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Rubens Belfort Junior

Rubens Belfort Junior: It is time for generic glasses (i.e. without a brand)

A specialist in geriatric ophthalmology says most Brazilians’ eyesight problems can be solved simply and cheaply

Rubens-Belfort-Junior_Eduardo-CesarEduardo CesarProfessor Rubens Belfort Junior comes from a long line of São Paulo eye specialists. The Belfort Clinic was founded by his grandfather in 1933 and inherited by his father. Today, the only members of the family who work there are himself and Rubens Belfort Júnior, the only one of his four sons who decided to follow in his footsteps. The family business notwithstanding, Belfort’s favorite place is the university. There he teaches, does research, supervises and initiates projects that range from the most basic research to applied studies of broad public interest.

In recent years, Belfort has focused on two themes. The first is the need for the government to distribute unbranded glasses to underprivileged people over the age of 50 as a way of improving their quality of life. The second is to promote constant awareness of the care that physicians in general and ophthalmologists in particular must have with the growing elderly population. He covers this in Oftalmogeriatria (Geriatric Ophthalmology), published by Editora Roca in 2009, which he wrote with Marcela Cypel.

A professor at the School of Medicine of the Federal University of São Paulo (Escola Paulista de Medicina da Universidade Federal de São Paulo – UNIFESP), Belfort is the only Brazilian ophthalmologist who is a member of the Brazilian Academy of Sciences (Academia Brasileira de Ciências), the National Medical Association (Associação Nacional de Medicina), the Academia Ophthalmologica Universalis (Universalis Ophthalmology Academy) and of the prestigious International Council of Ophthalmology. He has also chaired the World Ophthalmology Congress. Until last year he headed the Vision Institute (Instituto da Visão), part of UNIFESP’s Department of Ophthalmology, for which he has managed to build a new skyscraper, to be inaugurated this year. At present, he chairs the São Paulo Society for Medical Development (Sociedade Paulista de Desenvolvimento da Medicina – SPDM). It is the largest philanthropic organization in the field of Brazilian health care and has links with UNIFESP. It owns the São Paulo Hospital, manages 30 healthcare units and has more than 26 thousand employees across several Brazilian states.

At the age of 64, he can list a number of projects that are underway or awaiting their turn. Not all of them are just academic, but all draw on his work at the university. The highlights of the interview are below.

Last year the book you wrote with Marcela Cypel, Oftalmogeriatria, won the Jabuti award as the second best medical book in the country. Why has geriatric ophthalmology become important?
It’s simple. Worldwide, populations are ageing and the extending of the later phase of life results in a major impact on medicine. If you think of three or four eye diseases, you will probably remember glaucoma, cataracts and macular degeneration. All three occur in old age. Furthermore, it is in underdeveloped countries where one expects a larger increase in the population above the age of 70. We need to bear this in mind when considering the various scenarios for planning our research, education and welfare activities. I’m not talking about 65 year old people, but about those who are 80, 90 and so on. 100 year olds will be much more common among us. Furthermore, we need to look at the eyes of elderly patients differently.

Is it harder to treat elderly patients’ eyes?
A number of medical values are often not properly applied to the elderly. At a certain age, people become slower. We need to respect that response time and preserve something very important: the patients’ independence. When an 80-year-old patient comes into an appointment with her daughter, or sometimes with her granddaughter, there is a tendency for physicians to talk only to the person who is assisting, rather than to the actual patient. These details of psychology and communication are important. Furthermore, one mustn’t forget that, of all technologies, the most important one in medicine is still communication. However, other aspects are equally important. For example, the act of opening a bottle of eye drops and dropping them into one’s eyes is trivial for a young person. However, for an individual whose hands shake and who has difficulty reading the label, it is much more difficult. Elderly patients sometimes take 15 types of medication daily. Unnecessarily changing or adding a drug has not only economic but also social effects. Furthermore, if the patient can’t see or sees poorly it is much harder to perform day-to-day tasks. We have to improve the quality of life of the elderly rather than merely worrying about curing diseases, especially because sometimes they are incurable. We need to understand the diseases that affect quality of life and concentrate our efforts there. Often the patient also has cognitive or memory issues that are not yet evident. The person goes to the appointment and appears to behave normally, leaves with a prescription and, suddenly, it’s like giving a prescription to a four-year old who does not know what to do with the piece of paper. You only realize this when a family member calls and says, “What did you say to my father when he was there? He can’t remember a thing.” Geriatric ophthalmology addresses these problems, in addition to technical ophthalmologic issues, and is partly the product of Marcela Cypel’s doctoral thesis, for which we monitored octogenarians, nonagenarians and centenarians. We have already studied the eyesight of over 50 centenarians.

When did the project start?
Three or four years ago. We’re starting another very interesting project that will examine twins who are 70 or older, both identical and non-identical. We want to understand what is genetic and what is environmental. Does an 80-year-old individual have the same kind of eye problems as his twin? The coming years will increasingly reveal the impact of epigenetics and genetics.

Let’s talk about your background. You come from a veritable dynasty of ophthalmologists, right?
It’s five generations of doctors. My great-grandfather, José Nunes Belfort Mattos, in the early 1900s, was an astronomer. He was the director of the São Paulo observatory and he registered the city temperature and climate. For instance, he registered that in 1918 it snowed in São Paulo. In our family house, on Avenida Paulista, he had a private observatory, which was later integrated into the São Paulo government and the history of meteorology and astronomy in the state. Perhaps because of that – all those lenses – my grandfather, in medicine, became interested in ophthalmology. He worked in Campinas at the Penido Burnier Institute in the 1920s. In 1930, he came to São Paulo. He was an ophthalmologist, a politician and a communist. My father was also an eye doctor, as am I and one of my sons, who has just returned from Canada and the United States as part of his doctorate. However, it’s just a fortunate coincidence. I have four children and only one went into Medicine. Of the other three, one went into Economics and my two daughters went into Management.

Why did you first do a doctorate in immunology and then another in ophthalmology?
In college, I was interested in preventive medicine, epidemiology and infectious diseases. I worked with Drs. Walter Leser and Roberto Baruzzi, as well as the Villas-Boas brothers. However, at the end of the course, I changed. I began specializing in ophthalmology and became interested in infectious eye diseases. I took a course in basic science in the United States, where cellular immunology was apparently beginning to solve many of our problems. Here at the Paulista medical school I was fortunate enough to meet brilliant Nelson Mendes. He was a little older than I was and already held a degree in immunology. Furthermore, I took the World Health Organization course at the Butantan Institute on the topic. Then, thanks to the guidance of Nelson and others in the 1970s, I realized that, rather than a Ph.D. in ophthalmology, as an ophthalmologist I was better off doing one in immunology. After all, cornea transplants, uveitis, infectious diseases and even diabetic retinopathy and  so-called degenerative problems already appeared to be related to immunology, and, now, to molecular biology. As only the Federal University of Minas Gerais had post-graduate degrees in ophthalmology, I went the opposite way: I did a Master’s degree in immunology and Ph.D. in immunology with Nelson Mendes at the Escola Paulista and, simultaneously, although this was in theory forbidden, I did a Doctorate in ophthalmology with Fernando Oréfice and Hilton Rocha, in Belo Horizonte.

What was it like working at the Jundiaí Medical School (Faculdade de Medicina de Jundiaí)?
I had finished the Master’s degree. I was less than 30 years old and went there as a full professor. My residents were almost my age, which was great in terms of communication because we thought alike. Today, at the age of 64 and having been a professor from the age of 29, I see how it is increasingly difficult to reach the young: the gap is widening. Furthermore, something very interesting happened in this sector, which shows how important it is for systems to hand real power to young people. Two professors of ophthalmology who stood out in São Paulo, Newton Kara José, in Jundiaí, at the State University of Campinas (UNICAMP) and the University of São Paulo (USP), and myself in Jundiaí and UNIFESP, both started very young. Newton began in Jundiaí, and when he went to UNICAMP and I filled his position. When I left for UNIFESP, the place went to Ana Luisa Höfling-Lima, who was also very young. She is now a professor at UNIFESP. After I became a full professor at UNIFESP and before taking the job, I decided to take a sabbatical and went to the National Eye Institute of the National Institutes of Health (NEI-NIH), in the United States. I spent one year working in ophthalmology, immunology and molecular biology related mostly to HIV. I was hired by the NIH as a visiting scientist with surgical privileges. This meant I could operate in the United States’ glorious! I came back in 1990, revitalized.

Have you always practiced medicine?
Always. I’d starve if I didn’t practice, with the large family I have. Furthermore, the consulting room provides you with opportunities and challenges that are relevant to academia. Had I not practiced medicine and needed the money, I would have become a bureaucrat, and have had no contact with patients except in slides or in artificial situations. I think the experience and challenge of clinical and surgical practice are crucial. There I have to compete with anybody, usually someone younger, in the free market, and you don’t need Master’s degrees, Doctorates or Post-doctorates. At the university, we compete through formal procedures, through financing and in situations, which are often irrelevant to the problems that patients face. On the other hand, the university environment is critical and innovative and it is essential to keeping the practice up to date.

EDUARDO CESARYou practice at UNIFESP and at Clínica Belfort?
Yes and I also operate in the São Paulo, Einstein e Santa Cruz hospitals. When I started at the Clínica Belfort, in 1970, my father had 12 doctors working with him. Two years ago, my mother at the age of 83, told me. “We were so happy when you went to study ophthalmology. We never imagined that you were going to ‘destroy’ the family clinic.” The clinic was set up by my grandfather and he and my father dedicated their lives to it. My father was a professor, but his life consisted of practicing medicine. Naturally, he discovered that even though we were both eye doctors, our life paths were different. When he died, the clinic was just about reduced to the two of us. The office is essential to me, but the University is my home.

How many of you are there at the clinic today?
Myself, my son and another two ophthalmologists, also teachers, who work there on a weekly basis, to complement our service and cover for us when one of us travels.

How did the cataract surgery “task-forces” start?
I always thought that there was no point in having better and better medicine, if it was increasingly far removed from the population. Moreover, in the 1980s, thanks to my father, Newton Kara José and I met Carl Kupfer, who at the time was the director of the National Eye Institute in the United States. Kupfer was an unusual American, progressive and an internationalist. He introduced us to these ideas. When one mentions cataract task forces, one must always remember Newton Kara José. He was the leader. At the time he was already a full professor at UNICAMP, where nobody got in his way and they let him create new systems for caring for patients.

But how did it start?
Newton began radically criticizing the inefficiency of hospitals in which it was considered OK to operate on only one or two cataracts per day. Then he started doing 12, 20 cataract surgeries per day. This sparked, in myself and in others, the desire to do more and better by increasing the scale of surgery without jeopardizing quality. Then we wanted to do 50 operations a day. Furthermore, we began to compete. Newton was always a leader. He would go off somewhere in Brazil to do one set of cataract operations and I would go to another, always competing. We’ve been friends for over 30 years.

The task forces were always separate?
They were separate, but thanks to our common goal we managed to reach out to many people in Brazil and abroad. It was a movement that came from the university and that caught on with the Brazilian Council of Ophthalmology and state governments. The time was right because a new attitude towards healthcare had arisen here in São Paulo, thanks to the government of Mario Covas. I do not want to appear partisan, but it was when José Serra became Health Minister in 1998 that it all really started happening on a nationwide scale, because he understood the importance of it all and went on to lead new ideas. Once, Serra, as Health Minister, visited the São Paulo Hospital, having been brought in by Dr. Miguel Srougi, who introduced me to him. We started talking about diabetes and blindness. He replied that he knew nothing about it and asked me to go to his office that same evening. We had two hours of frank discussion about eye-care, doctors and public hospitals and I had to answer a battery of questions. I explained the importance of having task-forces for fighting ocular diabetes.

And he agreed…
Immediately. At the end of the conversation, he made me commit to doing what I had promised. Then he asked me to call an aide, Renilson Rehem de Souza, early the next day, in the ministry. I was worried maybe I had left with a false promise, but I did what Serra had asked and found Renilson the next morning already informed and working on the idea. That same morning we began the ocular diabetes task force, which spread throughout Brazil. After the cataract and diabetes projects, he accepted a third one, also very important, for cornea transplants. All of that changed eye-care in Brazil.

Was this the project that eliminated the queue for cornea transplants in the state of São Paulo?
Yes, patients had always had to wait for years for cornea transplants in all of Brazil, until the university, the CBO and the government came together to restructure the transplant program. Furthermore, today, in São Paulo, no patient waits more than a few days to do the surgery. Zero waiting. The Unified Health System (Sistema Unificado de Saúde – SUS) works. This was done by improving transplant rules to give proper importance to the issue of management and funding, which now rewards not only the number of transplanted corneas but also the number of donated eyes. This strategy was very effective in increasing the number of corneas for transplant and research and training. Now it’s ironic, iconic, and sad, that other states, even close to São Paulo, still lack cornea banks that work effectively. The message is obvious: federal regulation and funding will not work without appropriate local structures, social organization and political dedication.

Why did the city of Sorocaba, in inner-state São Paulo, become a symbol of transplant success?
For many years, Sorocaba has had a visionary, idealistic and excellent administrator in the figure of Paschoal Martinez Munhoz. With support from organizations such as the Freemasons, he developed an efficient method of collection, in which family members of the deceased were approached properly at the mortuary by someone who explained the possibility of donating the eyes, which can be removed even several hours after death. At the mortuary, the family’s pain is already reduced by practical concerns and it is easier for them to understand the social benefits of donation, in addition to the financial benefits, as certain expenses are covered by the donation. Furthermore, Paschoal understood how to use this adequately. In a smaller town, people started seeing better the effects of what they were doing and the community was proud of being the municipality that donated the largest number of eyes for general benefit. Sorocaba began exporting corneas to other cities in São Paulo and the rest of the country. This model has been replicated is now widespread in the state. Furthermore, the State Health Department, together with the Ministry of Health, played a key role in creating and equipping other centers.

What happened in the case of Pauini, the city in the Amazon that had the lowest literacy rate a few years ago?
Pauini came to light thanks to the Solidary Literacy program, headed by Ruth Cardoso. We used to talk about the difficulties of teaching reading and writing to the elderly and I commented on the experience of the military governments with Mobral in the inland Northeast. People did not learn and were sometimes regarded as stupid, but the truth is that they were elderly and did not see. Ruth immediately understood the need to first provide eye-care and only then begin the educational process. We went to Pauini before the Solidary Literacy program began. We examined all prospective students and delivered the glasses before the classes began. It became a mark of the fabulous work that Ruth Cardoso began and it continues now, after so many years. It was replicated in many other places. Furthermore, guess what. As a result of that work, which was no more sophisticated than examining eyesight and providing glasses, we discovered and published articles about a new eye disease in Brazil, caused by a nematode: Mansonella ozzardi.

What does it cause?
We don’t really know yet; maybe difficulty in seeing. At the moment we are preparing a project to present to FAPESP.

Do you attend the task forces?
I have been to many and still love to go. Not just to see patients being treated, but to feel the human solidarity and social involvement. The hardest service in those situations is still prescribing glasses. It is very important to provide glasses. Without glasses, adults over 40 cannot work, read or live well. No indigenous person over 50 can bait a hook or produce handicraft without glasses. Glasses are indispensable for the quality of life.

Is dispensing glasses undervalued by ophthalmologists?
Absolutely. It’s too easy to do. There’s no glamour. However, prescribing the right glasses can take longer than doing cataract surgery. Inadequate glasses are still a frequent complaint among patients of all levels in Brazil. Furthermore, this under-valuation of some activities is very bad, because disqualifying the job of giving glasses, in a certain way, is like disqualifying the work that gives people sight. Starting with the Solidary Literacy program, we began a project, supported by optician Miguel Giannini and entrepreneur Álvaro Ferrioli, in the Northeast, which culminated with an initiative that must be restarted by SUS: to avoid finishing an appointment with “Here’s your prescription. Now go away.” We had known for many years at the São Paulo Hospital that our patients had frequently already been to other hospitals and received prescriptions. The problem was not getting a prescription for glasses, but what to do with it. The problem is the population’s access to glasses. I don’t want to get involved in politics, but during Serra’s period at the head of the Ministry of Health, he approved a pilot program in which, at the end of the appointment, the doctor would say, “You need glasses. Choose one of these three models.” In three days the patient came back and had bifocals ready and included in the SUS appointment.

How many free pairs of glasses were distributed?
We made 1,200 in the first stage and 12 thousand in the second in São Paulo, Manaus and Recife, very successfully. The next stage was to move on to 120 thousand, but that didn’t work out. In any case, it is possible and buying on a large scale, the price falls dramatically. It works in the same way as unbranded, generic drugs. We need the equivalent of the generic drug for glasses. This brings us back to our first question, old age. People cannot spend money they don’t have on glasses. It’s a problem that is solved with political dedication. The most important cause of poor eyesight and blindness in Brazil is the lack of glasses. The doctor, leading an eye-care team, with some technology and technicians and an adequate healthcare policy, can make everything fast and efficient.

Has the blindness rate been falling in Brazil?
No. It has been growing, and it’s not the government’s fault. Everybody will need cataract surgery someday (unless we die before that) and there is no alternative treatment in sight for the next 10 years. It’s a global problem. There are several hundred million people with cataracts waiting for surgery in the entire world. Perhaps soon we will reach half a billion people. Brazilians now live much longer and blindness and poor eyesight among the elderly is something for which medicine still hasn’t found a good solution. That’s the case, for instance, with macular degeneration. Diabetes-related blindness is also on the rise, as are complications related to medical advances such as transplants and curing or delaying death among cancer patients. Diabetics now live longer, but unfortunately may spend many years with neuropathy, blindness, etc. Glaucoma related blindness rates also increase with age.

You seem to like management.
It’s not a matter of liking it; it’s a matter of necessity. Lack of proper management is one of the biggest problems in the university and hospital systems, more serious than the lack of investment. I arrived from the United States in 1990 and was a full professor. At the time, the department was big – it had around 50 people. Now it has 500. As a professor, I have to manage. I was lucky enough to be accepted into the MBA program at the School of Economics and Business Administration at the University of São Paulo (FEA-USP). It has helped me a lot at the university because it expanded my knowledge and learning possibilities. It lets me communicate more effectively with experts in the field. One thing I am proud of is that in our department there are other people who are also getting MBAs. We have a tradition of having many faculty members who are concerned about management. It was this knowledge that let us build the Instituto da Visão (Vision Institute) building and also to achieve world standards in clinical trials and so on. We have a team of excellent manager-professors in ophthalmology.

What is your position now at the institute?
I was its president until 2009. When I was elected president of the SPDM I left to avoid any conflict of interest.

Is the institute’s new 11 story building from your term as president?
Yes. It is the product of our management. It had to be built because we could not fail to build in this area of the city a skyscraper with the maximum height permitted by law. We always knew the building would be bigger than the ophthalmology department needed and so it was built bearing in mind that UNIFESP and Hospital São Paulo would need the space. This building illustrates the importance of good management. Part of the land was lent to us by the municipality for 50 years; another part was funded by the National Social and Economic Development Bank (Banco Nacional de Desenvolvimento Econômico e Social – BNDES). Managing is essential. You can no longer have a department made up only of scientists and educators – you also need a manager.