Women in developing countries are often confronted by socio-cultural factors that not only limit their economic and social freedoms, but also their accessibility to appropriate health care services. In fact, a myriad of barriers lower their standard of health care when compared to their male counterparts.
I am not ignorant to these restraints. Personally, I spent a large part of my childhood in a country where women weren’t allowed to drive, and weren’t allowed to travel without male supervision. As an adult, I once worked in a country where government imposed family planning was the norm in rural areas. I have also worked on two other continents that differed from one another culturally, but were grotesquely similar in that the majority of women had limited-to-no-access to power: where access to a hospital was considered an anomaly and where men owned their respective decision-making powers. Despite my environment, however, as a foreigner, I had the power of choice and I had access to information, funds and medical care, a luxury that wildly differed from many of the women in my periphery.
When looking at dry eye: this disease is a debilitating or even paralyzing syndrome for people in developed countries, so can we even imagine or assess its impact on women in rural areas in developing countries?
Social responsibilities surpass even national boundaries and require global strategies and responses.
I had the opportunity to speak with Dr. Gupta, who is standing strong, in a male-dominated setting, arguing that women’s access to health matters on many levels. While the UNDP has developed a Gender-Related-Development Index and the Gender-Empowerment-Measure, it is necessary to develop others that specifically consider general health and specifically, eye health.
TFOS: What are key issues within the industry in India and other developing countries?
GUPTA: The key issues are a lack of specific diagnostic and therapeutic modalities for dry eye. Those that are available – tear osmolality strips and MMP-9 kits – are expensive and unfortunately do not cater to the rural poor in developing nations. With respect to India, as the second most populated country of the world and the largest number of diabetics globally, MGD is a significant problem.
I belong to a country with a predominantly rural population, and the burden of dry eye is huge. The increasing digitalization and use of mobile screens and computers globally has only increased dry eye occurrence, as have an increase in air pollutants and more air-conditioned environments. This area also needs more investment in the South East Asia region, as there are very few researchers and clinicians working in this area despite a great need for them.
It pains me to see patients who have visited many physicians and tried every treatment offered but still suffer. Dry eye in India not only affects one’s quality of life but also has a bearing on daily life and health-related economics, including loss of work productivity, which is a substantial economic burden.
There is a need of increasing public education and awareness with a special emphasis on behavioral and lifestyle changes. In addition, there is also a need for doctors to perform deeper diagnosis of dry eye – while lubricants help, most physicians fail to look for and treat the underlying cause. We urgently need a specific, targeted therapy for dry eye. There is also a great need for research studies in this area in India and other developing nations.
TFOS: How do you see technology developing with respect to dry eye treatment and where are the gaps?
GUPTA: There is neither any specific assessment criteria nor test for all types of dry eye – as such, it is important to develop a single test in the future. Other gaps relate to symptom-based questionnaires for dry eye-OSDI needs to be modified as per the Indian population.
TFOS: Has the positioning of female dry eye patients and female doctors changed?
GUPTA: As patients, females are affected by dry eye more than males. Follow-up and compliance is an issue amongst females as they are usually dependent members of the family in India. The elderly and post-menopausal females have a higher prevalence of dry eye and since they are usually housewives in our scenario, eye health is not a priority for them. In addition, some females have more visual demands and the role of hormone replacement therapy in India is not known. Risk factors for dry eye also include kitchen smoke, use of cosmetics, contact lenses, and refractive surgery before marriage, because of social barriers to use of spectacles is common in developing nations and especially in India. Overall, female patients are more at risk for dry eye-autoimmune disease, rheumatoid arthritis, ocular cicatricial pemphigoid, post-menopause, depression and other ailments because, as noted before, they have poor access to healthcare and their health is not a priority for them, nor their families.
As a female doctor, I better understand the psyche and social roles played by our female patients: there exists a complex interplay between disease and social factors. As females, we are more understanding towards female patients and can play a pivotal role in educating, removing barriers in female patients and acting as torchbearers for the female community.
TFOS: How did you get involved in this ﬁeld?
GUPTA: I became interested in dry eye since the day I stepped into my career in ophthalmology. My postgraduate dissertation was on dry eye and that was the beginning of my research in this all-encompassing field. Since then, I have been involved in clinical trials, clinical and basic research and population-based studies in dry eye. The more I knew about the disease, the more I got involved. During my journey to treat and manage patients with dry eye, I won laurels at the national level and my dissertation was awarded as the best paper in ophthalmic research in the year 2005.
The other reason for my interest in this field was when I faced the ground reality that it affects a substantial proportion of our patients and there is lack of awareness amongst the community as well as clinicians to manage this multi-factorial disorder effectively.
I have always tried to make a positive impact on others by bringing dry eye to the forefront through scientific deliberations, interviews and awards at national and international conferences. We realized the first population-based study on prevalence of dry eye in the general population and its associated risk factors and its relation to global health and environmental factors. The Indian Council of Medical Research funded this study.
Personally, I am interested in the microbiome related to dry eye and its changing configuration with systemic disease and association with MGD. Other research areas can be prevalence of MGD with dyslipidemia, DM, CAD and dry eye.
TFOS: How can the TFOS community work together more?
GUPTA: I feel the TFOS community can work together and form a common platform to make dry eye a priority disease globally. Focus needs to be drawn towards its effect on health economics and quality of life.
More specifically, the TFOS community could help in the following:
v Increasing public awareness; providing information and educating the masses about computer vision syndrome, proper counseling before refractive surgery and other ocular surgeries.
v Incorporating what we learn-disseminate globally-TFOS is the right platform.
v Devising standards and promoting and recommending single standard line of therapy.
v Sharing any new ideas amongst researchers and promote collaboration and simultaneous application of research ideas globally.
TFOS can serve as a common platform for advocacy, spreading awareness among patients, physicians and ophthalmologists.
We, the like-minded ophthalmologists working towards a common goal, should share anything interesting – innovations and research and publish recent news and share publications related to dry eye and ocular surface disease on a common forum.
Dr. Gupta is a young, dynamic ophthalmologist with more than 15 years of teaching and research experience in ocular surface diseases, particularly dry eye disease. She is presently working as Cornea faculty at the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical in New Delhi. She has made significant scientific deliberations as chairperson, instructor, judge, speaker and faculty at regional, national and international conferences including World Ophthalmology Congress, ESCRS, AAO, ISGEO, IAPB, Asia Pacific Academy of Ophthalmology, TFOS and ASIA ARVO. Her work on dry eye has been lauded at the Annual Conference of All India Ophthalmological Society (Best Paper, 2003 & 2005) and published as the Cover Story in Ocular Surgery News (APAO 2012).
With more than 150 publications to her credit (H-index=13), she is a reviewer and editor of many national and international journals including IOVS. She has been instrumental in the planning and implementation of population-based studies on trachoma, corneal blindness, diabetic retinopathy, Rapid Assessment of Avoidable Blindness, Rapid Assessment of Visual Impairment, and impact of global warming on ocular health. She is credited for conducting the first population-based study on corneal diseases in India, as part of her doctoral research (PhD) at the prestigious All India Institute of Medical Sciences, New Delhi. She also conducted the first population-based prevalence study on dry eye disease in the Indian subcontinent. As a key ophthalmologist and expert, she has led national surveys on blindness and population-based trachoma surveys, and advocated the decreased burden of trachoma and blindness in this region.
TFOS Staff Writer