] aspect about this is the same, um probably more time outdoors looking at things further away is better than being indoors staring at screens. So maybe all your time playing sports is what helped you um retain your perfect eyesight. 

Dr. Abdul El-Sayed: That is that is a fair hypothesis. I wanted to zoom in on on a few aspects of this. Let’s stay with the hypothesis that it is near work. And is there evidence about whether or not paper based near work versus um screen based near work may uh make a difference in terms of in terms of the risk of myopia? I mean, we we sort of came up in an age and I’m being generous with your age. I don’t actually know your age, but I came up in an age where we did do a lot of near work, but the ubiquity of screens wasn’t nearly what it is right now. You watched screens that were actually far away. Usually it was television. You didn’t have screens up in your eyes. And so um I wonder if that may have an effect. 

Sarah Zhang: Um. That’s such a good question. I don’t know if there’s been studies that have uh really looked at whether paper versus digital screens uh really, like you know, somehow triggers something different. Maybe because of the brightness. Um. I would maybe posit that the difference may in fact just be that a phone or a tablet is way more engaging than a piece of paper. Um. I mean, I read a lot, but man, I you know was a bookworm as a kid. But, you know, there’s just something uh so much more addictive about a screen that constantly changes [?] entertaining you than a book. So I think you, maybe there is some effect to just like the screen itself, the brightness or the way the images come up on there. But I bet there’s probably like a time confounding factor as well. 

Dr. Abdul El-Sayed: Yeah so. Yeah, that that’s exactly right. So what you’re arguing is that it’s not just that we’re doing the same amount of near work on a screen. It’s also that when a screen shows you colors and uh moving images, you may just spend more time on that screen than you otherwise would have with like a, I don’t know, a Goosebumps novel like we did when we were kids. Um. I also wanted to ask about the the role of just time outside. And, you know, there’s there’s sort of an interesting question here of there are things that you can do indoors that force you to um sight faraway objects. So I’m just imagining sort of, you know, a kid playing hockey, um you’re indoors. It’s actually kind of dark in most hockey arenas. And yet at the same time, you are trying to find a very small black object on a white sheet of ice, which forces you to use your far sight in a way that that is different than, for example, playing football outside um and trying to find a, you know, a larger brown object in the sky. Um. And I’m wondering um how much of this is about just active time versus sun, because you could imagine a world where you’re just outside and you’re you know, you’re like sitting on a beach uh reading a book, right? But you are exposed to the light. And so have there been any attempts to actually differentiate out the the kind of activities that are associated with lower risk of myopia that are outdoors and, you know, recognizing the point that you made about um about our ability to actually recall this kind of evidence and with any real rigor? 

Sarah Zhang: Yeah, there’s sort of, there have been studies that kind of looks specifically at indoor sports and the amount of time kids are spend spending, you know, what are they when they’re indoors? What are they doing indoors? Are they doing homework? Are they watching TV or are they doing sports? Right. And as you say, like if you’re playing hockey, um you actually are using your your more distance vision. And and there are there are studies um kind of uh on the outdoor time of just like, you know, if you give kids like a break during the middle of school, like, you don’t even you don’t have to tell them what they to do, but just like make them go outside for a certain amount of time during school. Uh. What does that do? And that does seem to slow um the progression of myopia or either the onset, one or the other. But neither of these are entirely clear. You know, if it were entirely clear, I think I could give you an answer of exactly what’s going on. There have been studies that have looked at this, but there isn’t like sort of a, um you know, a magic bullet that tells us exactly what the answer is of which one is it. So that’s why it’s sort of still contested. I think just um the comparison of indoor versus outdoor, you know, when you’re playing hockey, obviously you are looking at things kind of further away, but um you still have things in your peripheral vision that are fairly crowded. 

Dr. Abdul El-Sayed: Mm hm. 

Sarah Zhang: And there is there is uh some theories some theories about how actually it’s not what you’re focusing on, but what’s in the periphery of your vision um that may be actually more influencing how your eye is growing and if you become nearsighted. 

Dr. Abdul El-Sayed: Hmm. That’s fascinating. I want to move to correction now because there is obviously a lot we can do um to correct it. At minimum, it’s it’s offering a child a pair of glasses. That changes as you talked about your experience of sitting in a classroom for the 7 hours a day that we asked kids to do that in most parts of the world. And then there’s uh even more types of correction. And then there’s also the set up between correction and prevention, right? The notion that uh, you know, one intervention against myopia isn’t just giving a kid a pair of glasses, giving a kid a recess outside. And I want to ask you about how um the the perspective around correcting myopia is is has changed, is changing. Um. And then some of the clear contrast that that sets up. Right. Giving kids recess is free. Giving kids glasses is not. And giving kids um even more extensive forms of treatment is substantially more expensive than even glasses. Can you speak to a.) The technology around correction and then b.) That implicit form of challenge that gets set up there? 

Sarah Zhang: Yeah. So correction, um which I’ll just sort of like take us like contact lenses, regular glasses and Lasik. Um. What they do is they change the way like light enters your eye, but they don’t actually fundamentally alter uh sort of the anatomical problem that causes myopia. So the real problem of myopia is that your eye grows a little bit too long. So instead of looking like a marble, it’s a little bit more like an olive. Um. So even Lasik, which can give you perfect vision. So you essentially seem like you have perfect eyes. Your eye is still a little bit too long. And actually, that is the thing that eye doctors really worry about, because if you have severe myopia, um it’s sort of correlated with a bunch of other, more serious eye conditions like glaucoma, renal detachment. I mean, the risks are still individually quite low. But once you’ve if you’re thinking about like a population wide, huge increase in myopia, this leads to, you know, [?] people in their in older age. They these are conditions that can actually lead to blindness. So one of the eye doctors I talked to said, you know, what we’re trying to do now is head off an epidemic of blindness, you know, maybe 60 years down the road. 

Dr. Abdul El-Sayed: Hmm. 

Sarah Zhang: So, you know, so, as I said, like glasses, contacts, Lasik, they can give you a pretty normal life. I wear glasses, and, like, they’re sometimes a little bit inconvenient, but it’s not really that big of a deal. But the, they don’t, like crack this anatomical problem. And so what’s really new now is something called myopia control or sometimes called myopia management. And this is sort of to prevent your eyes from growing too long in the first place. So we have, we can’t reverse this. Once your eye has gotten too long, it’s going to be like that for the rest of your life. Um. But there are now ways to actually slow that process down. In most cases, you can’t really uh prevent it completely. Um. But in kids, as I was saying earlier, you know, we often has this pattern of your eyes get worse and worse until you reach adulthood. And they kind of like are fully mature. In kids you can kind of interrupt that process and slow it down a little bit. And there are three main technologies right now that do that. So one are eye drops with a drug called atropine. Um. Atropine is a sort of um eye drop that’s already used for other reasons. It can dilate your eye, um it’s used to treat like lazy eye, but at really, really low doses, it seems, to somehow influence the growth pathway of the eyes so the eye doesn’t grow too long. Another option are um uh special contact lenses, multifocal contact lenses. And these change the way light enters your eye. And actually I mentioned a little bit about the peripheral vision. It especially changes the way that light enters um in your peripheral vision. 

Dr. Abdul El-Sayed: Hmm. 

Sarah Zhang: And this seems to somehow also give your eye a growth signal or actually stop signal to stop growing. Um. The last option is something called ortho K or orthokeratology, and those are hard contact lenses that you wear overnight and they um overnight reshape the clear front part of your eye to also change the way light enters your eyes. So without getting too technical, it sort of works in a similar way as contact lenses. Um. They’re trying to give your eye an optical signal to stop growing, and all of these sort of on average might slow the progression of myopia around 40 or 50%. So you’re not going to go from bad eyesight to perfect eyesight, and you’re also probably not going to curb the progression entirely. But uh it could could sort of keep you in like the low myopia range rather than the like really severe myopia range. That that may be worth it, especially because the risks of this other serious eye conditions I was talking about earlier kind of go up um exponentially as you get worse and worse eyesight like I have, which is too late for me. And I think the second part of your question was just about maybe the cost or the cost benefit of like what to do. Yeah, I think this is a really good question because these treatments are really, really expensive. You know, depending on exactly what you do, it might run hundreds or thousands of dollars a year. And currently eye insurance doesn’t cover it because for the most part they are um used off label. So all these treatments have been FDA approved um for myopia correction, but they for the most part have not been specifically FDA approved for myopia control, which is like. Defined as like actually slowing down the progression of myopia. So it’s used mostly off label. Um. Younger eye doctors tend to be an, up on it, like and older eye doctors might not have learned about it in school. So it’s sort of like not certainly not ubiquitous or universal yet though in cities it’s becoming more and more popular. And there’s sort of a question of like, well, we are kind of doing these really like intensive things for eyes to sort of like retrofit them for like a world that, you know, our eyes were not evolved for, right? It’s sort of like how we have to, you know, get on the Peloton and exercise because we no longer get the physical exercise that we used to get um as our bodies are used, you know, we’re adapted to getting. Um. So I think it kind of speaks a little bit to the way our just modern lifestyles have changed. It seems hard to, you know, how can you can you really take a smartphone away from a teenager? Like how would they live their lives without a phone these days? Um. I think it sort of speaks the way like our [?] modern lifestyles have just are so far removed from what our bodies were sort of originally, you know, evolved to do, you know, tens of thousands of years ago when we were hunters and gatherers and using our distance vision all the time. 

Dr. Abdul El-Sayed: Yeah. I mean, and you speak to that tension that I was I was getting at, which is to say, the minute that there’s a there is a treatment for something, even if it’s not approved, if it’s effective and or in demand, because the issue it’s intended to treat is so prevalent, you do set up an implicit tension between preventing the outcome that you’re trying to prevent in the first place versus treating it. And, you know, this is a bonanza for the industry that provides the treatment. Right. Um. And so I wanted to ask first, how has the optometry industry started to shift and change alongside the increase in demand for their services? 

Sarah Zhang: Yeah, well, the industry sees this as like a huge market opportunity, right? So there’s a there’s this one commonly cited statistic that by 2050 that maybe half of the world’s population is going to be myopic. So, you know, that’s that’s a huge pool of potential customers. Um uh. That’s a really large business opportunity. So the sort of eyecare companies have for the past four years spent a lot of money in R&D, developing new treatments. You know I said that for the most part, they’re not FDA approved. There is one FDA approved um contact lens on the market right now called MiSight. Uh. There’s probably going to be a lot more coming down the pipe. Um. They’re already in clinical trials um uh some cases they’ve already been approved elsewhere in the world. So it’s really just like a matter of time that we’re likely to see these um treatments also approved in the US. Uh. The thing that eye doctors are actually really excited about, what they think might really open the floodgates of myopia control are um not contact lenses, but spectacles that kind of do the same thing that can slow the progression of myopia. And that’s because, you know, the the earlier you start the generally the better it is, right? Because you want to prevent um a kid’s eyes from getting worse in the first place. If they’re 12 years old and they’re already uh myopic, like you can’t reverse everything that happened between the years of six and twelve, but if you start at six, you can prevent some of that. And so parents, you know, or kids, frankly, probably aren’t that psyched about putting something in their eye when they’re like five or six. But if you just get them glasses, um that might just be a lot more tolerable. So this is the thing that doctors are really excited about. And uh it seems really possible that this you know, it sort of gets compared often to braces, um you know which are something that are not, for the most part, not strictly medically necessary. But parents and usually not entirey covered by insurance or not entirely covered by insurance. But, you know, parents who can afford that, they will generally do it for their kids and it may be the case that myopia control becomes something like that in the future. 

Dr. Abdul El-Sayed: You know, the other side of it, though, is that preventing this, if we know that time spent outdoors in physical activity can help prevent myopia, there really ought to be a policy change around how we think about the school day, right? Spending more time outdoors, really biasing that time outdoors can prevent kids from from needing those kinds of treatments in the first place. Have has there been a shift in in school policy uh in accordance with what we’re coming to understand? 

Sarah Zhang: Uh. Not in the U.S., but in Asia you actually do start seeing this happening. Um. You’ve seen some schools sort of starting to require more outdoor time or more breaks in between classes. And, you know, as you say, there’s sort of this like tension between these like broad public health policy interventions and sort of these very expensive individual interventions on the level of, like, you know, buying your kid thousands of dollars in contact lenses. And in in China, which, like, for example, is a country that does see myopia as like a national problem, like literally they’re worried about recruiting of pilots who have good vision. There is sort of this push. More broadly on like a national basis to prevent myopia, which kind of manifest in things like sort of uh curbing the amount of school work young kids can do. Or going outside, um taking breaks. The eye doctors you know the opth– in the US sort of the associations like do sort of see or wish for these broader social interventions in the U.S., but it sort of requires that to become, you know, myopia [?] to become a priority. Right. There are so many competing things going on in schools right now. I mean, like, if you just want to take about like school politics, like there’s so many hot button issues right now, like, does this is this something that your school district is going to, like think is the most important thing? Um. So it’s really a matter of just competing priorities. And like, can you really get a wholesale like change in the school calendar for this? But, you know, this is something that they’re trying to raise awareness of. And, yeah, it would be, you know, probably uh a lot cheaper to think about how do we reorganize our daily life rather than to try to give everyone really expensive new glasses, but uh completely changing how we organize a daily life is like not a trivial thing that’s really difficult. 

Dr. Abdul El-Sayed: So much of this seems like going back to a time when things that seemed obvious were obvious, like kids should probably be playing outside because it’s good for them in a lot of different ways. 

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Dr. Abdul El-Sayed: The biggest issue here to me is one of equity, right? Because the kids who are least likely to have their vision corrected by way of old school pair of glasses, or especially these new school uh interventions that slow down the progression of myopia that are not covered by insurance. These are likely to be Black and Brown kids, likely to be low income kids. And I wonder about what it means in terms of the downstream consequences of that. Right. Because the inability to see a blackboard isn’t just about myopia unto itself. It’s about all of their learning that is lost and sieved away because a kid can’t necessarily see everything that a kid learns about themselves, about whether or not they’re a good student and is labeled as a quote unquote “smart kid” or is not may actually be a function of uncorrected myopia. Um. Because, you know, kids who can’t see get bored um and kids who get bored get into trouble. And I wonder um what that might mean or if uh your engagement with this has has led to any broader questions about what we can do to correct the not just the myopia unto itself, but the the broadening uh inequality that um both the increase in myopia coupled with uh differences in access to these treatments might create. 

Sarah Zhang: Yeah, I um I think having talked to doctors who work both in like really privileged populations and in sort of less privileged ones, right, this is a concern that comes up a lot, the cost of these treatments and just frankly, the cost of glasses themselves. Um. You know, I would say that the cost of just like regular glasses is in fact, probably a much bigger issue than the cost of these myopia control treatments, which, you know, work. But of course, as I said, aren’t perfect. So I think the first thing is we should try to get glasses to everyone who can afford them first or who ever who can’t afford them first. Um. I think this is also an area where I as we were saying, I wish we had better data on exactly what the current trends are um because going back sort of just looking at broad population trends, myopia is something that is highly correlated with uh wealth and highly correlated with education for reasons that, you know, might seem obvious because of the behavior, uh you know, because of like differences of behavior. Um. If you spend a lot of time on on education doing homework, you’re maybe more likely to have glasses, right? Um. I I wonder how much that is changing given the ubiquity of screens like how much this changes across class lines now. And I really do wish we just had a better sense of exactly what is going on. Um. I think when it comes to just like what treatments are available, uh the availability of just like just correcting people’s vision, even with just [?] very simple glasses, is going to make a world of difference. And that is like almost more low hanging fruit than thinking about these very expensive and currently like quite niche treatments, which um work to an extent but aren’t certainly aren’t perfect and are not, you know, panaceas. 

Dr. Abdul El-Sayed: You mentioned one of the downstream consequences of a increasingly nearsighted population around national security and the ability to find, you know, pilots. But were there others that that might have come up in your research on this topic? I can imagine, like increasing rate of traffic accidents if fewer people can see uh oncoming traffic. Um. Were there others that that came up as you um as you did this research? 

Sarah Zhang: Oh, uh I don’t know if there were I don’t know if there was sort of like the, much fear about like the broader social consequences. I think we sort of hope in the U.S., though as we were just saying. It’s not so true. Sort of a hope in the U.S. that most people who need glasses uh will be able to get them. You know, I think, you know, nearsightedness is one problem, but age related vision loss, which is not necessarily the same thing as nearsightedness, is another. And that may also be sort of in when it comes to traffic accidents, that may actually be another big factor as well. Um. I think the sort of the the larger fear is, as I mentioned earlier, is that really severe myopia. So like we’re talking about prescriptions that like are above like negative six for people who need glasses, you know, kind of roughly know what that means. Uh. Basically means you have to like look literally right in front of your face, um the really severe myopia, even though it can be kind of corrected with contact lenses or glasses, it doesn’t change the fact that you’re also more prone to these other like riskier eye complications. And that just means that, like, there will probably be more patients with glaucoma in the future or like, you know, there needs to be more eye doctors to take care of them. And I think there’s sort of for for eye doctors there’s there’s just like, oh, are we going to have enough eye doctors in the future when this highly myopic population is like in their sixties or seventies? 

Dr. Abdul El-Sayed: Yeah. You know, you bring up a really important point because the downstream consequences of a more myopic population hit hardest, actually not in childhood or even through their life course. That hit hardest in old age. And um people are living uh longer lives, which is, of course, a great thing. But then this means that they’re going to live more and more of their lives with with potentially a higher level of of degeneration visually. The other thing you know you couple it with is is hearing. I think I, you know, not not on topic exactly, but I think we are coming up to a pretty massive jump in age related hearing loss just because the ubiquity of of headphones is something that is very new. Um. All of us walk around with, you know, AirPods in our ears listening to whatever it is. And rarely do we actually uh adjust our uh our volume downward like the apps all tell us to. Um. But, you know, that kind of exposure to loud sound uh in a way that we haven’t had because of technology is something that we’re we’re about to hit. And as I think about this you know it’s pretty crazy to me that Medicare um the insurance program for seniors in this country doesn’t fund uh vision, dental or hearing, which are like the three things that are most likely to affect anyone who’s a senior. And so you kind of think about this and and the way that those things interact is if you’re losing your hearing and your vision, it makes the loss of either one of those worse. Right. Just because of how important both of those are to folks. Um. now, as you think about this, have have uh folks been thinking about the the long term consequences in terms of our ability to support people in old age as a function of this? 

Sarah Zhang: Yeah. Yeah, I think that’s absolutely a concern. Right. So if you have more people losing their vision, you know, when they’re 70, um that really changes sort of like their their mobility and their ability to um to function, right? Like it being sort of, you know, being born blind versus losing um your vision in old age after having sight your whole life is really different. It’s much harder to adjust when you’re 70 than when this happens to you, if you’re born or it happens to you when you’re seven. Um. So I think that is absolutely one of the big concerns that as we get older, we have a population that not only needs has more eye conditions, but then might actually also be become blind. And then this, um you know, and many as [?] conditions in old age like changes uh sort of the care that people will need, the amount of care, the level of um, level of care that they need. And that is one of, in fact, one of like the big sort of downstream concerns of, you know, what’s going to happen 60 or 70 years from now. 

Dr. Abdul El-Sayed: That’s the thing is that we uh we sometimes fail to adjust. And then you have these um generational effects that hit all at once and society’s just fundamentally ill prepared for them. Uh. I really appreciate you coming and joining us to talk uh about your article, uh Sarah where can people um find more of your work and learn more about um what you’re what you’re thinking about everyday?

Sarah Zhang: Yeah well so I’m uh um all of my stories are on theAtlantic.com. And you can also follow me on Twitter. It’s uh at @sarahzhang 

Dr. Abdul El-Sayed: All right, Sarah Zhang, thank you so much for uh joining us to talk about uh the increasing rates of myopia in the United States and um how people are thinking about the solution. We really appreciate you joining us.

Sarah Zhang: No. Thank you. Great talking to you. 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. The UK saw a 15% increase in COVID cases over the past two weeks worrying public health officials that we may be next. Critically, this is amidst a substantial drop in cases worldwide. So it doesn’t mean that we’re definitely going to get an increase in cases here. Importantly, the cases were mostly still attributable to BA.5. And that tells us that there’s not a new immune invasive variant that’s driving the surge. All of this reminds us, though, that while we certainly shouldn’t be freaking out, it’s worth staying vigilant. Part of that is making sure we have the resources and tools we need to fight a surge if one comes. And Congress yet again passed up on the opportunity to fund COVID preparedness this week as they reached a deal to keep the government funded. In good news, though, Monkeypox cases are down substantially over the past few weeks, down from a high of more than 500 new cases a day. Cases are now down to about 200 per day across the country. That’s the result of a couple of key trends coming together. First, the government’s finally gotten its act together on vaccinations, getting them out to the highest risk folks. But most of the credit, well, that’s due to the folks who have lined up to get them and followed public health advice to reduce the number of sexual encounters and partners. And yet the opportunity to fully eradicate monkeypox may have passed. Remember, eradication implies that you’ve stamped the virus out completely, and that’s unlikely considering the fact that monkeypox is a zoonotic illness, meaning it can take hold in animal reservoirs periodically jumping back out. So while it’s likely that public health efforts can vastly reduce the number of new cases, probability that we fully stamp it out has gotten far smaller, given how rapidly it was spreading just weeks ago. Finally, a new Alzheimer’s drug shows a 27% reduction in patient decline in a late stage human trial. The drug called Lecanemab was the first of its kind to show reductions in Alzheimer’s progression by attacking a unique kind of protein buildup called amyloid plaques observed in patients with Alzheimer’s disease. Other drugs had targeted these amyloid plaques, but showed no real reduction in patient severity. Toward this end, Biogen, one of the drug makers, was also the manufacturer of Aduhelm, a drug that was okayed by the FDA after an intense lobbying campaign. Despite the flimsiest possible evidence that it even reduced the level of amyloid plaques. This new drug has yet to be approved by the FDA. But if these findings hold and the drug is approved, it could prove a sea change for Alzheimer’s treatment. That’s it for today. On your way out. Don’t forget to rate and review. It goes a long way. Also, if you love the show and want to rep us, [?] drop by the Crooked store for some America Dissected merch. We’ve got our logo mugs and T-shirts and our science always wins sweatshirts and dad caps. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Tara Terpstra. Veronica Simonetti mixes and master the show. Production support from Ari Schwartz and Ines Maza. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sara Geismer, Sandy Girard, Michael Martinez and me, Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It is not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health.