Hosted by Dr. Hunter Cherwek with guests Dr. Umang Mathur, Dr. Rishi Raj, Dr. Munir Ahmed, and Dr. Rahul Ali.
Dr. Hunter Cherwek: There are so many things that need to be considered in order to safely deliver eye health care during the pandemic. For the Orbis teams on the ground, and for our partner hospitals, this has meant reconfiguring spaces to accommodate physical distancing, adding barriers to equipment, adopting mask protocols, and procuring additional personal protective equipment—among a host of other adjustments. In addition, we’ve had to adapt to the new ways people are managing their eye health. Are they skipping needed treatments? Are they hesitant to take part in training programs? How can we help with this?
These are the challenges our staff and volunteers are managing as they do their best to ensure everyone is protected from this virus while we continue to try and save sight.
I’m Dr. Hunter Cherwek, Vice President of Clinical Services at Orbis International and your host today for Sightlines. Orbis is an international not-for-profit organization working to end avoidable blindness and vision loss around the world.
In this episode, I’ll be talking to a number of people who are helping to ensure critical eye care continues – safely – despite the coronavirus. First, I’ll be welcoming Dr. Rishi Raj Borah, the Country Director for Orbis India, and Dr. Umang Mathur, the Executive Director at Shroff’s Charity Eye Hospital in Delhi. Dr. Mathur is an expert in systems management; in fact, he recently partnered with Orbis to deliver an online lecture for clinicians and administrators on the topic of Systems Management Post-COVID Lockdown. It’s a great lecture, and the recording is available online for anyone who’s interested. You can find it at cybersight.org.
During this episode, you will hear the term “slit lamp”. That’s the microscope that doctors use to examine your eyes – the one you put your chin on when you go to see the eye doctor.
And now let’s get into it. Here’s my conversation with Dr. Rishi Raj Borah and Dr. Umang Mathur.
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Dr. Hunter Cherwek: Rishi Borah's with us. He is the Country Director for Orbis India.
Rishi, maybe you can talk a little bit about yourself, where you're from, and the team you lead as part of Orbis India.
Dr. Rishi Raj Borah: Basically I am from Assam, one of the Northest part of India. Currently, staying in Delhi and leading a group of 20 colleagues in Delhi office - planning and implementation of Orbis mission and vision in India, Nepal, and Indonesia. Our basic work in India is around children's eye care. So, we started in 20 years back and we have been supporting our partner institutions across India. I think, probably, we've supported the world's largest children's eye care network with 33 partners across 17 states. And these partners have been providing eye care services for 1 million children they reach out to every year. Then, a similar kind of network we have established in Nepal which is also, Nepal is a small current country. We have 8 centers established there to have a kind of national level network for providing children's eye care across Nepal.
Dr. Hunter Cherwek: Assam, where you're from, is one of the most beautiful states in India. It has the greenest tea plantations I've ever seen in my life and Assam is such a beautiful place.
Dr. Umang Mathur is with us. He is a cornea specialist and I'd like to him to talk a little bit about his background and the work and the team that he is leading.
Dr. Umang Mathur: Thank you, Hunter! Thank you Orbis for giving me this opportunity. I am Dr. Umang Mathur. I am the Executive Director of the Dr. Shroff's Charity Eye Hospital, New Delhi. Dr. Shroff's is over 100 years old hospital, based in the heart of Delhi in the heritage building. Our association with Orbis has been for over, almost, 20 years, we were fortunate to be the first land-based project of Orbis that is focused on pediatric ophthalmology. And, with Orbis, we have not only grown as a children's eye care institution. Initially, our faculty was trained in some of the best institutes in the world and, with a lot of hospital based teaching programs that happened with the help of Orbis's support, now we are training: ophthalmologists, pediatric ophthalmologists, optometrists, nurses, anesthesiologists - to spread good children's eye care across India as well as other countries like Indonesia, Vietnam, Nepal, Mongolia, to name a few.
Dr. Hunter Cherwek: Dr. Mathur, you recently gave a Cybersight webinar on how COVID is impacting your practice, your hospital, your team and how you all are adapting to make sure you still allow patients to receive quality care. Maybe you could talk a little bit more about the points you raised in that Cybersight webinar and how you and your team are adapting to the COVID crisis to be able to continue the great training, the great quality care that you provide?
Dr. Umang Mathur: So, COVID was something new to all of us. We weren't quite ready. So, India had a pretty strict lockdown initially and that was a good thing because we got time to learn, we got time to establish systems. So, initially, we worked a lot on rearranging our clinics and changing patient flows. Fortunately, although we are in this very crowded place in New Delhi, we have five acres of land, so we just opened up a lot of gates and we worked with the patient flows, so that there is more social distancing.
Having established a lot of those systems, we were feeling quite secure with ourselves when we are seeing patients. There were shields that were put on slit lamps, all the staff had gloves, masks, caps and gowns, PPEs, and we had to create some barriers for a registration desk, and all those things we thought, initially, it was the patient was going to bring COVID into the hospital. Actually what happened was that, yes, we did all that right, but we realized it wasn't the patient but was our own employees who were a bigger risk, because they were coming from areas, and their families, where they probably had contracted COVID. There was a time in early May when 63 of our employees had to be quarantined, and that was difficult because you had to handle them emotionally as well as, you know, there was a lot of scare at that time.
And so we, again, rearranged and we said, let's work smartly, so we established some triaging clinics, where they, you know, were quick clinics to just look at things like conjunctivitis or surface allergies, that didn't require a whole lot of work up. We said, you come back later, we'll just give you what is required for now. And with that one fourth of the patients was checked out while those who had most, you know, needed for the examination were brought into the clinics. So, we regulated traffic, instead of calling all the wards at one time, because the workload was definitely low, we said okay, let the doctors come in two shifts, so that we have less staff coming, so instead of opening five ORs we said okay let's work with three so that they don't have to call all the OR staff. So, by reducing staff and whoever was there was get busier, they didn't get time enough to go and chat together or to eat lunch together and have coffee together because those were the things we always, you know, feel that our own people are safe and our guards come down. I think the important thing was to create this awareness that you are at risk with your fellow employees as well. And that took some time for people to adjust to, but having established that for the last about six weeks, we have not had a single person in the hospital who needed to be quarantined or tested positive.
Dr. Hunter Cherwek: Rishi, I definitely want to hear about in the work you're leading and why eye care and the programs and the team you lead are so critical during this pandemic.
Dr. Rishi Raj Borah: We had a lot of school eye health programs. Now, during this period, all the schools are closed and you don't know whether the schools are going to be open when and, then, in what form, so whatever strategy with partner we have developed was to reach out to kids going to the school. Now, probably, that strategy is not going to work out or the current situation also will not allow the school authority to give you a permission to conduct this kind of activities within the school. So everything what was planned now have to relooked at and this is a challenge, but it created a lot of opportunity to look at what we had not done earlier.
Now, small thing like when we go to school now and what we're thinking now is, first, we are going to teach the child how to do a proper handwashing. Earlier we haven't done it, we would have added this particular handwashing, hand hygiene and personalizing things along with school eye health, probably many of the little health problems in the rural school, like diarrhea and all this, would have been, a little, prevented, which is beneficial for a child as a whole, not only eyes [but] as a whole as a health of the child.
In the hospital, such as Dr. Umang said, different hospitals, they're developing protocols, they are developing guidelines to deal with this new normal. There are many of the hospitals are also trying to figure out how to deal with this particular situation in their own setup, develop a self assessment tool out of this particular guideline so anybody, any institution can use that guideline and see where they are and then what are the areas that needs to be improve upon in order to deal with this new normal.
Dr. Hunter Cherwek: No, thank you so much, Rishi. Obviously, I'm so proud of the team and the work that you lead.
Dr. Umang, obviously Rishi has talked about the concept of the new normal. What does that mean to you and your team as we're going through this COVID tunnel. How do you inspire your team, what vision do you provide to give people clarity on what is your new normal for eye care, both during and post COVID.
Dr. Umang Mathur: It can get pretty morbid with this COVID and all you hear on the television is how the numbers are rising. And so you need to keep the whole team together and focused and you still have to go on. I mean, going to a hospital and seeing patients can be a little risky but we've been fortunate that despite all these problems our team is pretty well motivated coming every day and enthusiastically. And over a period of time, I think, people have got more confident that we have a safe environment and it's okay to see these patients. I see it almost like, maybe, what HIV did to operation rooms and how it established norms as universal protection in the operation room, that you consider every patient as HIV positive. So, I think, overall, you've become safer. Overall, I think, it will help getting better systems in place.
I will go back to your previous question also. I mean, why it's so important that eye care should remain in focus. Because of poor access and the scare, patients have stayed at home and not coming to clinics for getting basic treatment. And so it's very important that we bring this awareness out that it's important not to ignore your other ailments during this time, and the focus on eye care is very important. I think it also highlights this fact that we need better training – that comprehensive doctors who are readily accessible in areas where, you know, patients live in villages or smaller towns – they should be able to handle certain of level of what we today call a sub-specialty. You can't have specialists in every small local corner. You need to have better trained ophthalmologists who can handle smaller emergencies, some bit of glaucoma, some bit of cornea or some kind of retina. It doesn't need a specialist to handle these cases. So, I think, it will be very important to establish better training systems, short programs. And here again, I think, technology can help. That we can have smaller courses, which are online; you don't have to close your clinic and talk for three months for training. Can we do that on a weekend hands-on those and, the rest of it, can it be established through online courses.
So, I think, COVID should be taken as an opportunity to, you know, do better training of doctors through technology. Primary care becomes very important. Vision centers are back almost 80% of their workflows than what it was in the pre-COVID, because they are accessible. People find them safe. They can reach to a vision center. So there needs to be a shift in having good quality paramedic training that can do some primary work closer to where the patients live. Again, technology needs to be brought in where through tele-ophthalmology from a vision center can you connect to a doctor, either in a secondary center or tertiary care system. I think those are rudimentary right now, but I think we need to give that more focus. More focus on primary care, focus on technology to help in connecting patients to the right people, creating that referral network. And better training, I would say, of comprehensive ophthalmologists, so that they can look after patients closer to home.
Dr. Hunter Cherwek: I think you said so many important things for our listeners and viewers to know. So much of blindness could be prevented, and as you said, late presentation, whether it be an infection, like a corneal ulcer or even an ocular cancer, an eye cancer like retinoblastoma, prevention and early recognition and treatment is key. And, as you rightly said, people are now hesitant to travel to the super sub-specialist like you, because of the distance from the communities.
You talked about the vision centers – that these are in the local communities. Primary eye care that is high quality, readily available, and they're almost back to pre-COVID numbers. Maybe you could just talk about the importance of vision centers and how those have really become pillars in the community – not just for eye care, but we're actually now doing COVID training about handwashing, signs and symptoms report in that. Maybe you can talk about vision centers and how that's so important to your strategic plans and the rural outreach that you do.
Dr. Umang Mathur: About 5 years back we established a school for training young women. And we've focused on women – they are 12th grade pass-outs, who are trained as eye care paramedics. So they belong to the local community and over a period of about two years, but essentially within about nine to 12 months, they are trained well enough to do refractions, to do a basic slit lamp examination, do a pressure check to identify common diseases and they know when to refer. We are able to look after patients closer to where they live, they can readily access them. These vision centers are open every day as primary care clinics and they do comprehensive examination, and not just a torch light examination, they do a full examination for the patient. And they have become like you said the pillars of our community work. And we right now have about 35 vision centers in our system and this year we're going to open another 20. Already, even during this COVID period, the vision centers have become the most important place for referral of patients, both for surgery and for medical treatment. So it's a very important link with the patients at the grassroot level.
Dr. Hunter Cherwek: You all are obviously leading that way and it's so impressive to see the quality at every level of Dr. Shroff's care, whether it be in the operating room in the clinic or now, you know, in the community with the vision centers.
I definitely want to thank you both. Not only for taking the time today to talk about the incredible work that you and your teams lead, but also inspiring us and having us think about what does the new normal look like for all of us as we go through this COVID tunnel. So thank you so much for your time and expertise.
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Dr. Hunter Cherwek: That was Dr. Rishi Raj Borah and Dr. Umang Mathur. Many thanks to both of them for coming on the show.
My next guests are Dr. Rahul Ali and Dr. Munir Ahmed.
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Dr. Hunter Cherwek: We’ll start with Rahul. Rahul, maybe you could tell us a little bit about yourself.
Dr. Rahul Ali: Hi everybody. I’m Rahul Ali. I’m an ophthalmologist by training. I’ve done my Master’s in Public Health and an MBA from John's Hopkins [University].
Dr. Hunter Cherwek: Thank you so much for being here. And, Munir, thank you for joining us this evening. Where are you at the moment and can you tell us your role at Orbis?
Dr. Munir Ahmed: Thank you so much. I'm actually now in Dhaka, Bangladesh, responsible for country office, country program in Bangladesh. My background, I'm basically a public health management specialist.
Dr. Hunter Cherwek: I want you to take a minute and talk a little bit about your country. I've been there many times for work and I leave always appreciating a new layer of complexity and the diversity that's in your country: the people, the cultures, the languages, the nature. Maybe you can tell us a little bit about your country first, the eye problems that you're addressing there and the great work that you lead.
Dr. Munir Ahmed: Bangladesh is a densely populated country, you know, 160 million population. And 70% of these population are living in the rural, remote areas. Actually, one third of the country is inundated during the flood situation. So there are a natural disasters, there are a lot of situation where the people are actually suffering.
Dr. Hunter Cherwek: No, you're right. I mean, if you asked me one adjective to describe the population and people that I've met in Bangladesh, it's resilient. And, as we're going to talk about later, the country has done an amazing job of treating the displaced persons or refugees from Myanmar who are there, the Rohingya population. And certainly you all face unbelievable challenges. As you said, you have extreme population density. For those in the United States, Bangladesh is about the size of Wisconsin and has about half the population of the United States and much of that is on a floodplain.
Dr. Munir Ahmed: The child population in Bangladesh is 64 million, which is very important for us, you know, as an eye health organization. And what you can see is that there is tremendous improvement in child's survival rates. There are 400,000 premature babies are born and, we know now, that at least 35% of these premature babies are at risk of Retinopathy of Prematurity. So this is an important issue. On the other end, there's the life expectancy has been increasing and that's why the degenerative diseases are also growing. So the cataract is also increasing. We can see that there are 6 million people are suffering from refractive error and 1.5 million are, actually, now in the need of glasses. So this is very critical for us, actually, to think about.
Dr. Hunter Cherwek: For those who don't know, refractive error means that you need to wear glasses. You can see that all three of us have refractive error and it's a growing problem in Asia and something that Orbis is addressing in schools as well as communities.
Now, I'm going to move a bit to Rahul and I want Rahul talk about how he has worked not only in India, but also in Nepal to treat refractive error and eye diseases in remote areas. And how he's done this. Now even more difficult or more challenged by the COVID crisis, how is he overcoming both the difficulties of distance and the difficulties of COVID. Rahul?
Dr. Rahul Ali: Eye health, high-end eye health is available in India. If there’s anything being done anywhere in the world, there will be somebody in the country who is doing it. Technology, techniques, research – all the way up to the top, I mean, world class facilities available in the country. Yet, if you go out to rural India, you will find elderly people with bilaterally blind from cataract because they haven't got an access to care. You will see children with very, very advanced stages of retinoblastoma; that’s an eye cancer, and I won't describe what that looks like, but it’s not a pleasant sight.
But the thing is, there are still so many people who are below the poverty line, who don’t have the means, who don’t have the access, and need help. That is what we try to do over there, help the people who can’t get it themselves.
So during this time of the pandemic, this has become an even more important issue for us. How exactly do you go out there and provide services and do your outreach activities. And you mentioned the example of REACH, that is Refractive Error Among CHildren, our innovative school eye health program in India and Nepal. Well, just to give you some idea of the scale we're talking about, in the last three years we've conducted more than 5 million screenings for school children across India through the REACH program. And I can't emphasize enough how much there is a need to continue these services. The problem is not solved by giving a child a pair of glasses the first time you see them; that child needs an annual checkup and support year-on-year. And there are so many more children who are in need of similar care.
So what we're trying to do is take the challenges the pandemic has thrown our way and use it to innovate in the way we continue to deliver our work and deliver our program in the areas we're working in. And at the same time to also make our work relevant to the current needs of the community. So first and foremost, we must ensure safety – the safety of the children we serve as well as the safety of our partners and their teams who want to provide the services – and this will require the use of appropriate PPE, hygiene measures, ensuring safe social distancing and adhering to all other recommended guidelines applicable to our work. We're also looking to see how we can provide these services to small groups of children and how we can leverage technology, such as photo screeners, to assess the refractive state or the power of a child's eye and do it accurately while minimizing physical contact.
One thing which has really helped us is, when we were planning the phase two of the REACH programs, we were already centering our work around vision centers. Now I’ll just stop and explain what a vision center is. Well a vision center is usually a fixed facility, about two rooms in a rural community or in an underserviced area. And it basically provides basic primary eye care services, which consists of a comprehensive eye exam, refraction and provision of glasses, and identification of all other eye issues or eye health problems and referral to a secondary facility or a bigger eye hospital.
Now, by planning our REACH program around the vision centers, that has helped us in really good stead in this time of the pandemic because the vision center is very easily accessible and conveniently located. So any school kid, girl or boy and definitely for girls, they can access this anytime without needing to travel all the way into town. And to make sure that we're addressing current needs, we've embedded basic COVID education into our work when we visit schools now. For example, just simple things like basic knowledge about COVID-19 and how it is transmitted, what do you need to be wary of, good handwashing and hygiene practices, how to wear masks, maybe even how to build or make your own mask. So, we're really trying to wrap everything around, and, I guess, only time will tell us as we move our way through this pandemic, what other challenges we're gonna face.
Dr. Hunter Cherwek: That was excellent, Rahul. Thank you so much for talking about our vision centers.
Munir, maybe you can talk about the Bangladesh experience with vision centers and how important these are for primary and community eye health in your regions with your partners in the communities that you serve.
Dr. Munir Ahmed: In Bangladesh, actually, we have been implementing with our 23 partners – there are 27 vision centers actually that we've been supporting. Interestingly, these partners also established 67 vision centers of their own, which itself says that the importance of this because the community acceptance and community utilization has been increased significantly. That's why our partners are actually trying to establish these vision centers, because it is linking the community with the eye health.
The vision centers just opened one month ago and now we can see almost hundred percent patients are coming to the vision center. Whereas at the hospitals, and the tertiary or the secondary level hospitals, we can see 50% of routine cases have been started. So you can just see that the comparison of the vision center, how it is being given importance by the communities. So, I think these [at the] community level, the vision center is playing a greater role now than before.
Dr. Hunter Cherwek: Again, I mean, you all both have talked about how these visions centers are not just providing eye care, but they're really becoming resources in these communities for now the COVID training and COVID crisis.
Dr. Munir Ahmed: In Bangladesh, actually, in general, I would say that COVID has given us sort of a scope to see and evaluate ourselves that how our health systems is working. We are a part of the health community and society, so COVID has given us an opportunity to rethink, to reshape, and to redesign our projects and programs.
Dr. Hunter Cherwek: I fully agree with you. I think one of the things I have always commented on about your team is their resilience and their innovation. And you've always been able to find opportunities to improve our work, find new ways and new approaches to do our work during a crisis.
And I definitely owe you a thank you for allowing me to come and work with you and your team and see the work firsthand in the refugee camps in Cox’s Bazar with the Rohingya population. And I didn’t really tell anyone this, but while I was there, I was walking with you and seeing the incredible work you lead, that you’re giving glasses and doing eye exams in some of the most challenged and stressed environments in the world and you’re doing it with research and computers and excellent eye care professionals that you bring in every day.
And for about 30 seconds – I don’t think anyone saw me – I took off my glasses and tried to walk around the camp, just to get a feel for what it must be like for our patients who have had to leave their homes, cross a very difficult border, and they’re now in a camp and don’t even have something as simple as a pair of glasses. After about 30 seconds I really, I think for the first time, realized the power of the work that you do in the refugee camp and the incredible gift and power you give to the people who have lost their glasses, never were given glasses – or doing the surgeries.
I think one of the things, I’d just like to take a few minutes, if you could talk about all the incredible work you’ve done in the refugee camps to help the displaced persons. If you could talk about how you do everything from finding eyeglasses for people who need them to taking people and children out of the camp to go and get more complex surgery. As we all know, the children when they have their eye surgery need general anesthesia, they need to be put asleep so that the doctor can do the surgery. And obviously that’s not possible in a refugee camp. I would like you to just to talk about all the things you’ve done because for me, until I saw it firsthand, I had no idea the power and the impact you’re having with that population.
Dr. Munir Ahmed: Thank you, Hunter. That's a great opportunity for me to share our experience in that. Because the camps, there are a lot of, sort of, barriers to bring the people from the camps to Cox’s Bazar and the Eye Hospital. So we've actually set up these vision centers at that level. And then we've set up these outreach centers. Also we have utilized the child-friendly schools in order to, you know, do the primary eye examination at that level – just like, you know, vision test and referring them to the vision center, you know, for glasses.
We have seen that there are 30 children there who cannot see – you know, somehow, they are blind. So what we've seen is that they need to be, you know, immediately transferred. And our partner hospital in Cox’s Bazar don't have that capacity, they don't have their facility. So, what we have seen is we have actually trained and built the capacity of our tertiary center in Chittagong – the Chittagong Eye Infirmary hospital. It has got a lot of energy to put into that, you know. And I have said this has been a tremendous sort of effort going on – and still going on, and now in a COVID situation. Now transporting from the Rohingya camp is an important issue. There's the restriction of movement of the transport, so you can't get transferred all the time. So, we are waiting for the reopening and restriction limitation removal of this restriction. And we are actually in consultation with partners to re-open the activities in a way with what we have been doing. So that will be a new normal.
Dr. Hunter Cherwek: Yeah, and you know, I think you said something very important. You always see the opportunity during a crisis. Whether it's a refugee crisis or the COVID crisis. You and your team always find an opportunity to make sure eye care is prioritized – that we find new innovative ways to do the best training, the best patient care. I mean, just all the levels of permission you need to secure to take a child from refugee camp to an outside hospital to get the necessary surgery is incredible. That is a labor of love and thank you so much for that work, Munir.
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Dr. Hunter Cherwek: That was Dr. Munir Ahmed and Dr. Rahul Ali.
Thank you for joining me for Sightlines today. I hope you’ll join us for the next episode and for the entire series.
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Until next time!
