A startup I interacted with while writing this book was Forus Health, a venture that took on the task of figuring out a low-cost technology solution to the problem of preventable blindness. It is interesting to review the iterations they underwent in trying to solve the problem in early days. The founders were neither ophthalmologists nor practising doctors, and that is what makes their story interesting.
The largest population of blind people in the world, more than 12 million of the 45 million worldwide, live in India. Most of them reside in the poorer parts of the country, without even basic healthcare facilities. What’s truly tragic is that in nearly 80 per cent of the cases the blindness could have been prevented if the patient had received timely treatment. Preventable or avoidable blindness, is defined as blindness which could be either treated or prevented by known, cost-effective means. According to the WHO, amongst the most common forms of avoidable blindness are cataract (can be cured through a relatively simple operation), glaucoma (treatable, but needs early detection to prevent permanent damage to eyesight), childhood blindness (caused by lack of Vitamin A and poor sanitation), and trachoma (caused through infection and requires surgery).
In 1976, as a post-retirement project at the age of fifty-eight, Dr Govindappa Venkataswamy (or Dr V as he’s popularly known) started Aravind Eye Care in Madurai, Tamil Nadu, with the goal of eradicating avoidable blindness. Today, Aravind Eye Care sees over 1.4 million patients and performs more than 200,000 sight-restoring operations every year. Its network of eye hospitals has collectively performed over 4 million eye surgeries and seen 32 million patients over a period of thirty-six years, majority of them done for cheap or free. It is the most productive eye-care facility in the world. It is also self-sustaining, even though two-third of its services are free.
In a video clip on YouTube titled ‘Infinite Vision’, which narrates the story of Dr V and Aravind Eye Care, some striking statistics were revealed about the impact of blindness in rural India. A blind person, in local parlance, is often referred to as a ‘mouth without hands’. In the video, an old woman, blind in the sunset years of her life, said that she lived on water for days so as not to be a burden on the family. Another man, who used to work in the fields and was the bread-earner of the house, was forced to depend on his daughter and live in utter poverty. Going blind doesn’t just mean losing one’s eyesight, it also means becoming a liability for the family. In rural areas, where savings are non-existent and the family members depend on the daily wages of a single individual, blindness essentially translates to starvation. The life expectancy of a blind person is less than two to three years. Dr V’s goal with Aravind Eye Care was to replicate the franchise model of McDonald’s. He explained in the video:
“The McDonald’s concept is simple. They feel they can train people all over the world, irrespective of different religions, cultures, all those things, to produce a product in the same way and deliver it in the same manner in hundreds of places. Supposing I am able to produce eye-care techniques, methods and make it available in every corner of the world, the problem of blindness is gone.”
Dr Shyam Vasudev and K. Chandrasekhar were working in Philips when they heard about preventable blindness during a talk at Philips by Dr Aravind Srinivasan, Director of Projects at Aravind Eye Care. Dr Shyam, a doctorate in real-time high performance computing systems, had specialized in parallel computer architecture from Indian Institute of Science (IISC) and had worked in a number of reputed firms throughout his career. Chandrasekhar received his master’s in science and technology from the Birla Institute of Technology and Science (BITS) Pilani and had worked in senior management positions in several well-known firms. Both had their roots in technology, but neither had ever thought of pursuing their own venture in healthcare.
During the talk, they were both shocked by the scale of the problem and the fact that some of the most innovative and visionary work in the healthcare domain was taking place near their hometown. They were completely unaware of it. That talk started the duo’s journey into eye-care. Chandrasekhar reminisced to me:
“We immediately went to Madurai. I was interested in going to Madurai anyway because of the Meenakshi temple, good South Indian food, some well-known idli shops. But then we went and spent time in a completely different field, with doctors, patients, an altogether different experience. At that time, we did not have any specific idea on what we wanted to do, but we got Philips interested in the overall problem statement. Nothing eventually came of that, but we became part of a think-tank on managed healthcare. Sometime in early 2009, I started feeling that if we had to live a dream we would have to try it. If I step back today and look at it, it was a stupid idea because I was getting into an area where I had absolutely no expertise or knowledge. Shyam probably had some expertise in healthcare, but I had none. I went into engineering because I didn’t like biology.”
Pursuing startup ambitions when you are in the mid-career stage isn’t easy, especially when you have responsibilities. Chandrasekhar had a son in the ninth grade and a daughter in the fourth grade at that time and there were significant financial considerations to be made. During this process of soul searching, the family went on a trip to the Kedarnath temple. The ups and downs in his career and life until that point had made him reasonably spiritual.
“In your career, you want to grow, you aspire for more, but you have somebody or something blocking your way,” Chandrasekhar said. “When I was sat in the Kedar hills, I asked myself if I was doing the right thing. During that time, I found an overwhelming faith and the belief that I should go ahead.”
After his trip to Kedarnath, he quit his job and decided to start a company. They registered Forus Healthcare on 20 January 2010. Initially, he took up an additional consulting job to earn money on the side, which he believed would serve as angel funding. However, when he started the assignment and remained at it for three-four months, he didn’t enjoy it at all. His co-founder, Dr Shyam, had a similar story; he was then consulting for Philips. However, both agreed that their consulting gigs provided some life support for Forus.
“Maybe it is destiny or sheer passion or a mid-life crisis. You are nearly forty and you don’t know what you’re doing and making blunders. Today I can say that I had a vision, but deep inside, I know what it was – I was completely clueless. The only thing I was very clear about was that we received divine intervention when it was required. And whenever it was required. There were times when I would feel really low. No money or stability. I never had to lie in my life. When suppliers called, I had to tell him I would have to delay payments. Employees had to be paid. I had never had to say no before. It used to make me wonder if had made a mistake. Sometimes, I would say, ‘let’s quit now’. Whenever I would go into that sort of thinking, there was somebody or the other who would call or send an email, saying that were doing something great … that we had guts. Such messages would pump me again and I would think maybe we were doing all right but we are unable to realize it. Then again, something would go wrong and we’d feel depressed. The only thing I have consistently felt was that we wanted to make a difference to the community.”
Chandrasekhar and Dr Shyam started visiting Aravind Eye Care regularly. Dr Aravind encouraged them and invested time in their idea on a regular basis. They narrowed down the biggest challenges of avoidable blindness to five conditions: cataract, uncorrected refractive iris, retinopathy, glaucoma and corneal tear. The other realization was that India only had 12,000 ophthalmologists. Most of these ophthalmologists would end up in metros or Tier II cities, in pursuit of a lucrative career. A rare few would end up in small towns and rural areas. The ones that do have no time to conduct preventive screenings, they would get too busy with day-to-day surgeries and dealing with a constant stream of emergencies.
The final fact was that the devices that were being used for screening were expensive and were designed to remain on hospital premises. So, they started delving into their functional components.
“The five diseases that I talked about require at least three or four pieces of equipment. A frontus camera, a slit lamp, a refractor meter, a non-contactable metre. Typically, they cost between Rs 25–30 lakhs and were designed to be kept in a hospital. If you move it around, it loses its alignment. We also looked at the behavioural challenges. One of the biggest ones turned out to be the fact that you have to dilate the pupil to examine the patient. Once you dilate, the patient can end up spending about three– four hours at the clinic and that alone was a huge barrier in preventive care. If you ask a common man on a daily wage to spend four hours on preventive care, he would rather continue with his existing condition rather than give up his food for the night.”
Chandrasekhar and Dr Shyam realized that if they could address the cost of screening technology, bring it within reach and increase accessibility, they could make a massive impact in preventing blindness. They also figured that if they could catch the disease at an early stage through pre-screening, that would enable a far more efficient screening process for the ophthalmologists.
“We said, let’s create a wish list, wherein we necessitate the availability of an integrated equipment which handles all five problems. Preferably a process where there’s no dilation of the pupil. It should be non-invasive, as we were going to take it to remote places. It should be portable and rugged. Finally, anyone from the community should be able to operate it. From a product design perspective, it must be very simple and easy to use. Why not someone from the local community? The patient would consider diagnosis more seriously if he was told that he had an eye problem by someone he knows, rather than someone visiting from outside. So the goal was to prevent blindness, not to make medical equipment. Medical equipment was a consequence of the gap in the system. We wanted to fill that gap through technology and thereby create a sustainable business.”
Along with the technological challenge that the device presented, they also knew that they would have to make it affordable.
“The people who have affordability, access and awareness is probably 15 per cent in India. Out of the remaining 85 per cent, 30 per cent have eye problems. I remember saying this to one of the investors and he told me politely that you are trying to solve a Bill Gates problem. He said forget all that for now, first make the device and sell it.”
While working on the pre-screening device, they had an epiphany: even if there were 12,000 ophthalmologists, there were more than 600,000 general physicians. Even if they were not eye doctors, they were doctors nevertheless, and hence had the trust of the patient. So, if they could have the doctor as the touchpoint and the final images could be checked by the ophthalmologist, it would lead to far higher number of pre-screenings than was possible otherwise.
“When we built this device, we also added cloud connectivity. If you have an internet connection, the images can be automatically uploaded and reviewed immediately by an ophthalmologist on a mobile phone. We also started on a research project of trying to develop an algorithm that could do a first-level identification of abnormality or defect of the eye. That way, instead of sending hundreds of images to the ophthalmologist, we just send the abnormal ones.”
One of their early ideas for the design of the pre-screening device was to make a head-mounted display. Both Dr Shyam and Chandrasekhar had spent a considerable amount of time in their career delving into electronics and computer science and were aware of the trends in the virtual gaming domain. They thought, with the head-mounted display design, the eyes would be inside the device, and in that darkness, the pupils would naturally dilate. They would simply need to mount high resolution cameras and grab images of the retina. However, when they showed the design to an ophthalmologist from the Aravind Eye Care:
“[…] they asked us why are you doing this. We said, we want to prevent blindness. They said, ‘What is your use case? Your use case is that you will train someone from a remote village to be your technician, he will take your machine put it on the patient, screen, images will stream to the hospital. You are already eliminating a doctor from the scenario and now you are proposing a device which won’t even look like an ophthalmology device. Why would any patient trust the output that comes out of that? It may be a great innovation, exciting. However, there’s no dearth of such innovations, where people use a mobile phone, take retinal images, perform refraction. None of them have seen the light of the day. It’s all very nice to write about in the press, but none of them work on the ground because the end user doesn’t trust the device. The second thing you must consider is the doctor. The doctor needs to make a living, and he cannot charge even ?100 if he uses a mobile-phone camera or headmounted display to take retinal images.’ After this feedback, our design decisions were much clearer. We knew that our product, no matter how innovative, would be completely useless if we couldn’t get it adopted.”
The first version of their product was ready by 2011. However, being a hardware device, every design iteration cost money, and therefore, saw plenty of cash burn. Moreover, their initial version did not work consistently. Transportation caused it to malfunction and they would need to send for someone to repair it. Furthermore, ophthalmologists were used to state-of-the-art equipment and they wanted quality which was comparable. For instance, they would ask for better contrast, or ability to zoom in. However, Aravind Eye Care helped to keep them focused on creating a pre-screening device and not compete at a commercial level against the existing players, who were all targeting the next level.
“Today the product is so sturdy that you can put it on a motorcycle and take it from one slum to another, install it, use it. Also, we keep our early customers reasonably happy by continuously upgrading them free of cost. Our first machine was handed over to Aravind Eye Care on 1 October 2010. It was primitive in design, but since it was Dr Aravind’s birthday, we wanted to make it happen by that date. The first official invoiced purchase was by Dr Col Despande of the Pune Blind Man’s Association in H.B. Desai Hospital. Next was Dr Shambeshwar Rao in Vijaywada. Being a retina surgeon, his purchase was a huge achievement for us. Today, he is our biggest spokesperson and it is only with the support from individuals like him that we have sold more than 500 devices.”
While their initial target market was India, they found that their device was equally relevant in other parts of the world, including Southeast Asia, Latin America, Africa and, surprisingly, even Europe and the US. Dr David Friedman of The John Hopkins Wilmer Eye Institute in the US became one of their supporters when he discovered their work. 3Nethra, as their device is called, has also been installed at places in rural China. Indian hardware is not known to excel in general, but Chandrasekhar and Shyam had managed to create something which was finding users around the world.
To understand the impact that Forus Healthcare is making, one must look at the lives the venture is touching. In one particular incident, an organization was conducting a refraction test camp, where individuals were being screened for refractive errors, and those with it were prescribed glasses. A lady who had been complaining of blurred vision was tested for refraction and prescribed glasses. An advance was collected and she was asked to return in two days to collect her glasses. However, one of the doctors present at the camp felt that she needed further tests, and that her problem might extend beyond the current diagnosis. He convinced her to get checked on the 3Nethra device as well. When they reviewed the image, they immediately discovered a haemorrhage in her eye. If it had gone undetected, the glasses would have fixed her eyesight temporarily, but within three–four months her retina would have been affected and she would have gone blind. After discovering the real problem, they returned her advance for the glasses and asked her to undergo retinal surgery.
“We have seen many cases. Our work has probably touched over a million people so far, saved blindness in at least 100,000 of those cases. So, it feels quite nice. I think what the last four years of struggle has taught us is that we are on the right path. The more we work with the people and the ophthalmologist, the more lives we are going to touch. We are now starting to create innovations that would allow us to reach more number of people.”
Companies like Forus Healthcare are often perceived by many as a ‘social’ enterprise, due to the potential social impact of their products. However, Chandrasekhar has a completely different take on the whole discussion.
“This company has three pillars. The first is innovation. There will be some innovation in everything we do. The second is scalability or ‘investability’. Whatever we do as a company we should be a darling of the investors who have believed in us. And the third pillar is the impact, which we are already creating. We play all three well. We never overplayed innovation or scalability or underplayed impact. Personally, I feel that ten or twenty years from now, every company will seem like a social enterprise, as you cannot move away from the society and do something. You have to have some social impact from what you are doing, and that’s how you reach true scale.”
I also asked him if he ever worries that larger players may end up copying their device, and if he would get affected if that happens.
“We have a paradigm in how we operate: we essentially innovate, implement and impact. Innovation is 30 per cent of the problem. The question that is more critical is how you implement something. Many innovations are better than ours, but they have not seen the light of day. Innovation is glamorous. You get name, fame, you are a scientist, innovator. The implementer is the one who goes to a village, is happy to make do with water from a tap, survive without electricity, or be happy with local food. Very few are interested in doing that. However, unless you do that, innovation has no value. Innovation without deployment, innovation without implementation is not an innovation. When we started with just the idea, in 2009, I remember Dr Aravind used to say that three more guys are trying the frontus camera, you are soon going to have a problem. I used to be scared, as the guys who were doing it were experts in ophthalmology. Ironically, we ended up making this device because we were not experts. And, because they knew the space they never made the product.”
(Excerpted with permission from ‘Flight of the Unicorns: Lessons from India's Startup Bubble’ by Soum Paul and published by HarperCollins India.)