How assembly line techniques brought eye surgery to the poor

People in Nepal often call Dr. Sanduk Ruit the “God of Sight”, because he has restored vision to thousands of people whose sight was gradually disappearing due to cataracts, which are common due to the country’s high altitudes. He has performed more than 130,000 operations, both in his centre in Kathmandu and in remote villages all over Nepal.

The poor pay nothing; wealthier people pay $100, which is still much less than such surgery costs in the ‘developed’ world. It reflects his philosophy of service – one that is shared with other equally innovative and inspiring programs that help protect and restore sight for people regardless of their income status. 

Kathmandu – Photo by Rohan Reddy on Unsplash

“It is important that the people do receive equitable service and not that haves receive and have nots don’t receive it,” he told the Associated Press recently. He has formed a foundation with British philanthropist Tej Kohli and aims to scale its work up globally where it’s needed, with the goal of carrying out 500,000 surgeries over the next five years. 

It is not a surprise that this is happening in Nepal, or that Dr. Ruit is associated with it. His work has been truly revolutionary, and his innovations have saved the sight of many people who probably have never heard his name. In 2006, when he was awarded the prestigious Ramon Magsaysay Award, the citation noted that he had placed Nepal “at the forefront of developing safe, effective, and economical procedures for cataract surgery, enabling the needlessly blind in even the poorest countries to see again.”

This goes back to 1986, when Dr. Ruit worked with the noted Australian eye surgeon Fred Hollows to develop a strategy for using inexpensive lenses in order to bring revolutionary small-incision cataract surgery to the developing world.

The two doctors founded the Tilganga Institute of Ophthalmology in Kathmandu in 1994. But, finding that available lenses were still too expensive for many patients, they raised the funds to start the world’s first low-cost intraocular lens factory in Kathmandu. This made it possible to produce the new lens much more cheaply than any lens then available in the world – $4 vs $200. (The lens is now used in more than 60 countries.)

The global magnitude of this development is hard to fully appreciate. 

In 2018, the Government of India awarded him its fourth highest civilian award, the Padma Shri, for “[his] innovation in the 1980s [that] led to a 90 percent reduction in the cost of cataract eye surgery, provides low-cost cataract surgery lenses to over thirty countries.”

Dr. Geoff Tabin, who co-founded the Himalayan Cataract Project with Dr. Ruit, describes it this way:

“Dr. Ruit had already developed a system with eye care delivery in which the quality, sterility, and infection rates were the same as we have in the best centers in the West. But when Dr. Ruit returned to Nepal, the least expensive lens implant on the world market was $200. That’s more than the average yearly income of a Nepali citizen. ….. Dr. Ruit developed a technique of doing the same quality eye surgery that I do for $3,000 in the United States, without the expensive machines, using locally manufactured material, for $20.”

“With this system, a single doctor in Nepal can provide more than 100 sight-restoring cataract surgeries in a day,” he explained.

The Himalayan Cataract Projects works in six other countries apart from Nepal – Bhutan, Ethiopia, Ghana, India, Myanmar, and Rwanda – with the goal of eradicating as much unnecessary blindness as possible, even in areas that don’t have electricity or clean water and where people are living in poverty.

The philosophy espoused by Dr. Ruit is the same as the philosophy held by the founder of India’s amazing Aravind Eye Hospitals. Dr. Venkataswamy, an ophthalmic surgeon who founded the original Aravind Eye Hospital with 20 beds in 1976, had built it to 1,400 beds, one of the biggest of its kind in the world. But by the time in 1992, when a Harvard professor came to visit, the 74-year-old surgeon was thinking even bigger.

And so he asked the Harvard professor, V. Kasturi Rangan, a question that might seem unusual: “Tell me, can cataract surgery be marketed like hamburgers? Don’t you call it social marketing or something? See, in America, McDonald’s and Dunkin’ Donuts and Pizza Hut have all mastered the art of mass marketing. We have to do something like that to clear the backlog of 20 million blind eyes in India. We perform only one million cataract surgeries a year. 

“At this rate we cannot catch up. Modern communications through satellites is reaching every nook and corner of the globe. Even an old man like me from a small village in India knows of Michael Jackson and Magic Johnson. Why can’t we bring eyesight to the masses of poor people in India. Asia, Africa and all over the world? I would like to do that in my lifetime. How do you think we should do it?”

Like Dr. Ruit, Dr. V. (as he was most often known) had been born in a small village, and had recovered from severe rheumatoid arthritis to become an ophthalmic surgeon. He retired as head of the Ophthalmology Department at the Government Madurai Medical College in 1976, freeing him to fulfil a long-cherished dream – the creation of a private, nonprofit eye hospital that would provide quality eye care. He named the hospital after an Indian philosopher and saint, Sri Aurobindo.

“When I go to the meditation room at the hospital every morning, I ask God that I be a better tool, a receptacle for the divine force. We can all serve humanity in our normal professional lives by being more generous and less selfish in what we do. You don’t have to be a “religious” person to serve God. You serve God by serving humanity.”

From the beginning, Aravind developed a model for large-scale surgery with treatment being free or heavily subsidized for the poor, with their costs cross-subsidized by the paying patients. Aravind established an outreach program in which its doctors did eye surgery free while cooperating organizations looked after the costs of establishing the camp and patients’ transportation and rehabilitation. All of this made it possible for Aravind to carry out five times the number of cataract surgeries being done in all of India, and possibly 16 times more than that of the entire U.S.

Like Dr. Ruit’s cataract surgery practice in Nepal, the Aravind model is an amazing blend that brings together things we are not used to thinking of together – selfless service to others and mass production systems focused on making the process as efficient as possible. Everything is organized so the surgeons and the surgeries can move quickly. And there is no difference in treatment of those who have money and those who don’t.

And that really is how there came to be similarities in the cataract surgery process and the McDonald’s hamburger production process. 

Both are focused on a similar question, if not necessarily a similar motive. How do you make your operations as efficient as possible in order to serve the most customers at the lowest cost, while still making a profit?

For the surgeons, the question is “how could you bring the same top-quality care to the poorest of the poor at an affordable cost?” But for them, the ‘profit’ is what covers the cost for those who have no money.


Nepal’s God of Sight eye doctor to expand work beyond border. Associated Press, Apr. 8, 2021

Our story. Himalayan Cataract Project.

India Eye Care Center Finds Middle Way To Capitalism. NPR, Nov. 29, 2011

The Aravind Eye Hospital, Madurai, India: In Service for Sight. Harvard Business School, Jun 7, 1993