Andrew in Madurai: February 2011

Sunday, February 27, 2011

Gone Camping...

As I've discussed previously, one of the missions of Aravind is to ensure that all patients who require it receive eye care, regardless of their ability to pay. One of the way that Aravind achieves this goal is to conduct multiple "camps" every week. Yesterday, I went to one of those camps about an hour and a half from the hospital to see what happens there.

Think of the camps as massive screening programs for people with eye disease. Local sponsors (in this case, the Lions club of the agricultural community where we were) advertise to the people. Two of the organizers were local general physicians (who see 80-100 patients per day) who told the patients who needed to see us to come. Patients travelled from multiple towns in the area. Some of them required hours of travel to get to us. They all came because they--or someone in their family--required eye care. This particular camp was held in a marriage hall which was donated for the occasion.

Patients lining up to be seen:

The patients come in and then they are each sent to every station present: one to test vision, one for refraction, another for intraocular pressure testing, a fourth for blood pressure, a fifth for vision testing. The people conducting the camps are efficient (notice a trend with Aravind yet?). There were fourteen sisters, two ophthalmology interns (first year residents) and one second year ophthalmology resident to do all the screenings. In about four hours, they saw 332 patients (Aravind is also remarkably good at record keeping). The sisters managed most of the stations and the residents managed one. Everyone who walked in the door had to see a resident. Through the miracle of mathematics, you can see that each resident had to screen about one patient every two minutes.

BP check:

Vision check:

IOP check:

Refraction:

The senior resident (in red, center) examining a patient:

Frankly, the three residents were swamped. They each had a chair on either side, with a huge line leading to each chair. They would examine the patient on their left, then right and back again. There was a never-ending deluge of patients the entire time we were there. The residents had to make assessments about ophthalmologic conditions and the potential for successful eye surgeries in 1-2 minutes. I'm not sure how they did it. I was extremely impressed by how many patients they were able to screen.

Patients who need glasses get them (for free) either made on site or couriered out to them because Aravind determined that just giving patients a prescription often meant that those patients would go without glasses. The residents were predominantly screening for cataracts. They gave out eye drops to some patients who needed them but otherwise recommended that people who came for problems other than cataracts come to Aravind on their own.

For patients who needed cataract surgery, however, two busses came to take them to Aravind for free-of-charge eye surgery. In most camps, 25-40% of patients are transported to Aravind, and this camp wasn't much different. Approximately 140 patients were transported. After their surgeries, the patients will be transported back to this location.

The bus:

I mostly observed and talked with the few English speakers among the organizers. I did manage to make friends with one of the men doing crowd control. He didn't speak English and I didn't speak Tamil, but we came to an understanding. He asked me to take this picture before we left:

Tomorrow, I'll try to find time to write about my first experience watching cricket: England vs. India in the world cup on TV (with Mike, two Brits and an Indian). I'll also talk about one of the side projects one the new up-and-coming leaders at Aravind (curiously, his name is Dr. Aravind) is working on.

Friday, February 25, 2011

Aravind and Efficiency

If you want to learn about how to make health care more efficient, take a trip to Aravind. Their guiding principle has always been that everyone deserves high quality eye care without regard to their ability to pay. Anyone can choose to go to either the free or paying hospital; it's on the honor system. For every one paying patient, they treat two free patients and still have enough money left over to invest in new hospitals, clinics and treatment camps.

The amount and variety of eye disease here is astonishing. This morning in the cornea clinic in the paying hospital, I saw two cases of an eye disease called macular dystrophy. Two cases is about equal to the number of cases Dr. Zegans (the ophthalmologist from Dartmouth who comes here every year and brought me with him) has seen in fifteen years at Dartmouth. Even though the people at Aravind currently see 2,000,000 patients per year and perform 350,000 surgeries, there is much, much more demand here.

So, back to how Aravind can afford to treat that many people for $20,000,000 per year: they also have an arm which manufactures surgical supplies they have a huge support staff for each ophthalmologist. The surgery they do here most often is cataract surgery. This surgery takes about 10 minutes to do: you cut a slit in the eye and then take out the lens, either by phacoemulsification (breaking the lens up with an ultrasound applicator which also sucks up the pieces) or you take the whole lens out through the slit. Then, you replace the lens with an artificial one. A few years ago (and still in the U.S.), the artificial lenses cost about $150. In a country where per capita annual income is about $1000, you can't charge $600 for a surgery (remember, the paying patients cover themselves and two free patients). So, Aurolab spun off from Aravind.

The Dartmouth contingent at Aurolab:

Aurolab figured out how to make lenses (of approximately the same quality as the $150 lenses) for about $5. Right now they sell them in about 70 countries and are a major supplier for Aravind. Because these lenses exist, the price for the "name-brand" lenses has also come down in India. Some patients still choose the Alcon lens (Aravind allows the paying patients to choose), but those lenses are now less expensive. All the free patients and many of the paying patients get the Aurolab lenses. They also use Aurolab surgical blades, suture and pharmaceuticals here and elsewhere around the world. I've seen the Aurolab facility and it is incredible to me how inexpensively they can produce such high-quality products. About 90% of the workers are young women who have finished high school and live and work at Aurolab for good pay.

A couple of other factors go into the efficient delivery of health care at Aravind: The support staff. Almost all of the non-physician care at Aravind is provided by the "sisters". The sisters are high school senior girls (some of the best at their schools) who choose to come to work for Aravind. They are trained for two years to do preliminary eye exams, screenings, prep patients, assist in procedures, administer some medications, etc. After that two year period (during which they receive housing and a stipend) they come to work for Aravind. They allow work to proceed more efficiently. In cataract surgery, for instance, a surgeon will work two tables simultaneously. A sister will prep one patient while the surgeon works on the other. When the surgeon is finished, a sister takes that patients and preps the next (while the surgeon is working on the patient on the other table). In between surgeries, the surgeon doesn't rescrub or write down notes (not much paperwork for physicians to do here). The surgeon just dips his or her gloves in sterilizing solution and moves on to the next patient. Thanks to the huge number of support staff, a surgeon here can do 6-8 cataract surgeries per hour (in the U.S., an ophthalmologist can do 1-2). The surgeon doesn't need to do paperwork because one catarct surgery is typically much like another and there are fewer regulations here. Even cutting corners that we couldn't in the U.S. (no rescrubbing), their post-surgical complication rate is lower than in the UK. Also, when a surgeon is in the operating theatre (OT), he or she can focus on just doing surgery.

One other observation: everything happens faster here. From a conversation from this morning: "You need a corneal transplant. We can probably do in sometime in the next couple of days."

Because of the way Aravind has innovated, they can treat an unbelievable number of patients (and they give excellent care here) for an extremely small sum of money. If you want to learn about innovation or effect health care delivery, come to Aravind.

I'm going to an Aravind screening camp tomorrow so I'll post about that when I get back.

Thursday, February 24, 2011

Let's Talk About Aravind

So, why am I in Madurai? Dr. G. Venkataswamy.

Dr. V. was a doctor in the Indian army who originally wanted to do obstetrics because he couldn't understand why so many of the young women in his village died from complications related to childbirth. Unfortunately, soon after World War II, he developed rheumatoid arthritis and was discharge from the army and was told he would be unable to deliver babies due to his disease. So, he decided to become an ophthalmologist.

After he retired in the 1970s, he decided that the next logical thing to do would be to found a hospital for people with eye diseases. In 1976, Aravind Eye H

ospital was founded in Madurai. Dr. V.didn't want to turn anyone away due to inability to pay, so he asked people who could afford it to pay and he treated everyone else for free. By the time he died in 2006, Dr. V. performed over 100,000 surgeries. Seriously. That's not a typo. The man, even with rheumatoid arthritis, performed 100,000 surgeries.

The paying hospital (300 beds):

The free hospital (600 beds):

The new hospital (opening in a month):

For every one paid patient they see, the treat two for free (and I'll tell you how tomorrow). Aravind now consists of (around India) 7 hospitals , forty clinics and weekly "camps" where they screen and treat massive numbers of patients for eye diseases. Last year, they performed 350,000 surgeries and saw two million patients, for about $20 million. They basically performed 2/3 as many cataract surgeries as the NHS in the UK for about 1% the cost (also tomorrow), all with a lower complication rate.

Along with the hospitals, they have a research center:

I'll be spending most of my time at the hospital but some of the time in the clinic.

To give you an idea of the quality of the surgical care here, there were two ophthalmology resident from the US here to learn some techniques and to see some patients they wouldn't get to see in the US. The residents were from Johns Hopkins and UCSF.

Anyway, it's bedtime now. More tomorrow.