- 3 years ago
Global aspects of transplantation medicine exemplified by corneal grafting
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00:00 [Music]
00:10 It's a great pleasure to have you with us today.
00:14 Pleasure is mine. Great.
00:17 So you will give me two minutes or three minutes just to present you
00:22 before I give you the micro to start your lecture.
00:26 Yeah, thank you.
00:28 So good evening everybody. We are going to start our
00:33 seminar after two months now.
00:38 It's a great pleasure for us to to have all of you with us but especially
00:45 Professor Rudolf Kittoff from Germany.
00:50 He's a very known person in research in ophthalmology in general.
00:56 He had accomplished a lot of
01:00 things in ophthalmology.
01:08 Professor Rudolf was born in Germany in 1948 and after graduating
01:15 from his high school in 1967 he studied human medicine at the
01:21 University of Frankfurt and from 1977 to
01:27 1985 he was a research assistant at the University of Hamburg Eye Clinic
01:32 interrupted in 1983 by a fellowship at Moorfield Eye Hospital in London.
01:40 In March 1992 he accepted the call to the chair of ophthalmology at the
01:46 University of Rostock which he held until to 2014.
01:53 From 2000 to 2004 he was the dean of the faculty of medicine
02:00 and since 2016 he has been leading a working group at the
02:05 University of Rostock as a senior professor.
02:08 Thank you for giving us the opportunity to meet again.
02:13 The first time it was in 2016 in Rabat and their working
02:20 conditions but besides that we had a lot of fun
02:24 at this hospital and also inside the beautiful town.
02:30 Last year Professor Pell-Mecke joined us at the German Ophthalmological Society
02:37 meeting in October. Also a great pleasure.
02:41 Today greetings from Rostock. It's a Baltic harbour town
02:49 in the northeast of Germany with a university
02:55 founded in 1419. This is the university main building
03:02 and this is the beach to celebrate.
03:08 Now let's switch over to our real topic today.
03:13 Tissue and organ transplantation ethical and economical considerations in
03:20 different health systems but also in different
03:23 cultural surroundings. In this seminar so far we have spent
03:30 most of the time with very recent developments
03:33 in our field. I will go through that outline in a way
03:37 to start with what is so special in transplantation medicine.
03:41 How can we evaluate transplantation medicine in general?
03:46 Which scale can be applied for quality check of our numbers?
03:50 Transplantation medicine will be exemplified for corneal grafting
03:54 as we are ophthalmologists and it's really a global challenge
03:58 to fight corneal blindness under very different conditions.
04:02 Relations between corneal and organ transplantation
04:07 are addressed and the interaction of financial,
04:11 technical, ethical and cultural aspects and its global difference.
04:19 We know we will need another update now in this seminar. We mainly talked about
04:30 physics and high quality treatment and diagnostics today.
04:37 So we are informed about recent developments in our field.
04:42 So we have updated our so-called standby knowledge with many facts.
04:50 But we know we will need another update in a year or two.
04:56 Standby knowledge does have a rather short half lifetime.
05:02 I am taking this opportunity to talk about today about
05:06 ethical aspects which may be addressed as oriental
05:10 knowledge, dealing with rules and considerations
05:13 known for hundreds of years which do have a long
05:17 half lifetime, maybe up to infinity. These topics
05:22 were addressed at the Leopoldina Symposium. The Leopoldina is the name of the German
05:27 Academy of Science where we had a meeting in 2017.
05:34 So it might be helpful to revisit these ideas from time to time.
05:41 Friedrich von Hardenberg named Novalis, a German writer and philosopher of the
05:48 Romantic period in the early 19th century, said
05:53 for every step medical science advances, medical ethics has to make three steps
05:59 to keep up. So what is so special
06:05 in transplantation medicine?
06:08 There is always a patient
06:13 and a doctor tending to help him.
06:18 But there is also a donor of whom, at least in our system,
06:25 a dedicated surgeon following highest professional
06:29 standards embedded in our local social and ethical system will
06:33 explant a required organ or tissue.
06:40 It may happen and does happen that we are dealing with a donor
06:44 from a foreign social and ethical system
06:48 of which the transplant surgeon may know little.
06:53 That's why it is relevant for transplant surgeons to think
07:00 globally before acting locally. And there so there is a need for global
07:07 ethics to embed all these aforementioned
07:11 elements, a real challenge for the newly founded
07:15 Leo Bondina section, global health. I am going to present
07:22 some ideas following rules which are given by
07:25 Galileo, you may know this name who fought against the
07:30 geocentric idea of the world and of our universe. He said
07:37 measure what is measurable, what is not measurable, make measurable.
07:46 But how to deal with the remaining unmeasurable
07:51 elements in medicine?
07:55 Which currency should we use? Thinking in a global sense,
08:00 we know we cannot use one and the same currency everywhere.
08:05 There are options, money, charity, reputation and so on.
08:13 How we are dealing for instance with cultural objects
08:18 and cultural values? I do hesitate to make any evaluation at
08:25 this stage of our considerations but at the end
08:28 we may come to Giovanni Mario's conclusion, he is a German professor
08:34 for ethics and medical in Freiburg, Germany. He said
08:38 each society generates that kind of medicine which it
08:45 deserves.
08:47 This sounds very rigorous, there are connotations of harsh, inhuman or
08:55 even brutal. But societies differ in terms of wealth,
09:01 self-conception and their willingness to prioritize
09:06 something like transplantation medicine into their
09:10 health care policies.
09:13 So transplantation medicine we try to exemplify now
09:20 by corneal grafting, the global challenge to fight global blindness.
09:30 To exemplify these phenomena, let me use corneal grafting
09:35 as a global challenge to fight blindness. As an ophthalmologist,
09:42 it's our aim to produce as many quality adjusted life
09:49 years as possible through the replacement
09:52 of the cornea or at least a part of it by donor material. Legally the cornea
09:59 is a tissue which can be stored under
10:02 under culture conditions in culture dishes for some weeks.
10:06 Worldwide we have approximately 216 million individuals
10:14 visually impaired and 4.5 million approximately 2%
10:19 have moderate to severe visual impairment due to a loss
10:23 of corneal clarity.
10:28 98% of corneal blindness is outside developed
10:36 countries. Because of corneal diseases primarily
10:42 affect the younger population, the number of disability adjusted life
10:47 years compared with for example cataract related blindness
10:50 is even higher.
10:57 Despite major advances in the field, only one out of 70 individuals with
11:02 treatable global blindness ultimately undergoes
11:06 surgery because of a multitude of region-specific factors.
11:12 This unreadable graph shows the situation
11:18 in 116 countries. The annual rate of corneal transportation
11:24 performed per million inhabitants on the left side
11:30 and on the right side the procurement in one country.
11:40 Both figures are dominated by the United States of America, the green arrow
11:45 here and there.
11:50 200 transplantations per million per year are nearly twice as many but nearly
11:57 twice as many donor corneas nearly 400 per million per
12:02 year. That means about 50% equals 60,000
12:06 corneas ready for shipping to other countries.
12:12 Germany, the red arrow here and there, is a pure self-supplier with about
12:19 the rate one by one. Japan, the blue arrow,
12:26 imports 50% of its needs, Pakistan even more. China is a very special
12:35 issue which I will address later. Why can the United States
12:41 be so dominant? To reflect the background of all these
12:46 figures published by French group,
12:50 I contacted 20 colleagues and friends worldwide
12:54 and I will quote some of their answers.
12:59 In the United States each hospital
13:06 is obliged to cooperate with an i-bank. These i-banks are non-profit
13:12 organizations. In order to increase the number of donors,
13:18 the i-bank locates trained non-professionals in each hospital
13:24 to communicate with potential donors or relatives
13:29 prior or after death. Inoculations are exclusively performed
13:35 by professionals.
13:38 Result, common buttons of tissue for organ transplantation exceed by far
13:45 the in-country need.
13:48 Export to other regions of the world is performed with great success for
13:53 Pakistan to Japan to Egypt, probably also to
13:57 Morocco.
14:00 In Germany, as pure self-supplier, we just, as a statistic we show, but might be
14:08 true certainly also in the United States, D-MEC
14:11 is taking over in many other western areas so the full
14:16 transplant is becoming rare, but nevertheless the need
14:20 of corneas remains high. What about Japan? The country with highest
14:27 standards in education, technology and economy.
14:33 I received a very personal answer from a close friend,
14:36 Teru Neshida from Yamaguchi. He was the head of the university of
14:41 that town, it's in the south of Japan. He wrote, and let me quote the part of
14:47 the letter, "The story will go back to the 6th
14:51 century when Buddhism was first introduced in our country.
14:55 In other words, your question, how we are dealing with it at present
15:01 regarding to transplantation is a worse iron on myself
15:04 personally who was been seeking the meaning of life in Japan. I was
15:10 baptized as a catholic, as a christian, but
15:15 my deep emotion feeling is to Shinto." On the right top, this is Teru Neshida
15:22 with his wife during his emeritus ceremony.
15:26 So we had a privilege to join the party some 10 years ago.
15:30 To summarize the Japanese situation, need for corneal transplant surgery
15:38 equals the one of the United American situation,
15:42 but due to ethical religious tenor of the majority of the population, tissue
15:48 and organ donation programs are not at all able to meet the
15:54 nationwide requirements. Also potential recipients are hesitant
16:00 in their decision due to ethical and religious
16:03 consideration. The concept of purity interacts with transplantation medicine
16:10 in general. You should not allow a part of a
16:15 deceased body to become a part of yours.
16:20 In Pakistan, professor Zanahullah Jan, a close friend of mine
16:28 from Peshawar, told me that 95 percent of corneal grafts are donations coming
16:35 from US American physicians of Pakistani descent.
16:39 They've even founded a dedicated society.
16:44 But since 2015, 5400 corneas had been grafted and
16:52 things are on change in some regions at the moment.
16:58 This is a program in Peshawar. It's exactly what I told.
17:07 They need 100 percent of import, but in other areas,
17:11 but they're improving, creating an eye bank at the moment.
17:14 But in other areas of Pakistan, especially in Faisalabad, not too far
17:19 away, they have started harvesting their own
17:22 corneas. So the majority there now, despite that
17:26 nothing, no religious purpose again, speaking against,
17:30 they have started creating their own eye banking systems with great success.
17:35 In China, the situation seems to be quite complex.
17:42 There are statistics about 40,000 corneal transplantations each year.
17:47 Professor Tao Yao from the university in Shenyang told me.
17:54 China is a multi-ethnic and multi-religious country. I quote,
18:00 most ethnic and groups and religion encourages
18:04 and support organ donation for corneal transplantation. Both
18:08 donors and recipients are not limited by nationality
18:12 origin. However, it's worth mentioning that the use of PICC-derived commercial
18:19 cornea products, it's not full corneas, is still limited to patients with Islam
18:24 of a special group because of religious beliefs and poor kind cornea and the
18:29 poor kind cornea is not the only choice in most cases. I
18:33 can't judge on this element. I couldn't find any
18:35 detailed literature on that. It is known, nevertheless, it is known that
18:41 executed individuals were used as donors for various organs, including
18:48 the cornea.
18:51 This is specified in a recent review published in the American Journal of
18:58 Transplantation with the Impact Factor of Age by Robertson
19:02 and Lavi, one from the United States, one from Israel,
19:06 revealing the following, because these organ donors could only have been
19:12 prisoners condemned to death, our findings strongly suggest that
19:17 physicians in the People's Republic of China have
19:21 participated in the executions by organ removal.
19:27 I do recommend to read this article. Doctors are going to be a part of the
19:34 execution procedure, so it's a very special way to harvest organs.
19:42 In the DRC, where we have been partnering for more than 20 years,
19:49 we received the information there is no legal framework for organ
19:54 transplantation in Congo. Bantu people never accept transplantation
19:59 medicine as he thinks he will live with another
20:03 soul from another person inside himself.
20:09 Obviously,
20:12 breaking taboos today is still a major issue.
20:19 If you are interested in that topic, I advise you to read Chinua Achebe's
20:24 novel, "Nigeria, Things Fall Apart." This author was the
20:29 awardee of the Friedenspreis des Deutschen Buchhandels in 2002,
20:33 the highest German award for literature in Germany.
20:38 Chinua Achebe's projection into the future sounds very positive.
20:44 Let's hope for the best.
20:47 We do not have the same past, you and we, but we will have exactly the
20:57 same future. The age of isolated destinies is over
21:02 once and for all. Maybe we should make a question mark at
21:08 the end of this quotation.
21:11 What about the relation between cornea and organ transplantation?
21:23 Is there any distributive justice globally?
21:27 Probably not. As far as we can see in Europe,
21:32 eurotransplant, living in the same cultural surroundings
21:36 in many countries, have quite successful in involving many
21:42 countries at the same standard and it works quite well.
21:46 Victor Fuchs, the Nobel Prize winner for economics,
21:51 stated in his book, "Who Shall Live?" The organization of medicine is not a
21:58 separate thing that can be subjected to study in
22:03 isolation.
22:06 It is an aspect of culture whose arrangements are inseparable
22:13 from general organization of a society. And this is certainly also true for
22:20 ophthalmology.
22:23 Alvin Roth, the co-recipient of the Nobel Prize for economics in
22:32 2012, tells us, "Doctors don't automatically think of ophthalmologists
22:40 as fellow members helping their profession. Generally, I think they are
22:44 money makers." He demonstrated, nevertheless, by game
22:48 theory-based algorithms, he could help very
22:51 successfully the kidney exchange program in the U.S.
22:56 and have more than double kidney transplantation rates by living donors.
23:01 He even sees a way that in future people might be able to be paid for their
23:07 kidneys, knowing that offering financial
23:12 incentives for organs is an ethical
23:17 argument that many, both inside and outside the medical establishment, are
23:22 against. But if you have wise and clever
23:26 decision-making processes and control of the system,
23:29 we may see in the future that this will work.
23:33 It works in Spain, does not work in Germany, as our legal
23:36 institutions are very slow, but at least the Americans, especially in the
23:42 New England states, they are extremely successful doing that.
23:46 He discussed very serious terms like criminalization of kidney donations
23:51 versus legalization of prostitution in a very
23:55 open manner. But we shouldn't be shy to be
24:00 offensive in trying to help people.
24:04 Kidney transplantation equals the risk of liposuction cosmetic procedure.
24:13 Why have to accept, we have to accept, that economical values are indispensable
24:22 to implement moral values. We need the economy urgently.
24:30 The cosmopolitan tradition,
24:39 the noble but flawed idol.
24:44 Nathalie Amiri, an Iranian-German writer and journalist, reported shocking news in
24:52 her recent book on Afghanistan. She visited remote villages with hardly
24:58 anyone with two kidneys. So no doubt there is a black market for
25:04 the red market of unknown dimension. To control this situation,
25:09 an overwhelming apparatus of legal and ethical control mechanisms is needed
25:14 and no one knows whether this is manageable.
25:19 Coming to some conclusions. The problems we have discussed
25:30 are permanent ones and we are not living as we are not in an ideal world.
25:36 The challenge will remain.
25:40 You can choose between the search for truth
25:50 and peace of your mind. But you cannot have both at the same time.
25:57 Kisrael Faldo Emerson, an American philosopher of the
26:01 19th century, maybe we can deal with both elements sequentially.
26:08 It is our privilege but it is also our duty as members of
26:13 universities to set aside from our daily routine from time to time
26:19 trying to have such kind of helicopter view
26:23 to look a little bit in the future.
26:30 For our daily life, Max Weber's terms "Gesinnungsethik" - ethics of attitude
26:37 and "Verantwortungsethik" - ethics of responsibility
26:42 may give us some relief in our clinical decision-making elements.
26:49 We would not be able to manage our daily duties purely driven by ethics of
26:53 attitude. We have to realize there are equal
26:58 duties to manage patient care, science and administration. This dilemma
27:03 of course was known to Max Weber. He just wanted to stimulate
27:09 us to see both sides of the medal. Thank you, Jamomed and Wolfgang,
27:16 bringing us together today, moving forward to any kind of cooperation in
27:23 the future with much pleasure. We need cooperation, we need
27:28 looking over our own little plate as we say in Germany. Thank you very
27:35 much. Thank you, Professor. It was a wonderful
27:40 lecture and a lot of questions.
27:45 I am doing corneal graft here in Morocco
27:51 and I receive a lot of patients from Africa and they know it's
27:58 absolutely not developed in a lot of countries
28:01 in Africa. So how do you see, how do you imagine the development of
28:08 graft in general and corneal graft especially in
28:11 those countries?
28:14 As I mentioned, we can't separate this from
28:19 from economical possibilities of a country.
28:23 You probably see people which are able to pay
28:26 for their airfare and for the procedure and coming maybe from countries
28:33 where they are not willing or not able to collect their own
28:38 cornea, despite the fact that they might be not
28:40 able technically to do transplantations. It is a real big ethical challenge
28:48 and sometimes I ask myself going to Africa,
28:51 where should I put, where should we put the energy there
28:55 in order to save or to create as many seeing years as possible?
29:00 It is a questionable thing to create in sub-Saharan Africa
29:05 i-bank systems which cost a lot of money instead of doing more cataract surgery
29:11 to create seeing life years. So I have no answer to that but
29:18 coming from outside and interacting with cultural
29:22 elements and the elements of a health system,
29:25 it brings us in trouble. So as the last quotation,
29:29 see there is something like ethics of attitude,
29:35 then we should do corneal grafting as much as we can,
29:39 but then there is ethics of responsibility.
29:43 Then we have to check whether we do cataracts or
29:47 corneal grafts with a cataract surgical rate of 100 or 200 per million per year.
29:57 How do you feel Mohamed?
30:00 For myself, I think that there are many aspects of this topic
30:08 and one of the challenging topics is the education of the ophthalmologist
30:14 about this surgery because many of them
30:19 don't have the experience of this and I think there is a lot of things to do
30:24 with the education of ophthalmologists
30:26 regarding techniques of corneal graft. This is first.
30:31 Second part, I think that there is a lot of things to do with the prevention
30:35 of the corneal blindness in general, especially
30:39 the prevention of infection during childhood and trauma during childhood.
30:48 The third one that you underline is the problem of the
30:54 management and the organization of the health system in general,
31:00 which is very important to establish a program of
31:04 of graft. What do you think Jutta?
31:09 I think the problem is that we do not have enough corneas
31:16 globally and I've heard from your talk from the US that they have a very
31:23 good system to get their corneas and they can sell
31:28 a lot of corneas all over the world. So I think we should learn
31:34 more from them. Even here in Austria we need more corneas,
31:42 but we have good luck. We have an opting out system,
31:45 so it's easier to get corneas here. Yes, but another question I have, it
31:52 was very interesting to hear that a lot of
31:58 cultures, they don't want to get a deceased part
32:01 in their bodies. So maybe an artificial cornea would be a solution for these
32:08 cultures, what do you think? Yeah, of course it would.
32:13 And the Chinese
32:16 mentioned the experiments with porcine corneas,
32:24 but at the moment practically the artificial
32:31 corneas are in a very early stage of development, even if people tried for
32:35 decades to do it. But besides the fact of the corneas in
32:39 Africa, in sub-saharan Africa, not only are the corneas
32:42 missing, but also the ophthalmologists are missing.
32:45 With two or three per million ophthalmologists,
32:51 would it be ethical to train
32:56 under 10 ophthalmologists per million per year
33:01 to train them in corneal grafting and leaving the cataracts alone?
33:05 Rolf, I think this is an important question.
33:10 It is not only a question of ability, it's a question of resources
33:17 and of priorities. As you say, we still have a lot of cataract
33:23 patients which are not served,
33:28 which is much easier than a corneal graft.
33:32 So, Mohammed,
33:37 I believe that Africa is not equal to Africa.
33:44 There are many countries with different requirements.
33:47 You may see that Morocco has a certain infrastructure, but other
33:53 countries are maybe far behind.
33:58 So, what do you think are the priorities
34:02 to help African countries?
34:06 For me, education is the most important thing.
34:11 There is a huge need for education and I think that
34:14 if we want to have something which is sustainable,
34:20 it is to work on education. This will allow us to have in the
34:26 coming maybe 20 or 25 years some results.
34:33 As you know, corneal graft is not only a problem of the surgery itself,
34:38 it's the problem of the follow-up after.
34:42 So, we cannot go there and do many cases and go back to home and
34:48 leave this patient without any follow-up.
34:51 So, it's absolutely very important to educate
34:55 eye doctors there. Yes, and I also think that you need,
35:02 everybody says it is almost impossible to have the infrastructure for corneal
35:07 grafts in Africa. I don't completely agree with that.
35:13 I think you have the advantage of having the salaries of each country.
35:21 If you want to import products, it may be very expensive.
35:26 I believe that it is better to help African countries to develop their own
35:32 infrastructure and to have their own corneal grafts.
35:35 Don't you think so?
35:38 It's also part of education.
35:42 It's a little bit out of the medical system and we would have to change the
35:49 mentality of some of the African leaders or some
35:52 of the African societies and the interaction between
35:58 major players in the world which are economically driven.
36:04 I work there, especially in one place, so I couldn't judge. I know that
36:08 Africa is such a complex and interesting continent
36:12 and you can't compare South Africa which is so well developed in many aspects and
36:16 probably Morocco is so well developed with typical areas like the one I know
36:21 which is the Democratic Republic of Congo.
36:25 And even there, 80 million people, 15 of them in the capital
36:33 and hardly any eye doctor outside the big cities.
36:38 So, what to do when the local system, when the local
36:44 politics, the local health politics
36:48 obviously don't put much effort in creating
36:52 a higher number of doctors, the higher number of
36:56 surgeries. Of course, we fully agree educating people
37:02 would be the way. It would even simplify the acceptance of being a donor after that.
37:09 Yeah, of course.
37:12 Professor Rudolf, we have a question about artificial cornea.
37:19 For me, but correct me please, artificial cornea is the last
37:24 chance for a patient who could not have the human cornea
37:28 and until now we do not have an artificial cornea, a keratoprosthesis
37:35 which can be better than a human cornea. But you can give your
37:43 feedback about that. I absolutely agree. In early times we try to create
37:48 artificial cornea using hydroxyapatite
37:53 connections. At the moment, the only one I
37:57 have seen working was the strampelli osteo-odontocardiopathesis, but this is a
38:03 major issue and only suitable for only eyes,
38:08 highly vascularized, unsuitable for any kind of
38:12 grafting. I know that also in, sorry, I've forgotten the name,
38:20 Kleismann in the US used artificial corneas with higher success,
38:26 but again left for those where every other method has failed.
38:32 Yeah, yeah, and we have probably to underline that
38:36 we hear in Congress about the culture of endothelial cells which have
38:42 been developed in Japan. Yes. Yeah, and maybe this could be
38:48 the future of endothelial diseases. Yeah, to replace DMACC.
38:55 Yeah, might be, yeah.
38:59 Hopefully these cells know that they should not invade the
39:03 chamber angle.
39:06 Yeah.
39:09 Any comments?
39:13 Wolfgang, any comments? You have worked on keratoprosis in the past
39:21 and you can tell us about your experience about this.
39:26 I think we could improve keratoprosesis. It's very challenging, however,
39:35 it is very challenging to make a keratoprosesis
39:40 and if we need to do that based on European
39:45 salaries, it will be very hard to provide this to African countries.
39:54 Even in Europe it's not acceptable to pay for the work effort of
40:02 several days in modifying a surface of a
40:07 keratoprosesis. So we have finally given up our own efforts
40:14 in providing such keratoprosesis
40:18 for economic reasons, frankly speaking. Yeah.
40:24 So on behalf of all of you I would like to thank Professor Rudolf Guthoff
40:34 who has honoured us to be with us
40:40 at least virtually. We probably need to see you soon here
40:47 physically to visit our university. It's now seven years that you have been
40:54 here, so eight years, I think seven, between seven
40:59 and eight years. So probably it will be a good opportunity
41:02 to have you here to see our young university and our young
41:06 doctors. I would like just to underline that our next
41:11 seminar will be in June 21
41:15 and it will be presented
41:21 by Professor Gisbert Van Sinten in June 21
41:27 and it will be about the problem of dry eyes in
41:31 cataract surgery. So the announcement is already here and
41:38 we hope to have many of you with us next time. Thank you very
41:44 much Wolfgang for being with us and for supporting us.
41:48 Thank you very much Professor Jutta. You are always a great support for our
41:54 university. Thank you very much. Let me make a final comment.
42:00 I had the honour to observe the development
42:05 of your hospital and your university, Mohamed,
42:08 and I'm really, really very happy for what you achieved. Good luck.
42:14 Thank you very much Wolfgang. So goodbye and see you soon. Goodbye.
42:21 Thank you very much.
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