On a Saturday afternoon in April 2011, an ophthalmologist speaking at the Unite for Sight Global Health and Innovation Conference described his observation of two eye clinics in the global south. During his slide show of photographs, he commented that the first Ghanaian eye clinic was âa one stop shop for eye diseaseâ with a âsystems approachâ featuring two surgeons performing surgery simultaneously in the same surgical theater, a well-organized flow of patients, and the use of a microsurgical technique to correct blindness from cataract disease. A cataract is the clouding (opacity) of the eyeâs natural lens; like the mist from a waterfall, a cataract inside the eye obscures light and detail causing visual impairment or blindness.
I was already aware that the groundbreaking microsurgical technique developed at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) results in very good patient outcomes despite the fact that expensive suture thread is not required to stitch the incision closed. Nor is this particular microsurgery disrupted by the rolling electricity blackouts that are frequent in some countries with overloaded electrical grids. As I listened, other parts of this systems approach were sharpening into focus: a radical aseptic technique to prevent pathogens from contaminating the surgical theater and unique labor-intensive logistical practices for the surgical theater. The speaker pointed out it was a âvery efficient flow system that even by American standards is quite admirable.â His comment, while appreciative, still manages to make the standards developed by ophthalmologists in the global south seem Other. He firmly places those clinics in a network of ophthalmologists broadly focused on population eye health. This network is subordinate as compared to the dominant network of ophthalmologists narrowly focused on individual eye health. His rhetoric also carefully delineated the boundaries between medical practices that are good for the global south versus what is good for the USA.
A live report from the 2010 Asia-Pacific Academy of Ophthalmology Congress in Beijing also emphasized the work of Aravind Eye Care System (Madurai, India) and Tilganga. This live report highlighted a growing scientific controversy in ophthalmologyâthe dispute between proponents of two different microsurgical techniques to restore eyesight clouded by cataract (Anonymous 2010). The incumbent microsurgical technique was made by an American ophthalmologist in New York City; the challenger microsurgical technique was made by a Nepalese ophthalmologist in Kathmandu. Before this September meeting, ophthalmologists, engineers, and managers at Aravind and Tilganga had spent many years creating South Asian eye healthcare institutions. These experts contested the definition of what true cataract blindness means in terms of visual acuity worldwide and helped to redefine blindness as a public health problem that is avoidable or preventable. Additionally, they performed the operations research, health education outreach, and community-building activities to make poor rural patients aware that blindness is often a preventable or solvable problem. They utilize evidence-based medicine to challenge the incumbent regimeâs cataract microsurgical technique because of its high cost. After they created the alternative microsurgical technique, they then performed the research necessary to validate this alternative technique as an appropriate option, both scientifically and economically viable, for poor patients.
Throughout this book, I will develop a theoretical framework for socio-technical transition called the dual regime thesis . In order to define this novel transition pathway, I will summarize existing literature on the multi-level perspective in transition studies, demonstrate the relationship of this literature to my case of community ophthalmology, and also develop the concepts of interlocking innovations, contestation, and systemic technology choice . In this book, I argue that community ophthalmology professionals are an example of systemic technology choice. Systemic technology choice illustrates a new shift in the global appropriate technology movement, where there is an emerging form of high-technology innovation that responds to the needs of low-income people. Unlike the previous appropriate technology movements, this new approach to development emphasizes systems thinking, where activists believe that technology transfer is the transfer of an appropriate system of artifacts, values, norms, and ideology.
The dual regimes emerge in part because of interlocking innovations: a novel constellation of context-appropriate processes or products in science , technology , and management connected to each other by a shared ideology. Interlocking innovations circulate through diffusion , appropriation, and translation to address problems of poverty in low-income countries. These interlocking innovations travel on a global stage to other less economically developed countries and even to the economic centers of the world economy. Finally, contestation explains how, in order to move from below, some actors use new forms of science and technology to challenge existing knowledge hierarchies and that this is a normal and productive part of scientific knowledge building and technology transfer. These concepts add a newer theorization of how knowledge and technology circulate as part of socio-technical system change to transition studies (Geels 2005; Smith et al. 2016), the political sociology of science (Hess et al. 2016), and feminist postcolonial science studies (Harding 2009; Pollock 2014).
In this chapter, I provide an overview of the goals of this book. The bookâs central argument is that the multi-level perspective in transition studies cannot be used to explain endogenous development of science and technology in the global south, unless we account for the occasional development of dual regimes. Endogenous development in this case includes a novel microsurgical technique used for high-volume, low-cost care for poor people in the global south that is supported by further innovations in surgical theater management techniques, low-cost technologies, and finance . This model is being successfully exported to other countries in the south.
The remainder of this introductory chapter has the following structure: Sect. 1.1 discusses the bookâs purpose to introduce South Asia as having multiple sites of low-cost innovation in the global field of ophthalmology; I describe connections between the problem of blindness, epistemology, and innovation from below. Next, Sect. 1.2 introduces the problem of avoidable blindness in more detail, including the startling facts that make this problem noteworthy; meanwhile, I also present the theoretical framework of multi-level perspective with socio-technical regimes. Scholars from science and technology studies , business, evolutionary economics, and, the government of the Netherlands, use this theoretical framework to think through science and technology adoption and governance issues (Geels 2002; Smith 2002). Section 1.3 describes the historical origins and current practitioner understanding of technology transfer, modern development, and appropriate technology in the global south. Next, Sect. 1.4 returns to the multi-level perspective and evaluates its limitations for understanding socio-technical change in the global south. Consequently, Sect. 1.5 introduces a new theoretical framework, the dual regime thesis , in more detail. Finally, Sect 1.6 concludes by summarizing Chapters 2â8.
1.1 Science, Technology, and Innovation from Below
The purpose of this book is to demonstrate how India and Nepal have emerged as sites of innovation in low-cost, high-volume cataract surgery. Cataract disease causes 51% of avoidable blindness worldwide, approximately 20 million out of a total of 39 million blind people (Pascolini and Mariotti 2012). This disease predominantly affects an older, low-income, and rural demographic (Pascolini and Mariotti 2012). While the causes are unknown, there is an increase in cataract incidence with age worldwide, where 1 in 5 people over the age of 55 years will have at least one eye with a cataractous lens (Pascolini and Mariotti 2012). The good news is that, in industrialized nations where prospective patients have regular access to eye health care, an outpatient surgical procedure can skillfully and quickly correct cataracts.
The bad news is that the infrastructure to address this problem in low-income rural communities around the world is largely absent. While significant gains have been made since the first efforts of rural ophthalmologists started in the early 1960s, there are still not enough trained ophthalmologists or hospitals to fight the problem as the average population age increases and likewise the incidence of age-related cataract disease. An exception to this bad news lies within two countries in South Asia, India and Nepal. India and Nepal are not known for being innovative in health and medicine. Still, in 2004, both countries had high cataract surgical rates, a measurement of surgeries performed per million people with blindness due to cataract (WHO 2004).
Ophthalmology experts from around the world are beginning to look to India and Nepal for models in efficiency and cost cutting in health services delivery. Each country contains many high-volume eye hospitals that are circulating blind patients from rural through urban areas and making them sighted.
In this book, I focus on ophthalmology institutions providing a valuable eye health service to the most disadvantaged in their communities, while utilizing an approach that maximizes their self-sufficiency and self-governance. The four high-volume eye hospitals I describe include: non-profit Aravind Eye Care System in India (est. 1976); no...