1. The Path to Aravind

ASCRS, American Society of Cataract & Refractive Surgery, 2013, San Francisco, California:  The conference seems to be catching fire with topics and exhibitors on femtosecond laser cataract surgery.  Most headlines in industry newspapers report about the purported benefits of this new cataract surgery technology.  Alcon, Optimedica, Bausch & Lomb, Zeimer, Lensar – the list of manufacturers showing off their wares are like the who’s who of the ophthalmic industry.  Though I find the technology fascinating, I feel that as ophthalmologists, we are merely looking for ways to justify new technology on account of our penchant to play with new things.  Are we becoming more and more like marketers for new technology?  Are we becoming sales persons to our patients, while we compare ourselves to the Joneses in our ophthalmic world?  Do we now think more about “ROI” – “Return On Investment” – for every piece of equipment we want to purchase, just because another ophthalmologist has it and is talking about it on the podium?  In our embrace of newer phacoemulsification platforms or laser platforms, are we not driving up the cost of cataract surgery?  What has become of our purpose in being a medical doctor to take care of patients?

Seeking a higher purpose to this profession, I attended SEE International’s ASCRS get-together, to understand this organization that coordinates eye surgery for the developing country.  There, I met colleagues who have chosen to spend part of their time providing surgical care to third world countries.  I was previously drawn to ORBIS – the “flying eye hospital” – that reaches out to third-world countries.  But some members of the ophthalmic community comment how this high-tech "flying eye hospital" did not help these third-world countries with their needs to cure blindness, or become self-dependent, when their own resources are so limited.  At this SEE International gathering, many doctors spoke of a technique called SICS, or MSICS, depending on whom you speak to.  I quickly obtained a lecture schedule on this topic, and decided to learn something about this surgery technique while still at ASCRS 2013.

I attended a talk in a small lecture hall.  Adjoining halls were filled with ophthalmologists listening to topics on various new surgical devices for cataract, retina or glaucoma, devices that again were expensive and costly.  The talk I attended was in a room, only 1/3 full, of about 30 – 40 attendees.  The presenting ophthalmologists were from a placed called “Aravind Eye Hospital”.  The moderator was an engaging surgeon, who said he had challenged Dr. David Chang to see who could perform cataract surgery faster – him using SICS while Dr. Chang using phacoemulsification.  I watched in fascination the surgical videos of this moderator and of his colleagues from the same institution.  They were exceptional surgeons.  Like an artist admiring the work of others, I was mesmerized in the elegance of their surgical technique.  They spoke of their institution’s mission to cure cataract blindness, of efficient and cost-effective surgery.  Between video images and their speeches, thoughts raced through my head, thinking of how this surgical technique could address the rising cost of cataract surgery in our developed countries of United States and Canada.  At the conclusion of their talk, I almost leaped to my feet and clapped “Bravo!”  As the audience sauntered out of the hall, I lingered to introduce myself to the moderator – Dr. Venkatesh – and I asked to connect with him so that one day, I could observe his surgery in person.

Months later, I found myself on the most amazing experience in my life.

.....Continue to "2. At Aravind, At Last"

2. At Aravind, At Last

Entrance at 3am

Seven months later, I found myself leaving Singapore’s ultramodern Changi Airport on my first-ever trip to India, to Chennai, in the state of Tamil Nadu.  At Chennai International Airport’s arrival section, from a throng of men holding signs of names, I was taken into a taxi, commandeered by a fearless driver, who navigated the next three hours of the trip, through unlit narrow coastal roads, dodging cows and stray dogs in the dark, to finally arrive at the gates of Aravind Eye Hospital in Pondicherry.  Saturday November 30, 2013, 3:00am we arrived at the guesthouse.  From the dark emerged two thin ladies who, without a word or a sound, glided toward me like fairies, took up my heavy luggage up the stairs of a two-story building, bringing us to our room.  The room was furnished with detailed English instructions on the door emphasizing “Do not give tip”.  It was sparsely furnished with foam pads on wood frames, a ceiling fan, an air conditioner, flush toilet with minimal toilet paper, shower, a candle and cream called “Odomos”, a phone, and numerous Type D outlets.  At 4am local time (3pm Pacific Time), I laid on the cot, with thoughts of anticipation for the coming month as I drifted into sleep.

Simple guest room

We awoke at mid-morning to a warm winter day of 30 degrees Celsius (86 F).  The sun poured into the courtyard of this building known as the guesthouse. Neatly decorated without extravagance, the square guesthouse was two stories high, with a central courtyard separated by a fine mesh screen to the sky above, and a small statue facing the central front door.  We seemed to be the only occupants of the guesthouse at the time.  No sooner had we walked downstairs, did a thin barefooted lady suddenly appear.  In polite but heavy-accented English, she introduced herself as a housekeeping “sister”, and a name which was too hard for me to pronounce.  She brought lunch, and politely gave us a verbal orientation of the guesthouse routines.  Turns out being barefooted indoors is the norm, a custom we adapted easily, since it is also a Chinese custom.  Soon after, I received a phone call from Dr. Venkatesh, welcoming us to Aravind.

The guesthouse at Aravind Pondicherry

Over the coming month, while this place became my home, I would come to realize that  “Aravind” is not merely an ophthalmology hospital.  It’s a belief system and a way of life.  I was not only at Aravind; I was within Aravind.  This month would profoundly alter my view of ophthalmology, and my view of life.

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3. Aravind Pondicherry, Dr. V's Final Creation

"Aravind", meaning lotus,  and statue of Sri Aurobindo,
grace the entrance to Aravind Eye Hospital Pondicherry

Aravind Eye Care System began with a humble hospital in Madurai, in 1976.  The Aravind Eye Hospital at Pondicherry is the 5^th hospital in the Aravind Eye Care System.  Dr. Govinda Venkataswamy (Dr. V) was the founding father of these hospitals.  His post-retirement goal of offering free cataract surgery to the masses became the seed of Aravind.  His determination inspired his youngest sister Dr. Natchiar and her husband Dr. Nam to return from USA to India and take on the same cause.  In their tireless efforts, they would begin surgery at 5am, finish surgery four hours later, and begin seeing patients in the clinic.  Dr. V held steadfast to the writings of Sri Aurobindo, and to the teachings of The Mother (nee Mirra Alfassa).  Black-and-white portraits of these two spiritual leaders adorn the entrance to every Aravind building.  Aravind Eye Hospital Pondicherry was conceived during Dr. V’s spiritual retreat to Sri Aurobino’s Pondicherry ashram.  At the time he was seeking spiritual illumination on transferring authority of the Aravind Eye Care System to his successor.  Instead, he was struck with a passion to build the crowning jewel.  Completed in 2003, Aravind Pondicherry was to be the last hospital construction he would oversee, during his glorious life on earth.

Photo of "The Mother" (left) and Sri Aurobindo
behind the triage desk in the main foyer
of Aravind Eye Hospital Pondicherry

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4. Aravind Eye Hospital, a World within Pondicherry

Driveway into the hospital campus

Frontal view of Aravind Eye Hospital Pondicherry

Entering the campus of Aravind Eye Hospital was entering into a different world within Pondicherry.  The mayhem, noise, dirt, and litter of streets in the neighborhood and nearby Puducherry city, seem unreal as soon as you enter the gates of the hospital campus.  Clean, paved road are divided by manicured bushes, leading westward past a tulip garden and a pond, into the 22-acre campus.  The hospital is centrally located in the campus, with separate entrances for the Inpatient, Outpatient, and Free Sections.  Flanking the south side are the residences for the doctors, the sisters, and the guesthouse; on the north side is a power plant for the campus.  The hospital is 5 stories of concrete with many open windows, housing the various ophthalmology clinics, patient beds, hermetically-sealed operating rooms, administration, IT department, library, classrooms, and meditation chamber.  Behind the building and surrounding the residences are acres of land intended for agriculture, where banana trees dot the fields, and goats walk lazily.  Slim agile young ladies – sisters – who are dressed in white or green sarees, glide quietly between the Sisters’ residence and the hospital, like ensembles of angels, following the spiritual purpose of everyone within Aravind.

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5. The Sisters

I have worked with nurses of all specialties since internship, in Canada & the U.S.  Nurses of the same training, typically R.N., develop a fraternity – a sisterhood – cultivated by the years of hardwork together.  Yet never in my 26 years of medical training and practice, have I seen such beautiful harmony as I’ve seen among the Pondicherry Aravind sisters.

Sisters and author in hallway by hospital library

Beginning at age 17 or 18, the majority of Sisters had applied to train and work at Aravind, inspired either by Aravind’s outreach to care for the blind in their rural communities, or pursuing higher education.  The applicants come from rural farming background.  Not all who applied were accepted into Aravind.  Only those with the proper combination of self-discipline, steadfastness, spiritual and family upbringing would be considered, and inducted into Aravind’s two or three-years of training.  Like white sheets of paper intended for the pages of an epic story, these Sisters were trained at multiple Aravind hospital sites, in all the departments, and posted at the end of training in the department suited to each Sister’s strength, whether it is administration, patient care, or housekeeping.  The training is rigorous and regimented.  Many a times, I would walk past the classrooms, to see groups of Sisters receiving didactic instructions, receiving hands-on training, studying for tests, or being administered examinations. 

Mostly in their early 20s, these young women live in the same building, eat the same food provided by the hospital’s kitchens everyday, and dedicate their lives to eyecare.  Over 400 of them live in the four-story residence, wearing white sarees wherever they go.  They clock-in early morning for work using fingerprint biometric devices at the hospital entrance, and clock-out the same 5pm every day, Monday to Saturday, and 1pm on Sundays.  In the residence, 4 to 8 sisters would sleep on the floor in the same room.  They share washrooms in the hallways, play simple games, or share the few TVs together.  When the month-long morning Pongal prayers began on December 15, the devout sisters would awake daily at 5am to chant Tamil prayers together, and decorate the footstep to their residence daily with fresh chalk art.

On December 25, some sisters requested the day off to pray at Christian churches 45 minutes bus-ride away in Puducherry, while the majority of them continued to work.  On New Year’s Eve, the sisters all celebrated the final hours of 2013 within the campus.  The communal spirit bonds the sisters.  When they are in the residences, they share stories, sing & laugh together, and encourage each other.  Though very few could speak English – and those that spoke English did so with heavy accents and limited diction – their pureness of heart and kindness shine forth from their young eyes and bright smiles.  These traits of love for fellow humans and dedication to their work, are chosen and further fostered for their supportive role to the Aravind ophthalmologists, whom they respectfully address as “sir” or “ma’am”.  They are the backbone for the eye care teams in administration, operating theaters, and outreach eye camps.

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