Heading back to the USA today

If you want to see my itinerary, check out the first post

It's been a great experience being here (other than my lysozyme never showing up). I still have more things to talk about so I'll keep updating the blog over the next week or two.

The next thing on the horizon is Melissa's Match Day on Thursday, March 14th at 12:00 Eastern Time. Good luck to all the fourth years out there!

Just a few of the things I've seen at Aravind

Warning, some links have some pretty graphic images/descriptions!

Macular dystrophy (more than once, so when the link says it's "rare" think "EXCEPT IN SOUTHERN INDIA").

An enucleated (unilateral) five year old retinoblastoma patient.

Corneal transplants, including one on a patient who already had had four transplants in the same eye.

Cataracts and cataract surgeries.

GLAUCOMA!

What chlamydia can do to your eye.

Surgery to repair corneal and eyelid lacerations.

Bad, ulcerated fungal keratitis (way more than one).

Viral keratitis.

Peripheral ulcerative keratitis.

A baby with congenital anophthalmia.

Surgical removal of an adenoid cystic carcinoma of the lacrimal gland (6 x 5 x 4 cm. Think, "a tennis ball under the skin next to the eye").

Surgical removal of a cavernous hemangioma of the orbit (bigger than the eye it was sitting behind).

Retinal detachment (I saw the fluorescein angiography and OCT).

A pharmacist from Tanzania bringing his father to Aravind from Tanzania for surgery for his retinal detachment.

A refractive surgeon talking a teenage girl out of refractive surgery.

A US MD/PhD student decide to come back to Aravind for his LASIK.

Cows. Everywhere.

Oxcarts.

Geckos.

Monkeys (at this temple).

The famous Meenakshi temple in Madurai.

Aravind Declares War on Cataracts

Actually, Aravind declared war on cataracts a long time ago. For those of you who don't know, cataracts are merely an opacification of the crystalline lens of the eye. There are a bunch of reasons why people get cataracts and excessive UV exposure is one of that. I don't know if you've looked at a map lately, but Madurai is mighty close to the equator and much of the industry around here is agriculture. Therefore, Aravind sees a LOT of cataract cases.

Fortunately, the cure for cataracts is easy. All you need to do is take out the cloudy lens and replace it with an artificial intraocular lens (IOL). We are very good at making IOLs; indeed, we have even created some multifocal IOLS. Cataract surgery is one of most immediately gratifying surgeries we can do. A patient can go from barely making out hand motions to having almost perfect vision through a 10 minute procedure.

The Aravind model for health care delivery should really be called the "Aravind model for doing a crap-ton of cataract surgeries quickly and inexpensively." Today, I spent some time in the operating theatre (OT. Silly British corrupting everything. Will someone hand me a torch? Cheerio.) at the free hospital watching a surgeon perform cataract surgeries. The surgeon was responsible for two tables side by side. While he was taking out one cataract, a patient was set up on the other table. As soon as was finished with his cataract, he'd swing the operating scope over to the next table and do the surgery without saying a word. There was a video camera attached to the scope so I (and the patients in the OT waiting to be operated on) could see a zoomed-in view of the eye and watch the operation in real-time.

Here comes the efficiency: the surgeon was using an older technique than is typically used in the US (he'd take the lens out of one incision, whole, instead of breaking it up with an ultrasound applicator, suctioning it out, and putting a foldable lens in) does the procedure in 5-8 minutes (I timed him). Because they're using an older technique, they can use cheaper equipment and (generic, made by Aurolab) lenses. Also, because the surgeon is working two beds, he doesn't have to wait for patients to be set up. For that matter, he doesn't even take the time to talk to them in between procedures. What I found surprising--and that doesn't increase their complication rates--is that the surgeon doesn't even bother changing gloves in between procedures; he just pours chlorhexidine on his hands in between patients and keeps on going. In the 45 minutes I was in the operating room, I saw the surgeon do seven cataracts start-to-finish.

In the US, we're not this efficient. Most ophthalmologists do maybe 2-3 cataracts an hour (pesky changing of gloves, talking to patients and each patient getting his or her own OR). Honestly, we don't have a reason to be efficient because there just aren't that many people (relative to the number of ophthalmologists in the US) who need cataract surgery.

Here, however, the need is enormous. Most of the 350,000 surgeries Aravind did last year were cataracts and they still haven't made an appreciable dent in the number of people with cataracts in southern India. There is a reason that Aravind does dozens of camps every week and sends busses full of people to the hospital for (free) surgeries from each of those camps. Aravind is planning to open two new hospitals in the next year because the need is so great. For the foreseeable future, the Aravind model will be necessary to treat cataracts if they hope make any appreciable dent in the number of people who are living with poor or no vision.

Rehab

I'm sorry it's been so long since I've posted. Things have been pretty busy here. Since my post, the rest of the Dartmouth crew has left for the Great White North (a.k.a. Hanover) and a new set of people have arrived: Four MBA students from U Michigan (evaluating a project which I'll address in a minute), an ophthalmologist (retina specialist) and his wife from FL, and a retired logistics manager from Fedex, his wife and daughter (NP who does heme/onc) from Boulder, CO.

The Fedex logistics manager is going to work for Aravind and help them more efficiently deliver care. He's here for a month with his family picking out more permanent living arrangements and he and his wife will return to Aravind in June for six months. Basically, he's retired and wanted to do some community service and saw Aravind as a place where his joys and talents could meet the world's needs. In a Steve Jobs-esque move, he has offered to work for Aravind for $1 per year.

The ophthalmologist and his wife are originally from India but moved to the US a couple of decades ago. Ironically, she is the only person to have become sick from eating the food here (kids, watch what you eat). They are both very nice and are visiting to see the temples in the area.

Now, let's talk about rehab and senior citizens. India's population is at right around 1.2 billion people right now. According to wikipedia (what other sources are there, really?) approximately 5.3% of the population is over the age of 65. That's about 64 million senior citizens. There is nothing like Medicare or Social Security in India, so in theory the elderly are cared for by their families. Note that I wrote "in theory" because in reality many elderly parents no longer live in the same cities as their children and some senior citizens are childless. Many children also work full time and/or are unable to adequately care for their parents in their homes. Unfortunately many of the elderly are destitute (see: lack of Social Security and Medicare).

Another phenomena (along with having a significant number of older people) that comes along with an improving economy is the presence of chronic diseases. In the developing world, people generally die of acute diseases: You're pretty worried about malaria and polio and cholera, not so much about atherosclorosis and Type II diabetes. In the developed world, we're not so worried about polio and TB but are about strokes, heart disease and diabetes. When you are able to cure the acute diseases, the chronic ones take a much heavier toll on your population (everyone needs to die of something.

Acute diseases are somewhat a problem in India. It's, for instance, one of the six countries in the world where polio is still active. We still see some pretty bad eye infections in the clinic here. But now there are lots of patients here with diabetic retinopathy and hyperthension. People are also living long enough to have heart attacks and strokes (and a large number are living). People are living through spinal cord injuries and amputations. Many of these patients are old. Alzheimer's and dementia are becoming bigger issues. All of these patients need some help (physical therapy, occupational therapy, PM&R (physical medicine and rehabilitation), etc.) but there are few PT services available and almost no PM&R docs.

To solve this problem, one of the ophthalmologists working at Aravind (coincidentally--or not-- named Dr. Aravind) bought a farm a few years ago. This farm is about 30 minutes from Aravind (near Aurolab) and looks like it's in Hawaii. It's peaceful and there are coconut trees (I had my first drinking coconut off of one of those trees), mango trees, a rice paddy, banana plants, a pond. Dr. Aravind has started building a rehab facility there (to US standards). It will be fully staffed with skilled providers (nurses, PTs, OTs, a PM&R physician imported from somewhere). There will be large windows, and wheelchair ramps accessible to outdoor areas.

The rehab facility is desperately needed (as our business students have confirmed with their study). Dr. Aravind is committed to following the Aravind Eye Hospital model of treating two patients for free for every one paying patient. Dr. Aravind is one of the new generation of leaders at the eye hospital (with a M.B.A. from Michigan) and is passionate about this project. He is already planning for the retirement facility he will build on the 40 acres attached to the 30 acre plot the rehab facility is on.

One of the things I've come to appreciate about India is that there is so much potential here, and not just economic potential. In some ways they have caught up to the West but in other ways they're still years behind. They can, however, learn from our mistakes and do things better than we have done (and I would argue that the Aravind Eye Hospital is in many ways something that was built with this knowledge). Dr. Aravind is one of those people who has the capability to shape the India that is still in the process of being created. Both the rehab and retirement communities could be a model for what is possible in India. I honestly believe he is one of the minds of his generation who can help India to become better at rehabilitating its injured and taking care of its elderly than the West has been.

More later...