MAKING MEDICAL TECHNOLOGY WORK FOR THE POOR

BY DR. SANDUK RUIT, Medical Director, Tilganga Eye Center
2006 Magsaysay Awardee for Peace and International Understanding
Presented at the 2006 Magsaysay Awardees’ Lecture Series
Magsaysay Center, Manila, 1 September 2006

Background

The current global estimates indicate that more than one hundred and eighty million people are visually disabled worldwide. Of this number, approximately forty five million are blind.

Cataract continues to be the most common cause of blindness worldwide. It is estimated that nearly 18 million people are blind with cataract and nearly another 100 million in the process of becoming blind. 90% of the blinding cataract is found in the developing world and the bulk of them in Asia. Due to an increasing lifespan and an expanding elderly population in the developing world, the prevalence of blinding cataract has been projected to double by 2020. The emotional and economic ramifications of cataract impairment on individuals, families and communities, particularly in the poorest parts of the world, are immense. These include a shortened life expectancy, decreased income, decreased employment, decreased social standing, decreased authority making within the family and an increase in the family burden. Surgical treatment for cataract is now fairly straightforward and predictable, however delivering modern cataract surgery with good visual outcomes had gone through challenging phases of materialization.

About 20 years back, the use of intra ocular lenses (IOL) in modern cataract surgery in developing countries faced severe challenges from establishment. Many considered that it was inappropriate to do modern microsurgical lens implant surgery. The 3 big challenges facing us to provide this service in developing countries were:

(a) Cost and complexity of the surgical technique.
(b) Cost of high quality IOLs.
(c) Cost and complexity of the equipment used.

It took us nearly five years to find a suitable, adaptable and affordable surgical technique. A suitable technique was duly standardized with a good manual of Standard Operating Procedures, which were written, with the help of the Fred Hollows Foundation. The training of this surgical technique moved globally and many surgeons were trained and provided with the essential equipment. Extensive research and development programs were conducted at Tilganga Eye Centre to find appropriate equipment and surgical instruments. All this had been possible through a truly wonderful partnership with the Fred Hollows Foundation and the Himalayan Cataract Project.

The cost of an IOL, which is made from a very special plastic material, manufactured in the West, used to cost about US$100, while the raw material used to cost just 50 cents per piece. TEC worked very closely with the FHF to manufacture these special IOLs locally of extremely high quality just for about US$4. This certainly made the ophthalmic community in the world very optimistic, for the fact that there was a strong possibility that now we could take this surgery to the poor big masses in the community, where it was needed very badly.

The essential ophthalmic equipment needed for the surgery and follow-up was very expensive. Tilganga was responsible for carrying out Research and Development to re-model some pieces of equipment such as the operating microscopes and YAG lasers. The mandate was to make them low cost, robust and portable but still of good quality.

The surgical technique over a period of time has been developed. Now we have cataract operations being done through a small opening with an ultra-sound fragmenter and inserting a foldable IOL (Phaco Emulsification), although this technique is difficult in mature cataracts that are causing blindness. In the developed world and many urban cities in this part of the world, Phaco Emulsification with Foldable IOLs has achieved many goals of safety and outcome. The technological complexity of Phaco machines and all the associated costs have been acceptable in these settings, where relative wealth has resulted in the expectation that good medicine is costly and the cost can be met. This luxury has not been available to the majority of the world’s population, who live in the poor countries, where the cost of a single case of Phaco Emulsification is hundreds of times the total per capita annual health expenditure.

We are committed to provide a successful model of high volume cataract surgery with a good vision outcome available and accessible in the developing world. This required continuing innovations, both in eye service management and surgically. The former includes our designing and implementing true ambulatory outpatient surgery and fee-for-service, arrangements with full cost recovery that allows subsidized surgery to the poor, through patient cross-subsidy. The later involves surgical modifications and a production line approach allowing a greater number of patients to be treated and a more judicious use of resources with a better visual outcome. Modification and application of a modern, manual small incision sutureless surgery suitable for developing world circumstances, is an example.

We were successful in developing a surgical technique and fine-tuning it to the extent that it is simple, low cost, but predictably good outcomes can achieved. The modified small incision sutureless surgery (SICS) is now suitable standardized and well documented. A randomized clinical trial, done comparing this technique with phaco emulsification, showed very comparable visual outcomes.

The SICS can be conducted in a non-hospital set-up with the support of a strong paramedical team, 2 surgeons can do 150 operations quite easily in 1 day. This gives the opportunity for the poor cataract patients to have their sight restored easily with a suitable system of technology.