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Is introduced um our keynote speaker, we're very privileged to have all the way from India today, Dr Ben Garage um like a cash and um I will introduce him. Um First of all, he's from Aravind Eyecare system, um whose purpose is to eliminate needless blindness and offers world leading operational excellence, productivity and profitability to achieve social impact at a staggering scale. Since inception in 1976 Aravind eye care system has treated over 62 million patients' and performed seven million eye surgery's 50% for free or significantly subsidized rates while transferring the lives of tens of thousands of young women who they recruit, train and educate, arrive in productivity levels are five times the norm. Their infection rates are the least in the world. They control 10% of the global intraocular lens market. And the profitability average is 39% at the heart of the organization is Doctor Wrenn Garage Venkatesh, who is the well list accomplished cataract and glaucoma surgeon, a passion for research and management and works with other stakeholders to keep innovating and executing a purpose driven culture that is progressive and inclusive. He's also the Chief Medical Officer at Aravind Eye Hospital, Pondicherry India and needs the Aravind Center for Eye care Innovation. Dr Venkatesh plays a key role in Aravind environmental sustainability initiatives and as a member of the I A climate Axion working group and the ASCRS I sustain and find screen board member. So I'm going to share my signs and thanks to whatever you need the next night, just let me know and I will um do that for you and I shall just okay. Are you able to see the slides now? Yes. Uh Thank you. So, just tell me when you need me to go to the next. Perfect. Thank you. Thank you for the kind introduction. I mean, it's nice to be a part of this uh interesting program happening online. And also I believe a lot of people are having breakout sessions and uh interacting with team to make healthcare environmentally sustainable. So I'm going to share with you in the next uh 2025 minutes about how uh urban being one of the largest I care providers in the globe, how we are trying to do a low carbon I care and the next slide and, and how we are in the race to zero next leg. So when we talk about sustainability and resilience in healthcare, you can keep clicking. Uh Either you can keep clicking. There are few. Uh so there are several things which are controlled by uh reusable supplies, disposables, a lot of electricity. Used and capital goods. You can keep clicking, lighting and ventilation and also related to travel of staff on patient food services uh which, which has, which have certain regulations. Yeah, you can click the next lied. So we at our been see it as a systems issue, especially in healthcare and we're going to share with you how we have resolved some of these systems issue, at least in this part of the world Next leg. So Arvin started way back in 1976 with 11 beds. And now we have, yeah, you can click the next seven tertiary cab centers and we have uh next slide, seven secondary cap centers. So these are services which two cataract and refer the specialty patient's to the tertiary care centers. And the next slide. And we have several uh city centers and community centers which mainly do outpatient work next line. And then we have a network of 108 primary eye care centers, vision centers know which are really in semi urban and Ruhr Allay area and providing an eye care to 30 to 40,000 people in that particular geographical zone. Next lab. So on an average every day, we see close to 16,000 outpatients, we do more than 2000 surgeries and we do a lot of outreach i camps where we go to the field, screen them and print and bust them back to the base hospital for surgery and being a high volume center, we do a lot of teaching and training, a lot of residents and fellowship programs are offered and also training programs for training, mid level of thalamic personal counselors, technicians, optometrist and several other programs happens throughout the year. Next leg. So when we talk about the low carbon I care, I want to put it into two buckets. One is the general aspects which normally most of the organization practice and I'll focus more on the service design which we do back at home next slide. So I think in, in in general, you know, these are general practices wherever possible. Now we have infrastructure which offers green buildings, at least in all our new facilities, which happened in the last 10 years. We have, you know, kind of architecturally designed green buildings. We have used energy efficient appliances and gadgets and we have strongly looked at alternate source of energy. I'll show you what happens in pondicherry and other facilities and we also minimize travel and transport, not only of our staff because all our stuff in all the new facilities are, they are housed within the campus. They have a quarters where and they can walk to the hospital and we minimize the travel to the patient's by doing outreach by doing these vision centers and also trying to make sure that we try to finish all the investigations and maybe procedure also on the same day. And we have a very strong consumable procurement. So that we can minimize the effort and optimize the frequency. And because we have our own manufacturing facility, you know, if we have a very good supply chain and whenever there is a need, we get the supplies from our manufacturing facility at moderate and a lot of importance is given to equipment maintenance. So we try to do preventive maintenance so that breakdown doesn't happen and also the life of the equipment extent. And we also offer a lot of training around this for people with engineering background to maintain ophthalmic equipments and not, but not the least about water and food. I'll also cover a little bit on this next slide. So can you click again? So this video keeps moving. Yeah. So what you see is the facility in uh Pondicherry which is in the east coast of India. This is our facility which is roughly 200,000 square feet. And you if you see the rooftop is totally covered with solar panels now because we have a nice uh sun all through the year. So almost 60 to 65% of our electrical needs is generated locally from the solar plants. So we only by 25 or 30% from outside. And also we usually buy clean energy next leg next line. So most of our facility, like I said, from Bondage Cherry and all the new hospitals in Chennai Neuropathy and the newer facility which is coming up. So we we we try to do green buildings where we leverage natural ventilation and lighting like how you see. And the orientation is also to a great extent so that you minimize the solar heat getting into the facility. And the layout also is designed such a way that the movement is also minimized. Like even the staff are housed inside the paramedical staff. Most of them stay inside in a hostel facility. The residents and fellows have hostile facility within the campus. So most of them walk to the hospital and all this helps us to minimize the maintenance with the right choice of materials. Like if you see this facility in Chennai, if you see the lights are only on the side where it is a little bit dark, know where you have a lot of sun entering with the most of the lights are even switched off in the daytime. Next lab. So this is just showing you the way we have at least done solar across all our hospitals. Next lied. So the pondicherry almost generates 60% but the overall in Irvine and also in our manufacturing facility, it meets almost 10% of our needs and we are constantly working on increasing this capacity so that we can even go up to 30 40% in the near future. Next line. Next let can we move on in there? Yeah, next leg. So uh the other important thing is in all our world facilities and also the new facilities. We have, we have moved towards energy efficient and the appliances and gadgets. So they all are trapped. All the lights have been changed to led lights. All the fans have been energy efficient fans and even the occupants like chillers and air conditioned plans have now been changed to really energy efficient so that we almost have no a kind of 32 even 50% reduction in the amount of energy consumed by some of these appliances. Sometimes this is so important that we need to really work on these gadgets so that you become really energy efficient at the end of the day. Next like. So this is again uh just a picture of showing the the water recycling plant which is there at Pondicherry, which is called the D wards, the Decentralized Wastewater. And finally, the wastewater which is stirred re re which is recycled, comes to the pond which is used for gardening and maintaining even some of the kitchen gardens which we have in the hospital. Next let okay. Next leg. So the Decentralized based apartment treatment plan almost kind of re cycles. 90% of the water we use in the facility. And uh this water is again used for garden and also some of the water is also now plum back to the toilet for flushing purposes so that we can optimally reuse a lot of rainwater harvesting happens. And then uh we also engage our own uh staff and patients' to uh kind of reduce the water consumption by having waterless urinals and also reduce water flow in the taps. And by this, you know, we are able to maintain a beautiful garden and most of our has hospitals which again kind of improves the overall experience of people coming to the hospital. And also this has won several uh best garden awards and stuff like that. Next, like so from the general aspects, I think I'll quickly move on to the service design, which is the most important part of my talk and how we are optimally reducing, reusing and recycling a lot of ticks next slide, next leg. So a lot of efforts happens towards uh reducing like closing the loop, uh like finishing off the investigations and uh the procedures if the patient's are prepared on the same day, for example, if a patient needs a visual field testing or a scanning for the optic now, or if he needs a laser for his glaucoma, a diabetic right now. But if the patient is prepared financially and also mentally, the procedure and the investigations are completed on the same day, there is no appointments given. And uh we have introduced electronic medical record across our system to reduce paper waste. And that there is a very rationalized use of consumables, which is evidence based. And also we have been uh producing a lot of evidence which has been now kind of globally recognized and a lot of uh procedures have been standardized so that we can really reduce the amount of resources which we are using. And then when we go to reuse and multi use, again, a lot of evidence based practice happens like eyedrops are used till the end of the day. Some at the end of the week, like an operating room. It's the end of the day in the outpatient department till the end of the day, end of the week. And very clear protocols are given for reuse and multi use. And there is a very uh important way, you know, we segregate lot of wasted source so that we can optimally recycle and also repurpose a few things in a different way next. Like so when we talk about any healthcare know even uh in high care, you know, there are several footprints related to access diagnosis, treatment and follow know we'll constantly look at the flow of patient's wherever there is a leakage, we try to fill that leakage and we try to reduce the waste which happens in whatever form it happens based of time or energy or efficiency. We constantly kind of look that and make sure that now we are bringing the highest efficiency into the system. Next. Let so, so this is just to show the assembly line process which happens in the outpatient department from registration, somebody has cuts and then uh auto refraction is done. Then the optometrist to refraction, the pressure is check BP, there is a pill, a binary work up done by doctors then a final and then they escorted either for counseling or medicine or glasses. So in all these processes, one person is doing one task and because they do one task, they become really skilful in doing that particular job. And this helps us to kind of attain a good quality also. And by this way, we are optimally and effectively using a lot of these documents which are used in diagnosis and treatment, which again reduces a lot of wastage next late. So beyond I hospitals, I was talking to you about how we reach the unreached. So this is one way we reach the unreached by a form of vision centers. Can you play that video? I think it should move on a click. If not, you have to go back and then play the video, it's on the video you have to play on the media. Yeah, thank you. So this is a vision center or a primary I care center, which is a 600 square feet facility which is in semi urban neural area with a population of 30 to 40,000 people. We have two staff who are taking care. One is one is a person who is doing now, the registration and Lantus Imaging. That person is called a technician and the second person is an optometrist. So these two people run these clinics, they see 30 to 40 patient's every day. Uh they do registration and then they check their BP, blood sugar and then they do refraction, they check the eye pressures. And at the end of all the investigations, everything is entered into the electronic medical record and the telemedicine happens. So one of our senior resident is there in the base hospital consulting these patient's. So each of our hospitals run 15 to 20 vision centers like in Pondicherry. Now we have 17 vision centers and you can see the telemedicine happening. The prescription is signed by the doctor from the base hospital, the drug prescription and the medicine prescription. And so once the prescription is printed and now they are counseled and then they get the medication, they have a selection of lenses right there, the vision center so they can choose their glasses and then get the glasses done in 24 hours. If it's already made class, they deadly immediately. So this is like a hub and spoke model. So 85% of care is given locally like a foreign body or conjunctivitis and things like press biopsy. A are people who need classes is taken care. Only 15% are referred to the secondary and tertiary care center for further care. So by this way, we are significantly reducing the carbon footprint of patient's travel because they can be easily accessed for the car. Next slide. Can you click on the video again here? Okay. So some of our vision centers are now a I powered know. So we wanted to improve the quality of uh the diagnosis of posterior segment diseases, especially diabetic retinopathy and glaucoma. So now we have this fungus cameras, you know, this is a company called Ray video. We have no financial interest and it's an iphone based technology where funders images and then there is an offline ai nowhere immediately you can generate reports within a matter of 30 to 40 seconds. You get a report to say whether it is a referable glaucoma or a referable diabetic retinopathy or you can follow up in the vision center. So we have also kind of explored technology now advanced technology so that we can make better diagnosis so that unnecessary patient travel can be reduced. And uh most of our vision centers are now powered by uh low cost technology which is validated and also with artificial intelligence like this, especially for conditions in the back of the eye or the posterior segment diseases. Next slide. Yeah, we can go to the next laid. So this is just to show you a map of or vision sent to a network of 108 centers. If you see, we're almost covering the state of Tamil Nadu and Pondicherry. So the idea is people with high care needs, should not travel beyond 15, 20 kilometers, at least for the basic needs only for any surgery or procedure. They have to travel a little longer distances next lied. So this is a work which we did during pandemic just to see how uh during the wave one and wave to where we had the peak COVID, how some of our centers did. If you can see the percentage of people going to primary vision centers are more than 75% or almost 80% during the second wave. This is before even when we had the vaccine. Whereas the tertiary and secondary care centers, we're only seeing 40 to 50% are only 60%. So that shows that the accessibility of care was so important even during pandemic. And this significantly reduced their travel because travel was such a big burden during pandemic because of uh he passes restrictions which happened between different states and districts uh back in India. So these vision centers did a lot of good work in taking care of at least they're high care in that particular region. Next slide. So this is just a map showing how uh they did well. No, the vision centers did really well during both the face. Uh I mean the way one and the wave to when compared to tertiary and secondary care centers. Excellent. Uh just click again, the video should run. Can you go back and click on the video again? Yeah. Okay. So this is another one which we regularly do for the last 40 years. But over a period of time, we have improved the way we do community outreach. So these are I camps where in a small team goes in a van, they set up this I camp in a small school or a community hall. And now we do again, uh low cost, we use a lot of low cost technology and we also have electronic medical record. So the patient's are registered a preliminary work up is done. Then the optometrist do refraction. You can see those makeshift cubicles and then the intraocular pressure is checked for screening for glaucoma. And then uh this camera is called a Bosch Fungus camera which is again handheld. It's like a small gun which is very easy and comfortable to take mydriatic fundus images. The images are wifi transferred to the laptop in front of the final physician were sitting there. And then he gives his opinion either for cataract or glasses or any referral for uh I conditions like glaucoma and diabetic retinopathy. If they have cat track, they are immediately bust uh to the base hospital. So 40 50 patient's come together in a bus, they have the surgery done and then we dropped them back after a couple of days. And after 30 40 days, we go back to the camp site. So whereby these outreach significantly reduce again the travel related burden and the carbon footprint for many of these patient's who need uh surgery in the form of cataract surgery, which is the most uh surgery done in I care. Almost 90% of our procedures is cataract surgery. Next let so these are some of the things which we regularly do in our practice and we incrementally improve. We have a lot of lean clinical protocols with evidence, standardized operating procedures. And most of that, as I said before, the process is designed to complete all the investigations on the same day, we get the specialty opinion, like a glaucoma opinion or retina opinion on the same day. And absolutely, there is no waiting period for surgery. I'm sure people in UK will be surprised when there is a long waiting list for cataract surgery. Whereas when the patient comes here the very next day, they get operated, know if they are ready for surgery, they can get an admission or they can go home and come as daycare and then the follow up is done in vision centers, our city centers or in the base hospital barrier, it is close by. So we have a system which is, which is very efficient so that we can deal with a good number. For example, in Pondicherry every day, we do close to 300 cataracts, surgeries. Excellent. So a lot of things happen around the supplies. So that is where I think uh optimally we reduce and reuse a lot of things. So there is a stringent sterile protocols. A lot of share ing happens between supplies and then we minimize the use of single use instruments. Wherever possible. We try to reuse very carefully. And then a lot of waste segregation happens at the generation point. And overall, you can see all these three happening next slide. This is an interesting video which shows you how in the morning, you know, when the staff is opening. So even the plastic and the paper is separated. Now when they're opening the knives, the carrot tomes, the sutures and the supplies which you need for the day, even the paper and the plastic is separated at source so that they can optimally be recycled at the end of the day. So almost 85% of the waste is recycled and only 15% which is biomedical waste, which you can see in the red buckets here which goes to the biomedical waste disposal center. So the surgery dress and down at the end of the day, you know what happens, then we wash them, launder them and then we do uh send a full cycle. Sterilization, the trays and pans also done at the end of the day, surgical instruments. After every case, the instrument will go to a flash autoclave where they quickly wash them, rich them and then do a flash cycle and then they get uh setback for surgery. At the end of the day, they go for a full cycle, autoclaving surgical glaus in between cases, we put antiseptic and we change the gloves every 10th case and then uh syringes knives, blades, everything at disposed after every case into the biomedical waste. Same way uh needles and blades, cotton swabs and gas. And uh like the video you saw the plastic and the paper, the packing materials, the booklets which come for the lenses and sutures are segregated at source so that we can optimally recycle at the end of the day. Next slide. So this is a work we did some time back. It was actually a Fulbright fellow from us, Casey tell who by accidentally I met her in one of the conferences. And then we said, why don't we measure the cat track waste and compared between what happens er been and in uh some of the hospitals in us. And this, we published a few years back to show that next lead. One uh cataract surgery in U S is equal and two traveling 500 kilometers versus just 25 kilometers in Darwin. So the waste generated was 1/20 of the waste generated in us. So this was an interesting study and a lot of uh media and other coverage happened following this publication. Next slide. Excellent. So this is just to show you some of the work which we have done our, the carbon footprint of one vehicle of us and UK is 20 times higher than Arvin at the same time. Next lead. Yeah, the end of tell might is red in Arvin is no, almost 3 to 4 times lesser than the average endophthalmitis reported in Europe. And also in us. So our endophthalmitis red is two in 10,000, whereas international standards have been almost 6 to 8 cases per 10,000. So the infection rates are less, the tasks and other allergic conditions are less. Uh in spite of uh 20 times lesser waste which we generate here at our win. Next slide. Yeah. So this is just to show you a comparison. Now, this picture is a very popular picture. A lot of people use this in that presentation. So on the left side, you can see one faecal case in uh I think it is Messiah near versus 100 faecal cases at Aravind Pondicherry. Next slide. So the main problem is all the waist which is generated for that one fake. Okay from the trip to the cassettes to the tubings, the fake oh material that the down everything goes into one particular bucket know that's the problem because it's not safe aggregated. So everything goes to landfill as know kind of biomedical waste. Whereas here in this 100 cases, almost 85% is optimally recycled and only 15% goes to either landfill or for incineration in the biomedical waste. Next side. So this is just to show that now by optimal segregation, we are also able to generate some money. It's not a big money, but it also helps us to employ some of the staff who are who are doing the recycled work we're handing over to the uh the vendor who takes all these recyclable items. So roughly around 200 to $300 every month, we can make just by optimally segregating wasted source in the operating room. Next letter, the next line next let. Okay. So this is a study we did during COVID times know because in COVID time, we also had some restrictions. So there was only one patient next slide in the operating room. We we were cleaning the room for every case. Uh the patient was wearing a gown asper the standards which is happening in UK and us. And what we did was we compared in the group, one patient's done before the COVID lockdown. And during the COVID phase when we started operating again with all the revised protocols and we found no difference next slide. So this particular work we just did to show that know uh practically there is no difference at the end of the day, even when you have, when you're doing the Western protocols. Next slide. So more the most important part know for the low carbon I care is leadership. There's a high level of commitment from our leaders to constantly look into the process and and keep looking at uh alternative energy generation and also the systems and processes. And Morley, you know, we do a lot of engagement with our staff and also with our patient's um identify in implementing any opportunities which come on our way. Lot of audit happens and then we rectify a lot of things depending on the audit reports and building this as a part of organizations D N A that has been a big challenge, but that really helps to think out of the box next slide. So this is a thing which happens every day in urban pondicherry. The caregivers of our cat track patient's uh roughly around 100 150 paying patient's who go for surgery. They come with caregivers. We engage them in a green tour. So one of the volunteers in the hospital, uh they take them on a green tour to show them how we uh do wastewater recycling the D watch plan, how much of solar energy we generate with our solar plant. Uh Ever me composed plan, how the kitchen garden is maintained, how uh the uh nursery is maintained. So this tour also helps to engage our patient's or the customers who come for cat. And also we teach them some of the things like how can they have their own kitchen garden or do over me composed or even do a small solar panel in their homes. So we engage them and then we have some QR codes for them to take home some messages. If they want more details, we help them. So we have been a very strong advocacy with A B B. Uh B B is International Association of Prevention of blindness. There is a climate Axion working group and uh we have been leading a lot of these actions, the 10 key areas which you see here, which are very important and we are supporting a lot of these activities and also collecting a lot of evidence to share with a larger audience. Next let. And this is one uh website I would like you to go and see. It's called the high sustained dot org. So this is started by American Society for Cataract Refractive Surgery and now E S C R s, which is the European Society for Cataract and American Academy are part of it. And every other day, there are a lot of people joining. Now, we have 35 different organizations who have joined and they are taking this surgical facility pledge which you see here. And a lot of excellent sustainability resources are available on this website, including a lot of evidence is which we have also done over the last many years. And we are doing uh sustainability symposium regularly for the last couple of years and we are also meeting the industry like size and Alkon and Johnson and Johnson to make sure that industry also start practicing sustainable practices. So we believe that know when you do environmental sustainability, it always leads to triple one. Keep clicking. Uh Yeah, happy patient's and uh when you have more patience, you can lower cost and you can be friendly to the environment. Thank you. There we go. My back in now. Can you hear me? Hello? Yes. Ok. Um Thank you very much, Doctor Van Qatamesh. Um, we haven't got time for questions just because we had such a late start, but we've put your profile with your contact details and all your websites and things and um what a fascinating presentation and um both the verbal explanation and I think there's something quite powerful in those videos and photos that you showed. Um, you know, whereas one surgery versus was 100 100 and 50 and um you know, really powerful messages and lots of interesting things for, I think all of us the world over to um to consider. So thank you very much for your contribution and to the share conference today. So I would encourage everybody if you would like further information to go to the pad lit, which um has the, the web links um that will add on to that Doctor Venkatesh is um shared with us. So we've had a slight change in the schedule just to um save for everybody. Um We were going to