CHALLENGES FOR THE FUTURE CAN BE MET IF THE WORLD OF MEDICINE AND THE CULTURE OF THE WORLD ARE UNDERSTOOD

M. Bruce Shields, MD

I.                     Historical milestones

A.     One hundred years ago

1.      On December 17, 1903, humankind lifted into the air for the first time

under powered flight.

2.      Three years later, in 1906, the introduction of glaucoma filtering surgery

marked another significant historical milestone.

B.     Today

1.      Aerospace research can boast of putting men on the moon, sending

exploration crafts to Mars, and providing the universal mode of world

travel.

2.      Glaucoma is the second leading world cause of bilateral blindness, having

having recently passed trachoma, and for many afflicted people in

developing nations, there is little hope.

C.    How can we explain this dichotomy in twentieth century progress?  Why have

we not been more successful in preventing the blindness of glaucoma,

especially in developing nations?

1.      Insufficient resources?

2.      Global priorities?

3.      Inadequate diagnostics and treatments?

4.      Failure to ask the right questions?

D.    Can the right questions (much less the right answers) be found through an

understanding of:

1.      The world of medicine?

2.      The culture of the world?

II.                   Understanding the world of medicine

A.     The challenge of glaucoma

1.      Vision 2020 – The Right to Sight, a consortium of the WHO and

international non-governmental organizations, is an initiative “to help

eliminate needless blindness by the year 2020.”

2.      They address “the five most severe and amenable causes of blindness:”

a.      Cataract

b.      Trachoma

c.      Onchocerciasis

d.      Childhood blindness

e.      Refractive error/low vision

3.      Where is glaucoma?  Is it not amenable?  Too difficult to even consider?

4.      This highlights the challenge of glaucoma in the world of medicine

B.     What questions must be asked to meet this challenge?

1.      What is the epidemiology of glaucoma worldwide?

a.      80% of blind and suspect cases of glaucoma in developing world.

b.      Predominance of OAG in persons of African heritage and ACG

among persons of Asian heritage.

c.      OAG twice as common as ACG worldwide, BUT:

i.                    10% blindness in OAG and 25% in ACG

ii.                  3.3 million blind from OAG and 4.3 million from ACG

2.      How to detect glaucoma before blindness?

a.      In developed countries, fewer than 50% with glaucoma are aware of it.

How much worse is the undiagnosed rate in the developing world?

b.      What diagnostic tests are feasible?

i.                    Biometric risk factors for ACG?  Assess anterior chamber

depth? Refractive error?  Gonioscopy??

ii.                  Optic nerve or visual field for OAG (or ACG)? Media

            opacities interfere with diagnosis in many people.

iii.                The fact is that many cases in developing world are detected on

basis of blindness in one eye, with hope of saving second eye.

3.      What treatments are feasible in the developing world?

a.      Medication?? (In Tanzania, Xalatan costs $12/month, but the national

budget for health care is $3/person/year).

b.      Laser (assuming availability, which is limited)?

i.                    Trabeculoplasty: limited value due to high failure rate

ii.                  Iridotomy: limited value,since high prevalence of chronic ACG

iii.                Cyclophotocoagulation: possible role, but high complications

c.      Filtering surgery?

i.               Currently the most commonly used treatment

ii.                   But at least 30% lose 2 lines or more (cataracts?)

iii.                 Poor follow-up/compliance

iv.                 Are some better off without treatment?

v.                   Clearly there is a need for better treatments.

4.       What about the role of education?

a.      Of the people?

b.      Of their government?

c.      Of the local healthcare workers?

d.      And, especially, of OURSELVES?

i.                    What other health concerns does the patient or his/her

family have?

ii.                  What other healthcare considerations does the local

government and healthcare workers have?

iii.                And we must educate ourselves to the culture of those who

we are trying to help.

III.                  Understanding the culture of the world

A.     How much emphasis should we actually put on cultural differences? 

B.     Are we more alike than we are different?

1.  Do we all have the same basic hopes and fears?

                  2.  Could placing too much emphasis on culture be misinterpreted as

being condescending?

3.      Is it best to treat all people the same?  

C.    But we do have our differences

1.      Consider that in the Swahili language there is no word for glaucoma.

2.      How does a person’s religion influence their views of foreign (or even

local) doctors and their medicine?

3.      How does an individual’s past experiences influence their acceptance of healthcare workers?  An ophthalmologist tells of two villages in Kenya:

a.      In one, the people literally fought to be seen be the doctor, requiring armed guards to maintain order.

b.      In the other, the village was deserted, because the people had fled for fear of the eye doctor.

IV.               Today, there are still more questions than answers.  But we must ask the right questions, before we can find the right answers. And that is probably where we should begin.

Acknowledgements: My sincere thanks to Drs. James Martone, Aaron Rose and David Yorston for sharing with me their experiences and thoughts, as well as their excellent photographs, from their work in overseas Ophthalmology.