What Even is Community Outreach? 

Some of the most interesting experiences this summer have come from seeing the Aravind model in action in a very wide range of places. I’m interested in healthcare delivery, and it’s been fascinating to see the different meanings their mission takes in different settings. There are many ways in which components of a system must work together to realize a specific goal, and in Aravind’s case, the goal is eliminating needless blindness. In practice, this means finding and identifying the patients who need care but are currently outside the system, improving access to basic eye care solutions like glasses, building the pipelines to ensure patients get the further care and referrals they need, ensuring a range of cost options exist to cater to different people, providing high quality treatment and surgical care for complex conditions, developing a workforce capable of responding to the challenges of eye care delivery in a state of almost 7 crore people, and so much more. Vision centers, the many free and paid hospitals, community centers, Aurolab, the Aravind Medical Research Foundation (AMRF), and camps, are just some of the parts of this very complicated, interconnected system. 

I’m really lucky that my project allowed me to see these parts interact with each other and develop a more complete understanding of what it means to really care for patients. I worked with the glaucoma department at the hospital and the vision center (VC) team at LAICO. A vision center, as defined by the Aravind website, is a “small, permanent facility set up to provide primary eye care services to semi-rural and rural communities.” A running joke in our intern group as we picked our projects in the first few weeks was pointing me when anything even remotely vision center related came up. I find rural healthcare delivery and the pursuit of universal coverage really important and interesting, and seeing it in action at the VCs has been extremely rewarding. 

My project aimed to (a) understand the current problems in the glaucoma teleconsultation system for VCs, and (b) pilot interventions to increase the number of patients utilizing specialist glaucoma teleconsultation to follow up. Aravind has an unusual model of connecting all VC patients with doctors at the base hospital through teleconsultation, to make sure even the patients getting primary eye care are able to meet a doctor and get high quality care from the get go. My project guide, Mr. Gowth, who manages vision centers at Aravind, initiated a similar teleconsultation system for glaucoma, where new and review glaucoma patients can get teleconsultations with glaucoma specialists at the base hospital. Unfortunately, the numbers of glaucoma patients being seen through teleconsultation were consistently low, the data tracking systems for the project had fully broke down, and there wasn’t a comprehensive analysis for what changes can be made to improve the system. Here’s where I came in.

My work involved a lot of speaking with and travelling to vision centers, speaking with doctors and fellows and managers in the glaucoma clinic, brainstorming and analysing potential solutions, and attempting to strengthen the connections between the VCs and the base hospital for more complex care provision. I loved the diversity of what I saw, and it has inevitably challenged and widened my conception of what community outreach and public health mean. Here are some of my favorite places and experiences on this journey. 

[13 June 2022] Alanganallur Vision Center: The town of Alanganallur, thirty minutes away from Madurai, holds the first vision center that we visited. In many ways, it wasn’t what I expected. Since the founding of the center in Alanganallur more than twenty years ago, the VC technician and the coordinator have worked there. I volunteered to get my eyes checked, as a demonstration for the many new Aravind doctors and other interns on the trip with us. I very quickly learned that my current glasses needed at least some tweaking (I was told that my face is small and my glasses are big, which is why I can’t read the last line, despite having the right prescription). The staff were unequivocally experts at their job, in their technical skills, their knowledge of the local population’s eye needs, and their clear sense of ownership and responsibility for their center. We read comments from visitors from around the world dating back at least fifteen years in the guestbook, and we left some of our own!

[23 June 2022] Kariyapatti Vision Center: Suhaas and I visited the VC in Kariyapatti in a car with Gowth sir and Jhansi ma’am (VC Project Manager). We were instantly greeted with tea and a lot of warmth by the VC’s coordinator and technician. For the first hour or so, we sat around and observed, as the afternoon rush of patients was seen. Through this deeper observation, I learned a lot about the needs patients present with in primary care and how patient flow works in a VC. Later, we asked questions related to our respective projects, about E-See, glaucoma camps, and teleconsultation. Getting to see a second vision center in action really illuminated both the differences in how primary care is provided — like the specific center’s infrastructure, the nature of the surrounding area, the patient numbers it received, the experience and responsibilities of its staff — but also highlighted the critical role these centers play in the communities they are in. Asking the staff questions was an interesting experience, since Suhaas understands but does not speak Tamil, and I speak an Indian-ised English but don’t understand or speak Tamil. We communicated in this patchwork of languages, the four of us translating phrases for each other, but it felt just right (and also just so entertaining). In the (really fun!) drive back with Gowth sir and Jhansi ma’am at 8:30 pm, filled with conversation about their work that day finding a place for a new VC, his past visits consulting in Africa, and takes on modern workplace culture. Through this visit, I was filled with a clearer sense of the questions I need to answer. I understood a lot more why this work mattered, which fuelled me for the rest of the internship. 

[7 July 2022] Gandhigram Vision Center: This might have been my favorite visit to a VC, primarily because the VC technician, Sister Rajathi, spoke both Hindi and English fluently. This was also at a time where I was flowing with questions about glaucoma, based on conversations across Aravind, and getting some answers was so gratifying. What data do the VCs get from the base hospital and what do they collect independently? How long do patients usually wait after arriving at the VC? How many of the glaucoma review patients do follow up visits when they purchase medication? How long are the doctors actually present between 3 and 4 pm? The VC felt very different from the others I had visited. Early in the week, it was absolutely bustling with patients. Simply being present there deepened by understanding of and respect for Aravind’s VC model and also exposed me to the huge room for improvement in small things like data systems connecting the VC and the hospital. Suganya ma’am, a LAICO faculty and consulting team member, accompanied me on this trip. She drove me on Sister Rajathi’s Activa to the Saravana Bhavana we had lunch at and then to Chinnalapatti, a town famous for its unique cotton saris. Sitting on the back of the speeding Activa in the light rain, full of project answers and Kothu Parotta, I felt genuinely so fulfilled and excited about my work at Aravind.

[17 July] Aathikulam Camp: The medical camp I visited was held in a school in the Aathikulam locality of Madurai. Early in the morning, a group of MLOPs, doctors, and I boarded a hospital bus to Aathikulam to help the school staff set up the camp. There were so many different ‘stations’: registration, preliminary doctor’s exam, refraction, refraction for returning patients, IOP and ducts check, blood pressure measurements, final doctors exams, counselling, glass orders, and more that I’m definitely forgetting. Most of them were staffed by MLOPs, mostly trainees, who ran a really efficient and beneficial camp serving more than 400 patients. The primary problems the camp treated were refractory error (providing glasses) and cataracts (diagnosing and transporting patients for surgery). For more specialised issues, patients would be referred to the base hospital. One of my favorite memories from this summer occurred at this camp. Since my role was primarily observation, I was walking around and taking notes. I saw a single elderly man approach from the back end of the camp. He didn’t have an attender, had obviously compromised vision, and seemed quite confused. On approaching him, he asked me where to get glasses. When I didn’t understand this question in Tamil, he made the gesture for glasses. As the conversation progressed, the language barrier really became a problem, so I asked a boy waiting nearby to help me understand. The man hadn’t gotten a registration slip, so we walked together to the seating area for registration. Somehow, this didn’t seem like the end of the story. I came back to check on him when he reached the front of the line for registration, and after his vision test and his registration slip, I walked him to the area for a doctors’ examination. This started a camp-long connection — I walked him from station to station, held his hand while his eyes were dilated, and he called for me (papa – the Tamil word for beti or young girl) when I strayed too far for more than a few minutes. As we were referred from the refractory section to the doctor’s exam and back, we gradually understood that he wasn’t going to be given glasses or any other treatment. The doctors would send him back to the sisters, since he kept asking for glasses.The refraction sisters thought the glasses won’t really help because his vision was too damaged already. I found myself somehow trying to bridge the gap between the tata’s anxiety and desire for glasses and the doctors’ and sisters’ frustration, without speaking a word of Tamil. In this experience, I saw more closely how profoundly isolating and terrifying the experience of losing your sight and needing treatment is, especially for the elderly. Sometimes, there isn’t anything medicine can do, but that doesn’t make it any easier for the patients stuck in their suffering. At the end, the tata held my hand and walked me to his house. He lived right before the camp, which is why he entered from the wrong entrance. He introduced me to his grandchildren, saying “Rajasthan!” when pointing at me, and offered me lunch inside his home. It’s easy for me to forget the love, connections, and resilience underpinning patient and doctor experiences in medicine, but I am filled with gratitude every time I am reminded like this.

[So many visits!] Free Hospital: When we kept turning up at her office reiterating our interest in community outreach when we were picking our projects, Dhivya ma’am reminded us that community eye-care isn’t just the camps or the VCs. It’s also having the systems in place to absorb and care for the patients that the outreach efforts find. Every visit to the free hospital showed how different it was from the paid. It was a lot more crowded, loud, and significantly poorer in the patients’ health and incomes. However, the very fact that it existed and helped a huge volume of vulnerable patients for no cost was incredible. It highlighted a very different set of problems with community care — the need for making it financially feasible as a business to provide high-quality care to the poor. 

In order: Gandhigram’s waiting area, a selfie with the sisters in Kariyapatti, me getting my eyes checked in Alanganallur, and Suganya ma’am and the Activa in Chinnalapatti.

Back to my project. In exploring how glaucoma-based teleconsultation could be made more scaled up and effective, and in exploring how much it actually affected rural patients with respect to the costs to AEH, I was questioning how the different components in a system like this interact with each other. My pilot suggestion after all the research was changing the hours of teleconsultation from 3 to 4 pm to the full work day, by working with the department to let fellows see OP patients at the same time as teleconsultation VC patients. I often found myself losing confidence in the project: the pilot was difficult to implement and speculative, the past data collection was spotty, the approvals were slow, everyone wasn’t as enthusiastic about the pitch as I was. But working with Mr. Gowth made it clear that it was my responsibility to hope. That doesn’t mean I shouldn’t respond to evidence or take feedback, it meant that I had to, as a poster on his wall said, be aggressive about change and respond to the resistance. Not every idea will work, but if we have reason to believe it might, it’s our job to try. In the end, my pilot led to a 257% increase in the number of patients seen, an outcome I was very surprised but nonetheless really pleased about.

I care a lot about public health, especially in India. My internship at Aravind has been so influential for making real and visible all the textbook challenges that exist in community outreach and healthcare in poor countries, but it has also provided me with a shining example of why that care matters and how to keep believing in and fighting for a future where people can access it. I know I’ll remember what I learned this summer for a long time. 

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About Manya Gupta

Hi, I'm Manya! I'm in the College of Arts and Sciences in the Class of 2025. I'm studying Economics and International Development on the pre-med track, and I'm from Jaipur in India. I spent the summer at Aravind Eye Hospital in Madurai.