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The following is a conversation between Dr. Geoffrey Tabin, Co-founder of the Himalayan Cataract Project, and Denver Frederick, Host of The Business of Giving on AM 970 The Answer.
Denver: And this evening, you’re going to hear from another one of the semi-finalists in the 100&Change initiative of the MacArthur Foundation. He is Dr. Geoffrey Tabin, the Co-founder of the Himalayan Cataract Project. Good evening, Dr. Tabin, and congratulations on being chosen as a member of this select and prestigious group!
Geoffrey: Thank you very much, Denver! It’s an honor to be here.
Denver: Give us a brief overview of the Himalayan Cataract Project and the work that you do.
Geoffrey: The Himalayan Cataract Project really originated with my partner Sanduk Ruit, who is an amazing man. He was born in a small hill village, 10 days walk from the nearest school, no roads, no electricity, no running water. And he emerged to become the leading ophthalmologist in Nepal. He trained in India at the best institutions. I was a climber who found my way to Nepal. I was a doctor interested in global medicine and trying to see how to make an impact, really looking to do something in public health… when I saw the unbelievable miracle of sight restoration.
Worldwide, there are 18 million people who are totally blind from completely treatable cataracts. I saw the problem in Nepal had one of the highest rates of cataract blindness, both from the high intensity of the UV light, but also lack of antioxidants in the diet, genetic factors, and overwhelmingly, a lack of doctors. Sanduk Ruit was the only man doing modern cataract surgery in Nepal. I was very fortunate to have just finished my eye surgery training in the best institutions in America, then a fellowship in Australia, and I came thinking I would teach something. I was actually just amazed and mesmerized by what Dr. Ruit had already accomplished in Nepal, and I basically signed on to work with him, and we began teaching cataract surgery in Nepal.
At the time, there were about 300,000 people blind from cataracts in Nepal– about 60,000 people going blind every year– and we thought it would be a lifetime to get a handle on cataract blindness in Nepal, let alone in adjacent Himalayan regions where no cataract surgery was being performed – in Tibet, Bhutan, Northern India, Northern Pakistan. I worked with Dr. Ruit, came back to the states and took a faculty job at the University of Vermont, and we started a 501(c) program so that we could fund the development training. It’s really training at all levels – nurses, technicians, assistants, doctors, and sub-specialists. And now, 20 years on, Nepal is the only country of the poorest countries in the world that has reversed its rate of blindness.
Denver: What’s the impact of someone going blind in the developing world, not just for themselves but for their family as well?
Geoffrey: It’s really devastating. There are no services for the blind. Usually, it takes an able-bodied person out of the workforce… or a child out of school… to care for the blind person. They become unable to do the tasks of daily living that a normal elderly person would do in terms of childcare, cooking, cleaning, taking care of the house garden or the local animals. It’s overwhelming the effect on poverty, the children who don’t go to school, people out of the workforce, but the blind people themselves get depressed. They sit in a corner waiting to die.
Denver: What is the impact that it has on the life expectancy of a person?
Geoffrey: Several studies have shown that once you go blind in the developing world, life expectancy is essentially one-third that of age- and health-matched peers.
Denver: Yes. I think a saying they have in Nepal is: “A person who is blind is a mouth with no hands.”
Geoffrey: A mouth with no hands. When you’re on subsistence/agrarian economy, a mouth with no hands is just absolutely devastating to the economics of the family, but it also really takes the child out of the workforce. There’s a lot of childhood blindness as well, and when a child goes blind, most of them don’t live to adulthood.
Denver: Oh, wow. Let’s talk specifically about the work you do and how you go about it. And the thing that really gets me is: how do you bring top quality eye care to the poorest of the poor in places like Nepal… that you just discussed… and do it at scale, and at an affordable cost?
Geoffrey: Well, it’s kind of multi-factorial, Denver. The big thing that we do is developing the system. It’s really training, teaching, and empowering the local doctors but also creating the system with training the nurses, technicians, and assistants.
When we began in Nepal, people didn’t know they could have their sight restored. It was just accepted. You get old, your hair turns white, your eye turns white, and then you die. So it wasn’t just a matter of teaching a man to fish; we had to teach how to sell the fish. And reach out to the villages, get local health workers, teachers… someone to go and basically screen all the blind people in every village… and bring them together where ophthalmic nurses could check them and see who could be helped.
Now, 20 years later, we’ve really permeated almost every corner of Nepal. People are aware of the services. Through a very high-volume surgery and creating a very efficient system of delivery, as well as manufacturing many of the materials… we manufacture the lens implant that restores excellent focus in Nepal for $4.
Denver: Wow! It’s like $200 in this country, isn’t it?
Geoffrey: More. The lens I used as my standard lens at the University of Utah is $300. But there are premium lenses that give you correction of astigmatism and give you both reading and distance vision that the patient pays usually $2,000 out of pocket – $1,000 to $2,000 depending on where you are for these added lenses. But we have them for $4.
A cataract is a clouding of the proteins in the lens of the eye, which focuses light, that sits just behind the pretty colored part of the eye called the iris.
Denver: How do you this surgery? And how long does it take? What is the total cost, including the lenses?
Geoffrey: Well, another thing that we’ve really been developing and promoting is a very efficient, low-cost way of giving the same quality surgery that we do here in America. Now, most of the state-of-the-art places in America have a million dollar laser machine that makes the incision; it opens the lens of the eye. A cataract is a clouding of the proteins in the lens of the eye, which focuses light, that sits just behind the pretty colored part of the eye called the iris.
In America and in the West, there’s been a focus on high-tech, ever more expensive solutions to more safely and efficiently remove the lens and put a lens implant back in. Dr. Ruit is one of the very few brilliant doctors who has focused his life on trying to create the same quality without the high cost of the most expensive machines. We make a small self-sealing incision into the eye wall, open up the lens, kind of like a peanut M&M. We open the outer candy shell, and we take out the hard peanut– it’s what really you think of as the cloudy cataract and also the chocolaty mass often turns white. And we suck that out. And then once we have a clear shell and a capsule– something really more of a consistency of the skin of a grape–Once that is completely cleared out… and we polish it clear, then we put a lens implant in that fits into that same spot, focuses the light very well, and then the wound that Dr. Ruit has—we first published back about 15 years ago—self-seals from the fluid pressure inside of the eye, sealing it. The surgery in the best of hands – Dr. Ruit will do often 12 to 14 cases an hour and I usually do around 9 or 10 cases every hour. The actual surgery, if there are no other concomitant eye diseases or problems with the eye, is under five minutes.
Denver: That’s remarkable! How long does it take for a patient to get their sight restored? And how would that restored sight compare to someone here in the West who’s having a similar kind of surgery… but a far more expensive kind?
Geoffrey: As soon as the anesthesia has worn off. We usually will patch our patients overnight to prevent infections. We inject the antibiotic into the eye and around the eye and put antibiotic on and put on a patch. When the patch comes off, it’s still one of my most favorite places to be is every morning in post-op. I’ve been doing it now for almost 25 years, and I still get tingles when we take the patches off someone who’s totally blind. There’s a moment of disbelief almost! And then they look, and then this amazing smile, and they see. And if there are no other diseases in the eye, we’ve published a study showing that 90% of the patients will see well enough to pass the American driver’s test one day after surgery.
Denver: That is impressive.
Geoffrey: And then just the joy – the joy of the family, the joy of the people, parents who’ve never seen their children. I just got back from Ethiopia. On my last trip, we had a woman who is 32 years old with four children that she had never seen. She went blind from cataracts at age 22. And to see her seeing her baby for the first time, having grandparents seeing their grandchildren for the first time…
Denver: You know, what always interested me was what it must be like for someone to see themselves again, that sense of self-discovery that “My goodness! Look how I’ve aged!”
Geoffrey: We’ve done that quite a bit with pictures on a cell phone and pictures on a camera and then showing the patient. But it’s interesting because in America, the vision is similarly great after surgery. But the expectations are different in that in America, people are expecting they’re going to see perfectly. So, if it’s even a little bit blurry, they’re kind of surprised…and they’re not going from blindness.
Most of the patients I operate on in America–we have in the United States, one ophthalmologist for every 18,000 people. And when your vision is a little bit blurry driving at night, or your vision is a little blurrier in your left eye than your right eye, you see your ophthalmologist. It’s such a wonderful procedure, and we do it so well that when the eyes are a little bit blurry, you have your surgery, and you expect to see perfectly. So it’s a common thing in America to have a patient seeing 20/20 the day after surgery who says, “What’s that red spot in my eye?” “Well, there was a little blood vessel that broke when I was fixating the eye wall.” “What did you do wrong? What’s wrong with that?” versus just absolute, unmitigated joy in the developing world.
Denver: In addition to what you’ve said, how does a person’s life change, and that of their family, once they do have this eyesight restored?
Geoffrey: It’s absolutely…again, it’s something that has kept me going on this for 25 years. The transformation is so dramatic. People will look like they’re 80 when they’re in their 50s and blind from a cataract. They’re going to be shriveled. And it’s miraculous. They straighten up. They stand, they walk, they go back to work. They go back to work with their families…the transformation from depression in the face, to joy in the face. But people return to having very, very productive lives. Even the elderly people, as I mention, will go back to child care, taking care of the house garden, cooking, cleaning, and contributing to their family rather than being a burden.
Denver: One of the cornerstones of Himalayan Cataract Project, which you’ve touched upon already, but I want to speak about it more, is this training and development of others from the countries and regions where you operate… to perform and help support these surgeries and to address this backlog. This has all become pretty extensive and very sophisticated. Tell us a little bit about that program.
Geoffrey: Well, again, we started in Nepal and we called it the Himalayan Cataract Project because it seemed so overwhelming just to get a handle on cataracts. But we developed really an overall training system. We started taking our best young cataract surgeons, sending them to Australia or America for sub-specialty training. We started a full residency program, which we’ve paired with the programs run by a professor here in the United States at the University of Utah, and really it’s a world-class training program. It then expanded into Bhutan and all of the adjacent Himalayan countries. The quality lifted the quality all around.
We have really great sub-specialty care, and it’s really become an overall eye care development program. We’ve expanded in Asia into Myanmar, into Indonesia, even into North Korea. And in the last eight years, I’ve been focusing much of my attention on Africa. Africa currently has about—sub-Saharan Africa has one eye surgeon for every million in population. But even that is deceptive in that Ethiopia, one of the main countries where I’m working, has 93 million people. They have 112 ophthalmologists, but 34 of those don’t practice surgery. And of the ones who do, almost 60 live in Addis Ababa, which has a population of 4.5 million. So for much of the country, there’s one eye surgeon per four- or five million people.
Denver: All told, how many of these surgeries do you do in a given year? And what would be the backlog of people that you simply just can’t get to right now?
Geoffrey: Well, that’s a tough question. In terms of the number that we do, our program–one of the things we’re really focusing on, Denver, is trying to create sustaining models, so that there’s a cost recovery. You need to have a reasonable income for doctors in the country, for nurses in the country, for people who clean up in the operating room to keep the enthusiasm, to get the best young doctors going into ophthalmology.
In Nepal, we’ve developed something that’s been called “compassionate capitalism,” where the paying patients subsidize care for the poor and we, by doing very high-volume and keeping the cost down, are able to still pay the doctors well and the nurses well. We’ve been working to create a system where we can reach out to patients in the more remote areas and really train and really develop the whole system and model for delivery.
As we’re going through the process, one of the exciting things about eye care is that every individual we treat, Denver, is cured 100%. They’re no longer a statistic.
Denver: Geoff, you are a world-class mountain climber, someone who has dared the impossible. As one of the very, very small handful of people to have climbed the highest peak on all seven continents… the seven summits: How has that sense of adventure and scaling new heights informed your work at the Himalayan Cataract Project and the corporate culture of the organization?
Geoffrey: Well, a little bit in that it brought me into what I’m doing because I first came to Nepal as a climber. And I might add that I used to be an okay climber quite a few years ago. I’m a much better eye surgeon than I am a climber these days, although I retain some enthusiasm. But when you’re attempting a big peak– or where I came from in the climbing world was really rock climbing and big wall rock climbing– You start up El Capitan, it’s one step at a time; you’re focusing on a very small area and focusing on one person at a time… or just reaching that next handhold.
And yes, the figures are daunting. There are currently 18 million people in the world blind from cataracts. We have about 36 million blind people on our planet, and just over half could be completely restored with cataract surgery. Another half of those– so about between 75% and 80%– either could be treated or could’ve been prevented by developing the care. But you have to focus on one step at a time. You don’t look at saying “I’m on top of Mount Everest.” It’s the process of climbing.
As we’re going through the process, one of the exciting things about eye care is that every individual we treat, Denver, is cured 100%. They’re no longer a statistic. They are cured. Their family has been restored. There are very few areas in public health or medicine where once you have the intervention, the person is good to go for the rest of their life. And it’s a process of really focusing on: Where is that next hold? Where is the next place we’re going? So to look and say: “We’re going to eliminate all blindness in the world,” is probably a billion dollar proposition, and there are political obstacles in a lot of countries. But we’ve been able to say, “Okay. We’ve been able to really transform eye care in Nepal. We’ve spread the system to Bhutan.” With the MacArthur grant, we’re hoping to really transform eye care in two African countries – in Ghana and in Ethiopia – and create a model that can then really spread, and show how we can break the back of needless blindness.
Denver: It sounds to me that the lesson you have taken is: Don’t get too far ahead of yourself. And take one step at a time. And be very cognizant of the present, and deal with that.
Geoffrey: And still to be thinking about your dreams. You’ve got to still dream big. We, in 1983, did the first descent on the east face of Mount Everest, the Kangshung Face, and a lot of the cognoscenti in the climbing world said, “That’s absolutely impossible.” We came to it with the idea that we could do it… and breaking it down into where we needed to go. It was a level of technical difficulty that had never been done on a peak of that scale. It’s the only first descent that’s been done on Mount Everest with no native support whatsoever. We just focused on each little increment, and that’s what we’re doing with blindness.
Denver: And I think about that climb, you said something along the lines of: “We may not have been the best climbers in the world, but we had the best team.” What are the key elements of a great, great team?
Geoffrey: I think you have to have a common belief. When we go to do a large cataract intervention—I just came back from Ethiopia where we did 2,000 cataract surgeries in one week. And we had an amazing team – a team of nurses, doctors, technicians, the people who were helping feed the patients, the people who were volunteers helping bring the patients to the toilet… The whole team has to really believe in what you’re doing and really have joy in the process of what we’re doing, and excitement about the possible outcome of what we’re doing.
Denver: And I think one of your axioms is that no one does anything that someone with lesser skills can do.
Geoffrey: Well, that’s a strategy Dr. Ruit developed. Also, he had spent two years at the Aravind Eye Hospitals down in Madurai in Southern India. And that has really taken hold. In America, we have so many regulations. We can’t put an eye drop in a patient without the doctor writing a note and having a registered nurse take the order. And in our cataract program, we really train everybody up, so everyone is doing things right at their limit, which also really helps with the team concept. And our whole Himalayan Cataract Project team here in America is so wonderful and fantastic and really enthusiastic about not just where we’re going, but the process of how we’re going.
Denver: Let’s talk about where you’re going, Geoff, and get back to the 100&Change initiative. If the Himalayan Cataract Project should be so fortunate to be awarded this $100 million grant by the MacArthur Foundation, how specifically are you going to do it… use it? And what would it allow you to do?
Geoffrey: Well, it will allow us to really break the back of needless blindness in sub-Saharan Africa and show that we can create a sustaining model and transform eye care and blindness in Ghana and Ethiopia. We’ll be expanding our training programs in Nepal, and bringing African doctors, nurses, and technicians for training. We’ll also be working with two of the best eye care systems in India, the LV Prasad Eye care system and the Aravind Eye Care system– expanding their training and their ability to train African doctors, as well as expand their outreach and cure more blind people in India and Nepal.
But we will really be able to complete the training that’s necessary to create the infrastructure, the skilled teachers. So we’ll be training the trainers who will then be teaching other nurses, training other technicians, and especially training other doctors and have a center of excellence in East Africa, in Ethiopia, in West Africa, in Ghana… and also create the outreach and primary eye care centers and cataract delivery hospitals where we can really transform blindness in Ghana and Ethiopia, which I hope will then spread in the way our program in Nepal has spread to Bhutan and adjacent areas in the Himalayas… will really transform eye care and reduce blindness in Africa.
Denver: Well, let me close with this, Geoff. You know you have seven very worthy and remarkable other semi-finalists in this MacArthur 100&Change initiative, but if you really had to make that final case as to why you believe that the Himalayan Cataract Project will have the most profound and meaningful impact on global society, what would that case be?
Geoffrey: Well, I think that the dramatic effect on individuals with the money from the grant, we will be doing an additional 500,000 cataract surgeries, and we’ll be training the doctors who over the next five years– after the period of the grant– will be doing an extra 20 million cataract surgeries. So it’s really going to expand outwards from the training model. We’re going to be directly transforming in a way that is easily quantified, easily followed. And it’s such an easy thing: These are the blind people, and we have the solution… but really unlocking the solution for such a large issue as needless blindness.
Several studies have shown that the return to the economy is more than 4-to-1. It’s a 400% return on money spent on eyesight restoration. So we’re going to have this huge economic impact that will keep filtering. But the big thing is that we’re going to be creating a model that will then spread, and I hope lead to more funding, more sources, people saying, “Wow! I’d love to eliminate blindness in Tanzania. You’ve shown us the model. Let’s go ahead and do this.” And also creating a similarly huge reduction in India and in China, other places of need. I think of the programs…. They’re all amazing things for transformation, but we have one that really has a very demonstrable endpoint. And as I said as the earlier example, each individual person we cure becomes no longer a statistic. They are fully cured. They don’t need additional help.
Denver: Well stated. Well, Dr. Geoffrey Tabin, the Co-Founder of the Himalayan Cataract Project, I want to thank you so much for being here this evening. If people want to learn more about the work that you do, what are some of the places they can go to find out?
Geoffrey: Well, our website for the Himalayan Cataract Project is www.cureblindness.org. There’s also a book that is out that was written by New York Times bestselling author David Oliver Relin, called “Second Suns,” which is the story of myself and my amazing partner Dr. Sanduk Ruit, who really is the genius behind everything that we’re doing. And it also is a bit of a fun read.
Denver: Well, my very best wishes to you and colleagues, Geoff, in the 100&Change MacArthur Challenge. It was a real pleasure to have you on the program.
Geoffrey: A real honor to be here, Denver. Thank you so, so much!
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