MAKING MEDICAL TECHNOLOGY

WORK FOR THE POOR

By DR. SANDUK RUIT
2006 Ramon Magsaysay Awardee
for Peace and International Understanding
Presented at the 48th Ramon Magsaysay Awards Lecture Series
1 September, 2006, Manila, Philippines

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.
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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.

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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 ultrasound 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 worlds 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 suture-less surgery suitable for developing world circumstances,
is an example.

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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
be achieved. The modified small incision suture-less 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.

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