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Clinical Update: Global Vision, Part Four
The Eyes of Latin America
In the annals of ophthalmic medicine, Latin Americans possess an especially accomplished heritage. Many advances in contemporary eye care, most notably in refractive surgery, were born in the region, and the Pan-American Association of Ophthalmology, the oldest and largest supranational ophthalmic organization in the world, was founded in 1939, after the early days of World War II thwarted a European meeting of the International Congress of Ophthalmology. The per capita ratio of ophthalmologists in Latin America now easily rivals that of Europe or North America.
Lands of enchantment and enterprise. The graceful geography of Latin America, embraced by three oceans and a sea and arched across the mountainous, tropical spine of two continents, bustles with more than half a billion people living in 21 countries. Some of the world’s largest cities, busiest economies and most envied ecological endowments are found here, as the region’s stock markets jostle with social reforms to propel their nations forward. Brazil and Mexico, in particular, are poised to join China, India and South Africa as political/industrial giants of the 21st century.
For a look at eye medicine in the region’s two pivotal countries, EyeNet spoke with Paulo Elias Correa Dantas, MD, director of the cornea and external disease service at Santa Casa de Misericórdia in São Paulo, Brazil, and Lourdes Arellanes-Garcia, MD, a uveitis specialist at Dr. Luis Sánchez Bulnes Hospital, in Coyoacán, D.F., in Mexico.
Eye on a Colossus
By both geographic and demographic reckoning, Brazil is the fifth largest country in the world. Its size, in part, allows it to nurture a productive medical research enterprise.
“We have a very prolific scientific community, publishing research results in journals around the world,” said Dr. Dantas. “We have, for example, a fantastic group in Araraquara, coordinated by Dr. José Cardillo, working with the microsphere delivery of certain drugs—steroids, antibiotics and immunosupressors—which can be injected intraocularly or into the subconjunctival space. We have also a group in Sorocaba, headed by Dr. Luciene Barbosa, performing a variety of therapeutic corneal procedures with femtosecond lasers, including lamellar and full-thickness corneal transplants. And I am working with Drs. Cristina Nishiwaki and Sérgio Felberg here at Santa Casa on surgical control of severe forms of dry eye.”
In addition to strong representation in international journals, Dr. Dantas said that many of his colleagues’ papers are published in the Arquivos Brasileiros de Oftalmologia, which is indexed on MedLine in Portuguese, English and Spanish.
Local pathology. The incidence and prevalence of various ocular diseases, at least in urban areas, are similar to those seen around the world, said Dr. Dantas. But, he added, “There are some particularities, of course. Ocular allergy is more sight threatening in our children than it is in North America and Europe. And we seem to have more aggressive vernal and atopic keratoconjunctivitis.”
The serious infectious diseases that worry all equatorial countries weigh on Brazil as well. “In remote parts of the northeast, in the Amazon Basin, people living in the forest and close to the rivers often present with onchocerciasis, and in the south, in Rio Grande do Sul, there are areas of endemic toxoplasmosis,” Dr. Dantas said. Brazil must also cope with one of the highest rates of HIV infection in the Americas, as well as a nagging prevalence of malaria and tuberculosis.
Access to medicine. Health care is guaranteed to all Brazilians, said Dr. Dantas, although there are caveats for both patients and providers. “We have an interesting situation in Brazil. The government guarantees health care for all citizens via a program called the SUS—Sistema Único de Saúde, or Single Health System. Any citizen, and even non-Brazilians, can be seen in hospitals and clinics covered by the SUS. It is not unusual for us to care for Bolivians, Peruvians and other visitors.” Unfortunately, said Dr. Dantas, “The federal government does not reimburse, adequately, our procedures, whether clinical, surgical or serological. For instance, they pay roughly $6 (U.S.) per consultation to the SUS-affiliated institutions and $500 for a phaco cataract extraction, including the intraocular lens. You do the math!”
The majority of middle-class patients have private insurance in the so-called complementary health system, said Dr. Dantas, although the insurance companies’ reimbursement is still not truly adequate, at about $25 for a consultation. A small, comfortable portion of the population can pay for completely private consultations, for which ophthalmologists can earn from $100 to $300.
High-level care for patients in need. As is the case in the United States, where people of few financial means can nevertheless find care at Johns Hopkins, for example, or the University of California in San Francisco, indigent Brazilians are often seen in the teaching settings of well-regarded academic centers. Dr. Dantas calls these the “high-complexity centers,” ones that have expertise in performing transplants and other complex procedures. And as in many countries, those very urban centers that produce bright young physicians tend to keep those physicians nearby, leaving rural populations without dependable health care. But Dr. Dantas sees a change on the horizon, and he has even given it an impressive name: decentralization and universalization. “Generally, most well-trained doctors work and live in the big cities, concentrating their services. But because of that very competition, we will see more physicians slowly drawn to move toward smaller communities and regions, eventually offering the same service as that offered in the metropolitan areas.” In this way, said Dr. Dantas, perhaps optimistically, the delivery of medical care will “universalize,” or spread itself out.
When asked what he would like to see happen in eye medicine on the international stage, Dr. Dantas quickly turned to medical education. “I would love to see a more effective and efficient interchange of medical students among countries such as the United States, France, Germany, Canada, New Zealand, Brazil, Argentina, Peru and others. This would benefit our patients and certainly would make for better ophthalmology around the world.”
Medicine in Mexico
Like Brazil, Mexico is often described as an emerging powerhouse. It is the newest nation in the world to surpass a population count of 100 million. Petroleum and tourism contribute to a resource-rich economy, one that could substantially reduce the historic burden of poverty in Mexico. “If that happens, it will certainly improve access to quality eye care for a greater population,” said Dr. Arellanes-Garcia.
Promise not yet realized? As it is, potential national wealth and traditional democratic sensibilities have not translated into universally available health care, Dr. Arellanes-Garcia noted. “Officially, medical care is guaranteed to every Mexican; however, that is not really the truth. Many rural towns may have a general physician, but diagnostic tools like simple x-rays and even basic drugs like pain relievers or antibiotics are frequently unavailable. It is clear that access to eye care is much more difficult than it could be.”
Until the nation’s potential enriches working communities, Dr. Arellanes-Garcia wishes that the private sector would step forward. “Many drugs used for chronic diseases, such as glaucoma drops, are very expensive. And some new modalities of treatment, like intravitreal drug implants, are both expensive and unavailable in Mexico. Companies developing these products should make an effort to help more people here get the adequate treatment.”
The shortage of pharmaceuticals and medical equipment is compounded by the familiar lopsided urban/rural distribution of physicians. “Nowadays most eye doctors are concentrated in big and medium-sized cities, so many patients have to travel long distances to see an ophthalmologist.”
The future is young. Issues of access aside, the Mexican ophthalmic medical establishment is robust. “Young Mexican ophthalmology residents are very interested in clinical and basic research. Artificial vision models are being investigated, and we also have researchers actively involved in the study of alternative treatments for ocular neovascularization,” Dr. Arellanes-Garcia said.
She also noted that ocular pathology in Mexico differs in some regards from what is commonly seen by ophthalmologists elsewhere. “Diabetic retinopathy is more common in our population than in other countries. And we see inflammatory diseases more frequently, such as pars planitis and Vogt-Koyanagi-Harada syndrome. Idiopathic epiretinal membranes are also generally more frequent in Latin American populations.”
My neighbor’s patient is my patient. Perennial concerns voiced by Mexico’s neighbor to the north regarding the millions of Mexicans now living in the United States have obscured a much less-discussed aspect of porous borders: Mexico now hosts the largest number of U.S. citizens living outside the United States. That fact could bolster the motivation of U.S. and Mexican ophthalmologists to collaborate on mutually beneficial research and care projects.
And like many New World nations, both Mexico and the United States share another demographic—both boast populations of tremendous heterogeneity. Centuries of intermingling between, for example, indigenous Mexicans and Mexicans of European descent provide substantial platforms for research projects. “Several immunogenetic studies have been performed in Mestizo patients with diabetic retinopathy, glaucoma and several inflammatory eye diseases,” Dr. Arellanes-Garcia said. “And we currently are developing a model of limbic cell cultures to study the immunopathology of peripheral ulcerative keratitis.” She is optimistic about the continuity of these research efforts. “I think that this trend will continue in the future.”