انتقال فن آوری پزشکی برای توسعه پایدار: مطالعه موردی تعویض لنز های داخل چشمی برای اصلاح آب مروارید

Cataracts account for almost 50% of blindness in the world (17 million people). The magnitude of this problem is stunning, and affects the sustainable economic progress of developing nations where 90% of the blind are located (and likewise 90% of the $19 billion dollars in lost global productivity each year). The Vision 2020 program has called for eliminating cataract as a cause of avoidable blindness through intraocular lens replacement surgery (IOL surgery), a relatively cheap solution with good outcomes. This paper will: (1) give background on the scope and problems surrounding international technology transfer of IOL surgery; (2) develop the international medical technology transfer framework adapted from work by Lall and Wei; (3) compare programs in the countries of Nepal and Nigeria; (4) evaluate the success of their technology transfer of intraocular lens replacement; and (5) provide recommendations for sustainable international transfer of IOL surgery.

1.1. Outline Many developing nations struggle to find sustainable solutions to their medical needs including infrastructure, human capital and technology innovation, in order to provide basic medical services. Technology transfer, or the process of moving both knowledge and goods from one institution to a second, is one potential solution. Who are the important players in this process? What makes such medical technology transfer successful? This paper will first summarize the magnitude of cataract disease and the cultural barriers to international medical technology transfer of the identified solution, intraocular lens replacement surgery (IOL surgery). It will continue with a short discussion of the important role of non-governmental organizations, and, development of the international medical technology transfer framework. Finally, it will compare the countries of Nepal and Nigeria, evaluate the success of their technology transfer of IOL surgery and provide recommendations for sustainable international transfer of IOL surgery. 1.2. Cataract disease 1.2.1. Cataracts, or occlusion of the lens(es), are the leading cause of blindness in the world Bi-lateral cataracts alone account for 47.8% (17.7 million people) out of the 37 million blind in 2002 [1] and [2]. With an aging population, the number of blind men and women is expected to increase annually, resulting in 76 million blind by the year 2020 [3]. This is especially a cause for concern in developing nations where 90% of the world's blind are located [4]. 1.2.2. The causes of cataract are not well known Clinicians have seen a high correlation to exposure to ultraviolet light, and vitamin A deficiency, and a very high association with smoking. A recent study performed in the United States shows a very high correlation to lead accumulation in older men [5]. Low weight before 1 year of age, a common condition in developing nations, may also be correlated to children having a higher risk for cataract development later in life [6]. There is no consistent correlation between size at birth and later age-related cataract [7]. This may indicate that the above-mentioned environmental conditions which impact personal eye health after birth are more important in cataract development than pre-birth conditions. However, the genetic effect of heritability has been reported as having significant correlation to nuclear and cortical cataract [8]. 1.2.3. Cataracts are one of the most easily corrected causes of blindness Several techniques are available including: lens removal and aphasic corrective glasses, lens removal and replacement, lens capsule draining and refill with a polymer substitute for the crystalline lens [9], [10], [11], [12], [13], [14] and [15]. Extracapsular cataract extraction and posterior chamber intraocular lens implantation (ECCE & PC-IOL, referred to in this paper as IOL surgery) is fast, and relatively cheap with good long-term outcomes for visual acuity [15]. 1.2.4. The blindness epidemic negatively impacts the ability of developing nations to sustain development Unfortunately, without the infrastructure and support systems common in industrialized nations, the blind are unable to live fully productive lives. In fact, the care they may require from a sighted family member contributes to a reduction in the economic livelihood of their families [16]. Visually impaired people are less well socially integrated, and at higher risk for suicidal behavior [17], [18] and [19]. The relatively simple outpatient surgeries described can dramatically improve the quality of life of the visually impaired [8] and [20]. 1.3. Vision 2020 In 1997, the World Health Organization (WHO) Program for the Prevention of Blindness and Deafness published a document called “The Global Initiative to Eliminate Avoidable Blindness” in which they outlined the global priorities to fight blindness by targeting: cataract, trachoma, onchocerciasis, childhood blindness, refraction, and low-vision services [4]. In 1999, the WHO joined together with the International Agency for the Prevention of Blindness (IAPD) (Hyderabad, India), to create the “Vision 2020—the right to sight” program with the goal of eliminating avoidable blindness by the year 2020. Operating on approximately $200 million USD each year, the objectives of Vision 2020 are to: (1) create awareness of the magnitude of global blindness and visual impairment, and, the fact that 75% can be cured or prevented with existing technologies and knowledge; (2) organize for more efficient mobilization and use of resources in developing eye care services; (3) implement sustainable and equitable eye care services at the regional level; and (4) prioritize locally and nationally available resources to control avoidable causes of blindness and visual impairment [1]. Vision 2020 organizes annual workshops for each country to develop individual Vision 2020 plans and national eye care service programs. The IAPB keeps track of Vision 2020 affiliated training programs under the following categories: ophthalmology, low vision/rehabilitation, community eye health, mid level ophthalmic personnel, eye care management personnel. The Vision 2020 Link Program run by the International Center for Eye Health (London, England) started exploring institutional links between ophthalmic departments in the UK and Africa in 2005 [21] and [22]. The goal is to provide “in-service training in which skills shared can be clinical, technical, community-based, organizational or managerial [23]”. This training is tailored to the specific needs of the developing nation's institution as defined by a “Needs Assessment”. The WHO has found that the Vision 2020 program has been successful in increasing cataract surgeries in Morocco, India, Nepal, Sri Lanka and Thailand. Other countries, particularly in the continent of Africa, have seen less success. In 3 and 4, this paper will outline the programs in the countries of Nepal and Nigeria, and evaluate the success of technology transfer of intraocular lens replacement with the international medical technology transfer framework which was developed based on work by Lall and Wei [24] and [25]. 1.4. Economic burden of blindness In 2000, the global productivity loss due to blindness was $19 billion (2000 USD) per year [3]. Due to an increasingly larger and older population, this loss has been projected to grow to an astounding $50 billion (2000 USD) per year by the year 2020 without intervention. A second analysis which includes both the costs of an able bodied family member providing care for a blind family member, and, the reduced productivity of persons older than 64, estimates that the annual projected loss will be $77 billion (2000 USD) by the year 2020 without intervention. However, because of Vision 2020s efforts to reduce blindness, the year 2020 estimated annual global productivity loss will only be $26 billion (2000 USD) (or $41 billion in the secondary analysis). Ninety percent of this economic burden of blindness resides with least developed countries who are already at an economic disadvantage, having a per capita income of less than $635 (1993 USD) compared to a per capita income greater than $7911 (1993 USD) in industrialized countries [26]. It has been argued that a stand alone program, such as Vision 2020, which does not simultaneously encourage economic development, will be ineffective in permanently reducing the prevalence of blindness [26]. However, this paper shows that under certain conditions, Vision 2020 can be an impetus for medical technology transfer and the creation of supporting infrastructure and human capital for sustainable development. 1.5. Cultural barriers to transfer of intraocular lens replacement technology Cataracts are the leading cause of both blindness (visual acuity less than 3/60) and low vision (visual acuity of less than 6/18 and greater than 3/60) worldwide [2]. Eighty-two percent of the world's blind (or 30.3 million) are over the age of fifty. Women are twice more likely to be visually impaired than men. This suggests that the demographic requiring IOL surgery in developing nations can be described as mostly women older than 50 with incomes below the poverty level. Any address of cultural barriers to intraocular lens replacement must carefully consider this demographic. One might assume that costs feature most prevalently as a barrier to intraocular lens replacement surgery. Among impoverished people costs are very important, however, the situation is a little more complex (as will be shown in the discussion of IOL surgeries in Nepal and Nigeria) and opportunity costs are closely linked to family support. Costs for human capital and infrastructure are static (not dependent on surgical volume), and costs for medical supplies are continually decreasing with successful imitation and innovation in developing countries [27]. However, even when surgeries and transportation are made available free of charge, there is still a poor response from potential patients. This suggests that the two most important cultural barriers to IOL surgery are poor awareness and poor family support. See Table 1 for a list of cultural barriers to intraocular lens replacement surgery. 1.5.1. Poor awareness Poor awareness can be further broken down into: lack of knowledge about what IOL surgery is, some knowledge of surgery but not the specifics of who, when or where, and, knowledge of surgery but little understanding of how it might be beneficial among those who still have some degree of physical independence [27] and [28]. This is complicated by illiteracy, as many studies have shown that literate populations are more likely to undergo the surgery than illiterate [28] and [29]. Some success has been found in increasing awareness by advertising through radio, but arguably the best results come from asking former patients with successful outcomes from IOL surgery to act as representatives to their communities. It might be worth the effort to study why targeted potential patients with some degree of physical independence reject surgery as having the ability to provide increased benefits and quality of life. Perhaps former patients acting as community liaisons are more successful in “selling” the idea of IOL surgery because potential patients: (1) accept them as a trusted charismatic disseminators of scientific knowledge and (2) receive said knowledge in a “safe” environment [30]. 1.5.2. Surgical and follow-up costs In addition to the fixed costs of infrastructure (building and equipment depreciation and maintenance) there are fixed costs for hiring, training and paying staff [27]. The remaining surgical costs are for disposable medical supplies including: dilating eye-drops, ciprofloxacin eye-drops, anesthesia (licodaine), Betadine, silk suture thread, buffered saline solution, rubbing alcohol, etc. used in surgery. Follow-up costs may include ciprofloxacin and dexamethasone eye-drops, pyrimon eye-drops and steroid ointment and if necessary the cost of further corrective surgery [13] and [31]. In total (without additional corrective surgery) the minimum cost for IOL surgery on one eye is $20–37. 1.5.3. Poor family support Poor family support can be further broken down into: travel costs, opportunity costs and incentives. Developing nations often have a very low ratio of physicians and surgeons per capita [32]. Medical personnel are concentrated in cities whereas the impoverished who need IOL surgery are more often found in rural areas with poor access to health care. Patients often must travel a great distance to reach an eye clinic for surgery and follow-up visits. The difficulty of poor roads and extreme terrain (mountainous or desert) may make travel costs prohibitive compared to the perceived value of surgery. Also, civil war or other political instability may cause travel to be hazardous. Opportunity costs are the cost the family suffers in lost income for an able-bodied member to take the blind member for surgery and follow-up. The opportunity costs are increased with increased travel distance and difficulty and again may be prohibitive compared to the perceived value of surgery. Incentives for surgery are tied into the blind person's emotional state and desire for surgery, and the family's desire for a more independent member who can contribute to family productivity. Older persons are considered to be less productive. Perhaps marketing for IOL surgery should be directly tied to some kind of “work-skills program”. Such a program would address the re-adjustment of blind persons to sightedness, as well as the decreased productivity of older blind persons. Studies performed in developing nations report psychosocial impairment due to blindness [28], which may account for part of the resistance to IOL surgery. A large part of the reluctance that some patients have to IOL surgery may in fact be the lethargy that is part of depression. Studies of the blind performed in Australia show that older adults with severe visual impairment or blindness may suffer from decreased self-esteem and confidence, and increased frustration, embarrassment and social isolation [19]. Poor social support was associated with increased suicidal ideation among elderly individuals with mild and severe depression in the United States [17]. Progressive onset of blindness is a risk factor for suicide among Australians of all ages [18]. Other mitigating factors to patient incentive may include bad service from personnel, historically poor outcomes (lens removal with aphasic glasses and no lens replacement), and cultural bias against female gender [13], [27] and [32]. Regional-specific culture can influence the impact of one barrier versus another, e.g., poor awareness and surgical and follow up costs were emphasized in studies done in Nigeria, whereas illiteracy and opportunity costs were emphasized in studies done in Nepal. However, the difference in literacy rates is small, Nigeria is 66.8% (2004) and Nepal is 53.7% (2001) [33] and [34]. How do these barriers tie together to create incentive or lack of incentive in the individual and the family? Family decisions to support IOL surgery balances costs with family incentives and perceived benefit. The social psychology of this decision needs to be understood and addressed before the demand for IOL surgery will increase.

The magnitude of cataract disease is a huge financial burden for developing countries. However, successful medical technology transfer of intraocular lens replacement surgery can facilitate sustainable economic development. Thus far, the success of international medical technology transfer for intraocular lens replacement has been characterized by international monetary support of medical technology transfer entrepreneurship through NGOs and a coordinated framework for evaluation through WHO as a “context”. This has been mediated by socioeconomic barriers to the surgical procedure, as well as, lack of infrastructure or trained medical personnel. With an aging population worldwide, understanding and managing cataract disease will become increasingly important to both industrialized and developing nations. Cataract disease being so poorly understood provides an opportunity for developing nations with a backlog of individuals with cataract, to make money while contributing significant international public health goods. These countries should use current resources to conduct clinical and public health research into preventive care, counseling, surgical procedures and epidemiological factors. This “applied” research serves the dual purpose of serving current local public health needs, and, establishing local expertise that will transform into international public health goods. Entrepreneurial NGOs that involve local stakeholders may prove the most viable way of conducting such research. Also, collaborations between local universities and government, entrepreneurial NGOs, and international partners (e.g. world-renowned universities, pharmaceutical companies) are necessary to build-up the infrastructure and human capital for “basic” R&D capacity.