Monday, February 23, 2009

Day Six – Remote Eye Camp, Pondicherry

Rock Stars

This is it – our last day in India. Dr. Nachiar, one of the founders of Aravind, picked us up to visit the Eye Camp, an hour outside of Pondicherry. I said that it was sure to be a big turn out once they knew she would be there, but she smiled, and said no, they were coming to see us. Little did we know what she meant until we arrived. Huge printed posters in English and Tamil announced our arrival, along with thanks to the “Bill Gates Foundation” (sic). The crowd was enormous. Politicians from all corners had descended, and were all waiting for us at the gate of the local school. Much handshaking and bowing greeted us, and a massive amount of picture and video taking. We felt like big celebrities, but weren’t quite sure why.

Once the initial greeting finished, we began our tour of the Eye Camp. This town has been hosting them for more than 30 years. These monthly eye camps allow local populations to receive screening and a host of other services. It takes place at an elementary school, with the teachers and administrators serving as part of the volunteer staff. There is an almost carnival atmosphere to the event, with children playing and attendees chatting with their neighbors while they stand in line.

The flow is the same system we saw at all the hospitals, starting with registration and blood sugar tests, and moving through refractory, glaucoma screening, cataract screening, and all the other stages of the well-care eye visit. Those thinking they have a cataract come to the camp with a bag of overnight items, as they will be transported from the camp to the hospital that afternoon. Both the transport and the surgery and stay will be free of cost. Anyone found needing glasses can pick out their frames and have the glasses made right at the eye camp. They bring an extensive selection of lens strengths, along with frame styles to the camp. There are also prescription eye medications available, if needed.

After our tour of the Eye Camp, we were seated on a dais for a short program in our honor. Many speeches followed, including one from the local businessman who started it all 30 years ago. He has nine children, and began his philanthropy when he was poor. Now his adult children help sponsor the monthly eye camps, and are all highly-respected members of the community. The visit ended with a lovely ceremony where we were all given gifts. We then had our pictures taken with some of the recipients of hand-cycles donated by the same family trust.

Pottu Varan
Back to Pondicherry for lunch, and then our last ride to Chennai to meet our planes. Our driver took us on a different road this time, one that winds along the coast. We passed vast salt fields, and areas affected by the tsunami. We also drove close to the temples of Mahabalipuram, an extensive archeological dig that unearthed a series of shrines carved out of the living rock more than 1,200 years ago.

We arrived in Chennai and said our goodbyes, both to each other, and to India. We all experienced an incredible organization in action, along with the background culture that has formed Aravind. What an amazing trip.

Pottu varan (“Goodbye” in Tamil) –

Sunday, February 22, 2009

Day Five – Auroville and Aurobindo Ashram

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Today was a bit of a departure for our group. Instead of looking to the physical and organizational backbone of Aravind, we explored some of its philosophical underpinnings. Aravind’s founder, Dr. Venkataswamy, was a follower of the scholar and spiritual guru, Sri Aurobindo. His teachings, and those of the Mother, one of his followers, were an ever-present guidepost for Dr. V in his pursuit of a more effective health system for eye care.

Our first visit was to Auroville, the Utopian realm envisioned by the philosophers. About 2,000 people live there now – approximately 1,500 adults and 500 children. Through a national mandate, residents of Auroville are not considered residents of India. Rather, they retain citizenship of their home countries. Auroville’s residents work in the community where all is provided for in exchange for a percentage of their income. Everyone there is focused on change: spiritual, global and internal.

After watching the video describing Auroville and its goals, two of its residents gave us a tour of their community. We visited a newly-built clinic, devoted to working with all types of medical treatment including traditional, ayurvedic, homeopathic and more. The doctor in charge is from Kazakhstan, and already has a number of practioners of various forms of healing on staff. We then had lunch with our hosts in their solar-powered Community Kitchen.
Later that afternoon, we visited the Sri Aurobindo Ashram in downtown Pondicherry where both the Sri Aurobindo and the Mother lived and are now enshrined.

After a bit of shopping, some of us walked along the Indian Ocean beach, stopping to admire the statue of Gandhi. Having the opportunity to explore the spiritual background of this amazing organization and country is tremendous. It gives me just a bit more insight into the incredibly altruistic actions of the leadership team. Tomorrow is our last day in India, and we will be closing with a bang – an eye camp in a village known for its cashews and longevity of service to Aravind.


Saturday, February 21, 2009

Day Four – Pondicherry Hospital, Pondicherry

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We gathered for our morning flight to Chennai (old Madras), where we were met by Aravind staff from the Pondicherry Hospital. Pondicherry is the most recently built of the five main Aravind base hospitals. Where the physical plant of Aravind Madurai was expanded as resources and demand grew, Pondicherry sprang fully-formed from the architect’s pen.

Situated on 70 acres just outside of the city, the campus includes two large residential areas that house not only the sisters that work at the hospital, but also many of the doctors and their families. This beautiful building is an engineering marvel. Many systems found in the other hospitals are found here, but it is also host to many new innovations. One of the most exciting is the water reclamation system. All sewage water goes into a series of celled cisterns, and left to sit for a certain period of time after which a mixture of aerobic and anaerobic bacteria is created. Through a series of containment and flow through rocks, the end result is water at the highest level of purity.

The central section of the main hospital building houses the operating theaters and specialty clinics. As you walk in, you are greeted with a beautiful open space in the middle of the building with lush plantings and statuary. The buildings on either side house the post-op recovery accommodations. The free side is on the left, with spacious rooms for mats or cots, and eating areas. The paying side is a bit more posh, with private and semi-private rooms. Again, the patient makes the choice of which side they will register. The eye wear “store” is huge, and replete with every kind of lens and frame design – all manufactured and fitted in-house.

The tour wends it way through the surgery areas, much bigger than anything we saw in Madurai. Many rooms are still unused, showing the main difference between the first and latest hospitals: Madurai is crowded, and always trying to squeeze more out of its space, whereas Pondicherry is looking to DOUBLE its present patient load before it starts to outgrow its space.

After a long afternoon of touring, we head back to our hotel and dine under the stars, overlooking the Indian Ocean. Just lovely.

Falling asleep, listening to the waves,

Friday, February 20, 2009

Day Three – Free Hospital and Vision Center, Madurai

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Apologies for the delay in posts as the internet connection here in India can, at times, be scarce. But back to the study tour…

Known as the Temple Town, Madurai boasts a series of 13 temples from different periods in Tamil Nadu history, and is the most famous of all temple areas in southern India.

Vision Center
We began our day with a short drive out of the city to the village of Alanganalure, which is known for its Bull Taming festival and the fierceness of the women from this region. Our focus was seemingly a bit more mundane, however, as we went to visit one of Aravind’s 37 vision centers in South India. Each of these centers is connected to one of five base hospitals. This one, for example, is connected to the one we visited in Madurai yesterday. Through a program with the U.C. Berkeley and Intel, they have a fixed point broadband system – with the vision centers at one end, and the base hospital at the other.

It was amazing to see this system in action. A doctor at the base hospital works with anywhere from five to 12 vision centers. The patient form the local village comes in to the vision center for a scheduled appointment, surgical follow-up or other eye issue. The vision center is staffed by two of the sisters – one who is responsible for the registration, patient flow and refractory products, and another who carries out the eye examination. Many of the same ophthalmologic tools in the hospital are in this facility – really an old shop-front about 10 feet wide and 30 feet deep. She will perform the routine tests of blood pressue, eye pressure, blood sugar, refraction, and fundus imaging, etc., right here, then connect with the doctor at the base hospital. This telemedicine technique is revolutionary as people unable to make the journey to the city can still talk “face-to-face” with the doctor, who has just received the test result for the patient electronically. The consultation takes place directly, and any medicines or corrective eye wear can be obtained immediately at the facility. Any surgical recommendations can be acted on as soon as the patient is ready to go to the hospital. The sisters are from the village, so have a good relationship with the patients, resulting in an experience that may be less intimidating than a hospital visit.

Besides the two sisters at the vision center, there are two field workers who are responsible for seeing one-half of the covered population (about 50,000) each year. Their task is to visit each house, and screen the vision of the inhabitants. They also encourage older residents to come in for annual glaucoma exam to decrease the effect of this disease. Because the loss of peripheral vision is so slow, a person with glaucoma may have no idea that their vision is decreasing until it is too late.

Free Hospital
After lunch, we set out for the Free Hospital at Aravind. Other Aravind hospitals around Tamil Nadu were built with free on one side, and paying on the other, and the surgery and specialty areas in between. Aravind Madurai started as an 11-bed hospital, and has grown in fits and spurts, adding space as needed. Because of that, the Free Hospital is on a separate campus, around the block from the Paying Hospital. Unlike in U.S. where free care only follows massive amounts of qualifying paperwork, the patients at Aravind select the hospital in which they are seen. There is a perception that if it costs more, it must be better, and that drives many families to sell a cow or take out a loan to afford treatment at the Paying side. Aravind does nothing to dispel this myth, as it keeps people more honest about their ability to pay. The interesting thing is that the care at Aravind hospitals do not differ at all, with the staff cycling though both hospitals during the week. The main difference is the accommodations. Instead of a private suite with one’s own bathroom, the Free Hospital offers mats on the floor or cots. This concept of choice also extends to the type of intraocular lens the patient selects.

A Little Sightseeing – Meenakshi Temple
After a reluctant goodbye to the Aravind staff, we headed back downtown to the Meenakshi Temple, tallest of the 13 in the city. We were hosted by two of the city’s leading authorities, and spent the afternoon exploring the beautiful stone interiors dating back thousands of years. This temple was built to honor Meenakshi, one of the forms of Shiva’s consort. She is Vishnu’s sister, and symbolizes the peaceful coexistence of the two lines of followers of Shiva and Vishnu. Some people believe it is why there is comparatively little religious conflict in the area. The story is that Shiva rode into town on his bull, and married the feisty goddess, making her submit (eyes down, etc.) before the marriage. When they were officially joined, the tables turned, and he submitted to her. On the occasion of the marriage, the streets flowed with milk and honey. We saw the Temple elephant being walked for his health, and the “People Tree” where women hang cradles in amongst the leaves and pray to have children.

All packed up, but sad to be leaving this land of milk and honey and the birthplace of Aravind. Tomorrow, we fly back to Chennai, and drive south from there to Pondicherry (Puducherry), an old French colony by the sea.

Dreaming of Madurai,

Thursday, February 19, 2009

Day Two – McSurgeries, Madurai

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What an incredible day! Day Two started off early so that we could observe a few eye surgeries. Study tour participants requested this addendum upon hearing more about Aravind’s efficient methods inspired by the McDonald’s assembly-line. Last year alone, Aravid performed 280,000 surgeries.

The first surgeries we saw were the cataract removal, Aravind’s signature procedure. Each operating theater has four beds and two surgeons. Each surgeon is stationed between two operating tables with one microscope. The apparatus swivels between, allowing the surgeon to switch between the two areas easily. The patient is led into the room, and prepped by the surgical team, comprised of trained sisters.

The surgeon deftly makes a small millimeter slit in the cornea, and inserts a surgical probe. After tearing a small hole in the sac surrounding the lens, she inserts a small ultrasound tool and proceeds to shatter the lens. She aspirates the lens bits out, and inserts the folded flexible replacement lens. With such a small incision, no suture is needed. The whole process took about 6 minutes. When she finishes, she replaces her surgical gloves and begins on the other table, with a new patient, clean tools, and different cataract. With this highly efficient process, a good surgeon will complete more than 30 surgeries in a day. The speed and grace of the surgical staff was wonderful to watch.

A Hospital
Next was our tour of one of Aravind’s Hospitals, following the same path as a patient would on a visit. We started in registration where a phalanx of sisters ran the intake area with an amazing smoothness, considering almost every patient is a walk-in. Aravind’s complex record keeping allows them to predict patient flows with a better than 0.5% accuracy, taking into account festival days, holidays, auspicious days and a myriad of other factors. Everywhere you see matrices showing the expected levels for the different surgeries, consultations and other services they provide.

Our tour continued through the pre-op areas where the patient is screened and monitored. After these metrics are recorded, the patient will meet with a doctor. There are not that many doctors, so the consultation lasts a very short time, consisting mostly of a diagnosis. The patient is then assigned a counselor who will spend a much longer period of time with each patient, going over the different treatment options, costs, recovery times and other follow-up issues.

We then moved upstairs to visit most of the specialty areas: glaucoma, diabetic retinopathy, low vision, uvea function and more. The areas were seemingly chaotic, but the time between registering and moving to your next area was very short. Aravind is also piloting a program where a patient is issued a card upon entering that will be embedded with a small microchip. Sensors in the building will chart the progress of the patient, and help forecast any sudden staffing or equipment needs. We also visited the research area where studies involving the Indian eye population are being carried out.

After lunch, we traveled to outskirts of Madurai where the Aurolab facility is located. Begun as a low-cost manufacturing alternative, Aurolab first developed a $10 intraocular lens when most lenses in the world were costing around $150. They now manufacture a wide array of lenses, along with ophthalmic pharmaceuticals, surgical blades, supplies and instruments. The level of cleanliness meets every standard in the world, including the FDA, but not all products are approved for use in the United States. Behind Aurolab is the new Aurofarm, an organic farm just recently started with the hopes of producing vegetables and providing a recreational area for the staff of Aravind. The layout is truly lovely, and includes a quarry pond, in-ground swimming pool and garden for their use.

Dinner included a program of indigenous folk dancing, including karagaattam, a dance where the dancer balances a pot on their head while balancing on a wooden ball, and silambattam, where the male dancers fight with long wooden sticks. The women also performed, including a version of the snake dance. The whole event took place next to a pool of water so smooth that it looked as if the dancer and her image were partners in the performance. Magical.

Tomorrow is our last full day in Madurai, and will include a trip to a vision center in the rural area outside of the city.

Until then,

Tuesday, February 17, 2009

Day One – Aravind Hospitals, Madurai

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The study tour begins with a trip to LAICO, the Lions Aravind Institute of Community Ophthalmology. Our group is met by LAICO staff with glorious garlands of aromatic jasmine and cedar. Madurai is world famous for its jasmine, especially for the single garlands, malligi, usually worn daily by local women. The scent is intoxicating, and the welcoming ceremony, moving.

The staff, led by Aravind Chair Dr. P. Namperumalsamy (Dr. Nam), began an overview of Aravind Eye Care System. The detailed presentation outlined not only the surgical/medical excellence the organization is known for, but also highlighted the other facets of their success – commitment to serving everyone in pursuit of eliminating needless blindness, and an incredible knack for business management. This illustrated the scope and efficiency of Aravind, and gave a preview of what the study tour will witness in the coming days.

After lunch, study tour participants heard from the division of AECS, the LAICO education structure. Starting with a tour of the building, they addressed how their teaching facility not only served their internal needs for training medical and support staff, but also the greater ophthalmologic community. Students and practitioners from around the world descend on Aravind daily to take advantage of educational programs. The subjects range from eye care, to professional and managerial development, to global partnership opportunities.

During the tour, they introduced our STPs to the concept of Aravind “sisters.” These young women are recruited right out of high school from the rural areas surrounding Madurai. They spend one year of residence, training to work with patients, and are usually chosen to serve as patient counselors. After two years, they are ready to assist patients in navigating the world of eye medicine by explaining the surgical options available to them, accompany them during the surgery, explain in detail the correct post-operative care procedures, and encourage them to return for follow-up in four to six weeks. As most of the patients come from the same rural areas the girls hail from, working with them helps to dispel much of the trepidation that may come with visiting the hospital. This increases the likelihood of a successful procedure, and the girls have an opportunity not usually available to them in their villages. My hope is that the financial and educational independence they gain will ensure a better fate for their own girls.

After a day full of new information and new acquaintances, dinner featured some friends of Aravind – NGO partners and local industrialists, all vitally interested in the success of Aravind. Tomorrow will be an early morning, with the study tour joining the doctors in the operating theatre.

Eravu Vanakkangal (“Good Night” in Tamil)

Monday, February 9, 2009

2008 Gates Award Study Tour

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The Global Health Council is hosting a study tour of influential global health leaders from around the world to learn about the work of 2008 Gates Award for Global Health recipient, Aravind Eye Care System. Aravind received the award in recognition of its groundbreaking work to prevent debilitating blindness and provide affordable, world-class eye care to the poor. Based in Tamil Nadu, India, Aravind provides an integrated approach to the provision of eye care services to a large population in southern India and has established a new model of financial self-sustainability.

Study Tour Participants:

Dr. Mulu Admasu, Chief of Eye Surgery, ALERT Hospital, Ethiopian Ministry of Health
Dr. Ponni Subbiah, Vice President and Head, Global Access Strategy, Pfizer Inc.
Dr. Suzanne Gilbert, Director, Center for Innovation in Eye Care, Seva Foundation
Fred de Sam Lazaro, Global Health Correspondent, NewsHour with Jim Lehrer
Maurice Middleberg, Executive Vice President, Global Health Council
Dawn Ellen Carey, Awards Program Coordinator, Global Health Council
Jim Wiggins, Independent Consultant

Join Dawn Carey, awards coordinator at the Global Health Council, and follow the Study Tour’s journey through Madurai and Pondicherry daily, as it happens.

Day 1 – Aravind hospital sites
Day 2 – Surgeries, Hospital and Aurolab
Day 3 – Aravind Free Hospital and Remote Vision Center

Day 4 – Pondicherry Hospital
Day 5 – Auroville and Aurobindo Ashram
Day 6 - Remote Eye Camp