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...

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.

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.

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.