 Well, good morning everyone. Thanks for coming in for on a Monday morning. I think you'll find this is going to be Well worth the time. I'd like to introduce my good friend and Colleague Dr. Bankatesh. He heads the glaucoma section for all of Ereman And he may go into a little bit of detail about how they all decide and get together but he but he also runs the Pana cherry version of Hot which is this hospital right here He'll give you some numbers about how many Do you know the number of patients a little bit today, too? So What we think of is giving care is and I think we do a good job of it, too, but when you talk about teams that are changing the world these It's really hard to beat the Ereman centers and Dr. Bankatesh is unbelievable teacher and As a host who either was no button There's no better place to go than to Pana cherry or any of the Ereman systems would particularly And I'd love to watch a surgery and learn from his skill at multiple different types of of Complex cataracts complex glaucoma cases and Fortunately, we're in the process of working out some Projects that we're going to do because we wouldn't really want to be we want to be their true partners in terms of an academic Set up and actually helpful And so I think you'll be fascinated to see I hope you mentioned something about the Google thing Maybe a little bit about that which is just a fascinating part of what? what the capability of a center like this is and Also for those that don't know Dr. Chamber here is from Nepal Tilganga, and he's part of the glaucoma unit there, and he will be spending three weeks with us and we get to keep Thank you for about two more days. So we're in everything you guys can It's a it's a pleasure being with you all it's been a long-pending visit to Salt Lake But I'm enjoying them since that from Saturday afternoon Alan We've still not figured out going around Alan Allen Crandall's house now, you know I need to make another couple of visits to complete the tour, but it's so so interesting both the city and The kind of warmth nurse which we get from the team here. So This is something which Which is close to our heart, but we didn't know how friendly we are to the environment But we are trying to understand that better and better now So I thought I will share with you because there's a lot of interest from this side also to kind of Be environmental friendly by reducing waste or segregation of waste and things like that So I choose this topic for the presentation In fact, this is the second time I'm doing it. The first one was at Kellogg's grand round so it was specially prepared for this particular session and I have I'm not an expert in environment. No, I'm just an ophthalmologist and glaucoma specialist forced to now Administrate a hospital in Pondicherry for the last seven eight years, but I enjoy the work and now we try to understand how The three P's which the environment experts called no when you are looking at people You're looking at profits to make profits in the form of patients and our customers and It's so important to look at the planet So when you're looking at people and profit, I think planet is so important But we also have to understand that when you look at the planet Profits will automatically come The only thing we'll have to negotiate with our own team their mindset and of course the regulations which you have around us but this this this presentation is just to kind of See overview of what happens at Arvind. So there's a beautiful campus in Pondicherry, which you can see like it's a 25 acre campus and This building is 200,000 square feet and now almost 60% of electricity is generated from the solar panels It's not like the Sun here. No way back in south of India 365 days you'll have some Even in a peak monsoon, there'll be couple of hours of rain and then you'll have some so you you don't need a dryer at home So you can always dry your clothes outside. So we can generate pretty good and you can see the Body feels right behind the campus. So we grow rice wheat and everything there for our own garden, I mean for our own canteen and the the condom where the staff and students stay there running their canteen everything is from Most of the products are there and then you have a beautiful Water recycling plant here one of the biggest in Southeast Asia Decentralized wastewater treatment plant d-wats. So basically it's got Organic inorganic bacteria and it's totally chemical free sewage treatment plant. So that Filters around 300,000 liters of water daily. So 90% of water we use is reused again for gardening and taking care of these Agricultural part of the campus How many of you are aware of this overshoot day here? Like what is the environmental resource we have for that particular year and how much we are what is the period? We exhaust that is called the world overshoot day So environment experts they make this for every year and depending on the previous years experience No, they come up with an overshoot day for each and every country I don't know where India is, but But I'm sure we can see where US is So rest of the months now we are using the resources which is there for for the next years or the next generations So if you take globally, I think it's August 1st 2008 and this over the years No, it's it's it's kind of from Being February to now August So we are depleting all these natural resources to take care of ourselves So this is what now environmental experts are worried about. Why are we getting cyclones? Why are we getting tsunamis unusual rainfalls? Which they say once we've never seen this in the last hundred years in the last hundred and fifty years so we had a one of the worst Cyclone and flood flooding in our neighboring state Kerala a couple of weeks back Almost 200 to 300 people lost their lives Several people lost the livelihood and it was one of the most popular tourist destination in the country God's own country Kerala I don't think they can get tourists for the next two years. It's so badly damaged So that is what is happening across the globe. No every other day. We heard about tsunamis in Indonesia So somewhere all these are related to how we are friendly to the Environmental so these are the SDGs which are going to transform our goals the sustainable Development goals and of which the 11 and 12 are very important now for health care and anybody working in our area sustainable cities and communities Responsible consumption and protection and climate action. So these are some of the important things where we have some control over it If you see this publication in Lancet it says climate change is the biggest global health threat of the 21st century And where is the opportunity for that? I think the opportunity is with us tackling the climate change could be the greatest Global health opportunity of the 21st century Both are on the Lancet front pages so We need to see how we can be Friendly so these are all the WHO guidelines for healthy hospitals a healthy planet and for healthy people So if you if you see number one will be energy efficiency how efficient we are going to be in using energy green building designs now where we can bring in a lot of daylight and Air condition only where it is required alternate energy generation Getting solar windmill and all the other ways of generating Transportation which is very important a lot of times people don't show any interest on this No, how are you getting your customers are patients in China to the system? How are we getting our staff into the system? It's so important when Jeff Dubbin travels all the way from No now When he was here in Salt Lake On the way to Park City, right? Yes When you're coming all the way from there and we have to see how much of carbon footprint we generate No, all these are very important. You're coming five days a week Morning ones evening again. We are going back. So there's a lot of carbon footprint related to transportation food Water and also know how do we conserve? And more importantly, how do we? Kind of work with our waste So the the 3p model which I was just telling you the the social impact Which Arvind was doing over the years of reaching down to each getting the people who cannot be assessed Meeting people who are in the bottom of pyramid. So we were thinking now. We were kind of doing a Social impact, but over the years we found that by doing a social impact. We were able to make profits You know with our 30 to 40% paying patients we were able to sustain 50 to 60 percent of Totally free or steeply subsidized Charges for another group of patients who can't afford services and we were reaching them It's not that the patients were coming inside to a facility We were going and finding them through outreach through vision centers But now we understand that we are also friendly to the environment So so that is where I think sustainable care delivery comes into place This is just to show you an article which was published in 2013 in Journal of Eye Where they calculated the carbon footprint of doing one feco emulsification and We have to extrapolate this to the number of feco emulsification We do across the globe and it can change from developed world to the developing world But again the point to understand is a single feco emits 180 kilogram of carbon equivalent and This equivalent of driving a car 500 kilometers Okay, so that is one feco waste which we generate and Over 50% of these greenhouse gas emission originate from procurement of supplies no you Just open a packet but for the packet to come inside into our system for the packet to be manufactured There's so much of energy efficiency and a lot of things which are being used and Usually the supplies nowadays are largely single use Dispossibles so if you just see this break procurement is 53.8% Building an energy use is 36.1% and Travel would be another 10% So Ophthalmology is one of the real high volume outpatient specialties That's why every institute has got a separate ophthalmic center or an eye center separately I believe you are also running a part of and at the main hospital or the children's hospital But if you go across us now every eye center is a different building. Maybe I over Wilmer Will's I institute because there's so much of people who are coming into the system and most of the procedures are again They care procedures where they come and leave they don't have to stay with us and there's got a high surgical throughput and Cataract surgery is the commonest It's almost 80 or 90% of our procedures are cataract surgeries with high disposable supplies and material components This is just to give you a globally Overview of how many million surgeries we perform 26 million surgeries in 2017 is almost near accurate data and The procedure volume is growing at 3.1% per year So 2018 we'll be doing another 3.1% more than the 26 million because we know the need for cataract is changing From somebody who had cataract now to somebody For a need it's a clear lens extraction for a narrow angle or maybe a clear lens extraction Because just because he walked into a eye facility That's happening. So there was an editorial sometime back in BJO and it writes about cataract surgery in India cataract in India because cataract is a malignant disease If you don't operate it will metastasize to the neighboring clinic So so that's the that's the kind of problem we see in in some of the urban centers and We know most of the procedures are fecal emulsification almost two-third in the globe but the one-third again of Developing what we do more of small incision than fecal This is just to give you an overview of Arvind in South India you can now we are just moving into a little bit into South India with our second tertiary care center which is going to be started somewhere here in Andhra Pradesh the neighboring state Where they speak Telugu and we have all been in a place where they speak Tamil or Tamil Nadu and Pondicherry and We have six tertiary care centers now Six secondary care centers six outpatient centers these outpatient centers are mainly doing follow-up They don't do surgery. They just to follow up, but there is a doctor available to see Post-ops and also glaucoma reviews and DR reviews and we have this 67 primary eye care centers which are already 71 and 72 yesterday We had the 72nd center, but as I'm just showing a data for 67 I just have 67 here and it serves a population of 80 million So this is what happens in a year and for the last few years We are close seeing close to four million outpatients and we are doing close to 500,000 procedures 300,000 cataracts and 178,000 other procedures speciality procedures lasers and injections and if you see almost 51% is paying now and 49% is free and subsidized the paying volume is Gradually increasing even after I started my career in Arvind when I was Resident in 94 it was less than 25% and Now the paying patients is almost 50% it's cross 51 last year for the first time for simple reasons India is developing and the other important reason even the people below poverty line Now are insured by the government of Tamil Nadu and this scheme is very popular scheme and now Our prime minister Narendra Modi has made it a national scheme called Modi care so that people below poverty line although almost 60 million people below poverty line are given 400,000 Indian rupees for four years to take care of Something which is life-saving and ice-saving So many of the people who can't pay for the treatment who are going to our free hospital now have a smart card and Your money is processed by an insurance company and within couple of weeks We are paid as equal to the paying services. So our paying is also increasing So when you take the process in the hospital, I'm sure it's Everywhere, it's the same. No one is the footprint related to access. How are they getting into the facility? So today morning when we drive and we see no terrific traffic now Saturday Sunday, I didn't see anybody on the road today morning. It was every signal Alan had to wait and said two minutes will be there two minutes will be there so there is a Way you have to access the care and then there is a footprint related to Diagnosis and advice. There's a footprint related to treatment and more importantly the footprint related to follow-up care Which is very important sometimes we can treat but some of the chronic diseases need regular follow-ups They have to come back three months six months for visual fields or lasers or whatever be the care so there is a significant footprint in follow-up care and These are all important when we see transport of staff visitors patients even the transport of suppliers How are they getting the goods inside into the system? Procurement of goods and services. How are we using the energy and more importantly? What are we doing with the waste? So when we take what happens at Arvind So the one thing which we have tried always to reduce the carbon footprint in access is we made the access Pretty long time. So the hospital is open from 7 a.m. To 6 p.m. So the registration started at 7 a.m. And closes at 5 30 p.m See even if we have to close the clinic by 6 37 we still do a basic examination and give them a follow-up and For any general Problems it's a non-appointment system Somebody walks in and wants a primary care like in the form of they want glasses or then they have a foreign body Yeah, they have a red eye. It's usually non-appointment system Only review or any procedures would be appointment system And they come back for a follow-up for a visual fields or OCT or they come back for a Incision and curatage or a laser procedure then it's appointment Otherwise, it's usually a non-appointment system and even if somebody fails an appointment walks into it. We still see It's like getting into the class after seven What is the point in saying I can't see you you know, you have missed the appointment He has to again travel back home and he has to travel again for another appointment day So let's see him. So that's how our system works and we do all care primary secondary and tertiary care So this is just to show you the flow of patients in the system from The patients are registered and at every step they are escorted to the next step The next step would be auto refraction and then our optometrist would do a regular manual refraction then their intraocular pressure is checked they There's a kind of opportunistic screening where most of the patients about the age of 40 We do blood pressure and also make sure we assess their blood sugar and then the preliminary examination is done and Dilatation and all the procedures rest of it is done before the final and then the patients are escorted to either pharmacy optical Or if they need surgery to the patient educators or counselors or if they need some specialty care They are escorted to the specialty clinic. So we try to do this all in two hours time in the non-appointment So we have a system to track when the patient is registered Entered into a clinic and from that point we make sure that all the tests whatever you see here is completed in two hours See that's the commitment. We want to give for anybody who walks into the system And how do we know the load? We know the load from our previous five years experience So we have a AI in place or we have a diary Which our patient educators prepare every year where for today? So today is a pre-festival day in in Pondicherry and Tamil Nadu Diwali the previous day tomorrow is Diwali, which is Tuesday morning So we know the expected outpatients is going to be 300 or 400 not the 1200 which we normally get so So we have a plan for that for the whole year. So we know when the holidays are Like your Thanksgiving Christmas, you know when we have quarterly and half early holidays or annual holidays in summer Between April and May we have the maximum load of patients So we know across that week what is our expected outpatient and expected cataract surgery, but not other specialties At least expected cataract. So this allows us to kind of plan ourselves the previous day or for the whole week No, we advise doctors not to take a leave on that week or unless it's an emergency And we request all the team to be available even the non-clinical team to support the clinical team No in helping in registration on escorting and things like that. So several things like that happen Basically again, no to to meet that volume Wherever it is needed So one person does one task and there is an effective utilization of the equipments Either be a Humphrey field analyzer or a OCT or a laser machine. It'll be optimally used Like for example my Humphrey, there are two Humphrey field analyzers in glaucoma clinic in Pondicherry Four in Madurai and more depending on the volume But each machine will be optimally utilized You know, there'll be noted down what time they started a patient What time they finished and then the next time when they started so roughly they can come they normally do 15 visual fields to 20 visual fields with one machine in a day The same for two machines same way any equipment. We know exactly Know how many patients they would normally use and if it is less probably the reason is they were not appointments Or the OP was significantly less on those days So when we talk again about access so we did a lot of outreach over the years where the people had to come to a Kind of a campsite so where our team goes and sets up a clinic and then the patients come to the campsite And they are examined so this camp happens once in three months once in six months in some places even once in a year so people were waiting for Accessing to these eye cams. So there was a lot of delay in treatment and we were not very happy with the way The quality of work up also was an eye cam There are a lot of reasons the crowd in the camp limited time to do examination unavailability of Technology to examine the patient. So so we started the vision centers. I'll just show you what vision tender does So this is a vision center, which is around 40 kilometers from Pondicherry So there are 10 centers with Pondicherry and totally now 72 centers across Tamil Nadu and Pondicherry So basically there are two Staff who are working here. One is a patient educator who takes care of The pharmacy the electronic medical record and the other one is a technician who's trained to do Optometry refraction services and also basic eye examination. So they do basic eye examination They do the blood pressure. Whatever I said in the OP happens here for the patient and and they also Take beautiful images of the funders You know after dilatation or even some cases non-matriatic way also the camera can take and then every patient has got a Personal consultation with a physician who is usually a third-year resident in the base hospital. So like each Doctor will have five centers connected and they will do only that work for that whole month So they'll be posted again. Somebody else would come up and do that job So that this is one way they learn how to manage a clinic also So they do tele-consultation and then the patients are offered most of the 90% of the problems are solved there 10% who need referrals for surgery or some other procedures are referred to the base hospital So so this is one way we reach patient. The other one is the camp and in camp only the catrack patients are transported So if you if you if you if you say a camp where we see normally 300 outpatients There'll be 75 to 100 inpatients who are coming on a weekend. So they will they'll be coming in two buses So you if we didn't do that No, they will be traveling in different modes of travel to reach the hospital. So that would again kind of You know increase the carbon footprint in their axis So we now understand that even by doing outreach and transporting them as a group in big buses We are helping the environment and then after the surgery We are dropping them back at the campsite and then review campus held at the campsite or in the vision center Near as vision center So they don't have to come back to a base hospital for a follow-up after a month or six weeks Or whatever period you want to see them back So we go to the campsite a small team goes and then they examine them there give them classes So these are some of the Centers know where they are located around the tertiary care center This is our own mother right around Tirunelveli around Coimbatore along Pondicherry. So so this pocket is still empty So I was just telling Alan that we're going to start a new hospital in Tanja over by 2020 So which will have vision centers around it and then the whole of Tamil Nadu would be covered So our idea is to have 200 vision centers and we know of all our eye cams and make sure within a Five to ten kilometer radius. They will have a good idea They can they can go to a vision center or a community center or to one of the tertiary care centers So they don't have to go beyond five to ten kilometers. So that's the aim for 2030 so by 2025 we're going to have 150 vision centers and by 2020 we will have 200 centers covering almost the whole Tamil Nadu and Pondicherry So now we are seeing close to a half a million patients in these vision centers. So this is the data for 67 vision centers 17 and 18 almost More than half a million patients. We are seeing through these vision centers So these are people who are living in that same town or same village So they are just going and assessing a care without much of a traveler. So average of about 2000 visits a day So this is again to show you a little bit more on the details. We're giving close to 86,000 glasses or spectacles to these outpatients and the best part is know the the glass acceptance Usually in an outreach, it is only 50% when you go to a camp and give them glasses If you give 100 only 50 of them by the other 50 don't buy But here the acceptance is almost 90% So the the major issues are refractory error and cataract and all the other conditions to follow So if we can do this in a better way, so that is what we are able to achieve through these vision centers And the cataract surgery advised if you see it's only 25,000. This is because Still there are camps happening around the centers So people prefer to go to an eye cap for a surgery in an a vision center For a simple reason is that they are being transported to the base hospital They're being followed up at the campsite So if they come to a vision center and they are referred for a surgery, they have to travel on their own So there is a travel cost. There is an Attender which they have to take and lot of other costs related to food and things like that So still people prefer to go to a camp But I'm sure these numbers will increase once we start weaning of the camps This is just to show you a very recent change which we did to reduce carbon footprint So what happens is in a vision center? The patient chooses a frame and the frame is sent to the central lab in one of the tertiary care centers so there is a two days which is involved in this and also No taking this frame and giving it There was a carbon footprint and there was a cost also involved and then lab fits the lens and then another two days For the glass to be completed and again to reach the vision center. So if you take totally, you know, it was like five plus days For the patient to get again. This was the reason or a barrier for some of the acceptance No, this is when you say four or five days They say no, I'll try somewhere else No, then what we did was we revisited it and we said well now Why don't we go online send the frame details by email? No, whatever you have selected the image of that or the number of that frame is sent by email to the Central lab and the lab fits the lens in this on the same day when you send it It's done on the same day and within a day now it comes back to the vision center. So now from like Four or five days now it's become two days So by this the acceptance went from 70 75 percent to 90 percent now so there are things which keep we constantly revisit and make changes which are Patient friendly and now we understand that it is environmental friendly also. No, so so I think I think that is where we are making more Profits again. So the acceptance when it goes from 75 to 90 percent your profits also go up So this is to show you some other ways of screening so When there is a patient's cannot access for a DR care So now we are putting up cameras in primary health centers which are Related to government and also in diabetic clinics where they don't have facility for Retinal examination because it's so important. We need to take care of the retina in these patients. They just take care Of the diabetism they prescribe medications But normally they come weekly one day to collect the medications in primary health center where it is given free medications are given so we have trained the nurses there and We have this low-cost funder's cameras and these images are Taken and then sent to the reading center and then we are giving Reports immediately to them so that they they they have an additional care now and these patients need not Traver all the way to any eye care facility So when it comes to Diagnosis and advice no, it's the system is designed and it allows All the investigations to be done on the same day if somebody wants a cataract surgery and he walks in today Monday And if he's ready He'll be operated Tuesday unless there is a contraindication Maybe ocular or systemic or he's an anti-platelet or we need some other Cardiologist fitness and things like that if he is a normal patient healthy adult Well-controlled diabetes hypertension Usually if he's prepared the next day is operated He's not shortlisted or he's not given a waiting list or an appointment for a month or two months for a surgery so so if most of the Investigations are done in the same day even if a diabetic You're proliferative retinopathy or a severe non proliferative if he's if he's already prepared No for a flu or zine or a laser or something like that. It's also done on the same day preferably or maybe the The immediate next day if he's ready to wait so there is no waiting period for most of the procedures so on the treatment also we try to complete the care in a day or in the visit like as I said before if he needs Any lasers or injections for vast in or some other loose entities or injections like that even then it is done on the same day and 85 to 90 percent of the spectacles are also delivered on the same day So all the tertiary care centers have state-of-the-art laps Set up by SLR and then they can grind and make sure the glasses are delivered in couple of hours So they give the prescription they take the order they go and have a coffee or a lunch And they come back and they collect the spectacles and leave so that they don't have to travel again back to get the Spectacles and patients who are at waste for surgery are also if they are ready for admission If they are coming from a far-off distance, they get admitted Otherwise they come as daycare the next day So one Area which I touched upon to begin with is again the cataract surgery and the large carbon footprint so High energy consumption a lot of capital equipments and surgical instruments and a lot of disposables used No for each and every surgery and there is a complex waste which is generated and And and also there is a lot of water usage for sterilization and washing and all other aspects which are related to surgery so Just to show you how System which we follow this is this is the patients after no in the morning These are charitable patients So you can see this kind of assembly line and each one will be doing and the task will be shifted to the next area So the eyes are marked clean and then they go to subtenance. So we have trained residents are Senior staff doing the subtenance and after that know the OT store nurse barcodes and then gives the lens To the patient and once the patient is on the table. They are usually guided by the running nurses inside the operating room There will be two running nurses for the single surgeon and two assisting nurses like this So you can see there are two tables the surgeon would move on from one table to the other table By the time he finishes this case the next case would be prepped and ready for surgery So so by this we are able to kind of maximize know the the surgeons productivity in the operating room And also we we try to maintain a very high safety and quality standards. So just to show how By just increasing the number of table and the nurses the productivity of a surgeon goes up See normally when you have one table one nurse assisting and then the patient has to go in come out inside No, even the best of the surgeon would take 45 minutes to an hour. So that is how most of the time It's not the surgeon is not skilled or the system is not efficient, but the way how we do so so here you see By the time you you finish a case then it'll be so orchestrated So know exactly at what step that the next patient will be on table and then it will be prepared The speculum will be applied if it's a small incision they'll put a bridal suture for you and then keep it ready So that you go ahead on the other side and you you start the next case She don't rig out and reglow Yeah So we we use an antiseptic solution on the glove and for every 10th patient we change the glove So that's a standard procedure. We follow So this is Just to show you the productivity of an eye surgeon at Erwin will be close to 2000 surgeries and the national average is less than 400 So the coming back to your question now This is what we do a lot of sharing of supplies minimal use of single-use instruments the use of single-use instruments with very strict sterilization protocols they are fresh sterilized and they come back for use and a lot of time goes into supply chain management and waste segregation and policy of reducing and also Recycling and reusing certain things which can be reused So just to give you an understanding of what a life cycle assessment is when you take a Chocolate like this. No, how do you get the chocolate? No It's so complex no from Feeding a racing cow milking it pasteurizing transporting the milk and then sugar can Cocoa and finally, you know all these come and then there is a manufacturing of chocolate which happens so this is the upstream and then the downstream Now after we eat the chocolate, you know the the paper which it is wrapped goes again For Disposal again all this have to be see where it is going So any any thing like this whether be our cassettes either be our tubings Either be our knives or blades. Whatever we use has got this life cycle And we need to see how much of energy how much of water? How much of transportation is going into all this to reach us and then how much of again energy we're going? Downstream to get rid of all this waste So that's more about the inputs and the outputs Which we see so just to show you what happens in our system The surgery dress and gowns at the end of the session They go for washing drying and then CSSD the the trays and pans at the end of the session again They go for full cycle in between they are all flashed The surgical instruments are all flashed and the end of the day They go for the central sterilization, which is full cycle surgical gloves disposed after eight to ten cases And in between we use an antiseptic made by oral lab, which is chlorhexidine gluconate So you apply that and then you do the surgeries and at the end of ten cases it goes to biomedical waste IV syringes end of every case to biomedical waste and same way any sharps needles and blades end of every case It goes for puncture proof container biomedical waste and cotton swab gauze Whatever use for that particular case goes to again biomedical waste and the plastic drapes packing materials are disposed And then they go for recycle and they are also sold and we make a significant money by Resellings many of these plastic drapes and packing materials and medicine and consumable containers again are disposed I Think this video ran actually, but this is just to show you what happens in the morning So how meticulously plastic and paper is separated at source. No, which is very important So all these are knives and blades know when they come with a cover. So that's that's what she's doing She's collecting all that and then Separating the paper the knives are already removed and it's on the table So what they do is if I'm going to do 20 fecos they will take 20 knives and keep it ready in the morning So these are all the boxes where the knives The your cartridges and all that are stored and that at the end of the day, they'll go into that container So it makes the job very simple for them in segregation of waste at source, which is very very important so this is just to show you the This is in cages actually the weight of the disposables which we are collecting. These are the resaleable waste so the paper waste The polythene the containers which we use big glass bottles Lens covers plastic paper Cardboards which come in packing material. So they all go for sale to the scrap vendor. So we're generating money from this waste because it is properly segregated at source Initially when we are not segregating it properly, we are not able to do this or somebody was segregating in a different place Which can again be a safety hazard. So now we made it a mandatory for the last many years We are doing a segregation at source So that at the end of the day you have something like this and it can be very optimally sold to the scrap vendors There's something which you are familiar of. There's a picture taken in Kellogg, but still I think it's the same here right at one feco case at us and This is 100 plus feco cases at Arvind. This is the end of the day. So this image was also We published this work sometime back on the carbon footprint of an average single feco at Arvind and in UK So so this is the UK study. No, it's showing you 120 plus carbon equivalents and in Arvind It's like running 25 kilometers Do you want to run 500 kilometers or 25 kilometers? We need to revisit a lot of things for that so lower the amount of waste produced, you know, we're trying to reduce and This is what we published in this work on cataract surgery and environmental sustainability It was a very good work done by K. C. Till She was a full bright fellow and I met her in one of the Arvo meetings at Fort Lauderdale and she said She's working on hysterectomy surgeries. I said you're an environmental engineer. What are you doing with hysterectomy? She said my area is waste management. No, I see the amount of waste we generate I said cataract surgery is the maximum done across the world Why don't we work on that and that's how this work started and she came and spent six months with us in Pondicherry and This work was widely covered in US media also In many of the US media saying, you know, how much of waste is generated for one feco surgery and we I would say, you know, we are we carefully reuse a lot of things like Like proff was asking about the glow. We have several publications to reinstate the statement that nowhere it has affected or compromised the safety or The infection or relate tasks or things related to cataract surgery. This is one of the big series We published again from Pondicherry looking at a year performance. No 42,000 surgeries and in the end of the mitis rate was point zero seven and After starting to use the intracameral moxie fluxes in the last three years It has come down to point zero two now from point zero seven, which is like one in twenty thousand So there's a significant reduction in end of the mitis even by reusing many of these Things and disposing it at the end of the day So recycle as I said, no, we are sending it to the scrap for recycling because of very effective segregation of waste and This is very important. No, we were briefly touching yesterday also on this about Repairing or the instrument maintenance how when many of you travel to Africa, you see a lot of beautiful equipments just lying in a corner beautiful microscopes machines feco machines or laser machines just because one IC is gone Or the bulb is not available. So we have a very important department called instrument maintenance department There are very few biomedical engineers, but a lot of technicians trained to repair of talmik equipments so they are there in all the tertiary care hospitals and What they do is they do a lot of preventive maintenance So every Sunday they go around oiling the slit lamps making sure the joystick works perfectly making sure the they the Dust is cleaned on the mirror so that you don't have breakdown maintenance So what happens is once you there is a breakdown your efficiency goes down You know you're wasting a lot of time on that So there is a lot of carbon footprint in getting somebody from Topcon or Zeiss or Alkan to come and fix it But if you can do preventive maintenance in regular intervals I'm sure the people are ready to teach but they will not teach unless we ask them because they are not interested They are ready to change a part But we'll have to make sure that it doesn't go. So some of our slit lamps You know the the first slit lamp we are changing is after 15 years in Pondicherry the Topcon SL1E No, we are we are not in fact condemning So we are trying to remove some parts and use it in some other slit lamps But this is the first time we have purchased four slit lamps after 15 years In Pondicherry to replace four worn out slit lamps And all the Zeiss microscopes are still doing well the the ones we got to begin with are still doing well Same way the FECO machines but FECO machines now because the technology is changing. They are replacing it So they are removing it and then they are replacing it but a lot of other things has got a pretty long life at Aravind because We do a very good instrument maintenance and we train a lot of people in this instrument maintenance from across the globe And finally as though this is a fifth hour. I like is to rethink now So this is a box Where our auto view lens comes So this box is used in the coffee shop To take coffee cups. So if you want to take multiple coffee cups So they use this no, it's like a stand to hold that So after that only it is disposed again to plastic and then it goes for resale So you need to rethink a lot of things How many of you get what this is? Any idea what this is in my box Yes It's the light bulbs from your Zeiss microscopes or what a microscope. So the light bulbs become beautiful flower vases Okay, so housekeeping department hunt for all these things and they make sure before you dispose it you throw it They'll take a look and they'll say okay. I can use this safely then they use it Otherwise, then it goes for dispose the same way even some of the Four shops when they become blunt They are used in the OPD to pick up the wiper or cotton and things like that They're just not thrown away because you can't hold your conjunctiva. It doesn't mean that four shops has been condemned So there's got another role for it to play. So you you reuse and rethink about it till the end of the life cycle So we also promote like this, you know to reduce the resources Lot of follow-up in vision centers This is one thing which we did again very recently in Pondicherry for the last five months We have been doing it and this is a three month data No, we're we never thought about doing this for for a lot of time in the meaning because we were doing daycare And the patients were coming back to the base hospital and one of The patient asked me doctor. Can I can I see in this vision center? I said why? Because I live in the same building I have rented the property for the vision center. I said we've never thought about it. No the nearest vision centers Even they have daycare procedures the people are coming back to the base hospital for review And that started this new system of finding out the nearest vision center So when you enter a town or a village, it'll say that this center is much closer than coming to a base hospital So we have a program now and the patient educators enter the the place of Where the residence is and then it'll say if you go to this center vision center It's much easier than coming to the base hospital the next day morning So now we are encouraging this and interestingly now we see almost 19 percent going to the vision centers This is a three month data where you see 19 percent of them going to vision centers 13 percent going to our city center in Pondicherry and 68 percent are still coming back to the base hospital because that is the nearest point for them And we have made posters like this to encourage patients now For them to engage you know the patient itself. I want them to ask So can I see my review on first day at this vision center? So we have made some posters to engage the patients now So this is what I told you in the beginning see how we bring Patients from our outreach. So this is how they come No in buses around 58 people can come in the bus like this And then they they go back like this And then you go back and review them And this is one interesting point No, which is is there across all are when except in moderate 50 percent of the staff live within the campus No, and we walk to the care building. I mean to the hospital No, we walk like this No not getting into traffic. So there are two Advantages one is reducing the carbon footprint second is you make sure they are in time For work as early as seven o'clock in the over and seven thirty in the opening So just I started this with Some of the other aspects which we do towards environment And this we have been doing for quite some time, especially the the debots plant which we have For wastewater treatment The solar plant which we have installed in all the elements in the last five years now pondicherry got this three years back The garden and vegetation which fortunately for pondicherry I'm not saying that it happens everywhere in urban, but fortunately because we have a Beautiful land and this land was agricultural land. No, we are still doing agriculture there No with the balanced land which is available behind the campus, which you see and When you come to energy efficiency, I think no, I will even today morning I was saying Salt Lake was much better if you go to many of the cities in us All the lights are on right even after they leave the office All the buildings are on all the shop lights are on No, we really don't understand why no, is it for safety or is it for showing how your office is beautiful in the night? No, even sometimes In an arbor my wife was trying to Do shopping and then she went to a art gallery. She was seeing a lot of things then we went for dinner We came back and the light was still on So she thought that stop is still open to get that small necklace or something since you walked inside and it says closed I said here all the lights are on don't worry. We'll we'll see how we switch it off later But but I think it's very important know how we brainstorm our team to be efficient in all this know how our team thinks so back at home only key areas are at condition and Recently in the last four four years again We have changed all our lights to led and very effective utilization of equipments like what you're seeing and preventing a lot of breakdown and even educating our staff and patients about electricity and Usage of electricity how they can minimize it effective instrument and maintain electricity maintenance and also Installation of clean energy like solar. So we're looking at energy efficiency So this is The plant know which gives you a daily calculation of how much of savings so since we did this us of 30th june 2018 the financial savings is 6.2 lakhs This is six months for me in 2018 So i'm saving 6 lakh indian rupees on electricity by having the solar because almost 50 to 60 percent of the Energy which is we conserve. I mean we use is coming from our solar plant So so that is where you can make profits also And regarding food We have these beautiful gardens where we do everything but also we try to Educate our staff, you know our nurses even our patients Like you can see this poster in in our canteen saying, you know Yesterday so many kgs of food was wasted and This can feed 50 people or 60 people Just kind of no kind of brainstorming and the importance of food and wastage And water in addition to the decentralized treatment plant We do a lot of rainwater harvesting and we also try to reduce water consumption by using some Efficient taps and things like that and also waterless toilets But I think the most important part is high level of commitment from our leadership Raising staff awareness and engaging the staff and whatever activities we do either be Recycle or rethinking. No, they should they should understand. What is this frugality in arwin? It's not being stingy It's being friendly to the environment, you know and being efficient in whatever we do And identifying and implementing new opportunities, you know, wherever we get And also we want to take this message forward and that's the idea of making this presentation And with IAPB we had a beautiful workshop in september called eye care delivery and environmental impact where a lot of Ngoi hospitals from india and few other Southeast Asian countries were also there and we this was the message we gave them rethink green be the change solutions for sustainable eye care and We also want to take this forward So it's a systems issue, right? So that's what we see daily In the operating rooms here electricity capital goods disposable single-use materials For off-talmic surgery, you know, there are so many drapes covering the whole body and The every staff has to change the dress and come back. So that is where we are going to travel 500 kilometers for every fecal case So if we can even reduce 50 kilometers in that Or jeff even if you reduce 50 kilometers, I'm still It's possible with all your regulations and Reimbursment processes Thank you. Yeah So I think it's always struck me about aravind is how socially I guess the social responsibility has been such a primary driver and And I recognize how unique that is and then also now to see Environmental responsibility being a core mission a core driving value and and it seems I guess the question for me is How do you create such a strong culture where that becomes the norm for everyone when it's not the norm? And and how do you maintain that? that's a Good question, but a very tricky and a difficult question, but the simple answer is Anybody at arwin is trained at arwin So that's one thing which really you know helps us to take this culture and value along neither be no frugality or There are seven pillars. I'll talk to you about that later for the arwin culture to stay stronger and Continue the legacy The thing is when I come into arwin I didn't come from shankar netrally or lb prasad or some from medical college in bombay. So I joined as a resident Then I was groomed there And now I'm at a certain position Same way emma lopi Comes from school. She does the training and then she continues Same way our fellows from different colleges. They have to do a fellowship at arwin And at the end of two years you decide whether you are suitable for this organization You want to continue or not or else you leave the organization after your training? I'm happy. You did a good residency. You completed your exams Okay, I'll give you a certificate and you can leave There are somebody who I think will Be groomed into this organization. Then I open up an option for him to be a consultant and continue So it happens on either side So that's the positive which we have so everybody comes is trained See that is where we are able to bring efficiency in any procedures. We do also everybody will do the same way If it is small incision, you know, everybody will do with the simcoe with the rexis No with the same indo-german or cosla or whatever But whereas if you see other systems, everyone will say I want this instrument. I want this knife I want this keratome. It doesn't happen there sir That question is part of the general problem Of how you affect disruptive innovations as opposed to sustaining innovations. This is a disruptive innovation and Exactly. It takes a break from ordinary activities. This was wonderful. Thank you so much for this comprehensive view I have two questions. The first is just rhetorical So the first question is will you run to be president of india? And the second question because it sounds to me like you could do an awfully good job for that country The second question has to do with waste Which I want to discuss with you after the meeting Because the waste is one of the ways you protect the planet And I'm wondering if you think we can really protect the planet Or this is just a stopgap measure until we destroy the planet And with regard to waste, I'd like to Just mention that you have not talked about waste associated with medical decision making And the institute of medicine Estimates in the united states and it appears to be true also in canada That somewhere between one third and perhaps a little more than one half of Medical care we deliver is either unnecessary or ineffective. So maybe we could talk about that After but this was just just a wonderful overview. Thank you. Thank you You should uh, uh, you should mention in terms of that the Google Capabilities now. Google has I don't know if you have that slide They can You know about this randy So there's a beautiful picture now which talked about What is statistics and what is activity? It's like your house now Put a nice frame over the switch box Then it becomes artificial intelligence when you say only statistics data No, it's nobody comes to that once you say artificial intelligence People's wrong around it. So while you're getting that I just want to give a A Little different take on the future. I'm not a pessimist. I'm an optimist And I think that what we're going to find is is that a lot of the things we're concerned about now Are are going to transition surprisingly naturally once the breakpoint comes We have the battery storage in which there's already technology out there that can do it In which our our cost per per kilowatt hour storage you know per per kilogram is is Dramatically less than what it is now and and there's already technology to cut that down to a fifth of what it is today And It's just simply much less expensive. I think things can naturally transition just like The Malthusian risk in regards to the number of new people on the earth Which had proposed his drop dramatically Mainly because once people get a little better education and wish things move along the birth rate starts dropping in their large areas of the world where Frankly, their biggest concern is is they're not producing enough babies and and Taking the western world and their populations are going to start drop dramatically the one exception so far Has been africa in that which continues to to not follow that general model, but india has dropped dramatic in birth rate asia has dropped dramatically so These these things tend to come along and one thing to think about is is it just think of yourself as a health officer in new york city in 1895 So what was your single overwhelming concern in 1895? Infection public health no no i'm talking about i'm talking about trying to deal with with with these kind of issues It was horse manure Horse manure was an overwhelming problem the city was growing everybody had to have a set of horses and the the amount of horse manure Was filling in about 10 city blocks about 50 feet high And it was a horrible health issue You know 1895 he knew about infectious diseases the rats and the rest they were talking about how this is impossible in the rest And yet, you know, even though it's created its own problems the rapid uptake of internal combustion engines has completely eliminated that problem in 20 minutes So I just want to be out there. I think that you're going to be surprised At how fast love these changes. There's there's already now ceramic tiles that also function as That have a thin coat could be put on them and are already your solar collectors and solar panels There's things on the outside. I mean that that could become made standard in Relatively short period of time. I think that the the transition will be breathtakingly rapid And we will see and I think you will see the day I might not live to see the day because I'm on old fart, but you younger people I think you'll see the day and what's the idea that you're burning hydrocarbon Energy will seem incredibly Savage and and old an old can't imagine, you know that that was something that was done so A lot needs to change and we could help it by what we do, but I just want people to know that Personally, I think these transitions Could happen relatively relatively rapidly the biggest thing that holds us back now and we can already do a lot In regards to the latest in solar is our storage capacity And You can already get a lithium battery that it increases its overall storage density That's how much it can store per kilogram five fold But then you get rapid temperature changes and those rapid temperature take them because fires But there's new technology that can can overcome that And it's already been proof test in small areas. So I I think this is the kinds of things we need to do I will also point out for us the united states and much of the western world It would require a profound regulatory change and they were close to where you are Yes, but I think you're showing that these things are possible without The marked increase in infections these and others is what will be required, but it's not just ophthalmology For us not to have to change a you know A gown and gloves And and all the rest Between every case would be something I have to change not just for us We have to change you know throughout all all us medicine. That's a huge part of our disposal And the fact that you reuse it Alan I remember days we used to reuse our drapes and the rest which would would be a huge profound saving But but sadly because our labor costs are much more than yours are That makes it much more expensive. So we need we need to figure out ways how That we think about this in a in a smarter way And There are countries already. I mean the the energy utilization and waste utilization Of a country like japan, which is doing in a developed countries doing way way better I mean they're getting along with doing this at about a third of what we're doing in the united states For instance, so those are the kinds of changes and best practices that I think could really make a very dramatic change Yeah That's very nice. I hadn't run that description. I just don't want to leave it on an atmosphere the world I think I think I think these changes are going to be amazingly rapid You know a lot depends upon How wealthy you are I remember uh following world war two living in europe in europe Every light switch turned off automatically in the hallway Every light switch and every air conditioner turned off automatically in a rented room Unless you put the card in that indicated you were there in the united states. You just turned all lights were all That changes and that and and of course that's all that's still the case in your I just got a lot of my time in sweet Our new building in mid valley now closes down when the room's not occupied Excellent the air conditioning and the airflow goes to 10 percent the lights turn off and turn back on so slowly we're getting there So I think a lot of people have to go we're 10 after 8 How are you paying for the new hospital It's all from the revenue generated from the existing hospitals So you're paying with private funds. Yes entirely No no donations no grants for starting new visits Other models have been self-sustaining. That's also So from a single from a single photograph Now google can predict the age of the patient The sex of the patient Whether they're into smoking or not smoking the whole thing is going to happen with apps and other things like that I want to give you a couple of examples today And I want to give you a couple of examples today Health care is one of the most important fields. AI is going to transform Last year we announced a worker con diabetic retinopathy It's a leading cause of blindness and we use deep learning to help doctors diagnose it earlier and we've been running field trials since then at Arvind and Sankara hospitals in India and the field trials are going really well We are bringing expert diagnosis to places where trained doctors are scarce It turned out using the same retinal scans There were things which humans quite didn't know to look for But our AI systems offered more insight Your same eye scan turns out holds information With which we can predict The five year risk of you having an adverse cardiovascular event heart attack or strokes So to me the interesting thing is that in a more than what doctors could find in these eye scans the machine learning systems offered newer insights This could be the basis for a new non-invasive way to detect cardiovascular risk and we are working we just published the research and we are going to be working to bring this to field trials with our partners And I want to give So it's like now you scratch on the surface Yeah So you can know the age the gender The the current smoker hba 1c bmi systolic diastolic blood pressure All from a simple retinal image Thank you