Globally, India shoulders the largest burden of blindness, estimated at 15 million people. Cataracts are the leading cause of blindness in India, but glaucoma and diabetic retinopathy also are prevalent.

The Aravind Eye Care System addresses this problem by offering affordable eye care to low-income patients. Nearly 70% of its patients live in rural South India, where there is an acute shortage of ophthalmologists. Two-thirds of Aravind’s services are provided free of charge.

Aravind always knew that it would have to expand beyond its five hospitals to reach the rural poor. Until recently, villagers had to walk as much as 12 miles and forego a day’s wages to visit an Aravind hospital. As a result, many people who needed treatment didn’t receive it. Aravind experimented with a few models of eye care delivery including mobile vans, to determine which would best serve the many rural residents who needed access to eye care.

First Aravind launched mobile clinics, sending vans to rural areas. But the clinics were cumbersome to plan, requiring Aravind to find local sponsors to host them. In addition, the vans could only visit a given area infrequently, and without a permanent presence, it was hard to promote eye-care education, which is one key to the prevention of cataracts.

Aravind also experimented with two permanent clinics in Theni, installing technology to enable remote consultations with doctors in Aravind hospitals. But the technology had limited bandwidth and thus poor video quality. It also was expensive, and involved recurring costs to maintain the network. And even if the clinic concept were viable, it would be difficult to scale. Before Aravind could establish clinics in other areas of rural South India, it had to wait for third-party network carriers to provide coverage to those areas. Rural areas of Southern India were sparsely populated and low priority for network carriers and service providers. It could take years before they provided adequate coverage.

To address these challenges, Aravind developed the concept of rural vision centers—primary eye clinics in rural areas, where patients can be remotely diagnosed by doctors via high-speed wireless videoconferencing; get prescription glasses, eye drops and blood tests; be referred to an Aravind hospital if surgery is needed; and receive post-operative care.

Intel and UC Berkeley researchers are collaborating to build an experimental research proof of concept long distance, high-bandwidth, point to point Wi-Fi network to connect the vision centers to Aravind hospitals. That will enable rural residents to have video consultations with doctors, eliminating the need for patients to travel to the hospital for routine eye care.



The collaboration is part of the UC Berkeley TIER (Technology and Infrastructure for Emerging Regions) project, which is tackling the challenge of bringing the information technology revolution to the developing regions of the world. TIER is led by Eric Brewer, the Director of the Intel Research Berkeley lab. Sonesh Surana, a Ph.D. student and intern at the lab, is managing the field effort for the Aravind collaboration, focusing on the design of the system and most of the deployment, training, and sustainability aspects of the project. UC Berkeley is funding the initial deployments of vision centers, through a grant from the National Science Foundation. Intel is contributing equipment and funding for the researchers, as well as project management by Brewer and Surana

To connect the vision centers to Aravind hospitals, Intel and UC Berkeley researchers designed a point-to-point long-distance wireless infrastructure that combines a variation on IEEE 802.11 (Wi-Fi) technology with off-the-shelf videoconferencing software and tools that hospitals can use to maintain the network. A key technical challenge the researchers faced was how to make Wi-Fi work over the roughly 10 miles between each vision center and the nearest hospital. The 802.11 networking standard, more commonly known as “Wi-Fi”, is defined by a set of international standards that limit its range to about 200 feet.

Customizing the networking hardware (mainly inexpensive Wi-Fi cards) to achieve longer distances would be costly. So the researchers redesigned the software, modifying the Wi-Fi Media Access Control (MAC) protocol, which is designed for short-range communication. Specifically, they disabled some MAC features that weren’t needed and implemented others that were, by creating a thin layer on top of the MAC.

By combining their modified Wi-Fi software with directional antennas and routers to send, receive and relay signals, the research team so far has been able to obtain network speeds of up to six megabytes per second (Mbps) at distances up to 40 miles (validated at another project in Ghana). These speeds are about 10 times faster than dial-up speeds and carry 100 times as far as standard Wi-Fi technology.

In this satellite map graphic of the Aravind network, green lines indicate links from the central hospital to rural vision centers in five rural towns. All distances are in kilometers. (Graphic by Sonesh Surana)

The prototype networking infrastructure was tested and validated at the first three vision centers deployed, at Bodinayakannur, Ambasamudram, and Chinnamanoor. At Bodinayakannur and Ambasamudram, the researchers replaced existing low bandwidth (33Kbps) wireless links with the new high-speed links. “We improved the quality of video-conferencing by roughly eight times,” says Surana. “And even with that improvement, the network is underutilized; there’s more bandwidth available.”

At Chinnamanoor, the new high-speed link enabled videoconferencing capability where it didn’t exist before. “Previously we had no other option for network connectivity in Chinnamanoor, and so we were not able to start a vision center there, despite high demand for eye care services,” says Dr. S. Aravind, Administrator of Aravind Eye Hospitals.

Intel and UC Berkeley researchers installed the links at two of the clinics, but the Chinamanoor link was largely installed by local technologists. “The TIER team has trained our local providers as well as our hospital network administrators in order to ensure continuity,” says Aravind. Based on our training, we were able to install the Chinnamanoor network ourselves, with very little help from the TIER group.”

In May 2006, local technologists installed two new links, at Periakulum and Aundipatti, with no help from the TIER researchers. The goal is to have all future installations done locally. “So many times people have come in to an area to do a project and then, when they leave, everything falls apart," Surana said. "It's been a very important part of our research to make this a project that people can build on and manage all on their own."

Early results are encouraging. The first three vision centers established—at Bodinayakannur, Ambasamudram, and Chinnamanoor—screen about 1,500 patients each month. (Numbers are not yet available for the two other centers, which came online in May 2006.) Roughly 5-10% of patients—already nearly 100 people a month—experience significant vision improvement as a result of treatment, usually via cataract surgery.

On opening day of the Periakulum rural vision center, a nurse and a doctor from Aravind Eye Hospital examine a patient. Normally, the center is staffed by a single nurse who uses a computer network designed by researchers at UC Berkeley to teleconference with an eye specialist at a hospital 10 miles away. (Sonesh Surana photos)

The Bodinayakannur and Ambasamudram deployments also validated that the vision centers can break even—a prerequisite for sustainability. Both clinics are projected to reach the breakeven point in less than three years, largely because the new networking infrastructure requires no annual subscription fees or ongoing maintenance costs.

The pilot project has proven so successful that the research effort will be expanded over the next two years to include five hospitals that will be linked to 50 clinics. These additional vision centers will be able to service half a million patients in rural South India—most of whom have no access to eye care today.

These vision centers will positively impact the health of the Indian economy. A recent study by the Aravind Eye Care System showed that 85% of the men and 58% of the women who had lost their jobs due to sight impairment were reintegrated into the workforce following treatment. “This makes the role of the vision centers even more crucial,” says Aravind.

The presence of rural vision centers that provide video access to doctors will encourage people to seek early treatment for vision problems—a pattern that’s already emerging at the three initial centers. That could decrease the average time to first diagnosis and reduce the higher costs related to treating late-stage illnesses. In addition, low-cost network connectivity could enable each clinic to be monitored for key indicators, such as prevailing diseases and treatment results, which could aid in prevention efforts.

The clinics’ networking infrastructure could be used to in other ways as well—for instance, to deliver other kinds of medical services, to stream training videos to the vision center staff, or even to generate income by offering movies or other services to villages at times when the center is closed.

"Self-sustainability is a crucial aspect of the Aravind model, so we are greatly encouraged by all the indications that show these vision centers will break even sooner than we had anticipated. Based on our experience with the three initial centers, and the success of the cost-effective technology implemented by the TIER researchers, we are planning to penetrate new areas by scaling up to 50 vision centers in South India that will cover a population of 2.5 million. “This is an exciting venture, and we believe it has the potential to effectively address the problem of eye care access in rural India. TIER’s partnership has been invaluable in enabling this approach to get off the ground with such speed and success." Dr. S. Aravind Administrator, Aravind Eye Hospitals