CENTER FOR ACADEMIC GLOBAL OPHTHALMOLOGY 10/01/19

Chapter 2: Madurai, Indian – Aravind Eye Hospital

By John Anhalt MD

I left Hyderabad yesterday and already feeling a sense of “homesickness” that I always experience whenever I leave a place I really enjoyed. My last four weeks at LVPEI learning MSICS were absolutely incredible and I look forward to building on this collaboration over the next few years. I also look forward to seeing a few friends from LVPEI at the upcoming Academy of Ophthalmology annual meeting this fall. Now, on to Madurai where I will have the opportunity to observe for about a week at the Aravind Hospital system.

Day 2:

I am greeted by Dr. Sankalp Singh, he is a cornea specialist who has graciously rearranged his busy clinical and academic schedule for the upcoming week to guide me through Aravind. Madurai is medium sized city in southern India (it would be considered fairly large by U.S. standards) and serves as the flagship hospital for the Aravind system. After a day touring the different clinic campuses in Madurai, I am again, awe-struck in the magnitude of patients treated. Aravind treats over 50% of its patients completely free of charge and in 43 years has become one the largest hospital systems in India. Its founder, a retired government ophthalmologist, Dr. Venkataswamy, started the hospital in 1976 as an 11-bed hospital in his hometown of Madurai. Now, in order to reach those most at need, the network includes 7 tertiary centers, 6 secondary centers, 6 community centers and 75 vision centers.

The hospital system was one of the pioneers of the tiered payment system that has been remarkably successful in Southern India. This model also been replicated by partner institutions in Africa and Asia. In the late 90’s, Harvard Business Review looked at this model which was then followed by a frequently cited publication in Strategy+Business titled the “The Fortune at the Bottom of the Pyramid”. The article showed how systems like Aravind could not only sustainably, but even profitably, fight poverty and work towards closing the socioeconomic gap. Of course, all of the proceeds from Aravind go directly back to patient care and to allow the expansion of the system to reach those in need.

Day 4: Vision Screening Outreach

At 6:00 AM, I arrive at the hospital entrance. Already the bus is idling and about 20 ophthalmic technicians (“Sisters” as they are referred to across the Indian healthcare system) are hurriedly loading all the supplies needed for today’s vision screening outreach. Everything is brought aboard: makeshift room dividers, visual acuity testing lanes, trial lenses, ophthalmoscopes and even lens grinders. Each weekend, many of these outreaches are happening concurrently, each reaching villages as far 5 hours away. Most of the physicians are assigned 1 weekend per month to help lead these outreaches. For our camp in the village of Kandanur, the bus journey is about 3.5 hours, interrupted only by a brief stop for tea. Once we arrive at the village, we greeted by our hosts who immediately bring us upstairs for introductions followed by a breakfast of idly, sambar, rasam, a delicious “cane-sugar goo” (which I can no longer recall the name) and, of course, more tea. The hosts are a family from the community who had been sponsoring the Aravind outreaches for their hometown for the past several years. Much of the family now lives in Chennai and Wisconsin but they all come back every year to help host this event – a remarkable commitment to their community.

After about 15 minutes, the mobile eye clinic is fully up and running and there’s already a line about 200 people patiently waiting. I asked one of our hosts how many people he anticipated coming and he was certain somewhere between 400-600 patients will be screened. I was fascinated to observe how the Aravind method of patient care from the hospital setting was precisely replicated and minified to function in the outreach setting.

Patients register and are given an identity card and examination form

Vision is checked

Pre-examination screening for gross ocular pathology
Physician exam for cataract or other surgical needs

If surgical, the patient will get lacrimal duct irrigation and eye pressure checked

If not surgical, will get refraction and glasses

Every step, except for the physician exam, is done by a highly trained and specialized ophthalmic technician. The workflow was remarkably efficient. After 8 hours, with a brief break for lunch, nearly 600 patients were screened. No one is turned away and any one who needs further care whether surgical, medical or just a refraction for glasses are treated 100% free of charge. At the end of the day, a second bus from Aravind meets us and all of the patients that were offered surgery are taken back to Madurai where they will spend the night before their surgery the following morning. Aravind will support the patient and 1-2 family members for 2-3 days to ensure proper presurgical planning and post-operative checks. The outreaches are a vital resource to the community. Without them, a majority of the community in Southern India would have zero access to eye care.

Perhaps no one understood this better than Dr. Venkataswamy as the outreaches have become a cornerstone to Aravind’s mission. Each year, nearly 2,500 screening camps are held which generate around 40% of all cataract surgeries performed by the system. After talking our hosts who helped sponsor this camp, this yearly event has become one of the most meaningful to his family. Given the magnitude of patients seen through the Aravind network each of these villages may seem like a drop in the bucket. However, at the end our long day in the vision camp in Kandanur our host sponsor remarked that he had recently noticed a yearly decline in the number members sent for cataract surgery. He felt this was testimony that, for at least for his community, Aravind was turning the tides on blindness.

The Madurai Aravind Campus has 5 hospital blocks dedicated towards patient care, research and education. A 2-3 minute walk down the street takes you to the international guest house were trainees and visitors are allowed to stay. The accommodations were excellent and included breakfast, lunch and dinner.

Ophthalmic technicians at Aravind checking vision, refraction and IOP — Ophthalmic technicians checking vision and IOP

The success of the hospital lies in its highly trained and specialized ophthalmic technicians. These technicians are almost always women from nearby villages and the job provides a source of education and income for them and their families. At the non-paying hospital block in Madurai, you can see screening lanes with technicians checking vision, intraocular pressure, refraction and performing a preliminary exam before the the treatment plan is finalized by the staffing physician.

Dr. Anhalt and Dr. Singh at the Aravind hospital complex

Dr Sankalp Singh, a cornea specialist, graciously took the week accompany me as toured through the Aravind Hospital system.

Part of Dr. Venkataswamy’s vision was to make ophthalmic surgery economically accessible to masses. To do so, Aravind started manufacturing its own intraocular lenses (IOLs) for a fraction of the price of the prevailing market. They have since expanded to manufacturing sutures, blades, glaucoma drainage devices, antiseptics and pharmaceuticals. I had the opportunity to tour the facilities (no pictures allowed inside), remarkable establishment. As an aside, the manufacturing plant produces its own organic produce and 30% of their electric demands are generated by solar power.