Reaching the unreached

The operation theatre inside the bus is self-sufficient, designed for real time monitoring and surgeries are done under local anaesthesia

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Afflicted with polio from an early age, 74-year-old Mariamma (name changed on request) of Peranambut, a sleepy, far-flung village panchayat in Tamil Nadu’s Vellore district, can hardly walk. And her vision was fading too with old age due to what doctors’ term a “white cataract” – cataract growth in its utmost severity that made one of her yes virtually opaque.

So frail was Mariamma that “we had to lift her from the operation table after a cataract surgery,” recalls Dr Rashmin Gandhi, ophthalmologist who turned around her vision with a high-precision cataract surgery in that remote area where she could not even go to a hospital some 50 km away.

A small trader’s plight at Peranambut, suffering from diabetes and hyper-tension, was only a shade different. He was finding it difficult to manage his shop as a cataract was closing in on his vision until he walked to the operation table in the IIT-Madras Mobile Eye Surgical Unit (MESU) that came calling on the village.

This was part of a new pilot project of the Healthcare Technology Innovation Centre (HTIC), a Bio-Technology Department-funded initiative formally inaugurated at the IIT-Madras, recently as a “platform to take relevant biotech and medical innovations for the country’s social transformation”.

These patients, who happily got back their vision, are but two of the 486 cataract surgeries “successfully done” by MESU in two villages of Vellore District – Peranambut and Jolarpettai-- early this year as a part of HTIC’s first bold foray in collaboration with the Chennai-based Sankara Nethralaya , after the Health Ministry gave its nod for the pilot project. Why envision a new mobile eye surgical unit? Of an estimated 12 million blind people in India, “cataract accounts for over half the blindness” and this is a major reason to trigger this project conceptualisation, Dr Rashmin Gandhi, an ICO Fellow from John Hopkins University, USA, who led the 8-member medical team,
including para-medics from Sankara Netralaya for this project, told  Deccan Herald.

With a substantial number of the visually disabled persons living in remote rural and tribal areas, the challenge was to make “high quality cataract surgery” accessible to them. As Sankara Netralya, under renowned eye surgeon Dr S S Badrinath’s leadership, had already made significant  strides in cataract surgeries and implanting artificial intraocular lens in place of the affected natural lens, IIT-Madras saw synergy to team up with it for this project, said Dr Gandhi.

A “twin-bus” (two buses conjoined by a side vestibule), a “first of its kind in the country” was designed and built for this project, according to Dr Mohanasankar Sivaprakasam of IIT-Madras.

Instead of one wide-bodied bus which may be unsuitable for narrow, kutcha-roads in rural areas, two slightly narrow-bodied buses were designed, one following the other until they reached the spot and converted into a MESU with a vestibule connecting both the units.

Thanks to a team of engineers from IIT-M’s Department of Electrical Engineering, including Mohanasankar, Dr Jagadeesh Kumar, Dr Jaya­shankar and Dr Jayaraj, burning the midnight oil, the basic design of the twin-bus was done by them after Dr Badrinath first mooted the idea of having a specially designed vehicle. The sturdy buses for narrow, dusty, village roads were then specially custom-built at a reputed automobile unit near Pudukottai.

“At every stage of the body-building, the IIT-M engineers visited the factory to ensure all the specifications,” said Gandhi. The vehicles’ designing took care that all requirements during a medico-surgical procedure like “water sterility”, “air sterility”, constant power supply provided by a 20 kva diesel genset, all to ensure “zero-infection” for patients during surgery and after were met, he said.

A “reverse osmosis plant” is fixed in one of the buses to ensure water quality, besides being fitted with air filters for air purity. People in any village who come for treatment are first prepared for the cataract surgery in the first unit and then led through the vestibule to the second bus where a full-fledged, modern operation theatre has been set up.

“The walls of the operation theatre are made of fine, food-grade steel so that bacteria will not stick,” said Gandhi. Both the buses are provided with hydraulic jacks to help them stand firm sans any jerks. MESU is parked in the village school premises for easy access by the locals.

In the past, “mass eye camps” had been held in rural areas, like in “kalyana mandaps” to perform cataract surgeries. But they caused lots of complications as the immediate environment and surgical tools were not sufficiently sterilised and surgeries done even without a microscope. Hence the Union Government did not allow cataract surgeries to be performed outside a “fixed operation theatre”.

To break this logjam, the idea of a special vehicle functioning as MESU was born, as a majority of  visually disabled people live in rural and remote tribal areas, said Gandhi.

“We had to think of a new way to reach the unreached, as a study showed that 26 per cent of those suffering from blindness do not attend the eye camps; worse, 36 per cent of patients screened in rural areas for cataract do not later turn up to the base hospital,” said Gandhi on the rationale behind.

The operation theatre inside the bus is self-sufficient, designed for real time monitoring and surgeries done under local anaesthesia under cardiac monitoring. The age distribution of patients in this pilot project ranged from 31 to 90 years, even as 58 per cent of the 486 cataract surgeries done in the two villages were on women. “In one village, we had a 91-year-old patient,” said Gandhi. “After the surgery, we went to each of their places for post-operative checks and again revisited them after a month to both the villages to check their glasses for use,” he added.

The project study results “were as good or better than the ones done in a base hospital.” The Health Ministry, which has now, in principle, cleared this eye-care delivery model for being scaled up and taken to other states, said Gandhi. “One of our dreams has turned into reality, by making a twin-bus and taking it to the villages to do cataract surgeries free at the doorsteps of the poor rural people,” summed up a visibly pleased Dr Badrinath, adding, it could “revolutionise” ophthalmology screening in India.