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A Passion for Global Health

A retina specialist talks about bringing eye care to those who need it most.

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For as long as she can remember, says Robin Ross, MD, of the Global Retina Institute in Scottsdale, Arizona, people have been asking her from where in the world she hails.

“So many people have asked me about my ethnicity, that it’s been something of a running joke,” says Dr. Ross. “I’ll often tell new patients that they get one guess per visit, and more often than not, their guesses span the United Nations.”

Dr. Ross and her parents were all born and raised in the United States. Her mother, of Japanese descent, was born in a Japanese internment camp, and her father, raised in Alabama and Michigan, is of both African-American and Scotch ancestry. Aware of being “a unique-looking individual” while she was growing up, and accustomed to endless queries about her ethnic background, Dr. Ross developed an early interest in foreign countries and the people who lived in them. Then, while in college, she received career advice from Stanford University’s president that pointed her in the direction of humanitarian work.

Work toward a career that will allow you to earn a living and provide for your family, while giving back to the community and the world at large, he told her.

During medical school, a Scudder fellowship took Dr. Ross to India, where she learned about “eye camps” and cataract blindness, and traveled with a mobile leprosy unit. Then, humanitarian missions to Brazil made an indelible impression on her. In 2000, she responded to a request to help integrate retina into a general ophthalmology clinic in Rodonia, in Northern Brazil, by implementing optical coherence tomography and teaching intravitreal injection and other retina techniques.

During a subsequent trip, she returned to Brazil to provide aid to the Paumari tribe, whose members were said to be going blind. After landing on a makeshift airstrip that was cleared with machetes, Dr. Ross and her colleagues began to obtain baseline examinations of tribe members.

“It turned out they could not see well enough to remove thorns from their feet, or to weave the baskets or make the beautiful carved canoes that they sold to local river traders,” says Dr. Ross. “We realized fairly quickly that what the tribe members needed were reading glasses. I later realized that uncorrected refractive error was a major cause of correctable vision loss.”

The fact that it could be so gratifying in many areas of the world to solve such simple problems would make a lasting impression. On the same trip to Brazil with the Paumari, Dr. Ross and her husband observed the tribe’s exchange with the river traders, which spawned an interest in fair trade. Soon she and her husband were selling artisan products to ensure fair trade while generating money to fund humanitarian eye-care trips and related student projects abroad. In 2008, expanding on this business model, Dr. Ross and her husband founded Red Rover Ventures.

“In global health there are many pressing needs,” says Dr. Ross. “The priority is saving life, so there is an emphasis on addressing maternal and child mortality and infectious disease — those are the things that are likely to receive funding. We saw that eye care was always going to be at the bottom of the list. But by raising our own money, and receiving equipment donations from colleagues, our organization began fulfilling some unmet needs.”

Clinical Research at Home and Abroad

Early on, says Dr. Ross, her awareness of needs abroad coincided with a recognition of urgent unmet needs in this country.

“What we call ‘local’ and ‘global’ are both components of global health,” she says.

At her first retina practice, near Flint, Michigan, she encountered many people for whom just getting to an eye clinic and paying for glaucoma drops and other medications presented a major challenge. The only way to provide access for these patients, she learned, was to enroll them in clinical trials or obtain assistance through nonprofit organizations.

“One drawback of clinical studies is that they typically recruit well-to-do or insured patients,” says Dr. Ross, “while African American, Hispanic, and other underrepresented populations often are not integrated to represent our changing demographic. To get started in clinical research we joined the diabetic retinopathy research network, and during our first year, because of our unique demographics, we ended up recruiting the highest percentage of minorities in the network.”

In exchange for participating in the research, her patients were seen every month, received transportation and a stipend, and met with the clinical research coordinator. With education and training, their A1c levels came down and their health improved.

Dr. Ross had already considered the potential value of clinical research abroad when the Ebola virus broke out in West Africa. Stories of the outbreak on the news revealed a severely weakened public health response to a deadly epidemic that was associated with serious ophthalmic complications.

“In Liberia, 14 years of civil war led to an extremely fragile state,” says Dr. Ross. “There were no surgical ophthalmologists in the country and really no infrastructure or capacity for managing the epidemic, which is why it spread so quickly.”

In 2015, she began to participate in the Partnership for Research on Ebola Virus in Liberia (PREVAIL), a clinical research partnership between the US Department of Health and Human Services and the Liberian Ministry of Health. Under Rachel Bishop MD, MPH, and Allen Eghrari MD, MPH, the PREVAIL 3 natural history study focused on documenting the prevalence of debilitating ophthalmologic complications of Ebola, including uveitis and complicated cataracts.

“Because of a documented case of persistent virus in the eye in an Ebola survivor,” says Dr. Ross, “the timing and safety of cataract surgery was unknown. One of our goals was to learn when cataract surgery could safely be recommended.”

During successive trips to Liberia, she worked toward expanding medical and surgical capabilities, in part by teaching ophthalmic technicians and physicians the slit lamp, indirect ophthalmoscope, and optical coherence tomography. In 2017, PREVAIL partnered with 9 institutions, including an Emory team led by Stephen Yeh, MD, Jessica Shantha MD, and Brent Hayak, from four countries (United States, Kenya, India, and Liberia), to launch PREVAIL 7, a surgical safety study of cataracts in Ebola survivors.

“PREVAIL is entering year 4 now, and we are continuing to document retinal complications in Ebola survivors over time, including macular puckers and retina detachments. Soon, in conjunction with the Emory group, we expect to complete Ebola consensus guidelines.”

Getting involved

For retina specialists, says Dr. Ross, participating in global work can be an opportunity to enrich their own lives and career while giving to others. The Fulbright Specialist program is one rewarding option for fully trained retina specialists. For skilled ophthalmologists who have completed residency, global ophthalmology fellowships, such as the Scudder fellowship, provide opportunities to address gaps in medical and surgical eye care in low-resource settings in geographic regions such as Africa, South Asia, and Central America.

“You hear a lot about burnout today,” she says, “possibly from increasing administrative demands. Global health lets you take a break from onerous office tasks, and reconnect with why we went into medicine — to positively impact the lives of people in need, who are often deeply grateful.”

Avenues for getting involved exist at every point during a physician’s career, beginning in medical school. Indeed, as Director of Global Outreach at the University of Arizona College of Medicine, Dr. Ross teaches global health and ophthalmology to first-year medical students. On trips to the Dominican Republic, students provide much-needed care while exploring the use of technology, such as smart phone devices that can take pictures of the optic nerve and macula.

“Medical students today have so much to learn in that 4-year period,” says Dr. Ross. “We’ve added genetics and countless other subjects to the curriculum, but we’ve never changed the length of medical school. During third-year rotations, students typically get to pick only 1 or 2 specialties, which means that many physicians will end up knowing little about the eyes when they graduate, despite the stats that 18% of patients presenting to primary care have eye problems.”

Medical students who have just learned basic skills like how to use a stethoscope and how to check pupils are at a “prime time” in their lives for learning about global health and ophthalmology, says Dr. Ross.

“To me, it is the best time to introduce ophthalmology and humanitarian care. We see about a hundred patients a day and the students are immersed. They carry away lessons that will stay with them for the rest of their lives.”

Figure 1. Tools that first-year medical students learn to use while on international trips with the University of Arizona College of Medicine-Phoenix: Rosenbaum Pocket Eye Vision Card, iCare Tonometer, Keeler portable slit lamp, USee self-refracting glasses and refraction kit (Global Vision 2020), and VisionSpring reading glasses in boxes. Not pictured are the Peek Acuity smartphone-based vision-check app by Peek Vision as well as a portable ultrasound.

Figure 2. University of Arizona College of Medicine-Phoenix first-year medical student Neeraj Vij (left) teaches AL-UCE (Academia de Liderazgo-Universidad Central del Este, San Pedro De Macoris, Dominican Republic) students Lisbeth Vidal (center) and Damian Kacper (right) to use the USee self-refracting glasses. AL-UCE students serve as additional translators for the University of Arizona College of Medicine groups.