INTERVIEW

Dave McComiskey, Director, CBMI-Canada, speaking with Dr. Allen Foster, Vice-Chair of the International Agency for the Prevention of Blindness, on the subject of the World Health Organization’s VISION 2020: THE RIGHT TO SIGHT program.

McComiskey:  Dr. Foster, the World Health Organization (WHO) recently announced a major initiative against avoidable blindness. What’s your opinion of this initiative?

Foster: I think it’s very important, first of all, to understand the situation we’re in at the moment. That is, blindness in the world is increasing, not getting less. The figures were around 40 million in 1990; now, in 2001, we are at roughly 45 million. So, we have to understand that this is a big problem, it’s an increasing problem, and something’s got to be done about it. We know that three quarters of blindness is avoidable, and we also know that there are a lot of interested people and organizations that want to deal with this problem. There’s probably around 30 international non-governmental organizations (NGOs) involved in the prevention of blindness around the world. So, the idea of the initiative is really to bring together the technical expertise and the standing of the UN system, and WHO, together with the grassroots experience of the NGOs, in a coordinated, focused effort that we’re all part of. It’s very important to do this, in order to try and adjust the population of people with blindness in the next 20 years or so. It’s very important indeed.

McComiskey: Do you see any major roadblocks in the way of achieving the goal of eliminating preventable blindness by the year 2020?

Foster: The two major ones would probably be, of course, funding and resources. Funding will be required, and the existing resources of the NGOs are not enough to address this problem. So, there has to be, first of all, a continuation of the existing funds, which is difficult to do year by year. But there has to be major new funding, as well. Now, it remains to be seen whether that will come from the private sector, through the NGOs, from the UN system, or from other government systems. It could well be a mixture of any of these. But then, the issue will be the use of that funding, and of those resources. That’s certainly one obstacle—getting the funding, and using it well. I really see coordination as the second obstacle. In order to achieve this, it is going to require a great deal of coordinated planning, and that’s going to be difficult to achieve with a lot of different organizations, and a lot of different sovereign governments. We’re talking about working in 150 countries in the world, each with its own ministry of health, and each with its own priorities and plans. Somehow, we have to get them to "buy into" this program, as well. So, to summarize, the two big roadblocks to overcome are the attainment of the funding, and the coordinated planning as to its use.

McComiskey: In reading over the initiative, it seems to me that the number one priority seems to be cataract surgery. Are there any special steps you see that need to be taken, just in the area of cataract surgery, to address this major issue?

Foster: Cataract surgery is the major issue simply because it is the number one cause of blindness. It is also a very visible and successful activity. It gives a lot of kudos to the program—if I may put it that way—and thus, of course, it helps to raise funding. The difficulty in cataract surgery, as I see it, is that there is a great deal of professional debate regarding new technologies, the best way of doing the surgery, and so forth. And we tend to get our energies diverted into those, if I may say so, rather "academic" debates. The real issue, in actual fact, is making cataract surgery available to people at an affordable cost, while still ensuring that it is good-quality surgery done by well trained people. If we could redirect our energies into that focus, I think we will begin to deal with the cataract problem. I think we’re getting there; it’s beginning to change. There are now lots of good models of high-quality, high-volume, low cost cataract surgery. It’s simply a question of taking those good models, and replicating them in different parts of the world. It can be done, but we’ve got quite a way to go with it.

McComiskey: Something else on the subject of cataracts, which you touched on already: We seem to be focusing not only on the quantity of surgeries that we’re doing, but also on the quality and the vision. It’s the whole idea of giving people not only sight, but the best vision possible. Of course, a lot of this centres around intraocular lenses (IOLs). Just briefly, could you tell us what is happening in the whole area of IOLs?

Foster: First of all, cataract surgery with spectacle correction, if it’s done well, is a very successful procedure. If you do cataract surgery with an intraocular lens, it changes from a very good procedure to a superb procedure. It makes the surgery even better. We shouldn’t negate or forget how good cataract surgery with spectacles is, but of course we should strive to do better. Better these days means intraocular lenses, not spectacles. Now, that wasn’t really possible for most NGOs five years ago, because of the cost of the IOLs. That cost was a minimum of $30, and it was often $50 to $100. Over the last couple of years, the cost came down to $10. We now have it at $7. And now, it means that cost isn’t the issue. As to what type of IOL is best, it’s a big debate. Like most debates, people take strong viewpoints on one side or the other. In practice, the middle position is probably best. In this context, that means a well-performed cataract surgery with an intraocular lens in front of the eye or at the back of the eye. As long as it’s a good lens, we’ll get good results. What we should be pushing is to get the operations done by well-trained people in a technique where they’ll be happy placing an IOL, whether that’s in front of the eye or the back of the eye. And that’s what we’ll be moving to in the future.

McComiskey: Just a couple more questions. Trachoma accounts for about 15 percent of the world’s blindness. What new strategies are being developed to combat this major blinding disease?

Foster: For a long time, it’s been known what to do about trachoma. People have known it’s a public health problem. If you have good water and good sanitation, the disease disappears. It was a disease present in Europe 150 years ago, and then it went away with better water and better sanitation. So we know that there’s an origin to the disease. In the short term, we know that children with active disease can be treated with tetracycline ointment. We know that those in danger of becoming blind from turned-in eyelashes can be protected by a simple operation. It takes 10 minutes to do, it can be done in their homes, and it’s very effective. So we’ve known all these different measures. What’s new is the concept of putting them together in a coordinated program, one step after another. It may sound obvious, but sometimes it’s the simple things that actually make the difference. The program was designed about two years ago, and it’s called the SAFE strategy. The letters stand for:

S – Surgery against turned-in eyelashes;
A – Antibiotics that fight against the disease,
F – Face cleanliness to stop the spread of the disease; and
E – Environmental improvement, meaning better water and sanitation.

So we now identify areas of the world that have had trachoma, and move in with this SAFE strategy, doing each of those things in a coordinated way. It’s hoped that that again there’ll be major developments in this over the next 15 to 20 years, and hopefully we can stop blindness from trachoma. It’s really a disease of the poor. It’s also a disease of women and children. Therefore, it’s a disease we should target, because it’s affecting the poorest of the poor in the world.

McComiskey: One final question: If you were able to give NGO donors one message, what would it be?

Foster: I think the message would be this: During the last 20 years, we’ve climbed halfway up the mountain, and we’ve still got a lot of the mountain to climb before we see the top. But, we are well on our way, and we’ve got to keep going, step by step, to reach the top of the mountain. The time will come, I think in the next 15 to 20 years, when we do reach the top, and we see that we’ve won the war against blindness. Then, it will be downhill from there, and that’s when we’ll gradually get rid of blindness. It’s really a sense of where we are: It’s a sense that we’ve come a long way with the support of donors, and with the gifts they’ve given. We’re on our way, but we’re certainly not winning, because we’re not on the top yet. We still need the support of donors, and there’s a lot of work still to be done.

McComiskey: Perhaps, with some sort of final push, we could really turn the tide and win the war against blindness within the next 15 to 20 years.

Foster: I think so. It would be very easy at this time to get terribly depressed at the increase in the number of blind people, but we know what to do about it, and there’s now the will to do it. There are good programs in place for all the major diseases, and good models of how to combat each of them. Cataracts, trachoma, and river blindness should all be defeated within the next ten years. So I really think that maybe the next five years will still be a long uphill climb, but I think we’ll then see the benefits into the next millenium. Then, we’ll be able to say that we’re getting there. Then, suddenly, we’ll go over that last hill, and we’ll be there. Until then, we won’t necessarily realize how close we are to our goal, until we actually have achieved it.