If you were to meet Paul Dubord at a night spot, you’d probably think he’s the resident bouncer. The pugnacious, stocky and straight-talking Dubord could easily come across as a Tony Soprano sidekick.
But Dr. Paul Dubord is in fact one of the world’s pre-eminent eye surgeons. The Vancouver-based corneal transplantation specialist provides advanced medical and surgical treatments for a number of conditions, including corneal transplantation, corneal cross-linking therapy for kerataconus, a degenerative disorder of the eye, and cataract surgery with lens implantation.
He is also a clinical professor at the University of British Columbia Dept. of Ophthalmology and an expert adviser on transplantation to the World Health Organization.
However, what truly makes Dr. Dubord unique is the unpaid humanitarian work he does in the developing world, primarily in India, to combat serious eye problems.
He is the founder and driving force behind Eyesight International (ESI) which has been working in India since 1990. During its 25 years in existence, Dr Dubord and ESI, in partnership mainly with the world-class L.V. Prasad Eye Institute (LVPEI) in Hyderabad, has restored or repaired the eyes of close to half a million Indians suffering from corneal-related and other ailments.
And those who cannot afford the treatment receive it for free.
Perhaps even more importantly, ESI and LVPEI have an ongoing program to train Indian doctors in advanced techniques for corneal transplantation and other eye surgeries. An indication of how important this work is that an estimated two-thirds of doctors who specialize in such high-level surgery were trained in this program.
Dr Dubord makes at least one trip per year to India as part of his work. Desi Today caught up with him on the eve of his latest trip to India. He discusses his work in India as well as his familiarity with other issues concerning India as part of our conversation.
Desi Today (DT): What exactly is Eyesight International (ESI)?
Dr Paul Dubord (PD): ESI is a charity in Canada recognized by Revenue Canada. It’s a non-governmental organization (NGO) that provides eye care and facilitation of eye care for people in the developing world.
DT: What exactly do you do?
PD: Basically, it’s all-round eye care. And ESI has been working in the developing world, primarily in India, since about 1992. What we do primarily these days is provide corneal transplants to people in need. In the world today, there are more than 10 million people who are blind due to corneal problems (the cornea is the front surface of the eye). Replacing those corneas is what we’re talking about.
We also teach people how to treat diseases of the front part of the eye. And as a nice sideline to what we do, we also become better cataract surgeons, removing cataracts from the inside of the eye and putting lens implants in. So we’re training surgeons to do better transplants and also giving them access to the tissue they need to do corneal transplantation.
We (ESI) have been doing this longer than anyone else and we’ve had some quite astounding achievements. We’ve created the largest corneal transplant service in the world. The hospital facility we’re working with, the L.V. Prasad Eye Institute (LVPEI) in Hyderabad, India, is the largest corneal transplant service in the world. It’s gone from 25 transplants in 1990 to more than 1,400 last year.
There is no other transplant service in the world that does that many transplants in one facility.
We’ve also created the largest eye bank in the developing world in Hyderabad that’s gone from providing tissue for 25 transplants in 1990 to 2,500 transplants a year.
And the other thing we’ve done – and this is the thing I’m most proud of – we’ve trained more than 200 surgeons at the sub-speciality level with prolonged fellowships – a year or longer – in how to do corneal transplantations and deal with external eye disease problems. We’ve trained more people overseas than any other similar NGO in North America or Europe at that level. And that’s unique. We’ve trained more than two-thirds of the active transplant surgeons operating in India right now.
DT: Is India the sole area of operation for ESI?
PD: No. But India is what I like to describe as the mothership. Ninety-five per cent of the blind in the world live in the developing world, and India has the largest concentration of those blind people, more than virtually any other country.
This is because of two things. One, the climate, and two, the size of the population.
DT: How does climate lead to blindness?
PD: You are looking at a tropical climate. Seventy per cent of the Indian population make their living from agriculture. So there are a lot more injuries they sustain – cuts from plants and other kinds of injuries to the eyes.
There are also some physical issues that are much more common in India than you get elsewhere, for example malnutrition, some kinds of infections, fungal ulcers, other kinds of bacterial ulcers.
We (ESI) also work in other places such as Sri Lanka, Ethiopia, Singapore, Paraguay. We’ve also trained people in India who are from Nepal, Indonesia, Pakistan.
DT: Do you personally do any surgeries?
PD: In the past, I used to do a lot of surgeries when I went there, mainly in a teaching role. I used to go to meetings and demonstrate surgical techniques. I don’t have to do that any longer because we’ve trained enough local people so that they teach each other.
My job there is to work myself out of a job!
DT: Most of your work is done in Hyderabad. Do your efforts cover the whole country?
PD: I’m going to India next week (late February) and our primary meeting is in Delhi. We’ve had lots of meetings in Delhi, we have partners in Delhi. We have partners in Rajasthan, and in Calcutta. We primarily started off in Hyderabad but we’re expanding beyond that.
DT: How is ESI funded?
PD: Purely by donations, period. And we get donations from people who say, we want to make a difference. And we are very, very efficient at using the moneys that are donated. More than 97 per cent of the money we get goes to the programs. Very few other NGOs can say that. They have much higher overhead costs than we do.
Why is that? Well, we don’t have any full-time employees, so that saves a lot of money. And we personally take care of a lot of other expenses. I’ve never had a cup of coffee paid for from ESI money. So all the money collected goes to the programs.
DT: Looking at the ESI website, it seems there are a number of organizations that seem to be linked to the operation. Can you explain what the connections are?
PD: Let’s talk first about Operation Eyesight Universal. I used to be the Medical Director for that and I helped them change up their programs some years ago, around 2002 and 2003. I helped them get going in India. They’ve been there for a long time. I resigned as the Medical Director three or four years ago.
SightLife is an American organization that I’ve been involved with now for about 10 years. Some of their people have come along with me to India. And they invited me to come and work with them in America. And this is once again a non-profit organization. I don’t get paid anything to help them.
So what they said was, you help us with our eye bank in Seattle, and we’ll scale up your Indian operations. So what that’s become is that now, SightLife in Seattle is the largest eye bank in the whole world. And while previously I used to do this program in India all by myself, now I have about 10 people working with me full time, developing eye banks, training surgeons to become much better at providing care to their patients.
Of the 10, about half are in India and the rest are in Seattle.
DT: How are the facilities that you work in in India? Are they up to the standards expected?
PD: They vary. Some of them are absolutely world-class that I’d be happy to have my cornea at if I ever need a transplant. And most of those are people who are our partners. On the other hand, some of the facilities there are just a closet, and not much else. So the standard of the facilities varies dramatically. And that is one of the problems we are trying to address, to raise the standard overall for what we’re trying to provide.
DT: What about government backing? Do you get the Indian government getting involved?
PD: Up to this point in time, we’ve had very little government backing. But that’s also because we feel we can be much more flexible and do a lot more without government backing.
That is changing now. We are working more and more with the government to set standards for corneal transplantation, to set up laws that help make corneal transplantation easier to happen, for donation of tissue and to work with doctors who work in government hospitals, and to work with government hospital eye banks.
DT: How about non-financial backing? Rightly or wrong, India has a reputation for bureaucratic red tape.
PD: Well, that’s the whole thing about working with them on legislation, and trying to change some of the laws to make it easier for people to donate tissue.
When I said in 1990 that I was going to be working in India, one of the first things that happened was that the CEO of a major international non-profit organization involved in eye care in India told me I was wasting my time because Indians won’t donate tissue.
Well, guess what, they were wrong. Indians will donate tissue, if they are approached in a culturally sensitive fashion. And that is the beauty of this. We’re impacting millions of people in a very positive fashion, and a lot of people had said it could never be done.
DT: From 1990 until now, which is about a quarter century, how many people do you think have been helped by this program?
PD: Depends on how you want to look at it. For every one who’s had a transplant, and is able to see and function, it frees somebody else up too. Because when someone is blind, they need someone to walk them around, to feed them and help them. Once they are able to see, they are able to take care of themselves.
So if you include everyone who has been helped (including those who had the transplants), it is millions. And the program has the potential to benefit millions more.
Where actual surgeries are concerned, it has to be around three or four hundred thousand people. And it’s not just corneal transplants, but other procedures too.
DT: You touched on cultural sensitivities. Among the poor in India, there are cultural taboos. Was it a difficult thing dealing with that? Was it a learning experience?
PD: It was a learning experience for me, and it was a learning experience for them. My philosophy was, they knew the answers to the questions I was asking. But they didn’t know they had the answers, and my job was to find out what those answers were.
We worked together, and we fine-tuned it, and we had some successes, and we worked off our successes, and it’s getting better and better.
DT: Was 1990 the first time you ever went to India?
PD: No, my very first trip to India was in 1977. I was travelling mainly through northern India, up into Kashmir, through the Punjab and Amritsar and through Delhi and into Pakistan. It was a social trip.
In 1989, I went to Karachi in Pakistan, where in fact the Indians approached me and asked me if I would start working with them in India. So the first trip for that purpose was in 1990.
I was there for about a month.
The facilities for eye surgeries then were very rudimentary. It was a huge challenge. But one of the things I really enjoy is identifying problems that other people may think there is no solution to or have walked away from. We started finding solutions. So I looked at this as not just questions and problems, but as how we can solve this, how can we make it better. And that’s what we’ve been doing.
DT: What is the average number of trips you’ve made to India since 1990?
PD: A minimum of once a year. I’ve been there three times in the last 13 months.
DT: Is it now a self-sustaining program in the sense that you no longer have to be so hands-on?
PD: I teach the teachers’ teachers now. I don’t have to do the hands-on so much. I participate in that, not because I have to, but it’s kind of fun to do. It’s enjoyable. They learn from me, I learn from them even today. But as far as surgery is concerned, they can do it all on their own.
DT: Coming back to the theme of learning from each other, obviously the people in India that you deal with have learnt a lot from you. Has there been a reverse process?
PD: Yes. There have been some surgical procedures and techniques that I use here that I learnt for the first time in India. And they’re fantastic and better than anything that we’ve got going here.
DT: Are there other Vancouver and B.C. eye care specialists who are involved with you in this effort?
PD: Not so much from B.C. Mainly I work with a lot of Americans. We have a much bigger infrastructure in Seattle than I’ve got here. But I do have some surgeons here in Canada that are displaying some interest in this area.
There are some other Canadian surgeons who do some other work in the developing world, but there is no one that works directly with me.
What is the cornea of the eye?
The cornea is the outer covering of the eye. This dome-shaped layer protects your eye from elements that could cause damage to the inner parts of the eye.
There are several layers of the cornea, creating a tough sheath that provides additional protection. These layers regenerate very quickly, helping the eye to eliminate damage more easily. The cornea also allows the eye to properly focus on light more effectively.
There are numerous diseases and disorders that can affect the cornea, some minor and others that can only be alleviated through surgery, including corneal transplantation. These disorders include various allergies, infections and dystrophies, conjunctivitis, keratoconus and other ailments.
In corneal transplant surgery, the surgeon removes the central portion of the cloudy cornea and replaces it with a clear cornea, usually donated through an eye bank. A trephine, an instrument like a cookie cutter, is used to remove the cloudy cornea. The surgeon places the new cornea in the opening and sews it with a very fine thread.
The thread stays in for months or even years until the eye heals properly (removing the thread is quite simple and can easily be done in an ophthalmologist’s office). Following surgery, eye drops to help promote healing are needed for several months.
DT: What is your relationship with SightLife?
PD: There are several things. I’ve been on their board for 10 years. I just finished as chairman of the board last January. I’m still on the board, and I’m also an Associate Medical Director with them.
DT: Do you also facilitate prevention in your work in India?
PD: We do, in the sense that we teach people not only how to do the surgery but also how to deal with diseases on the outside of the eye. And that is the preventative side to it. Do we do actual preventative programs, such as dealing with tracoma (a contagious, chronic inflammation of the mucous membranes of the eyes) directly, and giving people access to water supply etc? No, we don’t.
But we do train the medical doctors who deal with the problems to do things that make it less likely for someone to need a corneal transplant.
DT: Outside of your professional work there, you must be very familiar with India by now. Tell us about your experiences. Do you enjoy going to India?
PD: Of course I have to enjoy going to India. I love going to India. I love the people, I love the food and how it varies from place to place. I really enjoy the sights, the scenery, the geography, the culture, the music and dancing. And it’s fun because I don’t have to get “culturally adjusted” any longer. I walk off the plane, I get the smell and, bang, I’m there.
And I have some very good friends there too.
DT: Are you always based in Hyderabad when you visit?
PD: Where my programs are concerned, I work primarily out of Hyderabad. But we’re expanding way beyond that. Frankly, you have to work with the right people. People who are dedicated and show similar values to what you do. The first people who really stepped up to the plate to work with me were the people from the LVPEI.
And then we identified partners. And we worked with them. Some were very productive and we continue to work with them long-term. Others, we work with them for a while and then we decide maybe it’s not working as well as it should, so we kind of go our separate ways.
DT: Is your program to train Indian surgeons a kind of formal program?
PD: Very much so. What it is is that you graduate from medical school, and then you do what is called a residency in something. It could be eye care ophthalmology, cardiology, general surgery and so on.
What we do is we’ll take those residents who graduate from ophthalmology, and we put them into a fellowship training program where they get sub-specialized. So they become ophthalmologists who are trained to do corneal transplantation, external eye disease, retina work, paediatric work, glaucoma work, plastics work, specifically to the eyes.
What we’ve done is concentrate on the corneal transplantation and external disease group to train them.
Right now, we’re sponsoring the training of some 12 fellows. We fund any fellow who comes to the LVPEI who doesn’t come with their own funding.
They come not only from all over India, but also Africa, Indonesia, Ethiopia, Nepal – virtually from all over the developing world.
DT: Is the program affiliated with some medical school?
PD: No, it’s not. It’s a private institute, which is not an unusual thing in India.
DT: And you have a candidate selection process?
PD: Very much so. In fact, we interview lots of candidates. It’s a very popular program to get into at the LVPEI, not only the corneal transplantation program but for retina work and other fields. It’s very, very competitive because the training is so good.
We get people from all over India and the developing world applying for fellowships there. In fact, we’ve trained people there from South America, we’ve had residents who go there from Australia, we’ve had residents go from here to train.
DT: Do they have to pay for the training?
PD: No. the fellows that work in the cornea area don’t pay. Actually, we pay them because they work in the hospitals.
DT: So where does the program go from here? Are there plans for ESI to expand its operations?
PD: What we’re planning to do is to expand our fellowship training programs to formalise them with some other centres, for example Madurai and Chennai, and to expand our programs to other fellowship things to get more of a symmetry across the different training programs so that we train people at a higher level.
DT: Have you picked the language in India?
PD: Very little. There’s so many. For example in Hyderabad and Andhra Pradesh, there’s like eight different dialects. You know, within the same room you’ll have people speaking all the different dialects. I know a little bit of Urdu and Hindi, but not a whole lot.
DT: You’ve now been going to India for about 25 years. These are also the 25 years where India has, by all accounts, changed. This is the period when it opened up economically. Have you seen the changes?
PD: Very much so.
Number one is how much cleaner it is than it used to be. That to me is remarkable. In some states more than others. The change has been just amazing.
The quality of the roads has changed dramatically. And I’ve really been impressed with the improvement in driving, although it’s still scary to drive there. I don’t like to drive at night, I avoid that.
Unfortunately, in some areas such as Delhi, it is now much more polluted than it used to be. But that is one of those things they are trying to deal with. In Delhi some years ago, they tried to rule out two-cycle engines and all that sort of stuff. But it’s still a problem. And it’s going to be a huge problem in the future.
DT: Is there a noticeable difference in affluence levels among Indians?
PD: Overall, yes. And the stats will tell you that. But there’s still hundreds of millions of people at the bottom end. In India, you’ve got the world’s largest middle class by population and income, but there’s still many at the bottom end who are living on not much more than a dollar a day or less.
DT: And in your work, you get to interface with some of the poorest people.
PD: Oh yes. For example, the LVPEI is a private institute, but 50 per cent of the people who get care there don’t pay anything for it. And that’s just for people in need. If someone needs the care, they get what they need. The examining rooms are exactly the same for everybody, the operating rooms are the same for everybody.
Those who can pay, pay. And those who can pay, pay enough to support the people down at the bottom who can’t pay. So that way, everyone gets access to the care.
DT: You say ESI works entirely on donations. Do you get enough?
PD: No, we never get enough. We’re created a new video clip that’s on YouTube, and that’s getting re-released, and that will help get some donations in. But we always need more.
The more we get, the more we can do. And the more we do, the more people see and the more people give.
DT: Do you hold fundraising events?
PD: No, generally we haven’t had any fundraising events.
I don’t like to see a lot of money wasted. I’ve got this thing about going to a fundraising event where there’s a big fancy dinner, people having a real raucous time and spending a lot of money, and then they donate some of that money to a program. That bothers me.
I’d rather see more of that money used for the actual programs. It’s really important for me for the charity to have an impact, and not just what I call a high feel-good factor without sustainability.
If you look at what many charities do, if you stop the money flow, everything stops. That’s not what we’re doing. We are developing programs in India that will continue after we’re gone. And that’s the key issue. And that’s a lot harder to do than a normal charity.
If you throw enough money at anything, it can continue to operate. But to do development, where you actually teach people how to fish, that is a lot harder, but it’s a lot better.
–By Bachan Rai