Could Indian ideas help crack China's cataract crunch?
Editor's Note: In 2005, China was on track to exceed 600,000 cataract surgeries for the first time, still far behind the estimated 4 million-plus cataract procedures performed in India. Each is a developing country with more than 1 billion population, a hot economy and low-though-rising per-capita gross domestic product, and similar numbers of ophthalmologists. So how is it that India has achieved a cataract surgery rate (CSR)—the number of patient surgeries per million population per year—of about 4,000 (not far behind rates seen in the West and roughly 10 times China's CSR)? Using a series of interviews and industry presentations as his basis, Jeffrey Parker reports how India's key to success centers around two components: management and technology.
Setting aside decades of distrust, China's Premier Wen Jiabao hailed the vast potential for Sino-Indian cooperation in science and technology during a visit to technology export powerhouse Tata Consultancy Services in Bangalore.
Rengappa Ramakrishnan, chief medical officer at Aravind Eye Hospital's Tirunelveli hospital, attended an ophthalmic congress in Shanghai in 2005.
"It is true India has the advantage in software and China in hardware. If India and China cooperate in information technology, we will be able to lead the world," Wen told his hosts. Driving home his message in Delhi the next day, Wen pledged to "put in place a bridge of friendship linking our two countries . . . to the future."
From left: Jeffrey Parker, editorial director of the China and India editions of Ophthalmology Times; Dr. Ramakrishnan; and Hao Xiaojun, a young surgeon from Shanghai, convene during Dr. Ramakrishnan's visit. (Photos courtesy of Jeffrey Parker)
At virtually the same moment, far across the Himalayas in China's shimmering commercial capital Shanghai, three ophthalmologists—two from China and one from India—were already putting Wen's vision into practice, exploring Indian ophthalmic innovations that could help China raise its vexingly low cataract surgery rate. On the Chinese side were Professor Zhao Jialiang, president of the Chinese Ophthalmological Society, and Hao Xiaojun, a young surgeon from Shanghai. Visiting from India was Aravind Eye Hospital Chief Medical Officer Rengappa Ramakrishnan.
Professor Zhao kicked off the 5th Congress of Ophthalmology and Optometry China with a frank assessment of China's cataract situation in his keynote address, pointing to inadequate training of surgeons, the high cost of surgery, and poor public education for the frustratingly low levels of cataract surgery. He estimated that 450,000 people go blind each year in China—"almost one per minute"—and of that total 400,000 were due to cataract and preventable.
"As China's population continues to grow and age, without sufficient numbers of trained doctors with modern knowledge and skills, the numbers of blind will only grow," he said. "At today's growth rate, China's blind population will quadruple by 2020."
This was the central topic of the Indian visitors, who explained that India's key to success had two components: management and technology. Dr. Ramakrishnan said that Indian institutions such as Aravind have developed an approach to health-care management that generates demand with free community screenings and the offer of free surgery, the cost of which is subsidized by higher charges to premium-paying patients. Aravind, a not-for-profit institution, balances its books despite doing two-thirds of its cataracts free of charge.
The technologic advantage is India's embrace and refinement of sutureless manual small-incision cataract surgery (SICS), which allows high-quality surgical outcomes rivaling those of phaco but without the expense of the phaco system or the training to use it. India is clearly the world's leader in SICS, in which the nucleus is removed and a rigid IOL inserted through an incision of just 5 to 6 mm. Such is India's prowess that some surgeons are working through incisions of just 2 to 3 mm, microincision cataract surgery (MICS), though this requires a more expensive foldable or rollable IOL.
Dr. Ramakrishnan awed his Chinese audience with the staggering surgical numbers produced each year by Aravind alone through its five hospitals in Tamil Nadu. Aravind notched up 226,000 surgeries in 2004, of which 170,000 were cataract operations. While Dr. Ramakrishnan noted that this was more than in all of Britain, the Chinese doctors were shaking their heads calculating that this one hospital group in one Indian state was doing almost two-fifths as many cataract surgeries as all of China.
Dr. Ramakrishnan reeled off the performance statistics for Aravind's surgeons, dozens of whom perform more than 2,000 cataract procedures a year and in many cases 120 a day. He made a strong case for a careful division of operatory labor and investment in equipment, saying a single surgeon using one table, two nurses, and one set of instruments was limited to just one cataract procedure per hour, while the same surgeon using two tables, three nurses, and six sets of instruments could average six to eight cataract surgeries per hour.
It's not difficult to understand the Chinese disbelief. Though China has thousands of surgeons who can perform extracapsular cataract extraction or phaco, inefficient management at Chinese hospitals has severely retarded Professor Zhao's efforts to engender a climate for "high-volume, high-quality, low-cost" cataract surgery.
A typical Chinese surgeon might need 1 month or even 1 year to perform as many cataract procedures as an Aravind high-volume surgeon does in a day, and even top surgeons rarely put in double-digit cataract surgery days. Young doctors complain not only about low pay, but also about having to wait years for surgical training opportunities.
And then there is a little-known aspect of Chinese ophthalmology: Many surgeons with skills make substantial money performing illegal "moonlight" surgeries off their hospital's books. These surgeons have a strong incentive to hoard their surgical skills. Small-incision surgery, quite common in India, is rare in China.
Thirty-four-year old Hao Xiaojun is a believer—and a highly motivated one. Having read about Aravind, he organized his own training trip there in 2004 and hopes to return for a 2-year immersion program. Dr. Hao addressed the Chinese disbelief in his Shanghai presentation, titled "Impressions of Aravind—incredible, but true." He voiced a strong belief that Aravind-style management and technology can be successfully adapted to China's state-dominated health-care system. It was Dr. Hao who arranged the speaking tour of Dr. Ramakrishnan, who was visiting China for the first time.
Studying India's progress
Dr. Hao said a small number of Chinese ophthalmologists, including Professor Zhao, had been monitoring and admiring India's cataract progress in recent years, and it was his personal mission to learn more and bring Indian concepts to China. He is not alone.
Professor He Wei of Shenyang, in northeastern Liaoning province, has a half dozen or more surgeons performing at World Cataract Foundation's "master level" of 1,000 or more surgeries a year, though his clinics and training programs use phaco almost exclusively. Professor He told Ophthalmology Times China that his management model was borrowed in large measure from Aravind and the L.V. Prasad Eye Institute in Hyderabad, where he visited in the late 1990s, and similarly uses revenues from paying patients to subsidize large numbers of free or low-cost surgeries.
Li Wenhua, a young ophthalmologist from Taiyuan in northern Shanxi province who studied at L.V. Prasad, is now a full-time surgeon aboard the ORBIS flying hospital. Dr. Li, a retinal specialist, told Ophthalmology Times China of her intention to return to China to teach Indian approaches.
Indian curiosity toward China is significant. When a large delegation from the Bombay Ophthalmologists' Association visited China, Ophthalmology Times China organized an unprecedented clinical and social exchange at the Eye Hospital of the China Academy of Traditional Chinese Medicine, a major center in Beijing that combines western and traditional therapies. The Indian visitors peppered their Chinese colleagues with questions about traditional Chinese medicine therapies that are showing promising results in slowing diabetic retinopathy, retinitis pigmentosa, and age-related macular degeneration.
Chinese Ophthalmological Society chief Zhao's own prescription for cracking China's cataract crunch urged looking across the Himalayas and "sincerely studying the experience of India in blindness prevention." Though ophthalmic links between India and China remain nascent, especially at the grassroots level, this is changing.
The new political openness between Asia's two biggest countries has generated a flurry of commercial activity, and as Premier Wen predicted the exchange is likely to flow strongly in both directions with Chinese technology likely to make a strong showing in India. In recent months, teams from Indian ophthalmic makers Care Group and Appasamy Associates have toured Chinese firms like Suzhou 66 Vision-Tech and Beyonder Technologies in a search for high-quality Chinese equipment, including phaco systems and excimer lasers, at prices below major brands.
The early contacts hold out the promise of further discussions between doctors and companies in India, China, and the West about ways to organize cross-border training programs, share expertise, and address what many acknowledge are mutual suspicions about the quality of ophthalmic equipment, IOLs, viscoelastics, and other products made in each country.
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