A different way to measure success in health care | Andrew Bastawrous

0:07You're listening to TED Talks Daily, where we bring you new ideas and conversations to spark your curiosity every day. I'm your host, Elise Hu. Today's talk is part of our TED Fellows film series, adapted for podcasts just for our TED Talks daily listeners. We'll be releasing these special episodes showcasing our impressive fellows on certain Fridays throughout the year. The TED Fellows program supports a network of global innovators, and we're so excited to share their work with you. Today, we want you to meet eye surgeon and inventor Andrew Bastouris. Back in 2014, Andrew first shared his idea with Ted about developing smartphone technology to bring eye care to people in remote areas.

0:48Now, more than a decade later, his organization Peak Vision has reached more than 18 million people worldwide with a new goal to serve 1 million people every week. Now, amid his wild success, Andrew confronts a new question. What do we lose when health care chases speed and efficiency? He offers a quiet provocation to get better outcomes for patients and healthcare workers alike. And after we hear from Andrew, stick around for a deep dive conversation with TED Fellows Program Director Lily James Olds. It's coming up.

1:29When we enter the healthcare profession, none of us actually ever go in with an aspiration of productivity or efficiency. It's called healthcare for a reason. We go in because we care. Currently, the pressure on the healthcare system means we'll choose to see someone three or four times superficially, rather than once or twice deeply. I'd like us to show the evidence that once or twice deeply actually leads to better outcomes for both the patients and the health workforce. My name is Andrew Bastaurus. I'm an eye surgeon, a professor of global health and founder and CEO of Peak Vision. Years ago when I worked as an eye surgeon in the UK I was running a really busy clinic I knew that I had at least another four patients to see that day And I was already at time for the end of the clinic We had a clock on the wall, I could just hear ticking And that tick seemed to be louder and louder I'd also be more tuned in to everyone outside Complaining that they hadn't been seen yet And a lady came in to see me She looked weary, like life had been hard she'd also come in very late for someone with cataracts in the UK most people don't come in near blind and she shared that the reason she hadn't come was she'd been nursing her daughter for four years and her daughter had had cancer and she'd only just died in that moment it felt like she'd shared something sacred with me and just to pass it by felt like I was doing her an injustice I didn't really have to say anything, I just listened I think it was maybe around 10 minutes, but that 10 minutes I know meant more to her than the 10 minutes I spent operating on her eye.

3:06Her cataract operation went well, and a couple of days after that I saw her in my clinic. So I expected her to come in pretty happy. She did come in with a bag, but it wasn't a box of chocolates. It was a photo album, and one by one she showed me these pictures of her with her daughter. And the whole time I looked at her and I realised she hadn't mentioned that she could see. So I waited for her to mention something. I even prompted her and I said, Jackie, how's your eyes? She said, oh, it's fine, it doesn't hurt. And then she finished showing me the photos, she closed the album, and she said, thank you, you were the only person that listened to me.

3:45The greatest gift I could give her was not her sight, but to have her be truly seen. I think there's very few things in life that are as joyful as being able to help a fellow human being. People aren't inherently not caring or not compassionate. It's if the environment is one that doesn't allow people to stop and care, then people don't live to their values. Peak Vision started as a concept in 2012 whilst I was living in Kenya. And we were setting up 100 temporary eye clinics, taking equipment and trained staff to all of these remote locations. and it dawned on me that this would never solve the problem at scale, that there had to be a way to reach more people.

4:32And so we built ways of being able to screen and diagnose and refer people all on a smartphone in 2014. We'd seen 7 ,000 people over two years, but today we reach a million people every two months. One of the questions my team and I have been asking is, what are the unintended consequences of scaling? And I went back to that experience I had with Jackie, where there was pressure to see as many people as possible. And we realized we were potentially creating that same pressure. There was all of these metrics that allowed people to know how many seconds it took them to identify a person with vision loss, how many seconds it took to refer someone.

5:09And it was tracking everything around that efficiency performance. And we've decided, well, we started this not as a means of efficiency, but as a means of compassion. And this idea that compassion is actually inherent. provided the environment is conducive to people being allowed to care. And so now we're trying to encourage that when a screener finds someone with a vision problem that they stop and they slow down and they listen. We want to move from having soft evidence that being compassionate is a good idea to hard evidence that actually yields better numbers. So we have run this trial with our partners in India where half the group of screeners are given extra time and different measures of outcomes.

5:54Their key performance indicators are going from how many people they've screened and referred to how many stories they remember of the people they've seen. You'd expect if you're spending that much more time with people, you'll get through much fewer people per day, and we expect that to be true. However, we expect many more people overall to turn up for treatment. For many people, even going to see a doctor is a huge step of courage And a decision to take treatment that you don't necessarily understand or have evidence that works is all down to the relationship that you have with the person who suggested it.

6:28And so if that person's under pressure just to diagnose and send the referral, we think that's one of the reasons why not that many people turn up who need it. And so if trust is built, then we think they're much more likely to take up the care. The secondary effect is the doctors and the nurses providing the care will burn out less because they're more connected to the work that they're doing and they'll feel less pressure to see numbers and more pressure to see people. If patients are given more time to be heard and doctors have more time to listen, everyone will be happier and the results will improve.

7:03We tend to measure progress or success in terms of who's got the most and that could be measured in market share or the most dollars or the most power. but we all deeply resonate with there being something more than that. There's got to be a different game that we're playing. The measure of a life well lived isn't how much we do but how much we connect with one another, with the people that we love and the people that we serve.

7:42And now a special conversation between Andrew and our TED Fellows Program Director, Lily James Olds. Andrew speaks with Lily about why smart technologies like his matter in healthcare, how slowing down has reshaped the way he sees and experiences the world, and why this shift in pace is fundamental. That's coming up right after a short break.

8:09Hi, Andrew. Welcome. What a treat to get to talk to you today. Hi, Lily. Great to be here. So over the next four years, Peak Vision aims to serve one million people every week. It's really incredible. Thank you. I'm curious, in your experience as an eye surgeon and professor of global health, what urgent challenges are we facing globally when it comes to eye disease? And how does peak visions technology specifically help address those gaps? The problem people face with eye health is that across the age spectrum, people are losing vision and are largely unaware of it unless somebody intervenes.

8:52So if you take children in school, many of them have a level of vision impairment that's undiagnosed, much like I was living at school with vision impairment, failing, being very clumsy, and all I needed was a pair of glasses. So there's a huge number of children who can't see the board and a pair of glasses can unlock their education and hugely increase their future potential. The short-sightedness or myopia epidemic is growing in huge numbers, particularly if you live in a low or middle income country and particularly in Asia. And then you take the next age group kind of working age people. Once you hit 35, 40, it's normal to start losing near vision.

9:38And so people struggle to do basic tasks because they can no longer make out near objects. And so that affects huge numbers of people where the fix is a$1 pair of reading glasses and half a billion people or more still can't access that very simple treatment. And then in older age, you have people who start to lose their sight from cataract, which is a natural aging of the lens of the eye. And it's estimated close to 100 million people have vision impairment from cataract. And the majority of them live in low middle income countries. And if you are in a context where access to care is low, the likelihood is you will die before accessing treatment.

10:19And so how is PEAK able to meet these people where they are in a way that, you know, definitely wasn't possible before for doctors? When we started doing this work, we were setting up all these clinics and doing pretty comprehensive diagnostic assessments. And what I realized when embedded in these rural communities in Kenya was the issue was not actually diagnosing somebody. It was them completing their journey once they had been identified with a vision problem because the majority of people are not even aware that treatment is possible. And so they're not seeking to access care. And if they are made aware, they don't know where to go.

11:02And if they do know where to go, they have major barriers in terms of accessing it. And so we set about trying to solve for that by building technology that could be operated in the hands of anyone that's smartphone literate. So no need to have any healthcare background or eye care background, but just be able to use a smartphone. And we redesigned everything that I was running in that clinic so that people could do simple tests, could do basic assessments that would help us identify those with a vision problem or an eye health issue and determine where they need to go next. The very first implementation of this was in a school-based program where children were being screened and a good 5 % to 10 % of them had a problem, but only one in every five turned up for treatment.

11:48So we started to try and understand what is it that's stopping them access care. And the first realization was the child doesn't decide whether they get treatment. And so we realized we needed to connect with their parents or their carers And we built in an automated messaging service that would notify the parent or carer that the child had been tested and that they had a problem and where they needed to go. And that started to make a real difference. But interestingly, the content of the message made even more difference. So the language used, the way in which it was sent, the frequency, all of these things started to increase the chance of them coming.

12:22And one time we noticed that actually headteachers could be a key person in this system that we might be able to influence on this. So we started sending them messages telling them how their school was performing in terms of completed referrals compared to neighboring schools. And when they started receiving that message, headteachers would organize minibuses, start taking all the kids that had a problem straight to the hospital. You made it competitive. And it was just these lessons. And we learned so many lessons. How do you basically nudge people's behavior, whether it's the person who needs the care, the person who looks after that person, the person who has a vested interest in them being able to see?

13:00And over time, we started building this data platform that was connected from household and school to health center, eye clinic, vision center, eye hospital, and really connected the whole network of possibilities in terms of where that person might go and then increased the likelihood of them attending the place they needed to go to get the treatment they needed. The technology that Peak uses, does that open up more time for doctors to then do other things? Yeah. So the assessment that was needed to determine if that person needed to come for treatment could only be made by someone with specialist skills.

13:35That specialist had to make a choice of either work in the hospital or go out into the community and find people. But they couldn't be in both places at once. And so you were decreasing their productivity in the hospital. And the challenge that you face when you're in a context like this is you've got known need sat in the waiting room. You've got people who've come because they have a problem. Right. But then out in the community, you've got many, many more people that have a problem and they're not asking to come. And so that's the challenge health services face is if you just focus on who's already there, you're already busy.

14:12You've already got a workload, but then there are all of these people who will never come unless you go to them and do outreach. And so we try and make that challenge less painful for people so that they can increase their efficiency and throughput at the hospital level whilst also having non-specialists go and do the screening and bring the appropriate people to the hospital. And I'm curious to hear your take on AI. What else? It's all everybody's talking about. I'm curious, one, how you think about it as it relates to PEAK and that particular technology. And also, as it becomes more embedded in healthcare, do you see it as a tool that could give clinicians more time to slow down and be present with patients?

15:01Or do you think it could push us even further away in the other direction? So my shortest version of the answer is yes. and you know I think there are so many angles we could take on this but my view is that AI is going to amplify human behavior particularly our behaviors which are online and that could be for good or less good in terms of its utilization and my view is that the current kind of forces driving AI adoption and acceleration are moving in a direction that does concern me and equally excites me on one side because I look at some of the amazing new augmented or extended reality glasses that are out there that all the big companies are starting to push now.

15:50And they're phenomenal in terms of being able to get an overlay of a map or get interpretations and all of these other things. Yet as we're pushing the boundary in terms of extended reality glasses, we have this tragic reality that close to a billion people live without a basic pair of glasses, which is a 700-year-old invention, which is older than most nations, and it still remains out of reach for them. So this is neglect on a global scale. And I don't see people talking about how are we going to use AI to close that gap. So although it has huge potential, I don't see an incentive at the moment, which is utilizing this hugely powerful capability to serve those who are being left behind.

16:34I completely get its potential in terms of productivity gains, breaking new lines, but unless the underlying principles against which we are building these new capabilities serve everybody, I think those who are currently being left out are going to be left even further behind in the future. I guess, let me ask this to you personally, since it's a moment when your organization peak is reaching more people than ever. Do you hear any pushback about choosing to pause and slow down rather than just continuing to build more and more, which of course, whether it's with AI or anything is really what we are hearing again and again, that success is always about just doing more?

17:20The feedback I'm getting is that it resonates with people. I would say not even limited to healthcare. I think everyone just feels that they're in a hurry and that they're busy. You know, you ask anyone how you're doing and the usual answers aren't busy. And it's become the thing of our time to be busy. And I think we've created this kind of false idea that if you're doing lots of things, then that's good. And it comes down again to what are the incentives? So if within healthcare, everything is measured against activities and throughput, then whatever somebody wants to do in terms of be a caring human being, there's a lot of pressure on them to do the numbers, get through people.

18:02And so I don't get pushback at an individual level, but then the systems that people are operating in are just not designed to do this and to allow people to slow down. So that's some of the work I'm working on now with my team is can we create evidence that actually shows these things are not in tension with each other? You can slow down to speed up. You can do less and get more. You can exchange money for meaning and still be profitable and demonstrate with this with hard data that might start to move the needle a bit on this. I want to get into that more with you. But I think first, I would love to just ask you to reflect on that as a question personally.

18:44How do you internally reconcile with this pressure to scale your company, be a parent, be a partner, be a citizen of the world? What are your practices to do that, to remind yourself to slow down? I'm going to share two things with you. So I'll summarize them as calendars and headphones. So the first thing is I'm fortunate to be able to choose when I start my meetings. And I'd realized for a long time, you know, my first meeting of the day would always be at nine o 'clock and I'd be doing the school run in the morning, which meant by the time I dropped the children off, I had like five minutes to make a five minute journey home and then straight into that first meeting.

19:24And the consequence of that was if I saw somebody I knew or somebody made eye contact with me, I'd have to try and make some kind of gesture that was dismissive to say, you know, I'm in a rush. Sorry, I've got to go. I've got a meeting. And I thought, why am I doing that? I don't have to ignore these moments and these opportunities to connect. So I just moved my day to start at 9.15, which means that buffer means I can walk the kids to school without rushing. It means I've got time to talk to neighbours. And it's often in those unscripted moments that some really beautiful conversations have happened.

19:58And just a few months ago, after the school drop-off, walking through the park, there was an elderly man there who just looked isolated. and I could tell something wasn't right. So I wandered over to him and I just asked if he was okay. And he said, well, his wife died recently and he felt really lost. And we just stood there together for a few minutes talking and mostly listening. And, you know, it left with him giving me a hug and I just walked home glowing. I felt connected to another human being. I hadn't alleviated his suffering, but I had at least connected with him and he'd felt heard. And, you know, how many of these moments are happening all the time that we don't even recognize.

20:41The other I mentioned was headphones. One of the main stage performers at TED in 2025 was Joshua Bell. He did this kind of stunning piece on the violin and he had an orchestra with him. So I read up about him afterwards and it turned out he was part of a really interesting experiment almost 20 years ago in 2007. So a few days prior to this experiment, he'd been performing in front of hundreds of people for hundreds of dollars and people had traveled for it and dressed for it and sat down and they knew they were witnessing something great. And then a few days later, he was performing in the Plaza Station at Washington, DC, just before 8am.

21:20And he played for 43 minutes with about 1 ,100 people walking past on their way to work, you know, in the open, it was not hidden in a corner. and he was playing on this stunning 300 year old violin that's worth over three million dollars so it's been like handcrafted and passed down playing pieces that have lasted 300 years and he was one of the most talented musicians of all time and we would assume you have someone like that playing that kind of music in the open where there's no barrier anyone can walk up to him that he would have stopped. But what happened was because people were hurrying, it changed them to tighten up, to narrow, just to focus on getting to where they were going.

22:05People had their earphones in, their earbuds, and were listening to their own music, and almost no one noticed him. And it wasn't cruelty, it was absence. The fact that only a handful of people stopped at all, he raised only, I think,$30 in 43 minutes, given that more than a thousand people passed. And I think only Literally one person recognised him the whole time and stopped to really pay attention. And this isn't about a super talented musician. It's a story about us. It's about what speed does to our souls and how we're constantly rushing and we miss the kind of obvious beautiful moments that are happening.

22:44We miss one another. And so I suppose the invitation is just take your headphones out and when you come up the travelator, look up, See, notice who's around you because we're constantly missing these moments. And I think when we look back on our lives one day, we'll realise that our whole life is made of moments that you notice and the ones that you don't.

23:28So as much as I think all of us need to figure out, as you're saying, what are these small actions that can make us feel more present in our days and our lives, whether it's, you know, meditating or taking out the headphones or just adding 15 minutes, as you said before, or between meetings, I think it also is really interesting to think about it from this design problem angle, right? Because it's on each of us, but it's also these systems and how they're structured. And I know that your team is currently working on a trial to generate some of this hard scientific evidence that being compassionate to patients actually yields better numbers.

24:14And I know the study is still ongoing, but I'm just curious if in the meantime, you have any updates you could possibly share about how this is going and what you're finding? Yeah, absolutely. So as you might expect, programs are trying to optimize for throughput because the need is huge. And so they're looking for efficiency. And so when it comes to the screeners and their supervisors, what they're measuring is kind of throughput measures. How many people did you see? How many did you refer? How many turned up? And they're all good measures, but they are optimizing for productivity and not for care.

24:47And so our working assumption is that people are inherently compassionate, but there isn't the space to connect deeply enough. And we've seen it when we go and watch people do the screening. I remember in the early days being in Kenya and this lady who'd been kind of blind for 20 something years at this point, and somebody knocked on on the door did the eye test found that she was blind and she refused to go she said like once she didn't believe him that it was possible to be treated now he recorded the screening recorded the referral and he could have just walked on to the next house but instead he asked if someone else was home there wasn't but next door was where her son lived so he went and knocked on his door guy called philip got chatting to him and explained that his mother had cataracts was blind but could get her sight back.

25:41And he spent the time really trying to understand why were they scared? Why would they not come? And by just sitting and paying attention to them and helping them understand what lay ahead, they decided to take up the surgery. And I always remember this particular lady, so she was kind of known as Mama Philip, because she'd been blind for so long. Everyone assumed that she was not only blind but couldn't walk and that her memory had gone that she had severe dementia but the reality was she hadn't seen anything new in in two decades and then when she had her surgery the following week when she was brought home on the bus she got to the edge of her village and where they all got out she looked across at her house and she recognized it because it hadn't really changed and her son Philip was stood there looking really anxious like has this worked and she looked at him and didn't recognize him and so he still thought she couldn't see and then suddenly she kind of leaned forward and was like Philip is that you?

26:36And he said, yes, it's me. And I said, wow, you look so old. What happened? And then suddenly everyone else in that community who was scared to come realized that, wow, look at this. This person was blind. You can see again. How do I get treated? That one person just spent a few minutes taking the time to understand their fears and the ripple effect they have had in terms of not just that one person and their son, Philip, but all the other people who are now coming. That happened because they slowed down. Whereas if they'd just done their job, which was hit those numbers, that wouldn't have happened.

27:14So the kind of challenge we have and the question we're asking in Peak is how do we design for that? How do we design to create the space for those moments? And we realize if we choose to measure activities rather than the outcome we're after, you will always bias the system for more activity. So here the outcome that matters to us is that that person turns up and gets treatment that works as opposed to how many people were tested. And so that's what we're doing now. We're running experiments such as this, such as just giving them more time and changing what their key performance indicators are.

27:49So rather than tell me how many you've screened and referred, it's tell me a story about someone you've seen and referred. And that just changes the emphasis. And what we're seeing when we did our kind of pilot work was actually, although they are seeing fewer people per day, more people overall are coming for treatment. And, you know, we'll be really excited to see the final data because it's looking like there isn't a tradeoff. And in fact, when you do slow down, more people get treated. The health workers are happier and not burning out. And so retention is higher. And the patients and their carers are much happier and appreciating the service they're getting.

28:24Well, and it's also such a great example of how trust is so important in this process. And I love that example because it's how you're actually building it again into the design of this system in healthcare, which I just feel like so many people distrust, right? I'm really excited to see how those trials continue and if there's ways this can be implemented, obviously with others in healthcare, but also across so many sectors. Yeah, and absolutely. And it is about that tension between individuals and the systems they operate in. Because if we have the working assumption that people are good, but the system isn't designed for that, it is a problem.

29:07And, you know, we don't fail to act because we don't care. We fail because we haven't created the spaces for people to care. And so we end up serving the clock rather than one another. And when you put people under stress, whatever their value set, they're unlikely to live to it. And I think that's a key thing to take away. Anyone who's in a position of influence in terms of designing an environment, whether it's your home environment, your work environment, if you put people under stress, you will not create an environment for them to live in alignment with their own values. And I guess just building off that, what advice would you give to other leaders who are trying to, you know, redesign their own either work or home environments to value compassion?

29:49How would you advise them? There's so many things and I'm conscious that, you know, I'm absolutely hypocritical in this because I certainly don't do all of these things. But I think it can be from small things like not having your phone near you when you're talking to someone else. Because it's a sign of distraction. You're ready to have your attention diverted. Or if you have to pick up your phone and communicate or do whatever it is that you're doing to actually say, hey I'm just I'm just responding to so and so or I'm needing to do this because the assumption for the person on the other half is I'm not worthy of your attention and I'm super conscious of this you know having young children how how do we model those kind of behaviors because they'll only end up doing the same things we're doing and then I think you know things within home life it's also just I think creating the space to if you're someone that needs to be on your own occasionally finding those spaces, whether it's going out for a walk, whether it's the first thing in the morning, last thing at night.

30:49You know, I think most people need some space to themselves. And within the work environment, we're trying really hard. And I say really hard because it is hard to do it. You know, there's the usual whirlwind of activity when you're building something new, when things are going badly or things are going well, there's always work to be done. So you have to kind of work hard at creating the space to not be busy. And I think a lot of that comes from providing people not with certainty, because we can't do that, but providing clarity. So clarity comes from doing the deep work that means everyone really understands where we're going.

31:25Why do we do what we're doing? Because so much energy is misspent in the kind of dance around uncertainty. And I don't think we can solve for uncertainty. The future is unknown. But we can provide clarity. But to provide clarity, we have to slow down and do that kind of work. And that can be as practical as having a planning week per quarter, having a day every fortnight where there's no meetings, having an hour and a half every day where you just get to do deep work, having 10 minutes off every hour where you're not in a meeting. So you've got space to move between them. So it can be really small things, but these add up to giving you the space to keep perspective and maintain clarity.

32:06Okay, I'm taking notes. I'm feeling grateful that we can check back with each other and see how we are both implementing these into our daily lives. I'm so grateful to you, Andrew, for this conversation and your work. It just always gives me such a sense of depth and hope when I speak with you. I really appreciate it. Thank you, Lillian, and all the amazing TED Fellows team.

32:38That was TED Fellow Andrew Bastauris. The music you heard in the interview is Joshua Bell and the Chamber Orchestra of America. It's from their 2025 performance and talk on the TED stage. To learn more about the TED Fellows program and watch all the TED Fellows films, go to fellows.ted.com. And that's it for today. This episode was produced by Lucy Little, edited by Alejandra Salazar, and fact-checked by Eva Dasher. The audio you heard at the top comes from the short film made by Divya Gdenghi and Owen McLean. Story edited by Corey Hajim and produced by Ian Lowe. Video production manager is Searing Dolma.

33:14Additional support from Lily James Olds, Leonie Horster, and Allegra Pearl. TED Talks Daily is part of the TED Audio Collective. Our team includes Martha Estefanos, Oliver Friedman, Brian Green, Lucy Little, and Tonsika Sungmarnivong. Additional support from Emma Taubner and Daniela Ballarezzo. I'm Elise Hu. I'll be back tomorrow with a fresh idea for your feed. Thanks for listening.