Himalayan Cataract Project

The Himalayan Cataract Project (HCP) was created in 1994 by Dr. Geoffrey Tabin and Dr. Sanduk Ruit with a goal of establishing a sustainable eye care infrastructure in the Himalaya. HCP empowers local doctors to provide ophthalmic care through skills-transfer and education. From its beginning, HCP responds to a pressing need for eye care in the Himalayan region. With programs in Nepal, Tibet, China, Bhutan, India, Sikkim, and Pakistan they have been able to restore sight to tens of thousands of blind people every year since 1994.^[1]

In addition, HCP's assistance has been requested for a pilot study on eye care services in twelve Millennium Research Villages in Sub-Saharan Africa. The Millennium Villages Project was established in part to prove that successful implementation of the UN Millennium Development Goals is possible in the poorest, most underserved areas of the developing world. HCP has agreed to provide comprehensive eye care in each of the Villages (5,000 per village) and to demonstrate that the costs of these services will fit within the complex U.N. Health Budget for the Millennium Villages Project. So far, interventions have taken place in Uganda, Ethiopia, and Ghana with effective delivery of interventions such as cataract surgeries, refraction and distribution of glasses.

Background

According to WHO estimates, the most common causes of blindness around the world in 2002 were:

1. cataracts (47.9%),
2. glaucoma (12.3%),
3. age-related macular degeneration (8.7%),
4. corneal opacity (5.1%), and
5. diabetic retinopathy (4.8%),
6. childhood blindness (3.9%),
7. trachoma (3.6%)
8. onchocerciasis (0.8%).^[2]

Suffering from blindness affects not only the blind person but also members of his/her family. Where there are few paved roads and where terrain is rugged and mountainous, a blind person has incredible difficulty moving around and depends on a caretaker. There are no social services available to the blind, and individuals who are blind cannot contribute to family income. A blind person, unable to care for themselves in such a harsh environment requires a help of a family member, which essentially takes two people out of being able to contribute to family income, or community life. With sight restored, many patients would be able to return to work and to traditional roles in their families and societies.

Objectives

• teach ophthalmic care at all levels
• establish a first-rate eye care infrastructure through creating centers of excellence and mentoring facilities
• making all facilities financially self-sustaining
• addressing eye care from the public health level up to subspecialty care

In 1993, there were 15,000 cataract surgeries performed in Nepal, only 1000 of which utilized intraocular lenses. Most of these 1000 modern surgeries were performed by HCP's Co-Director, Dr. Sanduk Ruit, who brought microsurgery with intraocular lens technology to the region. Before this technology, cataract surgery consisted of intracapsular cataract extraction, in which the entire lens and capsule are removed from the eye and the patient is given cumbersome thick eyeglasses that provide no peripheral vision and distorted direct vision. At that time, the second and third leading etiologies of blindness after cataracts were aphakia due to the loss of these thick glasses, and failed cataract surgery.

In contrast, in 2003, over 118,000 cataract surgeries were performed in Nepal and over 98 percent were done with microsurgery and lens implants. Nepal is the only country in the Himalayan region performing more cataract surgery than the annual rate of new cataract blindness.

Skills-Transfer Program

The Himalayan Cataract Project has trained well over thirty surgeons to perform modern sight-restoring cataract surgery through a unique skills-transfer program. HCP utilizes a team approach, where a doctor, a nurse, and an ophthalmic assistant trains for 4–8 weeks at Tilganga. The surgeon takes an intensive microsurgical course, gaining dexterity under the microscope, while the team develops into a finely-tuned unit. The team then returns to its remote clinic, where it prescreens several hundred patients who are blind from cataracts. The HCP teaching surgeons follow and set up a high-volume skills-transfer cataract camp. The teaching surgeons operate on the first eye of each patient, while the training surgeon assists. Then the training surgeon operates on the second eye of each patient while the HCP surgeon assists. In the course of a typical skills-transfer eye camp, more than five hundred blind people will have their sight restored and each local team and surgeon will perform over 100 cataract surgeries. This is more surgeries than an American ophthalmology resident usually does in a three-year residency program. At the conclusion of the session, the Himalayan Cataract Project donates the operating microscope, surgical instruments, intraocular lenses, and consumables needed to perform an additional 500 surgeries. The HCP then follows up with additional training at the local surgeon’s hospital every year for the next three years. Several of the surgeons we have trained are now performing more than 1000 sight-restoring cataract surgeries per year, and have gone on to train other ophthalmologists. The cost of a skills-transfer program, including all equipment and supplies, is usually around US$25,000.

High-volume Remote Cataract Surgery Camps

The Himalayan Cataract Project travels into remote areas where medicine has not yet reached, extending eye care to those who perhaps need it most. In these remote villages where the population is too small to warrant training a doctor, the HCP performs high-volume cataract surgery camps. These camps differ from skills-transfer camps in that the focus is not to train physicians, but to provide eye care to as many people as possible. The goal of these camps is to move patients from total blindness before surgery to having good ambulatory vision on the following day after their eye-patch is removed. Complete vision is typically recovered within one month.

The cost of one sight restoring surgery, including the intraocular lenses, is $12 US, the most cost-effective intervention in all of medicine. The Himalayan Cataract Project teams are able to run remote eye camps for an average of $4,000 USD . Donors such John and Cecily Leach, who donated the HCP cataract camp bus provide a mobile clinic that gets medical teams to remote locations. Since 1994, Tilganga eye camps have examined nearly 150,000 patients and performed 25,000 eye camp cataract surgeries.

These programs also reach to Tibet, China, Bhutan, Sikkim, India, West Bengal, and Pakistan and are also rapidly improving eye care by establishing a sustainable eye care infrastructure. Through performing remote cataract camps, HCP has directly restored sight to tens of thousands of blind people in those regions. But the project’s impact goes much further because the HCP’s focus has been on training indigenous surgeons to perform modern cataract surgery.

Cost-Recovery

All of the Himalayan Cataract Project’s facilities strive to be completely financially self-sustaining through a unique cost-recovery program in which the wealthy patients subsidize the poor patients.

One third of the patients pay the full US$100 for a complete work-up, modern cataract surgery, and all post-operative care.^[3] Twenty percent of the patients pay a smaller amount based on what they are able to pay. The remaining third of the patients receive the cataract surgical care entirely free. With this model, the facilities are able to cover all costs.

Tilganga Institute of Ophthalmology

Tilganga Institute of Ophthalmology (TIOC) is the flagship of the Nepal Eye Program and the current facility was opened in 1994.^[4][5] It is a non profit, community based, non-government organization that is committed to providing eye care services and implementing the Vision 2020 concept of elimination of avoidable blindness. TEC's goal is to act as a model for treatment, research and training, in cooperation with all other eye care centres and organizations in Nepal.

Dr. Sanduk Ruit

Dr. Sanduk Ruit grew up in a remote village in Eastern Nepal. He attended school in India and completed his three-year ophthalmology residency at the prestigious All India Institute of Medical Sciences in Delhi, India. He also completed fellowships in microsurgery in the Netherlands and Australia as well as additional ophthalmic training at the Wilmer Eye Institute of the Johns Hopkins University School of Medicine and the University of Michigan. In 1986 Dr. Ruit met Professor Fred Hollows from Sydney, Australia while Hollows visited Nepal as a World Health Organization consultant. He went on to study with him for 14 months at Sydney’s Prince of Wales Hospital. Hollows was Ruit’s mentor and inspiration in the work that he does. The two men believed in the right of people with treatable blindness to have their sight restored, and that people in developing countries deserved access to the same quality of care and technology as those in the Developed World. They shared an ambitious vision: the elimination of avoidable blindness in the Himalayan region, a process they believed needed to be driven by local people.

When Dr. Ruit returned to Nepal he was instrumental in the formation of the Nepal Eye Program and worked on a large epidemiological survey of blindness in Nepal. He was the first Nepali doctor to perform cataract surgery with intraocular lens implants and pioneered the use of microsurgical extra-capsular cataract extraction with posterior chamber lens implants in remote eye camps. Although other important international organizations sponsored eye camps in the region providing eye care and training local ophthalmologists, the camps established by Dr. Ruit were the first to introduce the use of intraocular lenses in cataract surgery. Put simply, this is the removal of the cataract and insertion of a plastic intraocular lens.^[1]

Dr. Geoffrey Tabin

Dr. Geoffrey Tabin is Professor of Ophthalmology & Visual Sciences and Director of the Division of International Ophthalmology at the John A Moran Eye Center at the University of Utah.^[6] He graduated from Yale University and earned a Masters in Philosophy at Oxford on a Marshall Scholarship. He received his MD from Harvard Medical School in 1985. His background in philosophy and ideas of improving health care delivery came together after a climbing trip to Nepal on which he became the first ophthalmologist to summit Mt. Everest.^[7]

Dr. Tabin and Dr. Ruit vowed to add their own efforts to those of other existing eye care programs, with a goal of overcoming treatable and preventable blindness in the Himalayan region in their lifetime. Dr. Ruit established the Tilganga Eye Centre in 1994 as the first outpatient cataract surgery facility in the Himalayan region. In 1995 Dr. Ruit and Dr. Tabin formally began the Himalayan Cataract Project as a charitable foundation to support their work. From the start, the projects of the Tilganga Eye Centre have been a central focus of the Himalayan Cataract Project.

Dr. Tabin spends at least three months per year in Asia working with his Nepalese counterparts directing Tilganga Eye Centre’s efforts to provide an international standard of eye care and participating in the outreach programs. As the director of the Himalayan Cataract Project, he has over ten years experience administering an international charitable organization. He is a leader in both the local ophthalmologic community and the American Academy of Ophthalmology. Dr. Tabin is also the distinguished recipient of the 2008 Outstanding Humanitarian Service Award ^[8] given by the American Academy of Ophthalmology in recognition of his international humanitarian efforts.

In Print

In June 2013, a new book about HCP's Dr. Tabin and Dr. Ruit will be released by Random House. Written by David Oliver Relin, the co-author of Three Cups of Tea, Second Suns: Two Doctors and Their Amazing Quest to Restore Sight and Save Lives shines a light on the work of Himalayan Cataract Project ophthalmologists Dr. Geoffrey Tabin and Dr. Sanduk Ruit, who have dedicated their lives to restoring sight to blind people in some of the most isolated, impoverished reaches of developing countries in the Himalaya and Sub-Saharan Africa.

In Film

• Light of the Himalaya (2006) is a 9 time Award-winning documentary film by Michael Brown, produced by David D'Angelo in collaboration with Rush HD and The North Face. At the heart the most formidable mountain range on earth lives a gracious people who suffer from the highest rates of cataract blindness on the planet. The North Face athlete team joins eye surgeons from Nepal and America in hopes of making a difference. This film follows the doctors' work on the Himalayan Cataract Project all the way to the summit of a 21,000-foot Himalayan giant.^[9]

Recognition

In the December 2009 issue of National Geographic Adventure magazine the feature story (entitled "The Visionary") featured Tabin and his work with HCP.^[6]

References

• In Nepal, Doctors Cure Blindness Among Poor. National Geographic. 2003. Accessed 2011-6-6.

External links

• Himalayan Cataract Project website
• Himalayan Cataract Project page on Facebook
• Tilganga Institute of Ophthalmology
• Vision2020 The Right to Sight
• Light of the Himalaya at IMDB