BLOG: Global ophthalmology — looking beyond the biological causes of blindness

ByDavid Khorram, MD

Last time, we discussed two of the core elements of the definition of global ophthalmology: equity and universality. Today, we’ll take up the third core element of global ophthalmology, the need for a broad approach to the causes of disease and their solutions. Some refer to this as a multidisciplinary approach, a comprehensive approach or a holistic approach. I like the term “coherent approach.”

Generally, our approach to disease focuses on the biological factors. We consider, for example, that an infection is caused by a bacterium and that treatment of the disease requires antibiotics. We administer antibiotics, and from a biological perspective, we have treated the disease. However, in the field of global health and global ophthalmology, we have seen that this approach is not sufficient. Because we are seeking to bring about equity in health care for all people, factors beyond the biological come into play. Often, while we focus on the obvious biological issue, things run amok because of elements we have not considered. In the field of global health, we think then of disease not simply as a biological process, but as a biosocial process.

The conditions that bring about inequity in eye care are wrapped up in history, culture, economics, politics, ethics and a host of other factors. Ignore them, and you end up spinning your wheels. Addressing a problem like cataract blindness has to take these multiple disciplines into account in order to address a problem of great magnitude and scale. To be effective, our approach has to be comprehensive and coherent, and look beyond the biological.

We know, for example, that the majority of bilateral cataract blindness occurs in low-income countries and is closely linked to poverty. We can go to that country and operate on 50 people in a week, and it helps those people tremendously. Yet we don’t get ahead of the problem unless we begin to ask, “What causes cataract blindness beyond the biological?” What historical, cultural and political factors have led to this inequity, and how can we work to address those? Because unless we do, the problem persists. In order to address something like cataract blindness, one has to understand that it is not merely a biological disease that needs a surgeon, but rather a biosocial disease that is brought about by a broad range of social, political, environmental, ethical and economic factors that needs a coherent approach.

Here is an example to illustrate this. For several years, a group of ophthalmologists has been passionately involved with reducing cataract blindness in a low-income country. While for many years they would travel to that country to perform cataract surgery, they recognized that more would be gained by training the local ophthalmologists to perform high-quality surgery. So they built a relationship with the government’s teaching hospital and worked with the residents on a regular basis. That’s a seemingly straightforward solution, and one that is fully in keeping with a broader approach of moving beyond the biological into the educational aspects of the problem. But as they did so, some questions began to arise. Why, in a country with a pretty healthy number of ophthalmologists, were so few of them performing surgery? Why did it appear that a sizeable number of the residents did not seem interested in learning surgery?

These questions led to a deeper understanding of the problem of cataract blindness in this country. Cataract blindness is not only a biological disease, nor a disease that would be solved with education and training. As it turns out, bilateral cataract blindness in this country appears to be an economic disease. The country’s ophthalmologists have no way of getting paid to perform cataract surgery on the masses who need it. They do get paid for prescribing glasses. It is cost prohibitive for them to perform cataract surgery, so they focused their careers on dispensing glasses. Of course, the educational endeavors need to continue, but the truth is, you can train every person in the country to be an outstanding cataract surgeon, but you will have no impact on cataract blindness unless they go out and do surgery. And if ophthalmologists can’t afford to do the surgery, they won’t. So, while it may seem that we can address cataract blindness by training cataract surgeons, we miss the mark unless we take a much broader view, recognizing that the problem and solution cannot be addressed unless things like health care finance and upstream issues like governance, ethics, corruption and economics are also taken into account. This is not to say that the global ophthalmologist has to solve all these problems. But it is to say that planning a solution (“train more cataract surgeons”) without taking broader factors into account, and taking a coherent approach, is an exercise in futility.

Global ophthalmology looks beyond the biological causes of disease for the solutions, and thus practitioners of global ophthalmology often have a keen interest in understanding the social, cultural, historical, economic, ethical and political aspects of disease and health, equity and universality.