Why 15 people lost vision at Haryana eye camp, and how India can avoid it

The most robust solution to prevent such failures, an exception not the rule, is to invest more in upgrading and maintaining surgery centres.

 |  4-minute read |   04-12-2015
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There are several similarities between surgery and aviation: both require highly intensive training of professionals and tremendous teamwork, and are generally trusted by people despite the life-threatening risks involved. But the most striking similarity is how a single failure always (somewhat unfairly) stands out and eclipses previous successes. A lone accident of an airliner and a rare surgical complication in a hospital are remembered far more vividly than the hundreds of safe flights and procedures they might have respectively carried out.

Of course professionals in both aviation and surgery have come to live with it, and also continue striving to make their fields safer. For example, to talk about cataract surgeries, there was a time when the condition (which, in simple terms, occurs when the "lens" inside the eye turns opaque and causes partial or total blindness) was treated by inserting sharp tools into the eye and crudely manipulating the inside. Now ophthalmic surgeons use specialised instruments and expertly remove faulty lens and insert new artificial ones through incisions as tiny as two mm - that too in a matter of minutes. The field is advancing still, with researchers working on, for example, how to make artificial lens more perfect for vision in old age.

Today cataract accounts for 62 per cent of total blindness in India, making it the most common and the most easily curable cause of vision loss. Since 1976, with the launch of the National Program for Control of Blindness, the government has been providing cataract surgeries free of cost. In the early 1990s, realising that that this had not produced the desired results, it was decided that cataract control needed to be upgraded through more funding, better surgical technology, and intense specialist training. 1995 saw the launch of the World Bank-funded Cataract Blindness Control Project, and since then we have never looked back: we provided modern equipment to hundreds of centres, trained specialists in the most up-to-date surgical techniques, and brought down the cataract proportion of blindness from above-80 per cent to 62 per cent in two decades. Each day, literally hundreds of visually-impaired senior citizens get back their sight through surgeries done in scores of government tertiary hospitals and private centers of excellence. The International Council of Ophthalmology has generously lauded this "systematic approach" of India.

In the backdrop of such advances and the boastful presence of world-class institutes like Aravind Eye Care System, it is important to approach reports of "botched-up" eye surgeries with caution (like the recent incident in Haryana). In fact, branding the surgeries themselves botched is frequently misleading, as often "non-surgical" factors are behind the infective complications that affect sight: substandard drugs, improper autoclaving of instruments, and infected artificial lens material. It is tragic that surgeons are almost always the most convenient scapegoats in such situations. While there are indeed doctors who have committed frauds (like the "hysterectomy scandals") or been negligent, vicious comments against the general medical community that often follow such incidents demoralise and scare the rest who are committed to provide good care through honest means.

Recalling the parallels between surgery and aviation, one must note that disciplined teamwork is essential for success in both. Just as an airplane accident can occur if an air traffic controller, far away from the concerned plane, makes a miscalculation, so can a surgery go wrong if, for example, the person in charge of operation theatre disinfection does it improperly. Still, despite there being multiple ways in which any single cataract surgery can end disastrously, the fact that our health professionals successfully perform many thousands with negligible complications - 6.3 million surgeries per year - speaks volumes of the excellent quality of eye care in the country.

There are, however, issues with the quantity (which also often spill over and affect quality). The very reason we have eye surgery "camps" is that we have way too many individuals with cataract and not enough health professionals and eye hospitals. Some states are faring well (like Gujarat, Maharashtra, Tamil Nadu), while others need to catch up - for example, West Bengal should have ideally performed around six lakh surgeries in 2014-15, but could manage only 2.5 lakh. With population aging, the quantity issues are only going to intensify in the future. Perhaps, the most robust solution to prevent Haryana-like tragedies is to invest more in upgrading and maintaining the centres where such surgeries occur (especially district hospitals), and to produce and train more professionals - this is exactly what was done through the 1995 World Bank loan. It is public health issues like these which should be constructively discussed and debated by media, citizens, and politicians - but the fact that our public space is still stuck with age-old divisive topics is hardly encouraging.

Nevertheless, at least for now, there is no escaping the camps and the "assembly-line surgeries", and our efforts should be focused on making them safer and introducing more quality assurance. Ophthalmic surgeons have a central role to play, especially in terms of ethics (these are always the first casualty in the face of high patient volumes): a young surgeon I know once cancelled all scheduled surgeries of a camp when she saw a single ant crawling on the tray of operative instruments, in an otherwise clean and fumigated operation theatre. As long as the nation has passionate and dedicated professionals like her, 'botched-up" surgeries are doubtless going to stay the exception, not the rule.


Kiran Kumbhar Kiran Kumbhar @kiranskumbhar

Indian physician-writer. Harvard health policy expert.

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