Abstract
Clare Gilbert has worked as a clinical ophthalmologist for more than 10 years and has an MD in Surgical Retina. She is Professor of International Eye Health at the International Centre for Eye Health and has been a Medical Advisor to Sight Savers International since 1995. Since January 2006, Clare has been Co-Director of the International Centre for Eye Health. Clare is in overall charge of the research undertaken by the Centre and is a member of the School’s ethics committee. Over the last 10 years, the eye group has given technical support for national surveys in Bangladesh, Pakistan and Nigeria, and continues to support the implementation of effective eyecare worldwide. Clare’s recent projects include a national study of the prevalence and causes of blindness in children in Bangladesh, with an emphasis on childhood cataract, and a cohort and nested case–control study of retinopathy of prematurity in Rio de Janeiro, Brazil, to establish screening criteria and to explore risk factors. Ongoing projects include a study to explore the effectiveness of low-vision care for children in three countries in Asia and an intervention study to assess the impact of training neonatal nurses on the outcomes of neonatal care in Brazil, including retinopathy of prematurity.
▪ Your current field of interest deals with the epidemiology of blindness in children, particularly in middle- and low-income countries. What made you decide to go into this field originally?
I was always interested in overseas work, which is one of the reasons I chose ophthalmology. It’s always difficult to know when to branch out and do something ‘out on a limb’, but an opportunity arose when I met a colleague who worked at the Institute of Ophthalmology (London, UK), which at that time was affiliated with Moorfields Eye Hospital (London, UK). They had a vacancy for someone to work in the Department of Preventive Ophthalmology. Having already done some work on onchocerciasis in West Africa, which had confirmed that this was what I wanted to do, I applied and was offered the post. The job was to investigate blindness in children; a new and exciting area in international ophthalmology.
▪ What and/or who particularly inspired you to go into this area?
My parents played a key role. My mother was an army nurse in Ethiopia and India before and during World War II and she used to tell us stories about nursing malaria patients and people with big swollen tummies, and going on ward rounds on camels, so I think my interest in doing work overseas came from her. My interest in medicine came from my father, who was very encouraging. During my professional career the person who really helped me to get my original post was Allen Foster, Professor of International Eye Health at the London School of Hygiene and Tropical Medicine (London, UK), who I still work with all these years later. We co-direct the International Centre for Eye Health (London, UK). He is president of Christoffel Blindenmission (CBM; Cambridge, UK), which is an international Non-Governmental Organization (NGO) involved in the prevention of blindness. We now share the responsibility of running this department.
▪ Your current ongoing studies include an exploration into the effectiveness of low-vision care for children in three different countries in Asia, and a published study on ‘Presbyopic spectacle coverage, willingness to pay for near correction, and the impact of correcting uncorrected presbyopia in adults in Zanzibar, East Africa’. How did you get involved in these particularly significant areas of eyecare?
These are two topics:
The first project was a colleague’s idea. Karen van Dijk has spent all of her professional life working in the area of rehabilitation in vision in Asia, funded by CBM, Sightsavers (London, UK) and other international NGOs. She developed a standard method for assessing children who need low-vision care. She realized that she had the potential to collect a large amount of standardized information from each of the different clinics that she was involved with in a number of different countries. She came to ask me whether I would be willing to supervise her to continue this work as a PhD. The first part of the study involved a retrospective review of over 800 children who had received low-vision care. After analyzing the data she developed a hypothesis which she tested in a prospective study. In this study she recruited approximately 500 children and then followed them up for a year, ending up with approximately 450 children on whom she has baseline and follow-up data. She is currently analyzing this data and so we will know the results later in the year.
The second study had two parts: the first part was an investigation of the “prevalence of presbyopia and willingness to pay for near correction” in Zanzibar and this was conducted by one of our MSc students (Heidi Laviers) who is an optometrist. She found that more than 80% of middle-aged and elderly people who needed reading glasses did not have them. She then went back to Zanzibar to set up a community-based distribution scheme by integrating the service into the primary healthcare level. She went back again for a third visit a few months later to see what the uptake and attitudes towards the service were. It was all enormously positive. As a result of this study, the service has been rolled out across Zanzibar and will hopefully also be implemented in other areas of Africa as well. Evaluations like this are very useful, as lessons can be learnt and elements identified which can then be applied effectively elsewhere.
▪ What do you hope to achieve with your most recent set of publications focusing on retinopathy of prematurity?
My most recent body of research I have been conducting in collaboration with a Brazilian ophthalmologist (Andrea Zin) in Rio de Janeiro, Brazil, where she lives and works. The first large project was for her PhD and was to explore the incidence of retinopathy of prematurity (ROP) and to determine what the optimum screening criteria would be in the different units that she was involved with during the study. She found that, similar to other middle-income countries, bigger, more mature babies were developing severe ROP that needed treatment. The implications for screening are that wider screening criteria are needed compared with those used in the USA or UK. Interestingly, what her study showed was that even though more babies may need to be examined, the actual number of examinations required is not significantly increased, so widening the net to make sure that all babies at risk are examined does not increase the workload as dramatically as one might imagine. With this data we hope to achieve more effective screening programs for ROP in Latin American countries.
This work led onto another study which is ongoing. In this study, nurses in the intensive care units were trained so that they were better informed about how to adequately manage oxygen, control temperature, improve nutrition and prevent infection in premature babies. Controlling these factors is likely to reduce rates of ROP and also other adverse outcomes of prematurity. We hope to have some preliminary results from this study towards the end of the year. This second study demonstrates how research often raises further questions, which lead into other areas of research. If this package of training proves to be effective, we would love to see it becoming a standard training package for nurses who look after premature babies. These nurses often get overlooked as after their initial period of training they are posted to units where they care for the babies but, generally speaking, nobody thinks about their continuing professional development. These nurses are critically important as they have the hands on, day-by-day contact with the premature babies so they are the ones who really need to know how to care for them.
▪ Since 2006, you have been Co-Director and are currently in overall charge of the research undertaken by the International Centre for Eye Health, and are a member of the ethics committee for the London School of Hygiene and Tropical Medicine. What can you tell me about the processes these posts involve?
At the International Center for Eye Health, our mission statement is to provide ‘education and research which contribute towards global initiatives for the elimination of avoidable blindness’. My own particular research has been in the field of blinding eye diseases in children but we are also conducting research into different aspects of cataract, trachoma, glaucoma and diabetic retinopathy.
In addition to research, I also have a role in our other activities, including teaching on our 1-year MSc course in community eye health. I teach the study units on “skills for field research” and “childhood blindness and ocular infections”, and each year supervise two or three students for their summer projects. Our MSc course is for 12 months, but also we offer 6 months of the course as a Diploma. Our courses are intended for ophthalmologists from developing countries with a view to making them leaders and agents of change so that when they go back, instead of concentrating on clinical issues, they think more about the needs of their communities and how to plan, manage and evaluate prevention of blindness programs. We also have a ‘links’ program, which puts training institutions in the UK into partnership with training institutions in Africa. As a result of reciprocal visits, they work out a plan of mutual support so that the capacities of the training institutions in Africa are built upon. We now have 18 of these programs running. We also have a very vibrant website, which we try to keep up-to-date with material relevant to eyecare workers in developing countries. Last but not least, we produce the Community Eye Health Journal. This is a quarterly publication which goes free of charge to almost 30,000 eyecare workers in over 150 countries. The main copy is in English, but we also translate the journal into Portuguese and French (for Africa), and Chinese and Spanish (for Latin America).
My role within all of these activities is mainly to guide and manage them. For example, I’m the Chair of the board of examiners for the MSc courses and I’m on the Editorial Board for the Community Eye Health journal. I am also a member of the ethics committee for the London School of Hygiene and Tropical Medicine, which entails reviewing applications from members of staff and giving them feedback.
I am also clinical advisor to Sightsavers, so I spend about 20% of my time giving this organization advice on a whole range of areas, including program development, policy and evaluating programs. Recently I have been working with other members of staff at Sightsavers to determine how the organization can introduce quality assurance into the clinical aspects of the work that they support in developing countries.
▪ What, in your opinion, are some of the most interesting studies you are currently overseeing?
I have a PhD student (an ophthalmologist, Sophia Pathai) who is starting a study of immune recovery uveitis in patients with HIV/AIDS in India. In some people who have very suppressed immune systems from HIV/AIDS, their bodies do not recognize that they have an infection and there is little in the way of signs or symptoms. Once they start treatment with antiretroviral agents and their immune systems start to recover, their bodies recognize the infectious agent and they mount an immune response to the antigen. This can give rise to systemic as well as ocular complications. Sophia is exploring factors associated with immune recovery uveitis, which is the ocular part of this immune recovery syndrome.
▪ Could you highlight any exciting developments in your field at the moment?
I think we are becoming more aware of the wider international health agenda. There are several global initiatives that hold a lot of promise for the prevention of blindness because they move people away from vertical programs and top-down approaches. For example, there is now a greater emphasis on the social determinants of disease, which means the focus needs to be on making services more accessible and equitable. The population-based research we have undertaken in Nigeria, Pakistan and Bangladesh has helped to identify those sectors of the community who have not accessed eyecare services, and this information is of value to policy makers and program planners. In addition, there are exciting developments in relation to primary healthcare reforms; primary healthcare plays a vital role not only in prevention but also in identification and treatment at the community level. It is very important that eyecare becomes embedded within these reforms, and we are working with Sightsavers on a project that will be undertaken in Kenya, highlighting the need for eyecare at the community level. Furthermore, prevention of blindness programs and eyecare services should be integrated and designed so as to strengthen healthcare systems rather than being ‘vertical’, which can have the impact of weakening them. This is an area that is relatively new to eyecare, although there are organizations that have been discussing these issues for years. Eyecare has been a bit slow on the uptake. We have a new member of staff (Karl Blanchet) who will strengthen our research capacity in this important area.
▪ How do you think your work benefits the field of ophthalmology worldwide?
Our research is mainly epidemiological and operational, and our intention is that the findings be used either to develop new programs or to make existing programs better. To provide information for program planners and managers is really what we try to do. For example, we provided technical input to national surveys of the prevalence of blindness initially in The Gambia (the first one was 20 years ago), then more recently in Bangladesh, Pakistan and Nigeria. These surveys have provided ministries of health as well as NGOs with detailed information for evidence-based planning. As a result of advocacy within these countries, significant changes have come about and more resources for eyecare have been made available by ministries of health.
▪ What are some of the challenges that prevention of blindness initiatives currently face?
Since the launch of the global initiative VISION2020 – the Right to Sight in 1999, there have been great strides in the provision of eyecare services for conditions that are relatively straightforward to treat, such as cataract and refractive error, where the interventions are not expensive and give almost immediate improvement in quality of life for patients. Services for the detection and treatment of cataract and refractive error have expanded in all parts of the world, but particularly in countries in Latin America and Asia. In terms of the major preventable diseases, onchocerciasis and trachoma, there are global initiatives. A great deal is being done to control onchocerciasis in Western and Central Africa, and the strategy of “community-directed treatment” has been so effective that it is now being used to distribute other medications and health products such as impregnated bed nets for malaria control. The same can be said for trachoma control, with several countries having declared that the disease has been eliminated as a cause of blindness, or that they are very near to that point. Thus, a great deal of progress has been made over the last decade or so but more is needed. We are now entering an era of conditions that are more complex to control, such as glaucoma and diabetic retinopathy, and, in some countries, age-related macular degeneration. These are more difficult to deal with because there is no inexpensive one-off intervention, and diagnosis and treatment require more expertise and equipment. These more challenging conditions will become more prevalent as the world’s population ages and becomes more affluent. At the other end of the age spectrum, services for premature babies are expanding in middle-income countries and in cities in Asia. As more extremely premature babies survive, the risk of blindness and visual loss from ROP increases. Many middle-income countries in Latin America are rising to the challenge, and have instigated screening and treatment programs, but more needs to be done in other areas of the world.
▪ What sort of opportunities for the reduction of eye disease and visual impairment in developing countries do you hope to see over the next few years?
Renewed efforts to combat childhood cataracts, and continuing efforts to set up tertiary eyecare centers for children. We need to think more about how to involve communities and how to embed primary eyecare into the primary level of service delivery. I think these are some of the major challenges that we are facing at the moment, in addition to emerging diseases like diabetic retinopathy. There is also a need for strengthening research institutes and research capacities in low- and middle-income countries so that developing countries can collect their own evidence and have better opportunities for undertaking research that addresses their own health needs.
Financial & competing interests disclosure
Sightsavers contribute towards Clare Gilbert’s salary and she has been a recipient of research grants from Sightsavers. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.