American Academy of Ophthalmology Web Site: www.aao.org
Clinical Update: International
Global Vision, Part Two The Eyes of Southeast Asia
Words long used to stratify the nations of the world—industrialized vs. third-world, developed vs. developing—are steadily growing less descriptive. The World Bank, in fact, considers many countries in Asia, Latin America, the Middle East and the former Soviet Union as “middle” countries, neither rich nor poor. Thailand is illustrative of the new middle.
“We are somewhere between a developing and developed country, with both very poor and very rich people,” said Tisha Prabriputaloong, MD. “So we see large tumors or rare eye infections in people who have little opportunity to get to treatment in time, as well as diseases associated with wealthy nations—diseases related to longevity, like glaucoma, or related to prosperity, like diabetes.” Prosperity, in particular, comes at a cost. Traditional Thai cuisine, for example, was classically healthy, full of fresh fruit and vegetables. But Dr. Prabriputaloong said that is shifting toward more processed food. “More people are living in the big cities, and diets are changed by that. Now we have McDonald’s in Bangkok.”
Now a fellow at the University of British Columbia in Vancouver, Dr. Prabriputaloong grew up in Thailand and completed her education and residency there before beginning a fellowship in uveitis and cornea in San Francisco. When she finishes the program in Vancouver, Dr. Prabriputaloong plans to return to Bangkok to join the faculty of a university hospital.
Endemic problems. Dr. Prabriputaloong spent a year and a half working with Orbis International and encountered ocular pathology that physicians in Europe, Japan and North America would only rarely face. “We saw parasitic and amebic and fungal infections that are more common in tropical climates. And many of the infections and tumors were very advanced. I think there are two reasons for this. First of all, many people lacked basic knowledge of disease, and they might even think this is what God chose for them or that their disease is untreatable. Second, a lack of resources means that health is not their first priority compared to food.” (See “Late Presentation,” next page.)
A national profile. To identify the most important threats to vision in Thailand, the public health service recently conducted a survey of the entire country, said Prin RojanaPongpun, MD, an anterior segment surgeon and associate professor of ophthalmology and chief of the glaucoma service at Chulalongkorn University in Bangkok. “We found, to our surprise, that the most common cause of visual impairment now is uncorrected refractive error. It is higher even than cataract, which we had projected would be the most common.” Dr. RojanaPongpun is also the regional secretary for the Asia Pacific Academy of Ophthalmology. He said the survey demonstrated that many rural people do not have something as simple as spectacles when they need them. He added that cataract was indeed the second most common source of impairment, followed by glaucoma, macular degeneration and diabetic retinopathy.
Another surprise from the survey was that open-angle glaucoma was significantly more common than angle-closure. Although angle-closure is about three times more common in Asians than in Caucasians, it is still less common in Thailand, at around 28 percent of all glaucoma, than open-angle, which accounted for 60 percent. Conversely, macular degeneration is not as common in Asians as in Caucasians, said Dr. Prabriputaloong, possibly because of different pigmentation in the retina.
Dr. RojanaPongpun mentioned another area of trouble. “Trauma related to industrial accidents and automobile collisions is quite common. To raise funds to promote more car safety, and especially to reduce drunk driving, Thailand recently levied a 2 percent tax on alcohol and tobacco products.”
Delivering care. Like many countries, Thailand supports a bifurcated system of delivering medical care. “Our health system is partly socialized and partly private,” said Dr. Prabriputaloong. “To go to a government doctor, everyone pays a small nominal fee of $1 per visit for any essential medical service. And there is also an insurance industry that people with money can use to have access to private doctors or hospitals.”
To better tackle the incidence of visual impairment in remote agricultural areas of the country, Dr. RojanaPongpun said, a national network of ophthalmic “cells” was instituted about two decades ago. In this model, an eye surgeon trains a nurse in the specifics of ophthalmic medicine, and the newly skilled ophthalmic nurse then trains a community health worker. In this way rural patients who might be difficult for ophthalmologists to screen personally can be assessed in their community for obvious signs of vision loss or pathology, then referred to the nurse or physician in the cell when appropriate.
The work of the day. Thai physicians tend to divide their work evenly between the public health service and private institutions. The public service doesn’t pay as well but is usually accompanied by a university appointment and offers the attractive benefits typically accorded government workers in many countries. After a day in a public setting, most physicians then see patients in private clinics in the evenings.
Medical education. Thai people are proud of the historical fact that theirs was the only country in Southeast Asia never to have been colonized. Consequently, said Dr. Prabriputaloong, Thailand was not coerced to adopt the French or British approach to social infrastructure. Thai medical education, for example, was created with deliberation by Thai planners, who chose the U.S. system for a model, Dr. RojanaPongpun said.
Recent Thai administrations have made medical education a high priority, aiming to make the country a regional center in Southeast Asia. “The Thai ophthalmology society has grown very fast in the past 10 years because our government sent a number of young doctors for ophthalmic training in North America, the U.K. and Australia,” said Dr. Prabriputaloong. “And those physicians came back with lots of contemporary skills and connections. So you now see high-end hospitals in Thailand becoming a local magnet for medical tourists.”
Away from boutique medical care, however, the tools and techniques of modern ophthalmology are not what might be considered widely available. Only about half of all cataract surgeries, for example, are performed with phacoemulsification, said Dr. RojanaPongun, with the rest removed by older methods.
Helping neighbors. Having trained many of its physicians abroad, Thailand has itself now become a regional center for medical education. “Thailand is small in the world community, but we are growing with respect to Southeast Asia, and hopefully we can contribute more. Many countries around us have no ophthalmology training programs of their own. So we have arrangements with Laos and Cambodia for us to train their eye doctors. Cambodia currently has only eight fully trained ophthalmologists in the entire country, and Laos has just a few,” said Dr. Prabriputaloong. Dr. RojanaPongpun added that Thailand has about 800 ophthalmologists.
Dr. Prabriputaloong would like cooperation to expand. “I think there are good chances to collaborate with more neighbors, like Vietnam and Myanmar.” The government of Myanmar, Thailand’s neighbor to the west, is almost completely isolated from the international community and currently sends few young doctors out of the country for special training, Dr. RojanaPongpun said. Dr. Prabriputaloong hopes that can change in the near future.
Thailand faced its own political turmoil last year, but Dr. Prabriputaloong does not think it had a significant effect on medical care. “It did affect the economy—everything slowed down. But the medical sector was largely left to be independent of the political situation.”
Challenge in Indonesia
Tjahjono D. Gondhowiardjo, MD, spoke slowly and deliberately as he expressed concern for the ophthalmic needs in his country. “Indonesia has one of the highest blindness rates anywhere—1.5 percent of the population is significantly impaired. And half of that is simply due to untreated cataract. After that the common causes of impairment are glaucoma, retinopathies, high myopia, infection and corneal blinding diseases.” Dr. Gondhowiardjo is a professor of ophthalmology at the University of Indonesia in Jakarta as well as the president of the Indonesian Ophthalmologists Association.
Archipelagic eye care. Geographically and demographically, Indonesia is an enormous country, with 230 million people living on 17,000 islands in an archipelago that straddles 2 million square miles along the equator. “We have relatively few ophthalmologists per person, with about 1,100 ophthalmologists in the whole country and about 300 eye residents in training,” Dr. Gondhowiardjo said. And the tight supply of physicians is compounded by a dearth of ophthalmic medical supplies and resources. Even in the capital, Jakarta, where access to an eye surgeon is not particularly a problem, surgical tools and devices in public hospitals are not adequate. “The cataract backlog is not the problem of too few physicians. It is caused more by underutilization of those physicians because they don’t have the equipment they need.”
Like Thailand, Indonesia has a layered health system, with government insurance for public workers, private insurance for the financially capable and government-subsidized care for people who need it. And like Thai physicians, Dr. Gondhowardjo and most of his colleagues spend most of their day caring for patients in public hospitals and seeing private patients in the evening.
Official support lacking. Attention to vision health has not been a priority for the Indonesian government, Dr. Gondhowiardjo said. And that in turn has dampened the number of medical graduates attracted to ophthalmology, especially since other specialties, such as general surgery, obstetrics, pediatrics and internal medicine are afforded more facilities and resources by the government. In fact, he said, if young physicians will consider working in those specialties, the government will actually incentivize them with homes and cars.
Foreign friends help out. Dr. Gondhowiardjo said that international support for eye care in Indonesia is very welcome, especially through nongovernmental organizations and through fellowships for Indonesian physicians.
Eric P. Purdy, MD, of Fort Wayne, Ind., met that welcome when he responded immediately after the historic tsunami of 2004 raged across the Indian Ocean. Dr. Purdy had already applied his skills as an oculoplastics specialist on many volunteer missions to Central America when he heard through Academy Express that Project Hope was working with the U.S. Navy to send a ship to Banda Aceh, which sits at the northern tip of Sumatra, the closest point of landfall for the waves from the undersea earthquake.
The people of Banda Aceh reported fleeing a wave towering 30 meters high. When Dr. Purdy’s team arrived, the water, and thousands of human beings, were gone. “The first mile into town was almost completely denuded—whole concrete buildings had been washed away, with just their slab foundation footprint left,” Dr. Purdy recalled. “We saw a lot of fractures, near drownings and aspiration pneumonia. One boy had a globe ruptured by debris swirling in the water.” The pre-tsunami medical need soon became apparent, however. “Our ship, the U.S. Mercy, became the center for tertiary care because the hospital in town was inundated with emergency patients,” he said. “And after word got out that a U.S. hospital ship was there, people came down from the hills and we were seeing many non-tsunami cases—people coming in with horrible infections and massive tumors that had long gone untreated.”
Wanted: national priority. Visual health should command more consistent attention, said Dr. Gondhowiardjo. The government must be persuaded time and again to think of blindness prevention as a vital, ongoing project, and not just an occasional allotment of money. The Ministry of Health, for example, recently set aside money for cataract extractions but did not at the same time fund the purchase of IOLs. “We are always reminding them that the extraction is just one half of the surgery, and IOL implantation is just as important. We have to keep explaining the financial advantages of preventing blindness. We did, finally, get a commitment from the Ministry of Health to form a Prevention of Blindness Committee and make a specific plan for the committee to be effective. We want to make blinding disease a national priority, just as dengue and avian flu have been made so,” said Dr. Gondhowiardjo. He and his colleagues are eager to improve the situation. “We are giving charity time in public hospitals to reduce the cataract burden, and we are working with international NGOs to improve training of our surgeons. Ophthalmologists in Indonesia are willing to do what is needed.”