STORY OF THE ARAVIND EYE HOSPITAL - (Transcription of Ms Pavithra K - Author of a book "Infinite Vision")

2012

I come to the story through two doorways – the doorway of a granddaughter and the doorway of a story teller. Dr. Govindappa Venkataswamy (1918 – 2006) was my grandmother’s eldest brother – my granduncle. We called him grandfather. Actually we called him Doctor Grandfather. And that’s what he was actually to us. He was an elder and a healer. These were the twin roles he played. This man never married and never had any children of his own. But he left the world and incredible legacy. Today nearly six years after his passing I continue to find myself unpacking the gifts that  he embedded in our lives. I am a one-time filmmaker and a writer in a family of 21 eye surgeons and still counting. We have a few more in the pipeline. I worked on a book titled INFINITE VISION that follows the work of Dr. V. I saw only partly in jest to the family that these are my apologies for not being an eye surgeon. In the last decade of chronicling this story I come to learn a pretty humbling truth and that is that stories in a very real way can also help people see the world a little bit better, a little more clearly. And the story of Aravind and the story of Dr. V is one of those luminous stories that definitely have that potential. Where does the story begin? And before I jump into that I would like to bring in a little bit more of Dr. V through a journal entry he wrote way back in the early eighties before his vision had really taken root.


This is my grandmother’s eldest brother Dr. Govindappa Venkataswami known to many on this side of the world simply as Dr. V for obvious reasons. There were two major spiritual influences in his life Sri Aurobindo and the mother. Every morning for the last three years I had a daily 7 AM appointment with him. I would sit on the other side of that desk and we would read together one of Sri Aurobino’s book’s called SAVITRI – which tells about the evolution of the human consciousness. It spoke about the perfect ability of the human spirit. This is how he began his day for fifty years or more with a visit to the meditation room and then an immersion in wisdom. So the lines: There is a power within that knows beyond our knowing’s. We are greater than our thoughts. To live, to love these are signs of infinite things.



About 37 years ago he had got a business idea. He is just newly retired and has a crippling disease by the way. He had to tackle a global problem. He says let me and you put our life savings on line. We start a company; we don’t take any external funding. We give away sixty percent of our services for free. We market exclusively to people who can’t pay us. We commit to world class quality. We don’t take any donations and we will not do any fundraising. Are you in! Consider for a moment what you might have said to him at that time. And now think upon this. The organization that he founded on that seemingly absurd framework is today the largest provider of eye care in the world.



So I come from a family which has 24 ophthalmologists and we have a few more in the pipeline for three generations. I sometimes think that I worked on this film and on this book about their story as my way of apology for not being an eye doctor. On a serious note I have come to believe that certain stories are not unlike eye surgery, and do have the capacity to help us see the world and each other and our place here a little bit better. In this story is definitely one of those. This is a man who aligned head, heart and  hands. He integrated the heart of service with deep spiritual aspirations and the best practices of business. In business in a model that he created has gone on to literally light millions of lives.

The story begins at the southern tip of India in a little village where in 1918 where Govindappa Venkataswamy was born. He was the eldest of five children. He grew up walking barefoot to school and tending the family buffalo and writing his lessons in the sand. By the age of 10 he had lost 3 cousins due to childbirth complications. There was no doctor in the village and they could have gone to no one for help. So as a little boy that seated in him the conviction when he grew up he needed to become a doctor and prevent such untimely tragedies. He made his way to and through medical school and he had plans to become an obstetrician. In his early thirties he was struck by a rare and a severe form of rheumatoid arthritis. He completely twisted and froze his fingers out of shape. He was bedridden for 2 years. It’s a chronic condition and he never fully recovered. He called pain his constant companion in life. He never married either. However, he recovered to have just sufficient strength to return to the field of medicine. His condition barred him from the field of obstetrics. So he ended up in the department of ophthalmology. Sometimes I think that our greatest vulnerabilities drive us to the doorstep of our greatest strengths. He taught himself to cut and operate the eye with those twisted fingers. His surgeries were impeccable. There are 37 million blind people in the world. 80% of that blindness is curable. A large part of that is cataract blindness. A simple operation can cure sight. Doctor V in his early days worked like a man possessed, round the clock. Those fingers personally performed over one hundred thousand sight restoring surgeries. At that time he was still a government servant. When Dr. V reached the age of 58, the mandatory retirement age he could have merrily gone off and played golf. In 1976 he started an eye clinic with his five brothers and sisters and their husbands and wives. They were all eye doctors. The benefits of arranged marriage kept them there. And they put their life savings on the line. They sold the family jewelry. They put a mortgage on the house and they started this with very little money, no business plan and no safety net. But they had a mission. The mission was to eliminate needless blindness. There were 37 million blind people there and there were just 11 beds. It is a bit audacious. Fast forward - 37 odd years later that have fifty different facilities. And as I said they are the largest eye care providers in the world. What does that mean? In the last 37 years they have seen over 38 million patients. They have done over 5 million surgeries. The vast majority that has been done for free or ultra-subsidized. In the year 2008 Bill Gates gave them the Global Health Award. The following year they got the Health and Humanitarian Prize. The same year they were named among the 50 most innovative companies in the world. And in 2010 TIME magazine had Aravind’s Chairman amongst the 100 most influential people in the world. So, there he was with lady Gaga and he said, “It was a little surreal”. And for the last more than 20 years now the key study on Aravind is mandatory, it’s a required reading for every MBA student who goes to Harvard. Just a few years back we had Google’s cofounder fly in for his surgery. So what is all this excitement about? There are a few things about Aravind that come larger than life. The next slide illustrates that. It’s a comparison of Aravind’s surgical productivity with that of other countries. The bar on the chart which looks like a runaway train is Aravind’s. The average surgeon in Aravind does about 2000 surgeries in a year, when the national average in India is

400. In the USA it is about 200. So there is phenomenal productivity. But is this just a developing world story. Is there anything about it which is relevant to the West? The next slide compares Aravind’s volumes with that of the National Health System in the United Kingdom – which is their main provider of healthcare. In the UK about half a million eye surgeries are done in a year. Aravind alone does between 300 and 400 thousand. So a single organization in the developing world does about 60% of the volume of eye surgeries done in the entire UK. But that is not the punchline. It costs the NHS 1.6 billion pounds to deliver that care. It costs Aravind less than 1% of that. Now let’s talk about quality because that does come up when you talk about high volumes and low cost. They don’t follow any comparisons. When you compare clinic outcomes at Aravind with surgeons in the UK across twenty different complication types. Aravind’s quality met or exceeded that what was listed for the UK. So, we are talking about high-quality, high-volume, low-cost system. In that sweet spot companies all over the world are striving for. Where do they come from, where does that breakthrough innovation come from? Some experts say that it comes when you self-imposed creative constraints on your situation. So, if you are working with the same set of constraints that everyone else is than you tend to come up with the same solutions, or at best with incremental innovation. But when you throw in bonus rules for yourself then you tend to make the game harder. Then you really have a shot at the way the game is really played. And that is what Dr. V and his team did. They brought in these three rules and seeded them as the DNA of the organization right from the very start. The rules were really simple.



1. We can’t turn anyone away.

2. We can’t compromise on quality.

3. We must be self-reliant.



So this meant that whatever Arvind did over the course of its history it would have to do it with compassion, with excellence and with its own resources. So, think about that framework for a moment. It didn’t make it easy. But what it did was it gave Aravind’s founders the liberty to pursue their outlandish mission without compromising their integrity. This framework would not push them to compromise their principles. You’re looking at a set of constraints that push this organization and its people to overturn the conventional rules of business and to come up with this upside-down business model. The enterprise was not driven by some kind of business strategy. It was driven by a mindset, a selfless service. And these words selfless service, generosity, and compassion we don’t often think of them as business tools. They are not just tools in the system they are the drivers, the animating force, and the engine behind this. There is another line from Sri Aurobindo’s SAVITRI – ON INNER VALUES HANGS THE OUTER PLAN. That’s how it was with this organization. Dr. V kept a lot of journals in his life. I have read them all though with the doctor’s handwriting it was not easy to read them. There were two things, two statements which would come in repeatedly. Two burning aspirations came up repeatedly. First one was to GIVE SIGHT FOR ALL. And the second was to FEEL ALL AS ONE. Those two aspirations arc between the practical and the profound. And the story of Aravind dances on that arc. So, on the one hand you have the ultra-practical concern of how do you create a service delivery system to end one form of human suffering. And on the other how do you do that from the mindset that is rooted in an awareness of our fundamental interconnection - of the practical and the profound. We are in a world where there is a tug of war between the 99% and the 1%. Aravind straightaway made out its commitment to serving the 100%. And so they ripped the price tag of cataract surgery and made it available for free for those who needed it in a country where there are 12 million blind people and the majority exists on less than 2US$ a day. It’s a pretty baffling move considering they also had a constraint of self-reliance. Then they did something even stranger. They said we will let the patient decide whether he will pay or not. So, there is no means assessment, no eligibility criteria. A barefoot farmer can come in and get paid services. And the man who would become the future president of India can wander into the free section. And that actually did happen. President Abdul Kalam forgot his wallet and he strayed away from his security team. He ended up getting wonderful service at the free hospital, and he was thrilled. And the system is geared for that. Nothing will stop anyone from accessing what they choose.

The idea behind this is – one of the things which Dr. V stressed over and over again he said: Aravind is not here to mechanically restore people’s SIGHT. We are here to affirm dignity. So, they design for DIGNITY in this model. We are talking about a country where if you go blind in rural India then your life expectancy drops to about 2 or 3 years. Blindness is a failed disease in India – where sometimes if you lose your vision you lose your job your livelihood. You lose your place in your family, lose your place in the community and then you lose your own self-worth. And so his question was: How we do, is as important as the WHY we do. How do we affirm the dignity of these people who show up? And they did it through a unique and compassionate fee system. In the self-selecting user fee system the patients can select the FEES which start from ZERO and goes all the way up to the Market Rate. So, it is patients who decide. The sense is that OPTIONS determine DIGNITY. So, patients who can pay and are willing to, the money from them covers the costs for those who can’t. It’s the same doctors who operate both the free and paying patients. Service differentiation happens at the level of add-ons. So, a free patient might stay in a shared dorm with a shared restaurant, whereas a paying patient may decide an air conditioner in the room, an attached bathroom, and an extra bed for their attendant. The idea behind this is that they meet people where they are and to maximize for service not profit.



TAKE RESPONSIBILITY FOR IT ALL



One of the things which happened when Aravind began this process – they were offering free surgery and they found a very curious thing that not many people were coming. People we knew who needed the service desperately weren’t showing up. So, enlightenment came to them in the form of a beggar who was blind and he said, “You tell me your surgery is free, but to get to your hospital I need a bus.

Once I get there I need a place to stay, I need food. I really can’t come alone, and if my daughter comes with me she loses the day’s wages. So, your free service costs me Rs. 100. Free doesn’t automatically translate to affordable. So what did Aravind do with that information? It is not a transport company. It is not responsible for accommodation. But it decided to lower the barrier. IT DECIDED TO TAKE RESPONSIBILITY OF ALL OF IT. So Aravind sends medical teams – doctors and nurses out into the villages where they set up an eye camp and screen hundreds and sometimes thousands of patients in a span of a few hours. Those requiring glasses are fitted with and given to them on the spot. Those requiring surgery are bussed back to the main hospital where they are given food, lodging, treatment and return transport, follow-up care completely free of charge. This happens twenty-two hundred times a year, forty or fifty times a week at six hundred different locations, with 500 community partners. All of these camps take place in collaboration with community sponsors. Aravind does this in order to build that ownership into the community. This drives about 45% of the volumes Aravind sees. It’s tremendous in that sense. The even bigger thing is the trust that it generates, the goodwill it generates. The free patients who come to Aravind aren’t considered just as consumers of a service; they are seen as contributors. They go back; they become the strongest word-of-mouth marketers’ for this organization. They motivate the community, they mobilize more patients. And the whole systems around Aravind are so designed for those patients. So, it’s really interesting, it’s not a one way traffic in which you are contributing to the poor. That impoverished patient is as important in the system. So it’s really mutual. Be radically open. Dr. V was boyish in his excitement about new things and his ability to learn from the weirdest places. He was a great synthesizer too. He would integrate. He integrated East and West, he integrated ancient and modern, integrated science and spirituality. And he integrated McDonalds. So what has eye care got to do with burgers? When Dr. V came to the United States in the early seventies and eighties, he was fascinated by the Golden Arches that he saw everywhere and he completely sidestepped the public health implications of this global team. He was really looking at the standardization the power of that product to reach, the recognition, the reliability the scale. And he said over and over again. If we can provide eye care the way McDonalds provides burgers the problem of blindness is gone. People laughed, but they then they watched him do it. So he took the assembly line method, he took optimization techniques. He looks at every stage of the workflow and patients and then he brought in all these process improvements. This comes vividly to life in the operating rooms at Aravind. You have these rows of beds and you have the surgeons. Every shift surgeon is assisted by a set of four highly trained nurses. And as the surgeon is finishing an operation on one side the nurses are getting the patient ready on the other side. It is choreographed to perfection. And the lag time between surgeries is the time it takes the surgeon to swing the microscope over to the other side. So the fastest surgeons at Aravind – not the slowpokes can do a cataract surgery in three and a half minutes.



And these women you saw the nurses they come from the villages around Madurai. They are high- school graduates and they are trained in an intense program to become nurses and paramedics and technicians. The program they go through is accredited by the same Board that does the accreditation for Nursing Program here in the USA. So, it is high quality. Now, it’s Aravind’s financial sustainability that really captures people’s attention. This is a spectacularly profitable organization and a couple of years ago they made an operating surplus of 13 million US dollars on a revenue of 27 million dollars. Forbes called it an accomplishment because Aravind is a Non-Profit company. All there patient services, their growth and expansion are covered by patient revenue. So, they are able to hold that idea about universal access to their services and the idea of self-reliance very comfortably together. And a lot of health care a lot of business actually tends to be driven by that notion of scarcity - a fundamental assumption that there isn’t enough to go around. And Dr. V came up with this whole model with a mindset of sufficiency. His model very often was – DO THE WORK, THE MONEY WILL FOLLOW. And this organization always felt like that it had enough even when it clearly didn’t. This used to baffle granting and funding agencies when the offers of money were turned down. What that mindset did was it allowed it to identify and implement resources in a very different way. It allowed them to look at a High School village girl and say I see in her a world class medical professional. It allowed them to look at that impoverished patient and say I see a great challenge. Whenever doctors used to come and complain to Dr. V – I can’t find a good nurse, I can’t find a good administrator, I can’t find a good technician. Dr. V would laugh and he would tell them, “You can’t just find people, you have to build them. And that’s what he did. 100 percent of Aravind’s nurses are trained in-house. 95% of its doctors trained in-house. 15% of all eye doctors in India have undergone some form of training at Aravind. It regularly trains residents from Harvard from John Hopkin’s and from all over the world. This is because Aravind is not just a cataract hospital. It is a tertiary care facility. So they have all the specialty, super specialty clinics in eye care. One of the things which this element of self-sustainability allowed it to do – it gave it freedom to make these very unorthodox decisions. There was a time in the 1980’s when intraocular lens surgery had revolutionized the way cataract surgery was done. So, there was an implant which was put once the natural lens was taken out. And that lens cost between 150 to 300 US dollars when it first came. It was way too expensive for the developing world. But Aravind wanted this quality service for all of its patients. And at that time every single almost all international eye care providers including the WHO were very strongly opposed of having that ability come to the developing world – coming to India. They went even so far to say that it would be irresponsible to encourage an addiction to a technology that this country cannot afford. And Aravind listened very politely to that debate and then went ahead and did it anyway. They started an internationally certified manufacturing facility; they began to manufacture world class eye lenses. They brought the price down from 300 dollars to 10 dollars and then reduced it further to 2 dollars. Then they exported those lenses to over 170 countries around the world. And they don’t just help millions of people round the world to help see with these lenses, today they roughly own 10% of the lens market globally. And they also make ophthalmic pharmaceuticals – surgical sutures, equipment’s and a whole range of things used in ophthalmology. So, there you go, there is the story.



TRAIN YOUR COMPETITION



It is very clear they can’t have their finger on something, they can’t be secretive. They have got some magic in their hands. So what happens when you have something that powerful? Then do you build a fortress around it and hold it close to you and try and guard it with your life. But Aravind trained its competitors. They were open-source with their success. This is Aravind’s manufacturing facility. They are not only open source with their model they throw open their doors and actively bring in people and say, “We can help you, we can help you”. Aravind works in about sixty different countries, in hundreds of hospitals and train thousands of people in this way. The idea is that they really believe that when you hold your strength, when you hold your expertise to limit your impact. Sharing your strength amplifies it many fold. That’s a deep conviction for them.



This is the Meenakshi Temple in the center of the town where I grew up in. This temple is the prominent skyline of the town of Madurai. These temples are about 2500 years old and were built by generation of rulers across different dynasties. Dr. V would look at these temples and say INSTITUTIONS SHOULD BE BUILT LIKE TEMPLES. It was not the religious aspect of the temple but its longevity. So build something timeless. Build something that multiple people can hold a vision across different generations. Such institutions should be built not for the profit of one person but for the benefit of humanity at large. A place to practice truth. A place for head, heart and hands for all. That’s the vision which Dr. V held for institutions.

This picture is the photo of the founding team. All the buildings in-front of them behind them is a fraction of the empire which they created. I am giving you a very quick snapshot of the flow of things. It is much more nuanced, complex, riddles, struggles all of that in there. But I wanted to show you these are the second generation and the third generation of my family. There are 4000 other people there. These are very ordinary people. They are not super heroes. They are ordinary people and they have their fallibilities, they have their struggles. Yet, these ordinary people came together around some extraordinary commitments and they built something beautiful. There are a few quick takeaways. 

These are nuggets perhaps Dr. V’s unwritten directives:

1. STAY ROOTED IN COMPASSION. What he showed, he demonstrated that when skillfully channeled compassion can drive and dictate scale, efficiency, productivity, transparency, equality, inclusion. It can do all these things in such a way that each element reinforces the other and strengthens the whole. And it creates a finely tuned system which benefits everybody.

2. SERVE AND DESERVE. When you make this your core. When the core of your energy and attention goes with serving unconditionally the boundaries of your perception shift and you start to see value and relevance in very unexpected places. You generate trust and goodwill. Your work fires a magnetic quality. It sustains and aligns resources to your mission in a way, which just money can’t do. CREATE MOVEMENT NOT DOMINANCE. Not all of us train our competitors. We should be part of something bigger to be generous to stand to benefit from that.

3. PRACTICE FOR PERFECT VISION. This was something that Dr. V returned to over and over again. He knew that as there are external forms of blindness, so there are internal forms of blindness – anger, greed, jealousy. All these things clutter our vision and make it hard to see what is, and what the right next step is. So, he believed that the evolution of organizations hinges on the evolution of individuals within them. And clarity in thought and action comes from a discipline of mind and heart. And when you commit to sharpening your self-awareness and when you commit to working at the boundaries of your compassion than you tap into a higher wisdom which informs and transforms your work. You become a more perfect instrument for your highest quality.



Now I will share some of Dr. V’s words in his own voice.



I USED TO SIT WITH THE ORDINARY VILLAGE MAN; BECAUSE I AM FROM A VILLAGE AND SUDDENLY YOU TURN AROUND AND SEEM TO CONTACT HIS INNER BEING. YOU SEEM TO BE ONE WITH HIM. HERE IS SOUL WHICH HAS GOT ALL THE SIMPLICITY OF CONFIDENCE. DOCTOR WHATEVER YOU SAY I ACCEPT IT, AN IMPLICIT FAITH IN YOU. AND THEN YOU RESPOND TO IT. HERE IS AN OLD LADY AND SHE HAS GOT SO MUCH FAITH IN ME. I MUST DO MY BEST FOR HER. WHEN WE GROW IN SPIRITUAL CONSCIOUSNESS WE IDENTIFY OURSELVES WITH ALL THAT IS IN THE WORLD. SO THERE IS NO EXPLOITATION. IT IS OURSELVES WE ARE HELPING, IT IS OURSELVES WE ARE HEALING – Dr. Govindappa Venkataswamy (Aravind Eye Hospitals)



This was his retirement project. At one level it is a story of David and Goliath with intractable odds. David fought a good fight and one. And it’s not just that. It is a story that sits at the intersection of so many things – social entrepreneurship, good business, moral leadership, family business, sustainability. All these different things spill and spill to touch everyone’s life. Because at its core it is a story about our individual potential and our collective possibility. This is a story that for me demonstrates without a shadow of a doubt that in helping and serving others we serve ourselves. Our limitations do not define us and embedded in the human spirit there is a strength in wisdom that can rise to our greatest challenges. And together we can and we must like the world. 

Thank you.

See also Infinite Vision - Dr.Govindappa Venkataswamy - Aravind Eye Hospital