Sanduk Ruit is the third Nepali to receive the Magsaysay award. He was recognised for his outstanding work at "placing Nepal in the forefront of developing safe, effective and economic procedures for cataract surgery, enabling the needlessly blind in even the poorest countries to see again". He speaks to Rajesh Ghimire
Congratulations for the Magsaysay award. How do you feel?
I am delighted and feel great to be honoured with such a prestigious award.
What led you to research on cataract?
I finished my post-graduation in ophthalmology from the All India Institute of Medical Sciences (aiims), New Delhi, in 1984. Cataract was a major cause of blindness in this part of the world, then. It required surgery, which was very often done without microscopic aids. This created a lot of complication, most patients developed long-sightedness and they had to move about with thick glasses. But I found that many cataract patients in Nepal had given up on these visual aids. Most found it difficult to coordinate their movements with these aids, many could not tolerate the magnifications offered by the lenses.
So, we were virtually leaving the patients functionally blind, after surgery. That's when I decided to work on micro-surgical procedure of cataract surgery with intra-ocular lenses.
What were the main problems you faced?
If you are inserting something in your eye it has to be of extremely good quality. But an intra-ocular lens of extremely good quality used to cost around us $100 when we started our work. Most people in this region could not afford that much.
The second challenge was to reduce costs of modern cataract surgery without compromising quality. The third was to find out more low-cost but good quality equipment.
What exactly is the intra-ocular lens technology?
Intra-ocular lenses are small plastic lenses that are fitted into the eyes after the cataract is removed by a minor surgery. This operation is suture-less, cheap and most importantly, very safe.
How and why did you start Tilganga Eye Care Center?
We needed to have in place an organisation that had some flexibility in management. We also wanted to avoid bureaucratic hurdles characteristic of government institutes. That was the real motivation behind starting Tilganga Eye Care Center in Kathmandu.
Here we have modern training facilities, and also develop low-cost and high -quality techniques. We have addressed the requirement of producing very high quality intra-ocular lenses at very low costs. The lenses that once cost around us $100 are now available at just us $4. This massive price reduction has made modern cataract treatment affordable to poor communities.
Moreover, we have also started conducting research on basic equipment. Among the instruments that have been developed here is a surgical microscope. This normally cost about us $30,000. But we researched on this surgical aid and made available our studies to manufacturers. Our research bought the cost of some of portable microscopes down to around us $ 4,000-5,000.
But did you manage to avoid bureaucratic hurdles completely?
If you try to start a new venture, you are very likely to disturb those established in that trade. And, some may even try to vandalise your establishment. That's precisely what happened to Tilganga Eye Care Centre.
Is your venture commercially viable?
We export intra-ocular lenses and that is one indicator that we are commercially viable. But more importantly we are trendsetters. Tilganga Eye Care Centre is iso 9000, certified. We produce the lenses at a minimum price. So there is no room for profit. But, our main aim is to develop newer technologies and offer them to poor communities.
How do you manage human resources?
On the hospital side we have a core group of surgeons who share the Centre's vision. We are very particular about recruiting people; we never ever pay heed to bureaucratic, political and any other pressures. This is a major cause of our success and productivity.
Development of intra-ocular lens requires lot of effort because it is a totally new concept and technology. So with the friends from the Fred Hollows Foundation in Australia, we did some initial work on the older version of intra-ocular lens. But that did not work out properly.
We were undeterred, however. The same team went on to develop the new technology. It took us nearly two years: 1994 to 1996. After that we worked on building a team of Nepali scientists and that team is working smoothly, today. We also train other doctors from Nepal and abroad; Tilganga Eye Care Cente has already trained hundreds of doctors from various countries including Bangladesh and Tibet.
How did you manage financial resources?
The intra-ocular lens gave us the turnkey for financial support from the Fred Hollows Foundation. And for the centre, the Pashupati Development Trust, Kathmandu, donated the land; for the building we got donations from lots of organisations and local people. Another small community programme in Australia, the Nepal Eye Programme, provided the running cost for a year. Now we do not get any financial support for our institute: it's self-sustaining.
"After our research, intra-ocular lenses that once cost US $100 come for US $4. We don't profit much. Making profit is not our main aim"
Yes, they have shown tremendous interest and we have been very often lured by financial organisations. For example when we were in China, we knew that we were watched by a prominent Chinese millionaire based in Singapore. When we returned from the camp, he visited our centre three times. His idea was to take the team from our centre to a Chinese province and open centres where patients would be charged. We were offered money. We can understand business interests; they see lots of money in what we are doing. But our idea is different. We want to work with local technological partners and doctors, train them, get some international resources, provide our partners equipment and ensure that they can carry on locally.
What differences have you seen in the health-care systems of the countries you have worked in?
In countries like North Korea and Bhutan, which have very 'very strong' government, the idea of public heath-care system is people-centric. Health care is free here. Very often when you make the health-care system free, it lacks competition and there are chances that the quality might come down.
In my view, an effective pricing system works in the long run and is also effective, even in the poorer regions of the world. It does need some subsidy though. If we want to give quality health to the poor in our region, we should have strong paramedical forces and the health-care system should have autonomy. Financial autonomy is critical. If health-care institutes get such autonomy, they will generate income and will distribute it well. Our health care system needs quality and that is the most important thing.
But the problem with governments of this region is they do not want to give autonomy and the doctors do not want to go to the remote areas. So?
I think governments have to understand very clearly that they cannot force the doctors to work in remote parts of the country. If you force them they will not work well. Such measures have to be implemented in other ways: that means creating congenial situations for doctors to work in remote areas.
Is that possible?
I have a plan; I will start working on that after two years. The plan is to begin work in a remote district of Nepal and make it a model. This will enable us to have communities and the media on our side. That is the best way to pressure the government. Unless you show them that things are working well, the government is not likely to give you any autonomy.
You were educated in India; did you get any reaction from your Indian friends after receiving the Magsaysay award?
Yes. A few friends from King George Medical College, Lucknow, and aiims, N ew D elhi, sent me long, congratulatory e-mails after I received the Magsaysay Award.
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