Slow Down (It’s the Cataracts)

As our time in Madurai came to an end, I felt the intense urge to slow down time. Even when walking or eating a meal, I tried to take a breath and appreciate the wonder of my new routine. Slowly and then all at once, my brief time in India became the most transformative and enjoyable summer of my life. Here is my (rather long) attempt to articulate some more details in this experience.

Part 1: The Hospital

At AEH, more than half of operations are completed by 9 AM in the paying OT. This efficiency is impressive given that patients start being admitted at 7. The OT complex is divided into separate rooms for retina, pediatric, glaucoma, cornea, cataract, and orbit surgeries. Out of these, cataract surgeries are the fastest and most likely to have consistently good outcomes. Unoperated cataract is the leading cause of preventable blindness worldwide, and it can only be fixed by surgically extracting the cataract (clouded lens) and implanting an intraocular lens (IOL). So, cataract surgery is estimated to be one of the most commonly performed surgeries in the world. It’s also one of the most cost-effective interventions, with a high economic and mortality benefit. Generally, the cataract OT at AEH Madurai completes anywhere from 70-250 surgeries per day, which really speaks to the efficiency and dedication of the team. Dr. Jebinth Brayan at AEH Coimbatore gave a talk sharing how he is able to perform around 100 cataract surgeries over the course of one day, which makes him a standout among standouts.

Once a patient enters the AEH cataract clinic, the basic steps are to first register the patient and hand them a route card outlining each station. Then, the patient undergoes testing for vision, refraction, blood pressure, and intraocular pressure. Unless a patient has pain or redness, they will undergo dilatation. They will be examined for lacrimal duct patency and scanned with A-scan biometry to determine the IOL power needed. After the doctor examines the patient and gives their opinion, the patient can move onto counseling and an optical shop/medical shop or specialty clinic opinion as needed. After their consultation, patients can return the next day for a day care surgery, meaning that they will return home on the same day and then come back the third day for postoperative review. AEH Pondicherry has streamlined this process even more, so ~30% of patients can return to the hospital less times through more testing at a local center. In the free clinic, almost every single patient screened in the general ophthalmology unit has cataracts. The free patients are mostly elderly and from rural areas, so it’s important to minimize the amount of trips needed to the tertiary hospital.

The payment models at AEH, and especially the affordability, are a key part of what makes the surgeries so accessible. Patient charges for a cataract surgery are broken into four main categories on the bill: surgical spending, theater cost, medicine, and pre and postoperative medicines. Prices can vary based on the type of surgery (MICS or phaco) and the IOL cost. Overall, the total cost for one surgery in the paid hospital averages only a couple hundred dollars. And what if a patient has complications after the surgery? For example, posterior capsule opacification (PCO), often called secondary cataract, is when lens epithelial cells remain and differentiate, causing scar tissue to form behind the IOL. PCO causes blurry vision and glare, similar to a cataract. PCO is the most common delayed postoperative complication of cataract surgery; some studies suggest that PCO occurs in 20%-50% patients within two years after operation. YAG laser capsulotomy is the standard treatment, and it takes only five minutes. Most American providers charge at least $1,000 for the laser itself, not including anesthesia, imaging, and other visit fees. At AEH, YAG cap charges range from 0 rupees to a maximum of 800 rupees ($10) per eye.

Despite the impressive efforts made by AEH in the iron triangle of health care (access, cost, and quality), the cataract department at Aravind is still constantly seeking areas to improve. As Dr. Madhu Shekhar and Dr. Aruna Pai both explained, the issue of second eye surgery completion persists among patients with bilateral cataracts. Barriers to follow up for another surgery may be due to several factors, namely lacking an attender to accompany them, other personal commitments, work commitments, or religious festivals. 

During the celebration of Aadi Perukku on August 3rd, the streets of Madurai were quieter, and there were far less patients in the clinic than usual. After work, Aravind and I headed to Meenakshi Temple, which was filled with devotees and made for a breathtaking experience. Combined with the emptiness of departments as many doctors went to the Tamil Nadu Ophthalmic Association (TNOA) conference, this made our last week at work comparatively quiet and a time full of personal reflection.

Part 2: Hospitality and Heart

While I expected to see a lot of impressive work in the hospital, I was most touched by the people I met. Ushalini described Madurai as a place where people share “unfiltered love,” and I could not agree more. Happiness in India is simple and abundant, but I comfort myself with the knowledge that this same capacity for joy has been expanded just from the lessons I learned this summer. My favorite memories with the following people who made this happiness so easy are hard to describe in words, but here are my attempts to summarize why I appreciate them so much.

My pillars of support were my project mentors, Ushalini, Ramesh, Yesu, Suresh, and Sr. Selvi, along with Srilakshmi and Dhivya. Beyond being professional role models, they are all friendly and caring people with real passion for their work. Within the cataract clinic, Sr. Selvi, Sr. Kamatchi, Sr. Karthikadevi, and Sr. Mariammal always looked out for me and made every single day a treat. Sr. Selvi and Sr. Mariammal even joked that they wished they could adopt me or have me stay in their houses so I wouldn’t leave. In the OT/sterilization (CSSD) complex, I have to acknowledge the MLOP sisters, including Selsiya, Vidhya, Gayatri, Mounika, Jagadeeshwari, Nivethitha, and Deepika, who are unbelievably energetic and friendly. After being greeted with the sisters asking for my name, native place, and whether I finished my breakfast, they clamored to share more about themselves too. Every time I saw them, I felt overwhelmed with their enthusiasm. Jeyageetha and Kalaivani in the A-scan department, and Jothipandi and Ranjitha in the physician department, were so welcoming and patient with me as I learned the ropes. In short, the sisters are the backbone of AEH, and they’re fun to be around too!

Dharini in the Aurosiksha office taught me so much from her passion for life and her generosity. Her talent at making kolams with rice flour, stringing flower garlands, designing mehndi, making coconut leaf brooms, and cooking delicious South Indian vegan recipes completely blows me away. I will always treasure the hoop earrings she gifted me, and the drawing she gave me with the message “keep smiling.” Next to her in the Aurosiksha office, Atchaya is so kind and funny. Her smile is infectious, and she never fails to brighten my mood! Because we’re not too far apart in age, we can definitely relate on a lot despite our different cultural backgrounds.

The wet lab, which is used to train MLOPs and doctors in surgery, was another source of unexpected friendships. I always enjoyed talking with Mani (wet lab training coordinator) and Abinaya (MLOP sister), which made saying goodbye unbelievably difficult. With every hug shared between me and Abi, more and more tears were flowing. Because Abi is likely leaving AEH after next year, it’s hard to know when we will meet again. For now, we stay in touch with daily emails, and I am certain that we will maintain our friendship.

The wet lab was also where I first met Gunjan, a visiting surgical trainee who lived in the room next to mine at Inspiration. I was shocked that we didn’t meet until late in the summer despite living in room 1 and room 2, but we quickly became close. Our conversations after dinner were always so insightful, and I especially appreciate her love of exploring new places and her positive mindset. With her sense of adventure, we tried Jade Cafe, which was right by the Nilgiris supermarket but somehow always escaped my notice. She also showed us the Inspiration refrigerator (the keys are hidden in a coffee maker!) and the basement of the hostel. Visiting all of these “hidden” spots felt like discovering buried treasures, but (cliché alert) I will treasure our time together the most.

Another hard goodbye was seeing Picard right before he left for Dar es Salaam, where he could finally be reunited with his family after eleven months at AEH. What strikes me the most about Picard is his radiant smile, and how he is adored by literally everyone. As we walked to his preferred fruit store one night, he was stopped by so many locals to chat and ask after his family or how his training was going. He made a very compelling case for visiting Tanzania, and his mindset of hakuna matata (no troubles in Swahili) is one I will not forget. Also at Inspiration, Krishna and I spent a lot of time together, to the point where I now consider him as close as if he were an older brother. Fortunately, he is currently studying in Boston and we’re planning to meet again soon. At LAICO, Lisani became one of my best friends of the internship. Before she left, we hugged over and over again, just trying to hold on to each other for as long as possible. It’s hard to know when we will meet again, but we will definitely stay in touch and be lifelong friends. It’s rare to meet someone as compassionate as her, and I am so grateful we crossed paths.

And of course, I must give the biggest thank you to my fellow CASI interns Aravind, Manya, and Suhaas. Aravind’s knowledge on Tamil Nadu (and the world in general), combined with his mom’s planning help and his skill in Tamil, made every trip unbelievably smooth and fun. I appreciate his forward thinking and how he would always push me to “just try” new things. Despite not knowing Manya before the internship, I came to greatly admire her intellectual curiosity, commitment to her values and her family, and her care for others (including every single stray dog). Manya is always very thoughtful and quick to make you question your thinking, which is really special. Suhaas is everyone’s biggest cheerleader and supporter, and he’s a steady presence of good humor (along with some bad jokes). His ability to challenge his lactose intolerance at every turn despite the doubters (see: Krishna’s surprise at Famous Jigarthanda) is also very commendable.

Just when I thought I was finished saying all of my goodbyes, a moment of serendipity occurred. On my way from Madurai to Hyderabad to Delhi, I met Rinkal, a PG at AEH Tirunelveli who happened to be on both of the flights. We hit it off immediately, and our chance encounter was a gentle reminder that connections to AEH will keep popping up after this summer.

Finally, here are my tips for future CASI interns who have the extraordinary luck of spending a summer at Aravind Eye Hospital.

Plan your project realistically in terms of what you can accomplish each week, but be flexible to changes or delays in your schedule. The slogan “arise, awake, and do not stop until the goal is reached” was a slogan popularized by Swami Vivekananda in the context of breaking free from colonial rule, but the idea holds true at AEH. Come to work every day with a question or task, and keep at it. Almost every night, I would dream about the hospital or my projects in some capacity, so you will really will be consumed (in a good way!) with your work.

Keep two main points of contact — one project guide with a vision of the deliverables and goals, and one subject matter expert in the department — as your go-to people. They will help greatly with arranging meetings with other stakeholders and for providing ongoing guidance. After we chose projects and project guides, I found it most helpful to spend every single day working in their respective hospital office instead of the LAICO office we were given. Swap WhatsApps for constant communication instead of relying on emails as the primary form of communication. Tell everyone involved when you’re doing something. In general, over communication is vital because people are all busy with various tasks and deadlines.

Understand the existing challenges and see the bigger picture of why your project matters. For example, for my training project, I saw its importance because skills improvement leads to more safety and consistency. There’s a lot of room for improvement in optimizing MLOP training, given that MLOPs come with only a basic level of prior knowledge and some resources are inconsistent in quality. Within my time, I could focus on a few specific training areas and pilot them with MLOPs to see if they were effective. My cataract project was also based on the idea that resources already exist at the hospital, but they could be better compiled for practical use by other hospitals. The problem with partner hospital engagements is that lasting change is hard, and it’s easy to regress to square one. Hospitals need to be highly dedicated with a management focus to achieve what AEH can do, and there’s also many adjustments needed for different cultural contexts, different norms in surgical standards, and budget constraints.

Make time for casual conversations, take breaks, and stay hydrated. As Sister Selvi said, after almost 30 years of work, she still gets so engrossed in her tasks that she can forget to take breaks or go home on time. But almost everyone will take coffee and snack breaks for 10-20 minutes — once in the morning and once in the afternoon. The ground floor coffee shop is always popping, and you can learn a lot from talking with people there. Vasantham in the inpatient building is a large canteen frequented by both staff and patients, and they have great food. Beyond that, I was often offered snacks in the office, among which my favorites were Candyman choco double eclairs (think a tootsie roll with liquid chocolate inside), jackfruit, and kamarkat (made of coconut, jaggery, cardamom).

Don’t be too discouraged by language or communication barriers. There’s definitely a learning curve, as you’ll quickly have to understand new medical terms and countless other new concepts you can’t even anticipate. I was initially confused by the comma placement between digits. It took a while to learn that 1 lakh = 1,00,000 = 100,000, so 10 lakh = 10,00,000 = 1 million. Another new term was crore, which is equivalent to 1,00,00,000 or 10,000,000. Some things felt very counterintuitive — restaurants are called hotels, and the ground floor is floor 0. I tried to pick up on other nuances in speech, like adapting the phrases “today evening” or “today morning” and adding “only” for emphasis. I found other new phrases very charming, such as “do the needful” (do what’s necessary), “lady finger” (okra), and “dustbin” (trash can). Probably the most important modification to my speech was honorifics. It’s important to add sir or ma’am after names of your superiors for respect, and to learn the hierarchy of doctors — medical officers (MOs), long-term fellows, and postgraduates (PGs).

Learn as much as you can learn about any areas of interest, like patient education, a specialty clinic, surgery in the OT, patient counseling, community health and outreach, infection control and microbiology, AMRF’s research, or anything else you’re curious about. AEH’s scope of involvement is extremely wide! In the hospital, you can often just walk in and state that you are a project student doing an observation, even if the clinic you’re observing is unrelated to your main projects. Basically any department and personnel will be enthusiastic and totally open to your questions.

Meet with as many people as possible at all levels of seniority and experience, from the Chairman and CMO to the heads of department (HODs) to MLOP trainees and everywhere in between. You will learn so much when you can grasp both the details and the broader vision. You can also seek out other educational opportunities and talks because they will really open your mind. For example, Dr. Karl Golnik from the University of Cincinnati gave an excellent guest grand rounds talk on his tips for neuro-ophthalmology and the importance of proper screening, and many other internationally renowned experts work with AEH.

Get to know the other interns and trainees!! They might become your close friends, or at least provide fresh perspectives. There’s always many projects across different areas, and the interns we met worked on projects including implementation of total quality management, reducing clinic wait times, improving the electronic medical record functionality, financial management, data visualization, customized patient engagement campaigns, logo redesign, and more. Trainees come from diverse backgrounds, and when you live in the hostel, it’s easy to strike conversation in the mess hall or lobby.

Believe that you have unique perspectives to contribute. As Dhivya affirmed, interns help accomplish projects that might be on the back burner or were never even considered. Dr. Venkatesh gave an example of a Belgian project student, who was only there for one week and spoke limited English. Despite this, the student thought of the “simple but brilliant” idea of including monitors at the registration counter in AEH Pondicherry so patients can verify their information more easily. This small change led to a big reduction in transcription errors. You will also make a difference with your work, even if you might feel like a minor piece of the puzzle with only a small amount of time.

Assume the best in people and in outcomes. A big smile and an open, friendly attitude goes a long, long way!! Embrace taking photos for the memories because you will accumulate thousands. My phone’s photo gallery tagged both the hostel and AEH as “home” by the end of the summer, and I know you will feel at home too.

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About celeste xu

Penn LSM '24. Summer 2022 intern at Aravind Eye Care System in Madurai, Tamil Nadu. Aspiring trekker.