Ophthalmology off the Grid
Episode 46

Going Home for Charity

Gary Wörtz, MD, invites Leela Raju, MD, and her father, VK Raju, MD, to discuss their family's history of charitable contributions in ophthalmology. Dr. VK Raju describes his accomplished career, highlighting his extensive background in charitable work in his home country of India. Dr. Leela Raju shares her perspective of growing up with her father as a mentor in ophthalmology and comments on her own efforts to combat preventable blindness.

Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid. An honest look at controversial topics in the field. I’m Gary Wörtz.

Ophthalmology is unique in many ways, one of which is the tendency of this specialty to run in the family. I’m sure we can all think of at least a few related ophthalmologists. For most of us, ophthalmology is our passion, day in and day out. Unsurprisingly, that devotion can be contagious and sometimes ends up getting passed down from generation to generation.

For Drs. VK and Leela Raju, not only was a love of ophthalmology hereditary, but so was a dedication to public health. I recently sat down with this father-daughter team to learn more about their charitable work with the Eye Foundation of America, their views of various health care systems around the world, and their thoughts on how both parent and child can end up being one another’s mentor. All inside this episode of Off the Grid.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

Gary Wörtz, MD: This is Dr. Gary Wörtz, and welcome back to another episode of Ophthalmology off the Grid. Today, I get to interview a friend and her father, who is a new friend, Dr. Leela Raju and Dr. VK Raju.

Dr. VK Raju originally came to the United States in 1976, but a piece of his heart, I believe, was left in India. Ever since coming to this country, he's made multiple pilgrimages back to India and has done just an amazing amount of charitable work there.

I wanted to catch up with VK and also Leela, who's had the opportunity to follow his footsteps as a cornea specialist herself at NYU, and talk to both of them about the evolution of their charitable contributions in ophthalmology.

That being said, Leela and Dr. VK, thank you both so much for spending some time with me tonight.

Leala Raju, MD: I'm glad to be here. Thank you for inviting us, Gary.

Gary: So, Dr. VK, I'd love to just start with a little bit of background, if you wouldn't mind just giving us a little bit of your story, perhaps talking about your training and your trip over to the United States, coming here, and then how you began coming back to India to start doing some of your charitable work.

VK Raju, MD: After finishing my MD in India, I went actually to England. I did my ophthalmology residency, fellowship, training, and exams and am a Fellow of the Royal College of Surgeons. I was about to go back to India, but it did not happen that way. I was planning to do a fellowship in microbiology or biochemistry. Basic sciences, even today, is my love. Basic sciences and public health—I love them. I was applying for fellowship, and somebody who [received the applications] said, “They’re all filled. Next year, send another application, and next June or July, you will be the first one to get into microbiology fellowship.”

But, 3 months later, I was offered a faculty position in West Virginia for corneal transplants. It was ’76 of December that I came. I was about to leave, to go to Chicago or California, but I didn't leave. I am glad I am in West Virginia, 40 years now.

Gary: So, you came to West Virginia, and you decided that was going to be home.

VK: It became home. I didn't decide. It became home, and, after that, I never looked back. During holiday, after coming here, I was in London. I went on holiday, and a farmer came from the village to show me his eyes. I didn't have any instruments, and I felt like a fish out of water.

After coming to the United States, it will open all kinds of thinking. That's the United States. I did the first eye camp in ‘77. First visit to holiday in India, and then I made 140 trips to India and 25 other countries, including quite a few countries in Africa. Leela also went to Ghana. I did not go. We have a major problem in Ghana, and soon in Vietnam. So, we have two institutes in India.

My mentor in London used to say there are three solutions for any and every problem. First is education, second is education, third is education. I keep learning, and teaching is one of the best ways to learn. So, the foundation is in 25 countries.

Gary: So, this started with a love for public health, coming to the United States and thinking, “I can do more.” I have to say, in my American upbringing and background, I found it quite challenging just to go through medical school and residency and start a practice, and start a family, and all the normal things that we think about being stressful. But you've somehow found a way to do more than just the average person in ophthalmology, which I think we're all overachievers anyways. How did you find time to organize and create these amazing centers for charitable work back in India?

VK: I think, you know, this is momentarily—those frustrations will be there, but as long as you [do what you] want to do. For example, let's say some might sit down and watch football for 6 hours. I feel I don't think I have time for football, but I have time for this. It’s always your interest. My mother always used to say, "When you start a habit, something that you like, you keep on doing the same thing." In Eastern philosophy, the foundation's work is just the beginning.

Gary: So, tell me about your early days and a little bit about the evolution. Leela was telling me about this a little bit before we started the call, how you went over and you started doing the eye camp model, where you would set up and do screenings and do surgeries, and then you'd tear everything down and go. It was a lot of labor just getting everything set up, and it was not as sustainable or as comprehensive as you would like.

She actually mentioned that there were times when there would be mothers with children that you would have to turn away. I know that was super, really hard for you to do that. But tell me about how your model started and then maybe how it has evolved.

VK: Yeah, initially it was a problem, but later other doctors locally—some of them my juniors, some seniors—they were really attracted to it. At that time, we could not get the instrument. The first Ocutome vitrectomy instrument, I took it from there because I was starting to see, in ‘77 and ‘78, pediatric eye problems. At that time, India was still that the socialistic model. Everything is smuggled; you had to bring by smuggling. Customs did not allow anything to come in from other countries.

At first, I took that Ocutome vitrectomy instrument. Things have changed in India to now, you can take such instruments. Last year, I took two portable lasers. India has changed in the last 18 years incredibly. I always feel Indian ophthalmology and Academy of Ophthalmology really work together. They're doing some together, but really well, we can bring the world without childhood blindness. That is the dream of the Eye Foundation of America: a world without childhood blindness.

Gary: It sounds like that's a major passion for you. Leela, give me a little bit. I know you've been involved in this for quite some time. You're taking trips yearly. Give me a little bit of your perspective growing up in a household where your father's an ophthalmologist, but also you see his passion. That passion has to be contagious a little bit. Tell me about what it was like growing up, first of all with a father who was an ophthalmologist and then secondly, getting to participate in his passion projects.

Leela: I mean, I'm very lucky that I think I had a built-in mentor for so long, even from the beginning. My joke is that the brainwashing was complete as a child because not only did I go into ophthalmology, I also became a cornea specialist on top of that. But I think that when you asked about how you figure out your time, how do you use your time when you want to do something like this, I think that probably the most important thing that was instilled is that it becomes part of your vacation. Every time we went, we were lucky enough to still have a lot of family in India, and we'd see them. But I would also know that dad was going to the hospital or that we were going to do some sort of eye camp. It was always mixed in.

I think that in ophthalmology in general, for better or for worse, our work really feeds into everything we do. Even our non-work interests sometimes have to do with ophthalmology because we enjoy the overall, either the mental aspect of it or, like you, creating a whole company because you were interested in what else you could do in ophthalmology. Or, someone like my dad, who decided, well, I'm going to do international work as the other part of my life that will allow me to give back.

So, I was always lucky. I got to watch surgery from a very young age either here or in India and understand what the differences are in the health care systems. Even now, I tell residents that go or anybody else that's interested in getting started in international work, I think it's a wonderful gut check for us in the US because we tend to get so wrapped up in all of the paperwork details we have, or the new rules, or the new expectations based on EMR. You sometimes feel like maybe you lost a certain part of that practicing medicine that we all hopefully went in to ophthalmology for.

Then, I go there and I get to see these people that, or patients that, if I wasn't there to be able to do it, or we didn't have somebody there to be able to see them, then they may be going a long time, years maybe even in some cases, without getting care. You go there and you see that, and you're like, “Great. I feel like this is the impact that I really want to make.” But then you also understand maybe the restrictions of what you're doing for some people there.

Gary: Right.

Leela: People travel 3 days or 2 days to come seek care. Then I come back [to the US], and I appreciate everything we have here. It's just a wonderful balance for me. I think it reminds me wherever I go that there is wonderful things in both places, and you can learn from both systems or learn from both instances because it helps you balance how you're seeing your day to day.

Gary: Sounds like it's, and no pun intended, a very focusing endeavor, where your big why of why you became an ophthalmologist becomes very clear when you're in those moments, taking care of those patients that would otherwise perhaps not seek care. Leela, when did you decide you wanted to be an ophthalmologist. Was that just from the beginning? Did you ever question it? Tell me about that.

Leela: No. My dad can correct me if I'm wrong, but I believe I told him when I was 5.

Gary: Really?

Leela: Yeah. He said, "Well you don't have to be an ophthalmologist. You can, if you wanna be a doctor, you can do anything." I told him, "No. I'm going to be an ophthalmologist." I'm not sure I even said it properly at that point, but that's okay. But yeah, I think the goal was there for a very long time.

VK: Gary, let me comment about when she said I am her mentor. She became a mentor in many ways afterward. Now, I think she's a mentor to me, too.

Leela: Thanks, dad.

Gary: I think it's very interesting how ophthalmology tends to run in families. We have so many mutual friends, Leela, for whom it's a dominant trait. I've heard it said that your children have a 50% chance of becoming an ophthalmologist if one of their parents are. So, the dominant gene was clearly affected there.

Leela, you mentioned something, and VK, you're welcome to, I'd like to get both of your takes on this. It's very obvious that the American system is riddled with difficulty with regard to paperwork and regulations and spending a lot of time clicking boxes and checking boxes, and making sure that we're doing all the elements in the history, etc., for a level-four exam. I can go on and on. Then on the flip side of the coin, you have people where there's such an overwhelming demand for services, where you're really not even able to keep up with the demand in India, where it's sort of the exact opposite problem.

Talk to me a little bit about the two different, I don't even want to say “systems,” but I guess, in a way, they're systems, but they're more environments to practice in. Give me a little bit of your feelings on each. Maybe what you've learned from one system to apply to the other.

Leela: We are very lucky in this country to, while we don't have universal health care, in our expectation of it. I think what still we have to remember is you can go in to any emergency room and you will be treated. They cannot tell you no.

My most recent trip to a new country was to Ghana. I remember seeing one of the patients with one of my friends who does oculoplastics. They essentially told her, we can't do anything, or nothing can be done. While we still may have to say that, I think everywhere here and the perception and the reality is that you can go in somewhere and someone will try. And then what I'm talking about, if we're getting into public health, we're even talking about people who are going to lose the eye. We will try to save the eye. You will go to surgery. You know, they will try to do something. That's not the case there still.

In many developing countries, either they just physically can't get there to that hospital or, by the time they get there, maybe there was something that could have been saved beforehand, and it wasn't done. While I know we get frustrated with all the stuff we have to do here, it's also been born out of a system that's allowed us to treat more people.

Gary: Right.

Leela: And when that happened, I think that costs go up with that. Do I think the United States, after seeing other systems, has swung? That the pendulum has swung? Yes. We went from, I mean my dad can speak to this a little bit more, but he tells me stories of when he first came and how much was being reimbursed for cataract surgery versus where it is now. We almost did so well that they said, “Well, it can't be that hard,” when we know that it can be. You can very quickly get into trouble with cataract surgery. It's a very different scenario.

Gary: There's no limit to how punishing and unforgiving the eye can be, as we all can attest to. That's very true.

Leela: Absolutely. While the systems teach me to be appreciative of the quality controls we have here, unfortunately you still do hear of stories where people have gone into developing countries and gone to more rural areas and, because the follow-up wasn't there or because whatever they brought in may not have been the kind of equipment that we'd hoped for, that you have cases of endophthalmitis that, for all the cases done that day, developed.

Gary: Oh wow.

Leela: You want to be able to say that, “I want to give a quality of care that is not expensive for everyone.” I mean the Holy Grail of public health would be that or any kind of care that we can give. But there's always got to be a balance. I think perhaps, in the United States right now, we've tipped to the other side because there's an assumption that we don't need to be doing what we're doing.

I don't agree with that because I think, for the quality we would all hope and expect for our own family, we do need expectations that are realistic and hopeful. Because we'd all want the best we can, but someone else determining what the cost of that should or should not be has got to be a conversation that maybe more people are involved with—maybe more on the medical side need to be involved than maybe they are right now.

I wish I had a solution that could be, like I said, I think I would consider it the Holy Grail. But understanding the quality of care that we have …

Gary: It comes at a cost, it seems.

Leela: Yes.

Gary: If I'm summing up what you're saying, we have the quality because of the regulations. If we didn't have the regulations, there may be a temptation to have a lapse in quality. I get what you're going after there.

Leela: We also go to this point because we increased public health to the point where we were at a baseline level.

Gary: Right.

Leela: There is just such a big difference, a dichotomy in other countries, where that public health didn't bring everybody up to one level. You're just starting from totally different aspects.

Gary: VK, I'd like to get your perspective on this as well. You've clearly seen a number of systems from London, to the US and then you've been all throughout the world. What are your feelings about what Leela's saying, about the pros and cons of regulation and quality versus being able to just do your job without constantly looking over your shoulder and making sure you've checked all the boxes, just for the sake of satisfying the regulators?

VK: Absolutely. No, no, the United States really taught quality control to the rest of the world. No question. Because I practice in ophthalmology in England and I go frequently to England, but if I had to simplify it in a couple of words: expectations. In the United States, people's expectations are different from in other countries. In Britain, by our standards, we think that's not good care, but a lot of people think, "Oh, my doctor's done very good care." But the same care, most of the people think is not good care. The expectations are the biggest here, number one.

Gary: Let me add a question about that, VK. Do you mean, for example, cataract surgery with residual astigmatism or cataract surgery where you're off by a few diopters in the refractive results. What do you mean by “the expectations.” They're maybe a little bit easier to please in Great Britain?

VK: In other countries, too. Absolutely. Even in Canada. But here, [patients] hear so much in the newspapers. Take premium lenses. If you don't have a multifocal lens, some of my patients make some comments, not all, but some say, "Why am I not getting that [lens]? Why is Medicare not giving [me] that one?"

That's how people expect in this country, which is good for progress. I am not questioning that. But we are going too far. The 15th century philosophers said, "The dose makes the poison." In the ancient medical system of India, it is [about] balance. I think, overall, we don't have that kind of balance, and everything is exaggerated in such a way. But, in England, for example, the primary care and everything is excellent. A lot of people are very satisfied with that plan. And if a cancer drug is not available, or something a little rarer disease, if they are not exposed to them, [there] may be a little bit [of] news in the newspapers. But, by and large, people very happily accept it.

This is a very young country, only 200 years old, and we gave, during that time, incredible things to the rest of the world. It is not like society said, "Ah, I'm happy. I'm satisfied." That's not an average character in the United States because it is a very young country. One lady, when I was leaving England, she said, "The United States is the greatest country, wonderful country, but it is still terrible too."

Gary: Interesting. So, you feel like you notice an American spirit of always wanting a little bit more, a little bit better, and always a little dissatisfied?

VK: Exactly. Now, one, it is balanced well. I think that's the most important. When the intraocular implant came in, they're all fighting, and you know the history. In ‘47, the first implant was done. Until 1960, they're all fighting. The British and European surgeons, they used to remove the lens and give lectures on how the intraocular implant should never be done. It went on 15, 13, 14 years ago, why? They questioned the idea. The United States never questions the idea. They question why we are failing. How can make it better? If we lose that character, we'll become like any other country.

Gary: That is really interesting. Not to get too political, but it's very interesting to hear that perspective right now. I think America is trying to find its way and find our place in the world and how we continue to be great or to become great, we could argue. But thank you for that perspective. I really appreciate that.

I wanna talk to you a little bit, VK, about how you provide high-quality care and keep the costs under control in your international model. I would assume, as someone who is passionate about public health, that's sort of the Holy Grail of trying to find high quality but also low cost and accessibility. How have you been able to balance that equation in your clinics or hospitals?

VK: It can be done. India can be a very good model for something of that nature. But, if we constantly worry about legal or lawyers, we cannot do that. In general, they don't worry about everything. They'll do some informed consent on this. Some of the common sense, some of those things are unacceptable in this country. You take a bottle of topical anesthesia in the operating room; it has almost like one cc, two cc's maybe. The director surgeon puts a couple of drops, maybe two, three, four drops, and the entire bottle is thrown out.

If he uses some antibiotic, one bottle, and the surgery center, even in this country, we don't do it because the surgery center is not governed by the same regulations as hospital. Those regulations went too far, and they all individually agree. Collectively still to do that, throw things out. Do know how much I collect from my surgery center—the Weck cells? Unbelievable. Weck cells in Africa, we are trying to send to Afghanistan. A Weck cell is a pot of gold in Afghanistan.

Gary: Wow.

Leela: A lot of these we can sterilize using a process that keeps them from becoming wet or anything like that. But I would want to add to that, the other thing that we maybe don't focus on as much, partially because we already have that bar set for us here already, is what I'd like to call preventative ophthalmology—making sure that all the kids that need glasses get glasses, that you avoid amblyopia, and therefore avoid need for strabismus surgery.

We can always be better about screening. But diabetic screenings are always an issue. India specifically tends to have some very bad diabetic retinopathy in very young people because of the phenotype of the diabetes. Being able to skip to them and screen them earlier, to help avoid them going to the point where you have a 42-year-old walking in with bilateral tractional retinal detachments.

Gary: Right. Wow, that's tragic.

Leela: So, that kind of stuff. I think that's the part where we're still working in a developing country versus the United States because it goes back to what I was saying is that we've managed to get people, we all see people that we know didn't look for care or receive care as early as we would have liked them to have had it there.

But there, I think, you often need to go to patients. We have a screening program where we actually are helping teach teachers how to look for certain eye problems. So that even if we're not in there every year or more frequently doing school screenings, if the teacher notices the kid squinting or one eye turning in, then they can let us know and then we can get the kid, the student, the appropriate care. But that kind of stuff is, I think, where you really get more bang for your buck, when you're talking about doing something that has great efficacy and maybe doesn't cost as much.

Gary: Yeah, an ounce of prevention is worth a pound of cure. I think that's very, very true.

VK: Since you said that, just gave a talk in a diabetic meeting today. We need pounds of prevention.

Gary: Yes, yeah. That's right. We do need pounds of prevention. You're exactly right.

VK, as we wrap up here, I want to ask how can we help, as a community of ophthalmologists who deeply care about not only our profession, but about our world and patients who don't have access. How can we help either financially or with education or perhaps with participating in a mission trip. What's the best way for people to get involved?

VK: Yeah. I think LASIK, that kind of refractive surgery is a wonderful thing. I did it on my son. I believe in refractive surgery so much. But, from the beginning, it always bothered because I spent too much time in Kenya and Malawi in the very formative years. My first the trip in Kenya I went in ‘81. The International Ophthalmology someone knew and they actually surprised that they invited me and I went out.

It was a marvelous feeling. I did not know so much about things internationally during that time. I kept on giving the LASIK surgery, I never charged. Any of the multifocal lenses, the patient gives a check to the foundation, and we can get some write-off. Each time I did a LASIK surgery, 40 children somewhere got glasses because the second most common visual problem is children not getting glasses, lack of spectacles.

Gary: Wow.

VK: So, still that continues. Each surgeon, once in a year leaves one of his LASIK go to the Eye Foundation of America. If they do it reasonably, I'm going to fund from my retirement plan and match it.

Gary: Wow. So, you're going match the donations that the ophthalmologists give to the Eye Foundation of America?

VK: Secondly, 15% of the time, just at least once in a year, just make a trip, come with us. You help yourself when helping somebody. You're not going to change the entire world unless there is public policy. They always say, long ago some Australian sociologist said 40 years ago, “Anything to change really drastic in this world, we need political will, professional will, and people's will." Even people's will is also important.

We just keep on doing certain things, like certain organizations like the Rotary, they got involved. I'm a Rotary member for the last so many years. No more polio because Rotary worked with them. Ten major organizations, major governments of all the countries—after 28 years of work, no more polio.

Leela: And then, we're hoping that they'll also be interested in doing MMR vaccinations next maybe, because once again, we can help stop some pediatric cataracts, because most other countries don't vaccinate. So, there's still cases of Rubella and …

VK: Yeah, since Gary you said how we can. She brought up about MMR. The phenotype, diabetic young people becoming blind, some other countries. The real experts in this country, the topnotch guys over there, they're too busy to get involved in something like Eye Foundation of America. If they can, we'll get an avenue for them to everything. If they can get the best type of advice, I think we can really get that to people, the Holy Grail.

Gary: Right.

VK: You know, coming from somebody who spent all their life in it, daily wise, you keep on doing something. Yeah, we did some and it makes the news, but it did not have much effect at all. If we can reach the guy who is tremendously and knowledgeable and topnotch guy, he could advise the foundation. People like you can bring that kind of thing to the foundation.

Gary: Well, VK and Leela, I just want to say thank you sincerely for, VK, not only your leadership, but Leela, also for your participation in this. It's sort of like throwing a stone in a pond; you get to see the ripple effect of one small act not only on one patient at a time, but on a community and on a nation and eventually on the world.

So, from the bottom of my heart, thank you, VK, for starting this and, Leela, for carrying with it. I would just like anyone who's listening, I assume they can go to the Eye Foundation of America's website to find out more information. Is that correct?

Leela: Absolutely.

VK: What people do in this country. This isn't like in India, more Gary's will do things like that, connect. Honestly everything that's happening will have an incredible effect in India too because, in India, there are more ophthalmologists in India than the United States now that is a bigger organization today. But what you do is equally important, Gary, and I mean that from the depth of my heart. What you do, connecting people and all that, it is equally important.

Gary: Well, I really appreciate that. VK and Leela, thanks again so much for coming on and sharing a little bit of your story. We would love to try to figure out ways we can connect people. Perhaps we can go over and do a trip together someday. I think that'd be fantastic.

Leela: Okay, great, Gary. Thank you so much for inviting us.

VK: Absolutely.

Gary: As parents, we hope that our children find their passion—something that challenges their thinking, motivates them to grow, and inspires them to improve themselves and the world around them. In some instances, we get to share that passion.

Drs. VK and Leela Raju have a mutual dedication to taking their knowledge of ophthalmology at home and abroad and sharing it for the greater good. Their calling runs in the family but is inspiring to everyone around them as well. So, again, I’d like to thank Drs. VK and Leela Raju for the excellent work they have been doing and for taking the time to chat with us today.

Once again, this has been Ophthalmology off the Grid with Dr. Gary Wörtz. Catch you next time.

Speaker 2: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.

3/14/2018 | 35:45

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