Interview with S.S. Badrinath, founder and Chairman Emeritus, Sankara Nethralaya.

An ophthalmologist for nearly four decades, S.S. Badrinath has been a constant figure in the dramatic evolution of the specialty in India over the years. In an interview with Ramya Kannan on World Sight Day (October 14) Dr. Badrinath says that key to his practice, and the philosophy of his institution, is the conviction that ophthalmic services must be available, affordable, accessible and accountable. He also believes that Ophthalmology is a growing science, and that as it grows, it must take into account other sciences to provide speedier service to the people.

The National Blindness Control Programme is touted as one of the most successful national health schemes rolled out by the government. Is this justified? What are the factors that enabled this?

We were the first nation to have a national programme for blindness control. Since 1955 to the present day, we have reduced the blindness rate from 1.7 to 0.8. In the1950s, 85 per cent of the blindness in India was due to cataract, but it has now come down to over 50 per cent. That is a significant reduction. The government is also doing a lot of work on refractive errors, childhood blindness, and Diabetic Retinopathy now. NGOs have also played an important role in the prevention of blindness.

The success of the NBCP lies in the fact that the results are immediate. Word of mouth transmission of information that treatment is available and produces good results within a short period of time brings patients in. Also, cataract surgery can be done by people who have had good experience in cataract surgery and such people are available in India. I think the NBCP was very well-planned.

Is the health administration in tune with evolving issues in Ophthalmology? What is the path for the future?

We need to spend our money on diseases that affect a large number of people. How much money, how to allocate those funds, how many people should be targeted and where to focus on, are questions that require good planning. Unless an epidemiological study is done, disease prevention and control are not possible. Unfortunately, we have no definite, well-planned and executed epidemiological study in the area except one from the LV Prasad Eye Institute that was done eight years ago. At Nethralaya, we have now embarked on epidemiological research on two important areas — diabetic retinopathy and glaucoma.

I strongly feel that whatever innovations need to be done, have to be done with available resources. We need to find new methods, new innovations, and these innovations must be cost-effective. The results of the innovation must bring solace to a large number and must facilitate better outcome/results on application. We should also be able to reduce morbidity to the least as the result of this. Of course, this is possible only with research — a very important factor in the medical field.

Many benefits accrue from research — for example, in Sankara Nethralaya we found that in congenital cataract Rubella was the causative factor. Preventing Rubella infections in the mother is therefore the best way of preventing congenital cataracts. There is also a very interesting project where S. Ramakrishnan, former director of biochemistry at SN found that amino acids taken orally is likely to prevent end-stage complications in diabetes mellitus — retinopathy, nephropathy, neuropathy and cataracts.

The urban-rural divide in terms of availability of healthcare and shortage of professionals and infrastructure to tend to patients are issues that are agitating planners and health administrators. Are there solutions in Ophthalmology?

In the rural areas, the availability of healthcare is very minimal, if anything exists at all. I would like to make tertiary healthcare available at doorsteps in rural areas. There is indeed a scarcity of ophthalmologists; and efforts must be taken to make the manpower available. But until then, the specialty must absorb advances in other aspects of science — for instance, Information Technology. Telemedicine, which uses, ICT, is currently the best way of approaching the problem. We have had good experience in the last 8-10 years with tele-ophthalmology. Thanks to this, distance is no longer a consideration and the patient can have a comprehensive examination by the best of specialists without travelling far. We believe that the urban-rural divide can be overcome in the next 20-30 years, but only through tele-ophthalmology and tele-medicine programmes.

The costs incurred on medical treatment are increasing. India being a nation where the majority of the spending for health is out-of-pocket expenditure by the patient and family, are there financing options? Insurance, for instance, or subsidies by the state/hospitals.

We tried to work out an insurance package specifically for the eyes. Unfortunately the premiums were too high. The State government's Chief Minister's Insurance Scheme (Kalaignar Kaapeetu Thittam) is a good scheme. Under this, 16 eye conditions have been identified and expenses from Rs.6,500- Rs.7,000 are covered.

As for subsidies from institutions, the Sankara Nethralaya model itself is about making medical care affordable for the middle class in India and for the very poor.

Almost 38 per cent of our patients are treated totally free of cost and the remaining pay a nominal fee — just a little more than what it costs us to provide the service. The non-paying group receives quality care in no way different from the people who pay. Since we are a not-for-profit institution, any profit that accrues is ploughed back in, to finance education initiatives, and research.

If stem cell research has progressed significantly to therapeutics at all in any segment of medicine, it is in ophthalmology…

That is right, in Ophthalmology we have been users of stem cell therapy in a large number of areas especially for the front part of the eye — the cornea. For instance, when affected by acid or alkalis, a simple corneal transplant fails. However, when you do it with stem cells in the limbal area, it seems to work. There are also applications in retinal pigment epithelial transplant — this will be helpful in the future to treat diseases of retinal degeneration. We are also working, in our lab, on developing a synthetic cornea. Stem cell therapy has great potential, undoubtedly.

Your thoughts on medical tourism.

We have a large number of people living in India who require medical care and they need the attention of doctors who are already, in terms of numbers, insufficient, here in India. Instead of treating our own patients, why do we think about treating people from outside the country? The medical profession's priority should be Indian citizens and only thereafter, outsiders from other countries.

Ophthalmology wrote the opening paragraph of the organ donation movement. Is organ donation all set to grow?

The organ donation movement has picked up enormously in the last couple of decades. Essentially, it was the lack of knowledge on the part of the public that eyes of the dead person could be used to restore eyesight of a blind person that prevented them from donating. However, once that idea was taken to the people, eye donation became quite popular. I don't think, fundamentally, that there is any religious inhibition on the part of the people to donate eyes. All religions in India encourage eye donation.