MJM MedTalks
Global Ophthalmology: A Talk with Dr. Nathan Congdon

S02E07+08

Samy Amghar1, Nathan Congdon2, Katherine Lan1, Masha (Maryia) Samuel1, Renée-Claude Bider1, Esther SH Kang1, Vanessa Ross1, Jan Pack1, Khiran Arumugam1, Susan Joanne Wang1 for the McGill Journal of Medicine
Published online: January 26, 2025

1McGill University
2Queen's University Belfast
mjm.med@mcgill.ca

Abstract

McGill Journal of Medicine (MJM) MedTalks is a Podcast series where members of the medical and health science communities are interviewed on topics related to career, research, advocacy and more. The aim of MedTalks is to open a space where experienced professionals and researchers can share information and advice for trainees in healthcare and medical sciences. In a two-part episode, Samy Amghar, MJM Podcast Team member and second-year medical student at McGill University interviews guest-expert and global ophthalmologist Dr. Nathan Congdon. The first episode covers Dr. Congdon’s career, his experience practicing ophthalmology in low- and middle-income countries, and the importance of multidisciplinary teams in global health. The second episode focuses on some of Dr. Congdon’s research projects, including the ENGINE trials, discusses the future of global ophthalmology, and offers advice for trainees interested in ophthalmology and global health. The show notes include a glossary of terms, links to publications referenced in the episode, and a full transcript of our conversation.

     

Content overview

Episode 1

Episode 2

Glossary

Links and papers

Studies

News articles

Organizations


Transcript

Episode 1

00:01 Samy Amghar (SA): Welcome to this new episode of the McGill Journal of Medicine, the MedTalks series. In this series, we interview clinicians, researchers & clinician-scientists on various topics related to health, research, career, advocacy and more. The aim of our MedTalks is to open a space where faculty members can share information and advice for trainees in healthcare and medical sciences. My name is Samy; I’m a first-year medical student at McGill and a McGill Journal of Medicine podcast team member. Today, I have the pleasure to interview Dr. Nathan Congdon, Chair of Global Eye Health at Queen’s University Belfast, Professor of Preventive Ophthalmology at Zhongshan Ophthalmic Center (ZOC) in China, and director of research and senior advisor for the Asia region at ORBIS International. Dr. Congdon received a Bachelor of Arts from Princeton University and a Master of Philosophy from Cambridge, both in Chinese languages. He then received his medical and public health degrees at Johns Hopkins University, where he pursued an ophthalmology residency and a fellowship in glaucoma at the Wilmer Eye Institute. Dr. Congdon’s career has focused on reducing eye health disparities, especially in rural Asia. In addition to his public & global health research, a significant focus of Dr Congdon’s work has been the training of the next generation of ophthalmologists in China. He has received multiple awards, including the Wilmer Resident Teaching Award, the Outstanding Service Award, the Holmes Lecture Award from the APAO, and the Thousand Man Plan Award from the Chinese government. Thank you, Dr. Congdon, for taking the time to talk about your work and research. It’s a pleasure to have you on the podcast.

01:54 Dr. Nathan Congdon (NC): Thanks, Samy. It's great to be here. I look forward to chatting a little bit about the work we do, and hopefully, some of the things we talk about will be of interest to your audience. We are always looking for more collaborators in our work.

02:06 SA: Thank you! Before we dive into your global and public health research and practice, could you share with our listeners what exactly you do as an ophthalmologist? And more precisely, as a glaucoma specialist.

02:18 NC: Sure, absolutely. So, ophthalmology is the study of diseases of the eye. It's relatively unique among clinical specialties in the sense that we handle both the medical and the surgical side of things. So generally speaking, if you're a cardiologist and you have a patient who needs a valve replaced or whatever, you're going to hand that person off to a cardiothoracic surgeon. As ophthalmologists, we would generally do that surgery ourselves unless it is a highly specialized case that falls outside of our practice. It's a very satisfying specialty in the sense that most of the things that we see are manageable. That's great news for clinicians. It's also a little bit of an indictment in some sense for us as a global community in the sense that we really do possess the tools to alleviate or prevent all of the major causes of blindness. And yet we still have 10s of millions of people who are blind. The work that I do in a lot of ways is really trying to figure out how to better employ the tools that we have, particularly in low-resource settings. I think we often find, 90% of the research dollars are spent - dollars and euros and pounds - are spent in high-income countries, but 90% of the burden of blindness is actually in lower middle-income countries. The solutions that are researched in high-income countries teaches us about may not in fact work all that well in low-resource settings. And so that's a big part of my work, both as a researcher and also with Orbis. Just trying to figure out how to come up with better solutions that are more appropriate, more sustainable, more accessible in low-resource settings. The other piece, of course, is also to try to figure out how to get funding for that. How do we convince governments to invest in low-cost vision care? And we'll talk about that in more detail. Glaucoma is a particular condition that is the leading cause of irreversible blindness, meaning once you're blind from glaucoma, it's done, we don't currently have the ability to somehow reconnect the the eye of the brain when the optic nerve that makes that connection is damaged. Glaucoma is very common, present in around 3 or 4% of people over the age of 40 all around the world. Some people are more likely to get it than others. People of African descent, more likely to get open angle glaucoma. People in East Asia, more likely to get angle closure glaucoma. Nonetheless, the basic condition is the same. It's caused by a pressure in the eye that's too high to be safe for that particular optic nerve. The range of pressures that cause damage to different people are all very different. It's a somewhat complicated disease in the sense that it doesn't have early symptoms. People by the time they notice vision loss, it's often reached quite a severe extent. The vision loss is initially in the periphery and we're not as conscious of our peripheral vision as we are that central vision that we use to recognize faces and to read with. So glaucoma is a great condition for people that are interested in public health because you have to do screening to pick up people. A lot of people with this disease are not diagnosed, and the proportion that aren't diagnosed, it's probably as high as 90% in low- and middle-income countries. A lot of inherent public health problems in this condition: How do we pick it up? How do we treat it? We have both medical and surgical treatments for glaucoma, which is rare for chronic diseases; there aren't a lot of other chronic diseases that we have operations for. Those operations aren’t perfect, though, and we're always working on new approaches. Generally speaking, the three ways in which glaucoma is treated are drops, eye drops that are dropped down to the eye. There's compliance problems, challenges with those. Laser, which is generally not as widely used as it should be. The health economists show us actually probably the most cost-effective way of treating glaucoma, and then incisional surgery, doing operations to basically have a controlled leak that allows the pressure to come down and those are OK, but not great, not optimal, they can lead to infection. So, there's plenty of room for improvement in my specialty. What's nice about it as a clinical specialty is you get to know people over time. Glaucoma has a genetic component. I've certainly had patients where the parent was involved and the and the kid as well. You get to know whole families. And it’s something you get to know people over an extended period of time. Then if something isn't going well, you have the opportunity to be the one who steps in and does the surgery. So, it's quite an appealing subspecialty within ophthalmology, in a lot of ways. So yeah, that's kind of what ophthalmology is and kind of what glaucoma is. I guess one thing I would say about ophthalmology is it's quite a complicated specialty for such a small organ. We have neurology elements; they are inflammatory elements in terms of inflammatory diseases and their managed rheumatology, a specialty that has rheumatology in it. There's brain tissue in there, the retina is directly connected to the brain. There's a lot of interesting optical issues around glaucoma, so it's a small organ, but fairly complicated and involves a lot of systems in the body and the treatments that we have across ophthalmology can range from glasses to medications to surgeries to a number of different things. It's also a pretty research-intensive specialty: use of lasers, use of artificial intelligence. A lot of these modalities that are widely used now in medicine are had their, you know, first introduction really in ophthalmology. So, it's a very interesting specialty and I would say it punches above its weight class. You know, all of us at a certain point are going to get what's called presbyopia. Basically, the eye loses its ability to change focus as we get older. And so, when you are in your 40s or 50s, pretty much everyone in the world is going to need to start having reading glasses. So, the eyes are important to everybody. Vision is important to everybody. We have good solutions for a lot of the problems that are most common. And so, it's, you know, it's quite an interesting and potentially quite a high impact specialty. It’s also a great specialty for global health and that's really what drew me to ophthalmology originally.

08:56 SA: Thank you for this great introduction to the field and something I also find really impressive about ophthalmology is the wide range of sub-specialties you can pursue for such a small organ from, for example, neuro-ophthalmology to glaucoma and retina.

09:12 NC: Particularly in the United States. We have a strong tendency for folks to sub-specialize. And that's right. I mean the, the, the different systems within the eye can be affected are substantial. You know between the retina, the cornea, uveitis and then pediatric ophthalmology, which generally is looking at the muscles that control the eye, and keep them in alignment. Quite a lot of different specialties. So, there's a lot of complexity for such a small organ.

09:40 SA: Taking a step back, I'm curious about your journey. What sparked your passion for Chinese languages and how did it eventually lead you to pursue a medical career and specialize in ophthalmology?

09:52 NC: That’s a good question. So I came into ophthalmology, I came into medicine relatively late in life. I didn't start medical school until I was 26. I'd already had an undergraduate and a graduate degree in Chinese, and I'd spent some time living in China. So I got started in Chinese back in the 1970s, there was a time when there was a lot of interest in the United States In China. We had Ping-pong diplomacy and Nixon going over in 1974, the recognition of China occurring in 1978. So it was, you know, a part of the will that had been kept away from many Americans and Europeans for decades, and then suddenly, you know, came back onto the world stage. So, you know, I was affected by that as much as anybody. I started taking Chinese in high school. And then, when I went to university at Princeton, it just turned out, not that I had thought this through very carefully, but they had probably the best program in the world at the time in the late 70s for teaching Chinese. You know, a lot of language, Chinese language programs, where basically they were taught by the spouse of a physics professor or something. They often weren't really taken all that seriously. There weren't a lot of people studying, and the approaches were not great, often there was rote learning. A lot of the folks that were doing the teaching weren't really that experienced or weren't specialized in language teaching. Princeton made a big deal about having specialists, people who are doing research in language pedagogy, running all the courses. And so they were quite interesting. (11:20) They had Shanghai movie films from the 1930s and 40s. We used those as textbooks, so there was a lot of use of real-world materials and a big emphasis on speaking the language. If you went into the library or went into the office over in East Asian studies, you're going to be speaking Chinese because the secretaries and all the folks who work there spoke Chinese. So, it was a great opportunity to see that the language was a real tool. What really made me fall in love with Chinese was the written language. It's incredibly complicated, incredibly beautiful. And I got to say, I mean, what's it been now 45 years, 47 years? I'm still as fascinated as ever about the Chinese language. I've always got a Chinese novel that I'm reading, I'm always looking things up. Just today I was having a conversation in Chinese with a student. So, it's a big part of my life and also an important part of my philosophy, I guess. I, you know, when you're in, at university, when you're in college, that's the time you're figuring out who you're going to be when you're deciding your approach to the world and your personal philosophy. At that time, I was reading a lot of Chinese, so I got very strongly influenced by Mencius, Mengzi. Say the great sage of Confucianism. Mencius tells us that all people are, that people are fundamentally good as opposed to maybe a Christian idea of humans as being fundamentally full of sin. Mencius tells us that we're all good in the following sense. If you were to see a baby or toddler that’s going to fall into a well. So as any human would reach out to pull the kid back not because of a desire for a reward or not because they thought they would get famous, but just the idea of suffering of others is painful to us as people. That seed of interconnectedness, he feels, is the essence of humanity and the essence of our goodness. If we can just sort of build up that seed and foster that within ourselves, we will become good. The way he describes that in Chinese is “rén jiē yǒu bù rěn rén zhī xīn”, “All humans possess the heart that can't bear others to suffer”. I would say that's pretty close to being my philosophy. That would be my tattoo if I was going to wear one. That describes really what I feel I'm doing in the world. So yeah, Chinese had a big influence on me overtime, done a lot of work in China, but even when I'm not working in China per se, the influence is definitely still there, no question. So, I decided to go into medicine. I suppose it would have been, I had my undergraduate and graduate degrees, that was at Cambridge University studying Chinese on a Marshall Scholarship at Trinity in Chinese literature. And I was trying to find out what to do and I decided that medicine would be a good choice. The idea, which I think is quite how now in 2024 is with a lot of things that people do, being a reporter, working for the Foreign Service, a lot of those things have within them kind of an innate conflict of interest, if you will. If I was in China trying to do muckraking, telling the terrible truth about the Chinese Communist Party, or if I was in China representing the interests of the United States or representing the interest of a bank or something else like that, there would always be an inherent conflict of interest. Whereas the work I do in China now is basically about, you know, how do we help children to learn better in school by giving them better vision? How do we prevent dementia and older people by giving them glasses? I mean, those as things are pretty easy to get behind. They're not tremendously controversial things. And so I think the decision of following medicine as a path to connect and interact with China ended up being a pretty good one, and I still have a lot of connections in China. A lot of folks that I work with within medicine and in particular within ophthalmology. Ophthalmology, because there are, so many of the problems that we deal with are concentrated in the developing world because the solutions that we use in the developed world clearly can work. We have the ability to eliminate these problems, and yet we haven't. It makes it a pretty compelling global health career. There's a lot we can do; we just haven't figured out how to use those tools yet. That sort of balance of, we could really do something, and yet somehow we're not. I found that incredibly compelling. And so that's really kind of the gold star for me that's guided my professional career, has been trying to figure out the different ways in which we can improve vision and looking at the different ways in which improving vision really impacts on human life.

16:20 SA: It's really interesting how Chinese languages influenced not only your personal life, but also your whole career. And transitioning to a new practice in a new country, must be quite the journey, given your academic background you already have this familiarity with Chinese culture, but despite this foundation, what were some of the challenges you faced?

16:42 NC: So, there were a lot of challenges. It was interesting. Oh, the first thing is by the time I got there in 2006, after about 20 years at Johns Hopkins. My family and I relocated to initially to Hong Kong and then to Guangzhou (16:55) while I was at Zhongshan Ophthalmic Center, the largest Eye Hospital in China, ZOC. So the first thing is I was already quite fluent in the language, but I didn't know the ophthalmic terminology. So I had to learn the specific words and it's interesting. In some Languages, Arabic, Japanese, the terminology for, you know, very sophisticated English terms, it's kind of like English. Basically it borrows the use of English. French I know is an exception to that, French has their own way of saying things. China because the market is so large, because there's so many people, and because they've been in and they've had a long period of time, they were quite independent from the rest of the world in the 60s and 70s, independent or cut off depending on how you say it, there are Chinese ways of saying everything. So, if you wanted to say uveitic glaucoma, that’s “Pútáo yán xìng qīng guāng yǎn”. You could take that apart word by word and it it would make sense. You know, it’s the uvea, Chinese is the grape layer, and uveitis is the infection of the grape layer. You know it's coming from the original Latin of the word. So I had to learn that stuff and of course that was pretty appealing to me. I'm keen on language, I like to communicate, I like to connect with people and so learning all that stuff was interesting. I think that there's a lot of cultural things I would tell a lot of my friends when they would move to China, that China is very, very Chinese. They're different and different ways of doing almost everything. We would naturally think that you would address a letter by putting the name of the person first because that's the most important. It’s the opposite in Chinese. You start out with the country and then you go to the state and then the address and the person’s at the bottom. When you sign a letter, a letter that's going to be meaningful and important and paid attention to in the United States or in Europe, it has to have a person's signature on it. If you received a letter with a stamp from some government office in Montreal, you wouldn't really quite believe it. If you get an important official letter with someone's name on it, they’re all like who's he? They want to see the stamp of the government, and there's a bunch of little things. The “zhǐnán”, the the word compass needle it has in it the word South. So compasses point South in Chinese. We think they point North, so a lot of differences and a lot of those things were quite pragmatic. It taught me a lot about how to collaborate with people. You want to collaborate with someone, you have to start from the beginning of thinking about what's in it for them, what's the incentive for them? That's definitely something I learned in China. I think another really important thing I learned in China was that I didn't know anything. By the time I went in 2006, I've been studying that language for a while. I mean, 30 years, I suppose. But still, you know, an average 4-year old kid knew more about China and Chinese culture than I did. And I think that was quite refreshing in a lot of ways. You know, I'm 62 now and I think a lot of people, when they get into their 50s and 60s, they may feel that their learning curve is starting to kind of flatten out a little bit. Man, when you're in China, your learning curve is steep. Doesn't matter. There's new stuff born every day, every day, I would learn that there was something that I, not just thought, but something I knew about China that was just wrong. So that kind of steep learning curve is very appealing. I think one of the most important things that I learned, and this is a very Confucian idea in “Lúnyǔ”, the Analects, there's a thing that starts “sān rén xíng”. So, of any three people that you see walking in the street, one of them is your teacher. I think that's incredibly beautiful. I completely agree with that, and I tell all my students that now. Most of the students that I work with are students from India, Bangladesh, Vietnam, China, the countries we go working. Those guys are experts in their countries on a level that I never will be. And so, I always tell them you're my teacher as much as I'm your teacher, and I find that it's incredibly appealing. It's a wonderful thing to have the opportunity to learn from other people every day. And I think that hunger for learning, you know, it's a very Confucian thing. There's even a Confucian, Chinese word for “hàoxué”, in love with studying. We don't quite have a word like that in English, I gotta say, but I would say “yeah I'm hàoxué”. Yeah, I'm someone who loves to learn. And confucian has taught me a lot about, and living in China, has taught me a lot about the fact there's opportunities for learning all the time. The key is you have to open your mind and be willing to understand that anybody has something to teach you and you have to be willing to potentially revise your expectations and assumptions if you want to open to learning. There was another interesting thing about working in China. Frequently my Chinese friends and collaborators, I only spoke Chinese at work for the decade that I was there, they frequently would tell me I'd have an idea about doing something and they would say, “nǐ zhèyàng zuò juéduì bùxíng, jiùshì nǐ bù liǎojiě zhōngguó”, it's just you could never, that could never work, absolutely impossible, to do it that way; it's just you don't understand China. And I realized, absolutely true, but that there are also some benefits to not understanding why something couldn't work. And sometimes, if you don't understand why it couldn't work, it opens the door to the possibility that actually it can work. So, I do think that there's a tremendous synergy potential, there's potential for synergy between foreigners and Chinese people working together, coming from their different perspectives, as long as we work with mutual respect, willingness to listen and learn from each other. China is an incredibly rapidly developing society, it has had enormous successes. I think there are benefits still when China can collaborate with people who stand outside of China and perhaps see some things that Chinese people might not see about their own society. The reverse is obviously true. You know, I'm very aware of people understanding America or England better than I do because they come from outside. So, it was a very rich experience and even though we stopped living permanently in China back in 2015, I go back every chance I get. I was just there, you know, a couple of weeks ago, we’ll be going again in April, every two or three months. And I'm trying to convince my wife that maybe we could at least live for six months or so in Chengdu (23:53), at some point. So I’m always plotting for more opportunities to spend time in China.

24:01 SA: Amazing! And also probably the surgical techniques or the way of practicing in China is vastly different.

24:14 NC: Very different. An important difference is that I would say, in general, in Western societies, particularly, this is true in the US, and Canada for sure, and to a large extent in Europe, the medical profession is generally quite well respected, generally quite well compensated. That respect serves as the basis for a generally pretty healthy relationship, I would say, between patients and doctors. We’re always trying to revise it. Doctors sometimes we get on our high horse and we look down at patients. But I think generally having doctors be a respected profession; it's a good place to start a mutually respectful relationship. In China, there's not so much respect for doctors. It's not a very well compensated or respected profession compared to being a politician or compared to being maybe an engineer. And the result is you run into some problems because there's not the respect, patients don't have an automatic respect for doctors. Doctors also because maybe they don't have quite the same status in society, there isn't maybe so much of a tendency to be thinking a lot about things like codes of ethics and stuff. You know, if you're someone who is, you know, doing a job that's not particularly respected, you don't think so much about “What do I need a code of ethics for?” The result is that what they call “yī huàn guān xì”, the relationship between the doctors and patients; it's quite stormy in China compared to what you would see in the West. You have situations, not every day, but not uncommonly, of families that are unhappy coming in and beating doctors. I have to say there might be a lot of things that would happen. I've been in some pretty crazy emergency room situations. Baltimore is yeah, you know, not the most safest place in the world, particularly when I was there in the 70s, 80s and 90s, but patients wouldn't really go after and start beating a doctor, usually so. So that's an issue and that's a hard issue to solve. I think a lot of the things that we try to do in improving medicine, listening more carefully to patients, patient-centered approaches, they're based on certain assumptions about mutual respect. That patients will have some respect for doctors and the reverse should also be true. When that's not so true, as is the case in a lot of settings in China, then solving a lot of problems about how doctors and patients get along, building up that trust becomes much more challenging. So that was also very interesting for me. I think another major challenge in China with respect to medicine has to do with the differences between rural and urban settings. As I've got older, I'm increasingly aware that there are these differences in Western societies as well. I think people living in rural America often are facing some real challenges economically and certainly politically, a lot of rural Americans may feel alienated from the urban elites. But the differences are not as extreme as they are in China, I think it would be fair to say. In terms of life expectancy, the difference between what some rural Chinese can expect and what urban Chinese can expect, maybe as much as the difference between Denmark and El Salvador. Investment in education is good in China, but educational opportunities are not as fair and equitable as they should be. Pollution problems, much, much more poorly controlled in rural settings, and definitely access to good quality healthcare, much more problematic for an average rural dweller in China than than an urban dweller. So there's a lot of interesting challenges around the healthcare system in China, but it's fascinating. I mean, I've had the opportunity to work with some of the people from I've got the greatest respect. I had a chance to meet some of the most open-minded, creative, interesting people and a lot of people serve as role models for me. And so, it's, yeah, it's been a fantastic experience and one that I'm eager to keep pursuing for as long as they let me.

28:13 SA: Amazing. And that's something I can definitely relate from my personal experience. I'm from Algeria and having some family members, for example, an ophthalmologist or doctors in general because it's not well paid in general, it's not as well seen that in Canada or North America. And so that makes the doctor not taking their role sometimes seriously, not all, but some of them. And there are some big eye health disparities; for example, as an ophthalmologist, my family member couldn't until the last few years treat congenital glaucoma.

28:47 NC: Congenital glaucoma, pediatric glaucoma was a major sub-specialty for me at Wilmer, at Hopkins, there was a general agreement that I would see most of the kids. These cases are challenging, they're hard to do, but I love hanging out with kids and I found it very appealing. It's emotionally it could be gut wrenching, as any pediatrics specialty can be, but ultimately, you know, we have approaches that do pretty well. I had a lot of pretty happy kids bouncing and running around the waiting room. And that's one of the challenges, these are the kinds of things that I suppose are very upsetting to me, but motivate my career. The fact that we have these solutions and yet we haven't been able to utilize these tools, we haven't been able to mobilize these solutions in Algeria, in Nigeria, in low- or middle-income countries where 70% of the world's population lives. So that's something we've got a lot of work to do.

29:44 SA: And what's interesting also is that sometimes the solutions are quite simple. They could be implemented if funding was given if people were interested in helping these low- and middle-income countries, and so I think that's also what makes public health and global health ophthalmology so interesting because you can have a big impact on the quality of life of quite a big population.

30:08 NC: A lot of the work, the research work that my teams have been doing over the last decade, have been looking at these questions. Basically, how do we use low-cost interventions, even as simple as a pair of glasses, to really change people's lives, improving educational outcomes for kids, improving workplace productivity for adults, making safer streets for everybody. Leading cause of death between the ages of five and 29: traffic crashes. We're beginning to do some work now, trials in Vietnam and elsewhere to really show that a pair of glasses can make a huge difference in terms of saving lives. So yeah, a lot of these interventions can be quite inexpensive. We just have to figure out where and how to dispense them in the most useful way. The other thing that's worth remembering, though, is that just like it was for me in China, a lot of the things that we think we know about health, ophthalmology, come from rich countries, and they turn out not to be true when we look in poor countries. Screening glaucoma would be a good example. We've known in the West for decades that screening, population screening for glaucoma is not cost-effective. There's been work in Sweden, the United States, the UK; all rich countries. We used real-world data from urban areas of GuangZhou in China to create a model that was published in Lancet Global Health that clearly showed that screening for glaucoma was very cost-effective in China and likely probably also in other low- or middle-income countries. The cost is less, doctor’s time is less expensive, and the benefits are greater because the chances of not being picked up if you don't have active screening programs are much higher. Traffic Safety and vision. We have known for decades that central vision is not that important for driving safety. Well, that's true for rich countries; we do a very good job of keeping people off the roads who don't see well. In low- and middle-income countries that we've published a paper in Lancet Global health, a meta-analysis and systematic review drawn that the opposite is true in LMICs, where 3/4 of the world's population lives. A lot of people, including professionals, who are out there on the road not seeing well. The increased risk of crashes is 46%, substantial increased risk, and there's real policy failures. All countries in the world basically have laws that say you can't drive if you can't see, but numerous studies have interviewed people who are driving with poor vision and asked them saying “how did you get that license with the rigorous vision and testing process?” And of course, again and again in those studies, very high proportions of people are saying “well nobody ever tested my vision”. So, the things that we think we know in high-income countries may end up being the opposite in low-income countries. Very interesting. It's kind of like the experiences that I was having in China, but it's also one of the things that's incredibly interesting and working about working in global eye health. That there's a lot of opportunity in a lot of different fields to come up with completely different ways of thinking because nobody's really taken the time to look at solutions and situations in low- or middle-income countries.

33:40 SA: Could you touch upon the reason why it's so different. Is it because the problem is not the same?

33:46 NC: The problems may be the same, right? I mean, cataract is an important cause of blindness, you know, in rich and poor countries. We get glaucoma in the same way in rich and poor countries. The solutions are different. The solutions are different because people may not have as much disposable income, the solutions are different because external things like very tight controls over who gets to drive may be completely different in rich and poor countries. And the economic realities are different. What's cost-effective? What's worth doing? Varies a lot depending on how much things cost and certain things, particularly labour costs, much higher in higher income countries. So, the answers are different because the solutions are different, and it's largely economic differences that, that drive those differences. But it's incredibly interesting. There is an opportunity to kind of turn standard living on its head when you start to look at problems in low- or middle-income countries.

34:55 SA: Yeah, and then comes back to we're seeing more and more articles in public and global health ophthalmology of multidisciplinary teams from health economics to ophthalmologists, optometrists, and also working with people that are in the country. And that's so important because they know which solutions work the best, like you've mentioned with your experience in China.

35:18 NC: Both of those things are interesting. Of course, you have to work with local folks, and those local folks have to be seen as the leaders, the team leaders doing a project in Nigeria, it's gotta be the understanding that that's going to be led by Nigerian folks; same thing with India, with China. You mentioned about multidisciplinary teams, and those are also incredibly interesting. It's one of the things that makes the work I do still fun for me and makes me feel like I still have a steep learning curve at age 62. We're doing a lot of work around the impact of vision in a number of different areas of life and through that I get to work a lot with mental health professionals, I get to work with driving safety researchers, people who specialize in mobile phones and the use of mobile phones, a lot with economists, anthropologists, educationalists, people who specialize in analyzing what works and doesn't work educationally. And so it's fascinating and it's a really interesting learning opportunity, but it's also important, some of these complex problems and those are the ones our teams are trying to work on, the most complicated problems, they can't be solved unless we can pull together these teams with a variety of different skills. And for that to work, you have to be, again, mutually respectful, you got to figure out what is in it for the other person, why would they want to get involved? Often there's quite different ways of thinking about how to do analysis, how to do publications, and so you have to be open minded. All that stuff makes it incredibly interesting for me.

36:49 SA: Amazing! I’m excited to dive even deeper into this topic. In part two, we’ll continue our conversation with Dr. Congdon, exploring his current research projects like the ENGINE trials and discussing the future of global ophthalmology. This episode was edited and produced by the MJM podcast team. If you’ve enjoyed today’s discussion, connect with us on Twitter or Instagram, and don’t miss out on part two!

Episode 2

00:01 SA: Hello and welcome back to the McGill Journal of Medicine podcast series, MJM MedTalks! In this series, we engage with members of the medical community on a wide range of topics related to health, research, and advocacy. I’m Samy Amghar, a first-year medical student and a member of the podcast team at the McGill Journal of Medicine. In this episode, we continue our conversation with Dr. Nathan Congdon, global ophthalmologist.

00:25 SA: One of the last articles you published in JAMA Ophthalmology with your team and collaborators titled “Green space morphology and school myopia in China”, in which you address the impact of rapid urbanization and increased myopia prevalence in children in China. Could you elaborate on the possible challenges in eye care the nation might face in the upcoming years as it’s in fast development.

00:52 NC: So there's a lot of really interesting things to say about that work. First of all, Lin Haotian, who's the guy who runs it, is the head of the Zhongshan Ophthalmic Center. Now, he’s a very smart guy when working with him since he was a very smart young guy and he's now the head of the hospital. So, he’s now my boss in some important respect, very smart guy. So that work is very interesting. We've known for a long time that richer areas, more urban areas have more myopia. And I think we don't still fully understand why that is. And we would like to be able to understand better so that we can reverse some of the things about urban settings that cause so much myopia. Because at the end of the day in low or middle income countries, we know that the very large majority of people with myopia still aren't getting the simple pair of glasses that would help them to drive more safely, to learn better in school, to be more productive at work, all those things. Large majority of people aren't even getting a simple pair of glasses. So, prevention is of strong interest. The work that Lin Haotian and his group are doing around green space is very novel and interesting stuff. They're looking at satellite imagery; it has not been used by ophthalmologists in the past. Looking at images from Shenzhen and Shanghai in some of these big cities and finding that when you look at the amount of green space using different analytic tools, you find that they matter a lot. The amount of greenery around schools, where a kid goes to school, end up having a big impact on that kid becoming or not becoming myopic. So, it's very interesting stuff and it has the potential to maybe unlock some new solutions to prevention of myopia with development of green space, which is something that's good for a lot of different reasons. The challenge, of course, is to figure out cause and effect and a lot of this stuff we do. It's one thing to say A and B are associated, but for you to get governments to invest in programs, to get companies to invest in programs, you can't just say A and B are associated; you have to be able to say A causes B. Otherwise you don't have a plan, you don't have an intervention, you don’t know where to start. And figuring out what the green space morphology stuff, finding cause and effect, generally means doing experiments you know, like randomized controlled trials. Not so easy to say well, we'll build $100 million development over there and then randomly we won't put one over here. What we have to do is the best we can with before and after. And I think that's something I'm very excited to see if and Lin Haotian and his group are working on in the, in the future is to take advantage of changes that are being planned anyway. Green space that's being built and look at before and after and see if we can tease apart whether those changes of building green space are actually causing lower rates of myopia. Incredibly interesting stuff.

04:09 SA: Now I wanted to take the time to talk about the ENGINE program. The project directing involving 29 partners in four countries.

04:14 NC: Sure. Yeah. So engine stands for “Eye care, Nurtures Good health Innovation, driving safety and Education”. And the tagline for ENGINE is “Vision Drives Development”. That's the basic idea behind it. It’s a suite of trials funded by the Welcome trust to I like to convey my undying gratitude; around £4 million in funding for a suite of four trials in four different countries, each of which is basically looking at a different way in which vision care applied strategically during a certain period in human life, can be life-changing. Putting it another way, ENGINE is trying to look at specific ways in which vision care can help to propel the success of the Sustainable Development Goals. So, in each case, we're trying to be able to make a statement: vision care causes something good, something that we desire, and to make those kinds of statements to say a causes B, you have to do randomized controlled trials. Only RCTs can allow us to tease apart cause and effect. So, the kinds of things that we're interested in ENGINE, that we're looking at, I mentioned already briefly, we have a project called STABLE “Slashing Two Wheeled Accidents By Leveraging Eye care”. We like acronyms a lot on our team. STABLE is looking at vision care glasses to improve the safety of motorcycle drivers in Vietnam. Vietnam has not only major problems with refractive error, with myopia, but it also has in Southeast Asia, 50% of global deaths from motorcycles. So, two major epidemics, and we're interested to see if, how we can use the one to solve the other. In Bangladesh, we're doing a study called THRIFT: Transforming Households through refractive interventions and so through Refraction and Innovative Financial Technology. That's what it is. THRIFT is looking at the fact that the Bangladesh government has recently mandated that all social safety net payments to the elderly have to come online. It's a great idea, came out during COVID, safer for older folks, more efficient. The problem is that we found in our pilot work that about 75% of people who are beneficiaries for these results, for these these payments, they can't see a smartphone to go online. So that trial is looking very simply at providing glasses and very small amount, very simple training and how to use a smartphone. And our outcome is, our hypothesis, is those folks after that training and after those glasses are going to be much better able to access and use this money and that that's going to lead to better financial inclusiveness for them, better nutritional outcomes, a whole bunch of different things. In India, we're doing a study called CLEVER that stands for “Cognitive Level Enhancement Through Vision Exams and Refraction”. CLEVER is asking, for the first time in a trial, the question of whether low-cost vision interventions, like glasses, can slow the pace of cognitive decline, can prevent dementia. Dementia is pretty important in low- or middle-income countries, as these countries are, their populations are aging rapidly. Something like 1% of India's GDP is spent on caring for people with dementia. We don't have good low-cost solutions, yet, we've got some expensive drugs in the United States that are 20 or $30,000 a year, very modest results. That's not going to be a sustainable solution in low-resource settings. What we do know though is that there's a strong association between poor vision and poor cognitive outcomes. They marched together in step. It's kind of like where we were in the 60s with hypertension and heart disease. We knew there was an association, but it wasn't until we did the trials and we demonstrated cause and effect that lowering hypertension could reduce heart disease. That precipitated a major medical miracle, right? I mean, reduction of heart disease is one of the great success stories of modern medicine over the last 50 years. We're keen to try to do the same thing with vision and dementia. Our hypothesis is that there's a lot of… Vision takes up a lot of bandwidth in the brain, and that when that signal is not very reliable, they got a lot of noise; when there's a lot of noise and signal, then that's going to result in people having less leftover resources to be able to remember their wife’s birthday or remember their own address or whatever. So, the idea is basically that we feel if we can improve that signal, improve the vision, there's a real chance of being able to improve people's ability to to function cognitively. That's our hypothesis, carrying out randomized controlled trial to try to demonstrate that first ever trial of that nature in the world being done in India. And we're simultaneously about to start a similar trial in China as well. So, those those trials, I think, are pretty indicative of the kind of stuff that we're interested to do. In doing that work, we were sort of the background, I guess, I could say, for that work started maybe about 10 or 15 years ago in China when we did the first trials showing that glasses could help children to do better in school, “see well to learn well”. You know, there's a lot of factors that determine whether kids are going to learn well, just as there's a lot of factors that determine whether people can drive safely or whether people age with their cognition intact. A randomized controlled trial allows us to pull out a single thread and evaluate what the impact is. And we were very excited when we did this over a decade ago to find out that just a pair of glasses in and of itself, 5 bucks, can have more of an impact on the kid’s ability to learn than parental income, than parents’ educational level, and a bigger impact than any other health intervention that had been looked at in the school setting. So that has led us to do other educational studies. We're doing one now in Sierra Leone, in Africa, the first ever glasses and learning study in sub-Saharan Africa. We're about to start another one called SWISH in China, “See Well to Stay in ScHool”. About 50% of Chinese kids in rural settings go on to high school. One of the biggest reasons they don't is because of poor academic performance. We've already demonstrated kids can learn better if they get glasses. Getting better grades is good, going on to high school is life-transforming. If you go on to high school, you have the potential to go to university, and if you don't, then you're headed in a very different direction economically. So, the educational work was kind of the background for what we are doing now with ENGINE. The other major background has to do with the study that we did call PROSPER in India. Still probably the study I'm happiest with. The Economist published a little article about our study and I've got that hanging up in my office now and hanging up at home as well. We got a lot of attention, The Economist, the Financial Times, BBC World, all picked it up. PROSPER basically was the first to ever study that looked to see whether vision care could improve people’s workplace productivity, and we found a major impact. By giving glasses to tea pickers in India, we found that their tea production, the amount they could pick a day, improved by around 25% and in older, more presbyopic people, 35% increase. You know, something like twice the largest increase that had ever been seen with any other health intervention in the workplace, and it's led to some pretty significant changes. In Assam, the government has invested in these workplace vision projects. There's been a large investment by companies in the tea, coffee, chocolate, bunch of other sectors. We're doing further work now looking at textiles and some of these other things to try to ask more broadly about the impact of how, how can vision improve people's workplace performance. The tea stuff was extremely interesting. We'd love to try to expand that now to agricultural products. No one ever starved to death because they couldn't get tea. But how about food crops like rice? 50% of the world's food is grown by small home farmers. We're interested to do trials to demonstrate whether a provision of glasses and other health interventions can help folks that are growing food crops to be more productive. This is generally this, this idea about looking at vision interventions to, to look very specifically, using randomized trials to provide evidence of the life-transforming impact of vision I mentioned that's the major focus of my group right now. And our goal in trying to do this is to encourage governments to provide governments with evidence to drive investment in low-cost vision care. Potentially to companies as well. As I mentioned with PROSPER we've had some success in that in China. I think the work we did that showed that vision mattered for education also played an important role in China starting a project in 2018, a national program of myopia control. We spend a lot of time with economists. Economists are really the ones who taught us to do these kinds of trials. (50:40) The folks like Jay Powell at MIT. And I think speaking in economic terms, talking about things like productivity is crucially important to get governments to pay attention. We're also interested in expanding this work outside of vision care. We're interested in looking at oral healthcare, hearing care, looking at models to deliver those kinds of care relatively inexpensively on low resource settings and beginning to look at the potential economic benefit of those things. Having no teeth, edentulism, very common thing, about 50-60% of people over the age of 50 in a lot of low- and middle-income countries. You don't have teeth, your nutrition is very badly impacted. If you're not eating properly, obviously you become frail, much less productive. That last piece about the association between fixing people's lack of teeth in economic productivity, never been studied. We're very keen to do some trials demonstrating that impact. Hearing care as well. All of these things, the hearing care, the vision care, the dental care. They're important because they are salient. That is, people know that they can't eat because they don't have teeth, they know that they can't see. We're extremely interested in using these types of salient care, which have generally been left out of healthcare systems, not just in poor countries but in rich countries as well. We're interested in showing how incorporating these things, oral health, vision, hearing care can really not only massively improve healthcare systems by motivating people, incentivizing people to receive the care and NCD care, diabetes, hypertension care that they don't know they need. Can we use free glasses and free dentures and things to get people to accept the care that will save their lives, NCD care, economic benefit, mental health benefit; we're interested in exploring all of those things. So, I think there's a lot of exciting opportunities for us to look at neglected aspects of the healthcare system and integrate those aspects in ways that will potentially be transformative, not only the healthcare system, but also transformative of economies and of people's mental health as well. The team building part often involves conveying enthusiasm for a basic idea getting people interested in that idea, getting them excited about how from their specialty as an economist or as a mental health person or as a traffic safety person, how we can really look not just at the academic thing of documenting problems, but look at dynamic new solutions to those problems. People get pretty excited when they're presented with an opportunity to use their knowledge to create real change in the world. That's a big part of it, conveying that enthusiasm, conveying the potential for change to get involved in something exciting. That's the essence of building a team, I think. You have to get people together and building those teams, you have to be willing to say, you know, I'm not the boss, I have as much to learn from you as you have to learn from me. All of those kind of things are important in building these teams. The teams, generally, are led by people in Bangladesh, in India, in Vietnam. We're very lucky to be working in India with LV Prasad Eye Institute, one of the largest and most successful eye hospitals in the world, both very successful in service delivery and in research. In Vietnam, we're working with the Ministry of Transport with the policy going with the Ministry of Transport. Getting to work with policy workers you know is fantastic. In terms of how it works, we do have 29 different organizations, there are government ministries, there are academic institutions, there are NGOs. NGO's can play a fantastic role. I've spent for the last 20 years, 50% of my time doing NGO work and 50% doing academic time. NGOs often have great questions, great connections with communities; they can be incredibly helpful collaborators to get things done. All of our projects are being carried out with the help of NGO's like the Asia Injury Prevention Foundation in Vietnam, like MOMODa in Bangladesh. And then patient advocacy groups, we work with the largest Alzheimer's patient advocacy group, ARDSI, in India. We carry this stuff out by having all the meetings online, of course. So, I've been doing that for a long time before COVID came I was already doing all my meetings online. We also try to have opportunities for the different groups to interact with each other and talk about share lessons learned. We have sessions that we call the ENGINE room sessions. And then we also have,of what we call bilateral learning bidirectional learning sessions. We've had maybe 40 or 50 of those so far are meetings where different experts and by choice by selection, half of them in our low-income country, partners, countries and half of them in higher-income countries, talking about their work, sharing ideas that will be of interest to the broader group of people working in ENGINE. And those are quite well worth attended, we get, you know, dozens and dozens of people showing up. But we're learning from our colleagues in Bangladesh, India, Vietnam, and everybody as much as they're learning from us.

20:04 SA: Thank you, Dr.Congdon, for sharing about the engine project. I'm really looking forward to seeing the results and the impacts of these trials. As we near the end of today's episode, let's talk a bit about the future of eye health. Over the last few years, tools such as smartphone fundus imaging, teleophthalmology and AI-based screening have gained popularity, especially since the COVID-19 pandemic. Do you believe these innovations will help reduce eye health disparities and avoidable vision loss in underserved populations?

20:34 NC: That's something that clearly has the potential to be transformative in terms of reducing disparity. I'll give you an example. We published a paper in Nature Digital Medicine last year that was ranked by a major news organization that's one of the top three most important innovations in the AI space last year, we got beat by ChatGTP. We did a trial there in Bangladesh that showed for the first time that the use of AI systems could improve the productivity of clinicians; could improve the productivity in terms of delivery of vision care. And that's huge. It's transformative, it’s a 40% increase. It's transformative because, obviously, there's not enough of those specialists to go around, and if we can make each of them 40% or 50% or 60% more productive, and that's fantastic, it's the potential part of the solution to getting the, the fundamental problem. Right, how do we get the person with the ability to treat into the same room or the same space as the person who needs the treatment. AI offers tremendous opportunities. The challenge is those AI systems have to be trained, and, in general, they're trained on images that come from First World countries shot by professional photographers with $30,000 cameras on people who've already had their cataracts taken out. That produces a very different sort of diet of images than what we generate in our programs in developing countries. Very, very different. If AI has been trained to function in high-resource settings, it's not going to function as well in low-resource settings. It's just all part of the same thing. The answer is going to look different if you do it in a low-resource setting. So, there's an obligation to make sure that these systems are trained using images that are appropriate using data that is appropriate for low-resource settings as well. That won't just happen automatically. If companies are allowed to follow the dollar, which, of course, that's their job is to produce returns for their investors, they're gonna often naturally look for higher source markets, and they're going to train their products to function in those markets, and those products won't necessarily function in low-resource settings. ORBIS International, the NGO that I've been working with for about 15 years now, for whom I serve as the Director of research, is very keen about that; we have our own AI system. We spend a lot of time honing that system using images from our programs in low- or middle-income countries, and we're making a very strong effort to try to make sure that this will be a tool that's freely available to anybody who wants to use it in low- or middle-income country so that there is the potential for AI to address these inequalities. That kind of thing won't happen automatically, so there's a very strong need for those of us who are researchers, those of us are clinicians, those of us who are investors, those of us who are entrepreneurs to really try to think about how we can create equity. I'm working on a product now with a company called Alcon Vision. I don't do a lot of work with companies, but Alcon Vision has a vision about a product they're working with called the Eagle, which will allow the treatment of glaucoma. It’ll allow the delivery of laser treatment, SLT laser treatment, to the trabecular meshwork without needing a lens, without needing a corneal lens. Basically, meaning that the treatment is going to be much more accessible. You won't need a highly specialized person with a highly specialized device in order to deliver it. That's the kind of thinking that we need more of. So I think there's incredible potential for technology to address inequalities, but there need to be people, researchers, entrepreneurs, investors, the public, all of them pushing for those innovations to be used in the right way and trained up and delivered in the right way to reduce inequalities. The potential for them to increase inequalities is absolutely there; there's no question about it. If we train AI to only work on first-world images, then they're not gonna work in developing countries. So, I want to be clear, I'm an eternal optimist, but I'm also a very pragmatic optimist, and part of that pragmatism is we have to be vigilant; we got to push for this to happen.

25:24 SA: It's interesting you've mentioned not only the benefits, but also the pitfalls of AI, because there's been a lot of articles in the last few years about AI perpetuating health disparities.

25:38 NC: There's a lot of these problems and you know, I think at the end of the day, that's how it is as we develop these tools. We've got to hold ourselves up to a high degree of scrutiny to make sure that the tools are being developed in a way that will improve equity. And part of that is having actors, like ORBIS International and others, who are committed to that space and are going to, you know, get involved in these areas. So, and a lot of excitement, and I think I would say for this, you know that young audience we're talking to, you guys are the ones, you know, your generation will be the ones that will really determine what AI and what these massive changes do, not just within medicine but within society generally. I would encourage you to step up to the plate and keep those equity issues foremost in your mind as you guys are coming up with these solutions. So, it's exciting stuff. As I say, I'm an eternal optimist. I'm very interested to see how it works, but these decisions, a lot of these things are going to be done by your generation, no question about it.

26:43 SA: Thank you for sharing your perspective on this subject. At the end of each episode, we'd like to ask every speaker the following question. What would your advice be to young trainees whether they want to pursue a career in ophthalmology, global or public health, or want to practice internationally, for example, in China?

27:02 NC: Fantastic! So broadly, let's say we're talking here about the global side of things because I think I mean there's 100 people who could answer the question about how to get into ophthalmology residency. Let's focus here on the global side of this; global eye health, global health generally. There are a number of things that are important. I think I would say building up skills is important. These jobs are not tremendously, these opportunities are not tremendously easy to find when you're looking for these opportunities. If you come in and say, look, I know how to analyze data, I know how to program, I speak a language, I speak Algerian Arabic, or I speak Chinese, or I speak Hindi or, you know, I speak Punjabi. That's going to help a lot in the right place. Those language skills, those technical skills, hugely important, that will make your grandmother so happy. You know, if you if it's a home language. Yeah, so that's one. Mentors, I think, incredibly important. We see this, you know, certainly in terms of equity, you know having a mentor who looks like you. But I think also in terms of a career that you might like to pursue, you could go through an average ophthalmology residency and never meet anybody who was doing global eye health. I was incredibly lucky when I was at Wilmer coming out as a medical student to get to meet people like Al Summer, Sheila West, you know people who are real giants in their field, who are doing global eye health. So, I saw that people could do that. I saw that as a real possibility. You have to look for those mentors because without that sort of real-world example, it can become, it can come to seem very kind of abstract like it couldn't be possible, whatever. So definitely reach out, look for, look for mentors. Build up the skills so that you'll have something to bring to the table and I think the other most important thing is if you are interested in working in global health, global eye health, you need some opportunities to work in low-resource settings. You gotta spend some time working in those places. It comes back to the same thing that we've been talking about throughout this entire episode today. The answers, the approaches, the solutions are just going to look different in low-resource settings from how they're gonna look in high-resource settings. If you want to begin the process of readjusting your mind to think about how to come up with solutions that are gonna work on with low resource sense, you gotta go and spend some time functioning in low-resource settings you gotta do it. So, having those opportunities to spend chunks of time overseas in Africa, in Asia and Latin America, those things are incredibly important. I would say pretty much everybody I know who is seriously involved in global eye health spent a good chunk of time living overseas in an LMIC. Look for those opportunities. Seek them out early; you know, the opportunity cost is less the earlier you're doing. Taking a year off from medical school or whatever is less costly than taking a year off during residency, which is in turn less costly than taking year off once you're fully qualified. That what you're giving up in terms of salary is a lot more the longer you wait in your career, and you're more likely to have spouses and kids and a lot of other things that could make it difficult to move. Taking my family around the world over the last 20 years, and that's not an option for everybody. I would say look for those opportunities to spend a chunk of time in a low or middle-income country. Look for them early in your career and just do it. It's never going to get easier to do, you know. It's only gonna get harder to do so. Do it. Do it early. You know, do it as early as you can. Another thing that's really important, Samy, in terms of things, specific advice I would give to young people who are contemplating a career in global eye health or global health generally, public health training is incredibly helpful. Public health training is really, I mean, it's the set of tools, it's the language that we use to try to solve problems in low-resource settings. I'm not seeing that people don't get sick or go blind individually as people in low or middle-income countries. But what I am saying is that that public health approach, that society-wide approach, it's a really crucial adjunct. It's a crucial perspective to supplement the perspective that you'll get as a clinician where you're seeing your patients one at a time, and I think it's a particularly well-suited perspective for working globally. So, I would definitely encourage any of your viewers, who are early enough in their career, your listeners who are early enough in their career, to think about getting public health training as early as you can. And just like taking time in low- or middle-income countries, the opportunity costs are less the earlier you do it.



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