MORAL OBLIGATION

What sort of moral obligation do we, as young, w e l l - t r a i n e d ophthalmologists have to the rest of the world? What is expected of us in terms of “giving back” to a world that has been so generous to us and so much less generous to the rest of humanity? This question has been popping up with increasing frequency in my mind, largely due to the connections between our eye hospital in Rotterdam and an extraordinary clinic in Rwanda: the Kabgayi Eye Hospital. It all started with a recent vitreoretinal (VR) surgery fellow, Dr Piet Noë.

Dr Noë is a Belgian ophthalmologist who lives and works full time in Rwanda. There, he performs thousands of eye operations of every sort per year. He came to Rotterdam for an intense surgical training programme. Since Dr Noë returned to Rwanda, two of my colleagues have gone to work with him. One colleague went to teach; the other went to learn. Marc Veckeneer, a senior retinal surgeon, went to Rwanda for several months to operate. He also put the finishing touches to Dr Noë’s VR skills. Peter van Etten, ophthalmology resident, spent a month assisting Dr Noë in the clinic and in the operating room.

In an email to us during his first week there, Peter wrote: “What Piet Noë does here is truly amazing. Here’s an example of today’s operating schedule: one enucleation for retinoblastoma, two congenital cataracts, two corneal perforations, three vitrectomies for retinal detachments, a conjunctival flap for a Mooren ulcer, debulking of what seems to be a periorbital lymphangioma, a few pterygia, 10 cataract extractions and a dacryocystorhinostomy to drain an orbital/ethmoidal abscess. Oh, and a trabeculectomy.”

QUALITY OF LIFE
Impressive. I must admit, it’s difficult to concentrate on treating blepharitis (Is it anterior? Is it posterior?) when I know that more significant problems exist just a half-day’s flight from my doorstep. It’s interesting to consider how many thousands of euros can be spent on a single cataract operation in western hospitals, knowing this amount of money could be spent treating hundreds of people in poorer countries. “It’s amazing to fully realise that ophthalmology is really such a surgical profession and thus ideal for the tropical countries. We can permanently improve a person’s quality of life with just one operation,” Dr Veckeneer wrote in an email from Rwanda.

Geoff Tabin, co-founder of the Himalayan Cataract Project, calls cataract extraction “a little miracle – the single most effective medical intervention on earth.” This is particularly true when the vision of patients with mature cataracts and functional blindness can be restored for less than €20 per patient. And this operation can be repeated hundreds of thousands of times with outcomes comparable to those seen in Europe. A National Geographic journalist, observing Dr Tabin examining patients postoperatively, wrote, “Dozens of patients who have regained their sight stand to sing. Sometime in my life, I may hear a sound that expresses joy more purely. But I can’t imagine when.”

RESPONSIBILITIES AND POSSIBILITIES
So, back to my original question: What is our responsibility, as residents and young ophthalmologists, to the world’s blind? With few exceptions, we have all been handed the world on a silver platter. We have benefited from excellent, inclusive educations in safe environments. Our futures look rosy, despite our general tendency towards fear and obsession over every financial “crisis” of our highly developed and generally stable economies.

And besides our responsibilities, whether they are measured in financial or surgical assistance, what are our possibilities? Can we just get up and go to Rwanda or Bhutan, live there for a year or two and operate as many cataracts as we possibly can in that time? Half of the residents in my programme have children. They have bought houses and have bank loans to pay. Getting away isn’t easy.

And if we were able to leave our lives for a year or so, how useful could we be to the treatable blind? Could we successfully operate a mature cataract? A post-traumatic cataract? A congenital cataract? The old maxim of “See one, do one, teach one” might apply when it comes to placing an IV or a vaccination, but intraocular surgery is a complex skill. We get just enough surgical training to handle basic, uncomplicated cases after graduation. Can someone train us to be of surgical help in Ethiopia? Or will we just get in the way of those who are already there?

After I graduate, I will probably follow a well-worn path through fellowship and straight into practice. But maybe we should all try to blaze a path outside our comfort zone and into the wider world, where we are greatly needed, while we still can.