With the passing of Govindappa Venkataswamy, MD, 87, founder and chairman of the Aravind Eye Care System in Madurai, India,
on July 7, the worldwide ophthalmology community lost a visionary and inspirational leader.
Dr Venkataswamy, known to many as "Dr V", founded his first Aravind Eye Hospital in Madurai, a city in the southern Indian
state of Tamil Nadu, in 1976. The 11-bed hospital was the initial step in his long-term goal of preventing needless blindness
in a region plagued with a high incidence of cataracts and other eye diseases that relegated patients to lives of dependence
or premature death. This original clinic is now part of a system that comprises five Aravind Eye Hospitals, four vision centres,
two community eye clinics, two managed eye care hospitals, the Lions Aravind Institute of Community Ophthalmology, an ophthalmic
manufacturer that produces low-cost IOLs, a medical research foundation, a postgraduate institute, community outreach programs,
eye banks and a tele-ophthalmology network.
A twist of fate?
This amazing ophthalmic system is a testament to its founder, Dr V. Born in a small village in 1918, Dr V's childhood duties
included taking the family's buffalo out to graze before school. After medical school, he completed his training in obstetrics
and gynaecology and served as an army doctor in World War II. Soon after, the unthinkable happened to this young doctor. He
developed a severe case of rheumatoid arthritis, which left him literally agonizing in pain and bedridden for two years. His
hands became permanently disfigured, and he realized his career as an OB-GYN was over before it even began. He found comfort
in meditation and a new purpose in his meetings with a religious leader, Sri Aurobindo. Despite having to learn how to stand
and walk again, he enrolled to become an ophthalmologist and quickly became a top cataract surgeon (designing his own instruments
for his twisted hands)!
Inspired by a chain of fast food restaurants!
Then a merging of ideas occurred. Dr V became frustrated that the incidence of visually significant cataracts was much greater
than the ability of India's ophthalmologists to remove them. He also became an admirer of Ray Kroc, founder of the McDonalds
restaurant chain (despite being vegetarian). He saw that they were able to maintain high volumes and good service, serving
low priced food with a workforce of relatively low-skilled employees. Around this time, Dr V was forced to retire from his
position as the head of ophthalmology at Madurai Medical College because of his age, but he had too much on his mind to rest.
In 1976, he mortgaged his house and started the 11-bed Aravind Eye Hospital in Madurai. He convinced his brother (a civil
engineer) to help with construction, and his sister (Dr Natchiar) and brother-in-law (Dr Nam), both ophthalmologists in safe,
well-paying positions, to join the mission of eliminating needless blindness — for the rich and especially the poor.
Implementing the high volume, good quality system
The current hospitals operate in much the same way as the original did. Designed to be self-sustaining, the hospitals rely
on the fees paid by around 30% of patients to subsidise the free care for the remainder. Thinking of Ray Kroc's high volume
system, Dr V implemented a system whereby, at any one time, there are two patients in the operating theatre. As the surgeon
operates on patient number one, patient two is being prepped and draped by the nursing staff. Once the procedure on patient
one is finished they are moved into postoperative recovery and patient two moves to bed one and another patient comes in to
be prepped, an so on. The surgeon does not change gloves in between cases but simply rinses with 0.5% chlorhexidine/70% isopropyl
alcohol solution. Despite the simplicity of this, the rates of infection in Dr V hospitals is lower than US rates!
Aravind prides itself on being self-sustaining, i.e., no VIP donors, no government grants and no bank loans. The technology
is cutting-edge (all the newest phaco machines — the same models found in the United States, including Alcon's Infiniti).
Paying patients may choose their rooms (from sharing a room to a private, air-conditioned room), the type of surgery (extracapsular
cataract extraction [ECCE], small-incision cataract surgery [SICS], or phacoemulsification) and type of IOL (ranging from
Aurolab's basic rigid lens, foldable lens or Alcon's AcrySof lens). To put this into perspective, the most premium service
— deluxe air-conditioned room, clear-corneal phaco and an Alcon acrylic lens — costs just over 300 in total.
IOL mass production proves to be a success
As IOL implantation became the standard of care, Aravind found the cost of the lenses to be prohibitive. In 1991, Aurolab,
a separate non-profit company, was created to manufacture lenses, sutures, capsular dyes (trypan blue), spectacle lenses and
pharmaceuticals. Aurolab products are made to exacting specifications and have earned many international quality awards; it
sells its products in more than 90 countries (less than 20% of its production is consumed by Aravind). The production facilities
are currently housed on the hospital campus, where more than 700,000 lenses are produced yearly with the cost of a rigid IOL
being less than 4. Business analysts have concluded that Aurolab has driven downward the cost of IOLs around the world.
Taking the treatment to the patient
Aravind spends considerable resources seeking out free patients; they conduct screening "camps" in rural areas, bus the patients
to the hospital, provide for their housing and food, perform the SICS or ECCE surgery including IOL implantation and bus them
back afterwards. They even return to the rural area for the one-month postoperative follow-up (and give patients glasses as
needed). The government reimburses Aravind approximately 500 rupees (almost 10) for every camp patient surgery.
It is not unusual that camp patients need to be convinced that going blind from cataracts need not be a part of growing old.
They sometimes don't believe that a short surgery can make them productive once again and they certainly don't believe that
they can afford such a treatment. Thus, Aravind has actually had to create its market.
How did Dr V influence others?
The success of Dr Venkataswamy's vision is evidenced by the fact that Tamil Nadu now has a rate of eye disease 20% less than
that of India as a whole, while the incidence in that region was considerably higher than the nationwide rate when the eye
care program began.
Dr V's dedication and accomplishments draw praise from many. "He was probably one of the greatest and most visionary ophthalmologists
I've ever met. He was able to think outside the box and was able to conceptualize things that nobody had ever done before,"
said Alan L. Robin, MD, associate professor at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore,
USA. "He was able to create a sustainable, profitable healthcare system in India that has enabled more people to be able to
see and maintain their vision than anybody I've ever known. He has done more good for mankind than almost anybody I could
imagine." Dr Robin has been working with the Aravind system since 1989 and made about 40 trips to India. He received the American
Glaucoma Society's outstanding humanitarian service award in 2005, in part for his involvement with this organization.
According to Dr Robin, Dr V's success is even more remarkable considering that he became a successful surgeon despite having
rheumatoid arthritis and that he started the Aravind system as a second career after he retired as the head of the ophthalmology
department at Government Medical College in Madurai. He remained at the forefront of the Aravind system for many years, although
the reins of authority had largely passed to a new generation of leaders within the last decade. "He started the Aravind Eye
Hospital at the age of 58 and went on over the next 29 years to develop his programmes when many physicians would be in retirement.
That is testimony to his drive and commitment," said Harry Zink, MD, president of the American Academy of Ophthalmology. Dr
Venkataswamy received the International Blindness Prevention Award at the academy's 1992 annual meeting.
While the Aravind model might not work in all countries for various reasons, including its two-tier system based on ability
to pay, the system is valuable beyond the Indian border for other reasons, said Peter McDonnell, director, Wilmer Eye Institute,
the Johns Hopkins University School of Medicine, Baltimore, USA and chief medical editor of Ophthalmology Times. "They have such a high volume that they are able to do certain studies that we would have great difficulty doing in the
US, so they can enhance the state of knowledge through clinical trials," he said. A recent example is the fusarium outbreak in the US, Dr McDonnell said. Fungal infections in the eye are rare in the US but extremely common in India, where
doctors and hospitals have accumulated extensive experience in treating them. "I think that's a knowledge that can be shared
across national and continental boundaries," Dr McDonnell said. "If an outbreak like this does occur, there's an opportunity
to learn from institutions like Aravind."
Dr McDonnell also cited the Aravind system's ongoing success at expanding its mission. Dr Venkataswamy's legacy extends beyond
cataract surgery," Dr McDonnell said. "While he focused, particularly initially, on the tremendous need for a cost-effective
way to deliver cataract surgery to the masses, his institution now includes retina specialists and glaucoma specialists. A
lot of them have spent time in the United States, some at my own institution, and so they're able to extend that expertise
and successful model that they used for cataract surgery to other ophthalmic disease areas and other specialties."
July 2006 saw the loss of a legend
Despite the sad loss of its founder, Aravind will not be resting on its laurels. According to Aravind Srinivasan, ophthalmologist
and nephew of Dr V, future and current goals include establishing new eyecare hospitals in various underserved areas of southern
India and taking the organization to a new level by addressing chronic conditions such as glaucoma, age-related macular degeneration
and diabetic retinopathy with the same systematic approach that has been so successful with cataracts. Research will also
continue on developing new products and therapies.
A resident's experience at the Aravind Eye Hospital
By Parag Parekh, MD, MPA
It was the 8th of July 2006. My wife and I had been in the city of Madurai in southern India for just a few days when we read
the news in the morning paper — Dr Govindappa Venkataswamy (Dr V), founder of the world renowned Aravind Eye Hospital, had
Parag Parekh, MD, MPA
By coincidence, July 8th was also the day I was moving into Aravind's guest house for a month-long surgical rotation. On that
sun-scorched Saturday, we rushed to find any white clothing we had (the traditional colour to wear at a funeral) and headed
to Dr V's house to pay our respects. Located just steps from the guest house, Dr V's house was over-run with mourners, crowding
the vestibule and flowing into the street. Unsure of the proper etiquette in such a situation, I luckily found a friendly
face, Dr Prajna the Director of Medical Education at Aravind, my contact person for this rotation, and Dr V's nephew. He invited
me into the house where Dr V's body lay in a glass-enclosed casket, surrounded by friends and family. Before his body was
driven to a nearby park for cremation, I had the honour of saying goodbye to this giant of ophthalmology, a servant of humanity
and a role-model to me.
Residents from the United States typically spend a month at Aravind, splitting their time between ECCE and phaco cases. I
had the chance to do two cases a day, six days a week making for the ideal way to start off my third-year of residency. This
seemed like a lot of volume to me, until I realized that the senior surgeons would easily do 30 cases before lunch! The hands-on
teaching is outstanding, and once you feel comfortable, you are operating on your own (with very perceptive scrub nurses,
all trained at Aravind, who are able to predict problems before they happen and get you out of a jam when necessary). If there
is a complication, there is always a highly-skilled surgeon close by.
The living accommodations at the guest house are superb. Large, air-conditioned rooms with private bathrooms, three tasty
meals per day, wireless Internet and laundry that costs pennies. They think of every detail here.
The learning does not stop at the hospital doors. India will change your perspective on the world and on what's truly important
in life. And it will do so quite abruptly. Venture out into the city of Madurai and you get a small sampling of India's magnificent
countryside, world-famous architecture (Meenakshi Temple), beautiful clothes, crowded markets, chaotic driving on dusty roads,
beautiful resorts and dire poverty.
The nicest thing about Aravind is the hardest for me to capture — the personal relationship that the Aravind community builds
with you, almost from the instant you arrive, and the warmth with which you are welcomed is astounding. Even the most senior
faculty went out of their way to invite me to their operating room or to their afternoon clinic to teach me about their sub-specialty.
Everyday, they would ask me how I was enjoying my stay and if there was anything I needed. They made me feel like they were
the lucky ones to have me there.
I feel privileged to have visited Aravind, especially at the momentous time that was July 2006. Dr V became a hero to me when
I read a case study five years ago and being at his hospital was everything I had hoped for. I did not expect, however, to
feel so attached and so changed by the place. At Aravind, you truly feel like you are part of the family — including the mourning
that goes with the passing of a loved one and the celebration of his charmed life.