The Hard Case of White Cataracts: Appropriation of Surgical Science

  • Logan D. A. WilliamsEmail author


Through a process of appropriation, the challengers created incremental and radical innovations in the niches. South Asian community ophthalmology professionals adapted and reinvented the surgical science of extracapsular cataract extraction to make it into a microsurgical technique and therefore provided the unique benefits of microsurgery to their patients. They were reconfiguring the users of microsurgical science from being wealthy urbanites to the rural poor. These professionals also created interlocking innovations that are multiple and complimentary, and composed of radical, incremental, and sub-system innovations. Aurolab (India) and Tilganga-FHIOL (Nepal) together sell more than 7% (by volume) of global intraocular lenses. Such a high market share represents a fully developed technology that can move from niche to regime. The linked finance, management, scientific, and technological innovations are now called interlocking innovations.


White Cataract Innovation Engagement Community Ophthalmology Small Incision Cataract Surgery (SICS) Tilganga 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The essence that we all kept in our mind was equality. For example, we are always interested in developments in technology. Our role in Tilganga was to see how best this technology could be translated to the benefit of the community, thus making it more accessible and affordable. Furthermore modifications and simplifications are done so that the impact could reach hundreds and thousands. (Dr. Sanduk Ruit , unpublished interview, 2012)

In June 2009, I was in Nepal on pilot fieldwork to confirm or refute my tentative thesis: Science and technology disseminates from the global south outward. Tilganga Institute of Ophthalmology, situated in Nepal, seemed an unlikely place to confirm this thesis because of the country’s small, poorly funded science and technology infrastructure (Singh and Bhuju 2001). Nepal represented a hard case, where, as sociologist Harry Collins (1982, 142 Collins Emphasis) explains,

to prove a general thesis you endeavour [sic] to prove it for the case where the thesis seems least likely to hold. The idea is that if you prove it for the case where it seems least likely to hold, it is fair to generalize to cases where it seems more likely to hold, whereas one has no warrant for generalizing in the other direction.

If I could prove a low-income country both produced and exported modern high-tech science and technology, then there was a chance I could make a more general case for innovation from below: Knowledge and artifacts developed by experts in the global south who are marginalized in the global field of science. Accordingly, I spent several hours in the operating theater at Tilganga to observe the new surgical technique for cataract surgery produced by Nepalese surgeon Dr. Sanduk Ruit. Dr. Ruit invented manual small incision cataract surgery (SICS); this surgical technique has helped to make Tilganga prominent among ophthalmology institutions in Asia.

In the operating theater, I stood to the medical resident’s left, and she stood to the Nepalese surgeon’s left. Together, the medical resident and I watched the Nepalese surgeon’s microscope feed on the video monitor. The medical resident, who was from a US hospital and visiting Tilganga on a several month observership, explained everything I could see on the video monitor. The resident and I oscillated between gazing up at the monitor and looking down at the patients during their operations. Most patients had completely opaque cataractous lenses—white, with hard centers. However, I was confused because the surgeon used the expensive ultrasound phacoemulsification probe. I wondered, why did this surgeon use phacoemulsification instead of the inexpensive manual SICS technique? When I indicated my confusion, the resident pointed to another video monitor across the room where I could watch the renowned Dr. Ruit perform the inexpensive manual SICS technique.

Unmet surgical needs are 11% of the global burden of disease (Ozgediz and Riviello 2008). Nevertheless, surgery surgical facilities and training surgical personnel are neglected globally (Farmer and Kim 2008). South Asian community ophthalmology professionals have long been leaders in addressing this neglect. Hence, expert-users, such as these South Asian ophthalmologists, are adapting surgical techniques to meet their ideological and service provision goals. Therefore, Indian and Nepalese ophthalmologists appropriated cataract surgical sciences in the global field of science. While cataract surgery is one of the most frequently performed surgeries in the world (Minassian et al. 2000), judging by the WHO (2004) cataract surgical rates map, ophthalmologists most frequently perform cataract surgery on patients with early stage cataract in wealthy industrialized nations in the West or global north.

White cataracts are both a literal and figurative hard case for surgeons. They are physically more difficult to surgically remove than early stage cataracts. Above, I have described how white cataracts are an allegorical hard case for epistemic sovereignty (Healy 2003), that is, whose knowledge counts as science. Thus, South Asian ophthalmologists had at minimum two motivations behind appropriating surgical sciences from Israel and the USA. In this chapter, I will discuss the fact that their first motivation was to make these surgical techniques useful for treating the physically “hard” case of white mature cataracts, and the second motivation was to move from being consumers of science to producers of science (Eglash 2004).

I have organized the remainder of this chapter, as follows: First, Sect. 6.1 summarizes theory on appropriation in science and technology studies. Section 6.2 describes why white cataracts are a difficult technical problem for both patients and surgeons. It also introduces a second technical problem—the long recovery times patients suffered when undergoing a specific cataract technique, the gold standard in the 1960s, called ICCE; and illustrates how Dr. Kelman solved the second problem by introducing phacoemulsification in the USA in 1967, which was too costly for widespread use on low-income patients. Thirdly, Sect. 6.3 utilizes appropriation theory to explain how Dr. Ruit created SICS in Nepal to again solve the problem of long recovery time, but to benefit low-income patients. Next, Sect. 6.4 again uses appropriation theory to expound on how Dr. Vasavada modified phacoemulsification in India for the advanced stage cataracts that typically occur in low-income rural patients. Subsequently, Sect. 6.5 illustrates how ophthalmologists from Ghana, Kenya, Mexico, India, and Nepal are conversant in the economic and scientific reasons to choose SICS versus Phaco for cataract surgery. I suggest the novel finance model discussed in Chapter  3 will not function effectively unless the South Asian surgeons are skilled in both the incumbent Phaco technique and the radical SICS technique. Section 6.6, concludes by indicating SICS is a radical innovation produced by domestic experts who have previously been identified by Westerner experts as consumers of Western scientific knowledge. Their identity is beginning to shift as they become knowledge producers—creating surgical sciences such as SICS and phacoemulsification. Finally, as an afterword, Sect. 6.7 reflects on Chapters  2 6 and discuss the multiple, complimentary knowledge and artifacts that are coming together with a radical ideology to form an interlocking innovation. These interlocking innovations are unique to the outsiders challenging the incumbent regime.

6.1 Theory: Appropriation

In this chapter, I argue that challengers to the incumbent regime use appropriation inside the appropriate technology niches to create radical innovations. Since diffusion and appropriation are concurrent in the niches, interlocking innovations form from the newly linked, incremental, and radical innovations that are multiple, complimentary, and contain sub-systems.

Appropriation is the movement from solely consuming a science or technology to actively producing a science or technology through: re-interpretation, adaptation, or re-invention (Eglash 2004).

Appropriation , however, can be a two-way street….people outside the centers of social power…have been able to use materials and knowledge from professional science for their own kinds of technological production. (Eglash 2004, 4–5)

Eglash (2004) explains, users acting closer to the consumption side of the spectrum are engaged in reinterpreting the semantic association of a science or technology, a change in meaning. Users engaged in adaptation are midway between consuming and producing science and technology to suit their needs; they are both reinterpreting and re-using science and technology. Finally, toward the production side of the spectrum, appropriation involves changing the structure of a science or technology in addition to reinterpreting its meaning or changing its use. At this final stage, users have become producers, where they are engaged in reinventing science and technology and maximizing their social power.

Appropriation is bilateral and unidirectional; science and technology transfers one-way from a dominant to a subordinate position in the field. However, by moving from simple consumption to production of scientific knowledge and technology, the subordinate position can increase its social power.

The problem sequence of addressing white cataracts within the global field of ophthalmology demonstrates appropriation . A large domestic population of patients with white cataracts was a global problem in the 1940s until foldable IOLs were invented in the late 1980s. Then, it became a problem unique to countries with scarce health infrastructure in the rural global south. Two surgeons in South Asia each created a solution to this problem. Dr. Ruit reinvented the new surgical technique of SICS , and later explained to The Kathmandu Post (2003), “we have successfully adapted the technology to local conditions without compromising on the quality and outcome.” Meanwhile, Dr. Vasavada adapted phacoemulsification for use on white cataracts. The two ophthalmologists encountered other problems while reinventing SICS and adapting phacoemulsification that they had to solve to make their surgical techniques viable for their target population of patients. I will illustrate how the appropriation of SICS and phacoemulsification resulted in the economically viable cost recovery schema I previously described in Chapter  3.

6.2 Hard White Cataracts and Lengthy Patient Recovery Times

White cataracts are advanced stage (or mature) cataracts that cause complete blindness. In white cataracts, the natural lens’ nucleus is often swollen (or hardened) at the center making it opaque to light with a white appearance.

[White cataracts] used to be [common]….The story was don’t operate until they are nearly blind because the outcomes [when operating on early stage cataract] weren’t nearly so good. And I was in training in the early 60s — early 50s and 60s when people waited. The farmers …would come — had to be led in almost when they had white cataracts. But you don’t see that so much [anymore]. (U.S. ophthalmologist and former President of the International Council of Ophthalmology, Dr. Bruce Spivey, unpublished interview, 2013)

Insufficient preventative eye care services mean there is often a time delay between cataract onset and opacified lens removal. This delay between onset and removal is more likely to occur to patients in LEDCs. In comparison, private health insurance and government medical care are more widely available for patients in wealthy industrialized nations. At present, patients in the global south are more likely to have white cataracts than patients in the global north (Chakrabarti and Singh 2000). Therefore, at the Lions Eye Hospital–Loresho, in Kenya, the chief medical officer, Dr. Fayez Khan (unpublished interview, 2011), is skeptical of how early cataractous patients in the USA, Europe, and Australia receive surgery; he deals with “real blind people” (a subtext he tries to prevent wealthy privileged people from undergoing surgery too early).

There are three types of white cataracts: intumescent, mature, and hypermature. Intumescent cataract is very soft having some swollen and opaque natural lens fibers (Chakrabarti and Singh 2000; Tabandeh et al. 1994). Mature cataracts occur after intumescence. The natural lens is completely opaque in mature cataracts. Opaque mature lenses sometimes hide a dense, hardened nucleus. A mature cataract may infrequently develop in a younger patient; typically, younger patients have a softer nucleus (Tabandeh et al. 1994). Hypermature cataracts occur after maturity when the natural lens fibers have liquefied or the anterior portion of the natural lens capsule is fibrous (Chakrabarti and Singh 2000).

Working on white cataracts was very common for Dr. Ruit in the late 1980s when he first started performing cataract surgeries. It was physically difficult for the surgeon. The surgeon’s work was furthermore complicated by poor access to surgical equipment, including microscopes and surgical instruments. While the problems with the procedure were many, one in particular stood out to Dr. Ruit—the recovery time for patients was too long. Sir Wilson also described this common problem with cataract surgery in the Royal Commonwealth Society for the Blind surgical eye camps in India, Pakistan, and Bangladesh:

If it is possible to have a ‘bottleneck’ connected to a ‘backlog’ then the bottleneck in most eye camps is the time patients remain in the camp after treatment. The operation takes about 10 minutes, the convalescence from seven to 13 days. (Wilson 1987)

Typically, in most eye camps, only one doctor was available to perform examinations and surgeries. Dr. Ruit would usually go alone or might occasionally bring a foreign colleague along to participate and observe. Ophthalmic assistants had to carry patients into the surgical building (or tent) and out again. The patients had to spend two to ten days recovering from the (typically) ICCE surgical procedure before they could walk upright. With such long recovery times, a surgical eye camp meant almost a two-week commitment, including travel, surgery, and patient recovery.

Family members tasked with feeding, bathing, and generally caring for patients in the camp found such an extensive convalescent time period prohibitive. These family members would lose the opportunity costs of daily work over that time period (Williams 2008). Ophthalmology professionals throughout India and Nepal typically worked in government hospitals and private clinics. They would volunteer their time to participate in eye camps (funded by the government or NGOs) to help reduce the rural cataract backlog. These ophthalmology professionals likely also found this extensive time commitment daunting.

One solution to reduce the extensive time commitment of patients, family members, and community volunteers, in addition to eye hospital staff, was to make the recovery process shorter. With a shorter recovery time, the inpatient procedure becomes an outpatient procedure and patients could quickly return home with sight. Making the surgery ambulatory had the added benefit of increasing surgical acceptance by persons with blindness.

Thirty years earlier, a US ophthalmologist named Dr. Charles D. Kelman also found this problem of making cataract surgery into an ambulatory procedure interesting. As the story goes, Dr. Kelman was reclining with his mouth open in his dentist’s chair when it occurred to him to create an ultrasound probe to emulsify the natural lens inside its capsular bag (making the procedure an adaptation of ECCE). The first phacoemulsification trial on a human subject occurred in 1967 (Hillman 2017).

From the early 1970s onward, Dr. Kelman, Dr. Robert Sinskey, and other prominent ophthalmologists perfected and diffused phacoemulsification technology. Ophthalmologists found it difficult to master the new phacoemulsification technique for various reasons (e.g., lack of training, lack of interest, and the controversy it caused in US ophthalmology circles). Many US ophthalmologists simply continued to remove cataracts with intracapsular cataract extraction using a large incision. Nonetheless, some prestige comes with knowing how to perform the “latest” and “most advanced” form of surgery; problems may be viewed as a challenge. It became preferred over manual ICCE in the USA by the late 1980s (Hillman 2017). The development of the foldable IOL gave surgeons an incentive to use a smaller initial incision into the eye which eventually led to the preference for Phaco.

Originally, the phacoemulsification ultrasound probe could be used through a small corneal incision (3 mm). However, the ophthalmologist would then have to enlarge that same incision in order to put the hard stiff plastic intraocular lens (5–7 mm) into the eye. This stiff plastic IOL was fabricated from the same inexpensive material, Perspex, as used by the British ophthalmologist, Sir Harold Ridley, for the first IOL he implanted in 1949 (Apple and Sims 1996; see Chapter  5). Since then, the design and materials had been refined, creating a lightweight and more easily implanted lens (Jaffe 1996). However, the surgeon still had to enlarge the small corneal incision before placing the cheapest (and most popular) stiff plastic Perspex lens inside the eye.

With the foldable intraocular lens, came the advent of a small corneal incision that remained small throughout the entire surgery. In 1984, Dr. Thomas R. Mazzocco created a foldable intraocular lens from silicone, a plastic-like material much softer than Perspex (Boyle 2007). One could place this foldable lens into the eye through the small corneal incision without enlarging the incision. The ability to keep the small corneal incision small through the entire surgery is preferable because it has three desirable outcomes: (1) it requires fewer sutures to close; (2) it heals faster; and (3) it reduces the incidence of post-surgical myopic astigmatism. Post-surgical myopic astigmatism is a form of nearsightedness (where the patient sees well up close, but has trouble seeing distant objects). Post-surgical myopic astigmatism is caused by the corneal incision deforming the cornea. For the patient to have closer to 20/20 vision, he or she would need to pay for additional vision correction for better distance vision: either eyeglasses or Lasik™ refractive surgery.

Phacoemulsification clinical trials with the new foldable lens design started in 1986 (Boyle 2007). Dr. Charles Kelman presented a paper on small incision phacoemulsification in 1988, calling it SICS (Program for the LaserPhaco Symposium 1988, March 27). The smaller incision enabled the eye to heal faster, which meant patients could leave the hospital right away, thus converting what was previously an inpatient procedure into an outpatient procedure.

Patient interest in an ambulatory (or outpatient) procedure provided some pressure on US ophthalmologists to learn phacoemulsification. However, the phacoemulsification technique was difficult to master, and some surgeons were better at it than others. Also, in comparison with ECCE, it was very expensive to maintain the phacoemulsification equipment and invest the high capital costs for remedial surgical training. Nevertheless, by the early 1990s, ophthalmologists in the USA most frequently performed phacoemulsification (instead of manual ECCE) because it was an ambulatory procedure that involved a very small incision decreasing the recovery time for the patient.

Wealthy white-collar US patients receiving the surgery appreciated the new ambulatory procedure. In 1993, ophthalmology surgeries represented the most frequent (28%) ambulatory surgeries performed at the independent surgical centers throughout the USA which were rapidly increasing in number (Durant and Battaglia 1993, 84). By 1994, 80% of the cataract surgeries in the USA were ambulatory in comparison with 8% of the cataract surgeries in the UK (Chell et al. 1994). British patients who underwent ambulatory cataract surgery reported they would recommend it to others even though it was not yet a common procedure in the UK (Chell et al. 1994).

6.3 Inventing SICS in Nepal

Making the cataract surgery into an ambulatory procedure was an important innovation in global surgical technology-practice that involved adopting microsurgery. To do this in Nepal meant creating a new type of ECCE by appropriating mini-nuc to create SICS in 1994. Ophthalmologists in Nepal believe they performed the first ambulatory surgery in the developing world when they utilized SICS technique with IOL implantation in surgical eye camps in the Himalayas during the 1990s. They felt their novel SICS technique was very controversial in the global field of ophthalmology during the mid-1990s. Not only did ophthalmologists debate ambulatory surgery, but additionally Nepalese patients themselves resisted ambulatory surgery:

We had to start. If we had to admit the patients, then the staff would double; the running costs would be another 30-40%; so we started that on our own to make it easier to run the whole show… We had resistance from the patients themselves as well. All their lives you have the surgery then they have to be in the hospital. Now Tilganga is saying, “go home and come back the next day… you will be fine”… Now the patients don’t even ask; it’s the norm. If the patient is admitted now, then they ask the doctor “why?” (Ophthalmologist at Tilganga Institute of Technology 2012)

By the 1990s, US governmental agencies were providing health remittances for cataract surgeries such as phacoemulsification with short recovery times because they were less costly than cataract surgeries such as ICCE and ECCE with longer recovery times (Metcalfe et al. 2005). Similarly, this Nepalese ophthalmologist (see above quote) was cognizant of the huge cost differential and, therefore, preferred to provide the less-expensive outpatient care. Over time, Nepal followed the West and ambulatory surgery became the new standard practice for patients with cataract disease. This was only possible because Dr. Ruit appropriated mini-nuc to create SICS for inexpensive ambulatory surgery for Nepalese patients with white cataracts.

Dr. Michael Blumenthal invented the mini-nuc technique in Israel in 1994. Mini-nuc was novel because it did not require expensive viscoelastic (an artificial, biologically non-reactive, soft plastic or silicone material) nor suture (thread for sewing wounds closed). Dr. Blumenthal’s procedure uses a small sclera-corneal tunnel incision (5–6 mm) to enter the eye. The small sclera-corneal tunnel incision that Dr. Blumenthal uses takes a long time to learn, but when performed properly it does not require expensive suture for the self-sealing wound (Blumenthal 1994).

The continuous curvilinear capsulorhexis is the first incision into the natural lens capsule. Consequently, after the continuous curvilinear capsulorhexis incision, the surgeon next utilizes hydrodissection: he or she directs the intense water pressure to separate the natural lens into the epinucleus and nucleus inside the natural lens capsule. Then, the ophthalmologist removes these two parts from the natural lens capsule and (through the sclera-corneal tunnel) out of the eye (Blumenthal et al. 1992). This procedure must occur under positive intraocular pressure in order to keep the lens pieces from damaging the cornea as they are removed (Blumenthal et al. 1992).

Throughout the surgery, a re-usable device called the anterior chamber maintainer sustains positive intraocular pressure inside the eye. The anterior chamber maintainer provides positive intraocular pressure from a constant feed of balanced saline solution elevated above the patient’s head. This is why the mini-nuc technique never requires expensive viscoelastic (Blumenthal et al. 1992; Blumenthal 1994).

Dr. Blumenthal shares the results of his new procedure in a letter to the Community Eye Health Journal (which is circulated around the world by the World Health Organization Vision 2020 program at no cost to the recipients). In this letter, he says,

[T]here exists another system which is suitable to any part of the world and any economic situation. I developed the mini-nuc technique. With a very small number of instruments one can achieve safe and very high standard cataract surgery, with or without an [intraocular lens]…There are the means to perform perfect cataract surgery around the globe safely, no viscoelastic material, no sutures, very cost effective. The only thing to be done is to learn how to do it! (Blumenthal 2002)

Certainly replacing expensive single-use ophthalmic consumables with re-usable instruments or new techniques made Blumenthal’s mini-nuc technique more viable for low-income patients.

Creating SICS required innovative changes, including reinterpreting the name from Kelman’s phacoemulsification and modifying Blumenthal’s mini-nuc technique to make it quicker and even less expensive. Both Aravind and Tilganga needed to determine which microsurgical technique (extracapsular cataract extraction, mini-nuc, or phacoemulsification) would have good post-surgical outcomes and keep costs low. In his publication about his technique, Dr. Ruit defines the problem as such:

Innovations that reduce the cost, complexity and operating time, but without compromising ocular safety and vision outcome, are urgently needed in the surgical management of cataract in the developing world. The size of the back-log and new caseload of cataract blindness, and the limited human and material resources most countries have available to devote to the problem, mean that any such innovation can have a disproportionate benefit in the numbers of patients treated effectively. (Ruit et al. 2000)

Dr. Ruit (unpublished interview, 2012) recalls Dr. Blumenthal demonstrating his technique when visiting Tilganga. Upon Dr. Blumenthal’s death in 2007, Dr. Ruit (with his US and Nepalese colleagues at the nonprofit Tilganga Institute of Ophthalmology) had already standardized and begun disseminating an adapted form of Blumenthal’s technique (Ruit et al. 2000, 2007; Tabin and Newick 2008; Tabin et al. 2008). The South Asian ophthalmologists (and their Western colleagues) working at Tilganga call Ruit’s adaptation of Blumenthal’s mini-nuc technique “small incision cataract surgery” (Ruit et al. 2000, 2007; Tabin and Newick 2008; Tabin et al. 2008). Dr. Kelman had previously applied the term SICS to his small incision phacoemulsification with foldable IOL. In fact, when I spoke with three US ophthalmologists in 2010, they were unfamiliar with the South Asian SICS; they thought I meant phacoemulsification. However, community ophthalmology professionals have now reinterpreted the name SICS to mean a manual, non-phacoemulsification, sutureless, microsurgical ECCE technique (Chakrabarti and Singh 2000; Natchiar and Kar 2000; Ruit et al. 2000).

Ruit and his colleagues performed one primary modification in order to reinvent mini-nuc into SICS making it cheaper and faster. Their modification was to use air to keep the anterior chamber at the correct depth instead of relying upon saline from the anterior chamber maintainer (Ruit et al. 2000). In Ruit’s SICS technique, once the surgeon successfully implants the intraocular lens, then he or she irrigates the anterior chamber of the eye with water to force the air out. With these modifications, SICS does not require: suture, viscoelastic, or an anterior chamber maintainer. It does require a higher degree of surgical skill to complete the surgery safely without those consumables and tool. Ruit also indicates his technique uses hydrodissection for early stage or immature cataract (similar to Blumenthal’s mini-nuc technique). However, hydrodissection is not necessary for advanced stage or mature cataract (Ruit et al. 2000).

Dr. Ruit is recognized as the inventor of SICS and is the most well-known champion of the procedure in Asia. As one ophthalmologist at Tilganga explained,

I can’t tell you if we are the ones doing it first, but we are definitely continuing to modify it so it is easier to learn or more cost effective…. It will be easier, or, there are different things going on, like, if I do it this way, I [will] use less instruments going into the eye, you know, that sort of thing? …. They are very small things which make a large difference, but at the same time if I say, this is one of the modifications that we do—then others will say, that is not a modification, that is just one thing you do. Training is the main way of dissemination. (Ophthalmologist at Tilganga Eye Center, July 2009)

So this Nepalese ophthalmologist does not know who first created or used the manual SICS in South Asia. However, since patenting surgical procedures varies with national laws, the scientific literature serves as the evidence necessary to resolve priority disputes and name the first inventor. In this scientific literature, Dr. Ruit claims the title of inventor (Ruit et al. 1991a, b, 2000).

Similar to Dr. Ruit, Dr. R. D. Ravindran was one of the first South Asians to perform M-SICS in the region. By his own account, Dr. Ravindran introduced microsurgery to his colleagues at Aravind after attending an ophthalmology meeting in Boston in 1991. While the exact timeline of this introduction is unknown, since the late 1990s, the Aravind Eye Care System has taught and utilized a scleral-corneal tunnel incision with an instrument, called an irrigating vectis, and the consumable, viscoelastic, for their version of M-SICS (see Natchiar and Kar 2000).

While the additional instrument and consumable make Aravind’s M-SICS more expensive than Dr. Ruit’s SICS, M-SICS is also very popular. The most likely reason for M-SICS’ popularity is that more ophthalmologists have been trained in it. Alternatively, Aravind’s M-SICS might be more popular because it is easier to perform than Dr. Ruit’s SICS.

Some might argue SICS and M-SICS are not innovative as they involve removing a high technology (or a salable product, the phacoemulsification machine and attached ultrasound probe) and adding an increase in the surgeon’s surgical skill. However, these ophthalmologist-inventors and their allies report significant modifications which make the technique more efficient: 5 minutes for SICS in comparison with 15 minutes for phacoemulsification (Chang 2005a, b; Ruit et al. 2000). Tilganga conducted an “expert clinical trial” with the prominent US phacoemulsification surgeon, Dr. David F. Chang (Ruit et al. 2007; Wormald 2007). They point to this expert clinical trial as evidence SICS and phacoemulsification are two comparable surgical techniques with equivalent outcomes.

To promote their SICS, Tilganga published in prestigious English-language journals as Current Opinion in Ophthalmology and the American Journal of Ophthalmology as part of their dissemination strategy (Latour 1987; Tabin et al. 2008). They also participate in regional and international conferences and train domestic and referred (foreign, from all over the world) ophthalmologists in their surgical techniques. Later—perhaps because of their high visibility in the global field of ophthalmology—Tilganga and their partner NGO, Himalayan Cataract Project, were asked to demonstrate financially viable, high-volume cataract surgery to the United Nations Millennium Villages Project in Africa (see Chapter  7). Dr. Sanduk Ruit demonstrated M-SICS in instructor sessions at six American Academy of Ophthalmology (2018) meetings from 2001 to 2006. Likewise, Dr. A. Haripriya, the chief of the cataract clinic at Aravind Eye Hospital, Madurai, demonstrated M-SICS in skills transfer sessions at the American Academy of Ophthalmology (2018) meetings in 2010, 2011, and 2012. These peer-reviewed short courses establish that the surgical techniques of SICS and M-SICS, reinvented by South Asians, helped these community ophthalmologists to accrue social power in the global field of international development and in the global field of ophthalmology.

6.4 Adapting Phacoemulsification in India

Around the same time Dr. Ruit worked on appropriating SICs, other ophthalmologists were pondering a third technical problem: Poor post-surgical outcomes made phacoemulsification inappropriate to use for advanced stage white cataracts (Wormald 2007).

Phacoemulsification’s global popularity with ophthalmologists seems incongruous considering its poor suitability to remove white cataracts. Initially, the idea was phacoemulsification would make removing the hardened natural lens easier (Metcalfe et al. 2005). However, patients with hard white cataracts commonly experienced poor post-surgical outcomes in the form of capsular plaques. The hardened (or dense) nucleus is a poor candidate for phacoemulsification because, after emulsification, the hard lens pieces are more likely to damage the natural lens capsule’s endothelium (Vasavada et al. 1998). A damaged endothelium often results in later capsular plaques, which block vision and necessitate further surgery (Vasavada et al. 1998). For this reason, until the late 1990s ophthalmologists have not favored phacoemulsification surgery over extracapsular cataract extraction for this advanced stage of cataract (Chakrabarti and Singh 2000; Jaffe 1996; Vasavada et al. 1998).

My explanation contradicts part of the problem sequence described by Metcalfe et al. (2005). These business scholars claim phacoemulsification was the trigger for further innovation in lens design and surgical procedure, in part because of its usefulness for “hard cataracts” (Metcalfe et al. 2005). In contrast, I suggest the following two important points, based on the medical science literature as well as interviews with US ophthalmologists. Firstly, that phacoemulsification was not universally accepted as “the right tool” for the job (Casper and Clarke 1998) before the late 1980s. In other words, phacoemulsification was not widely utilized to correct cataracts prior to the introduction of the foldable intraocular lens which turned it into an ambulatory surgical procedure. Secondly, phacoemulsification was not particularly useful for hard white cataracts because it caused a post-surgical complication in the eye again resulting in blindness for the patient.

This alternative explanation still matches the diffusion charts made by Metcalfe et al. (2005), which demonstrate the increased uptake of phacoemulsification by ophthalmologists in the US and the UK starting in the 1980s. Additionally, this alternative explanation provides rhetorical space for describing a second important contribution to modern medicine made by marginalized ophthalmologists in the field of ophthalmology: An Indian pediatric ophthalmologist appropriated the phacoemulsification technique in order to make it viable for white cataracts in India.

Dr. Abhay Vasavada started the Raghudeep Eye Clinic in 1984. It is a for-profit clinic located in the state of Gujarat in western India. Raghudeep Eye Clinic has a dedicated research center affiliated with the Indian Department of Science and Technology. Volunteers from the Raghudeep Eye Clinic provide free cataract surgeries at the local Red Cross Hospital. They perform all cataract surgeries by phacoemulsification. All lenses are the expensive, high-quality Alcon AcrySoft® brand. Dr. Vasavada has been working with AcrySoft® lenses for more than a decade; he won a “best paper for session” on this research at the 2000 American Society of Cataract and Refractive Surgery meeting. He also won awards at the American Society of Cataract and Refractive Surgery meetings in both 2007 and 2008. Dr. Vasavada’s journal article (see Vasavada et al. 1998, 1) detailed the changes in both the phacoemulsification technique and the operation theater necessary for the successful removing white cataracts with good post-surgical outcomes.

One adaptation was adding an endoilluminator, a tiny cylindrical light typically used to illuminate the inside of blood vessels, to the operation theater. Removing a white cataract with phacoemulsification is difficult. The opacity of white cataracts creates poor visibility conditions for a surgeon operating within a patient’s eye. Changes were necessary in the operating theater to adapt it to performing phacoemulsification on white cataracts. Dimming the lighting in the operating theater and using an endoilluminator relieves the poor visibility for the surgeon operating upon eyes with white cataract (Vasavada et al. 1998; Chakrabarti and Singh 2000).

A second adaptation was adding a consumable, viscoelastic, to the technique. The intumescent (extremely swollen) cataractous lens is difficult to remove due to the increased intracapsular pressure. The increase in intracapsular pressure makes the continuous curvilinear capsulorhexis incision more challenging. Vasavada and his colleagues describe the necessary changes in the continuous curvilinear capsulorhexis incision required to adapt phacoemulsification for white cataracts (Vasavada et al. 1998).

While utilizing the ultrasound probe, the anterior chamber pressure should be carefully maintained to prevent natural lens material leaking from the natural lens capsule. If natural lens material leaks out, then viscoelastic is needed to fill the natural lens capsule and maintain anterior chamber depth so the ultrasound probe can continue to emulsify the lens without damaging the natural lens capsule endothelium (Vasavada et al. 1998; Chakrabarti and Singh 2000). Vasavada’s phacoemulsification technique successfully demonstrated using viscoelastic to reduce the chances of post-capsular plaques after operating on white cataracts. After the ultrasound probe has completed breaking the lens, the surgeon suctions out the lens pieces and places the soft foldable intraocular lens into the natural lens capsule. Finally, a single suture (and occasionally no suture) seals the 3 mm corneal incision into the eye.

The Raghudeep clinic continued to report their successes in innovative surgical science at the American Society of Cataract and Refractive Surgery meeting in 2009. Dr. Vasavada gave the prestigious Binkhorst Lecture, which he entitled, “Pediatric Cataract: The Compelling Quest,” for the 2011 American Society of Cataract and Refractive Surgery meeting. This invitation from the American Society of Cataract and Refractive Surgery reveals Dr. Vasavada’s increased stature in the global field of ophthalmology primarily results from his pediatric ophthalmology work, not his incremental adaptation of phacoemulsification.

In summary, a South Asian ophthalmologist appropriated the phacoemulsification surgical technique for treating advanced stage cataract disease. His suggested changes include small modifications to the surgical technique itself (in the form of new tools from cardiovascular surgeries, a slight change in incision style, and the standardized use of viscoelastic) and to the operating theater (in the changes in lighting and magnification). With these adaptations in the technique and the theater,

[w]hite cataract has ceased to be a contraindication to phacoemulsification … [h]owever… [i]f there is difficulty at any stage (hard nucleus, repeated nucleus prolapse into anterior chamber), we recommend timely conversion to the manual nonphacoemulsification sutureless technique, which preserves most of the benefits of small incision cataract surgery [(also called phacoemulsification)]. (Chakrabarti and Singh 2000)

Due to Vasavada’s inventive efforts, phacoemulsification can safely be used in the hard case of white cataracts with the qualification: If there is a problem during surgery, then the ophthalmologist should immediately convert to the manual SICS technique. The similarities between phacoemulsification and SICS are obvious: Each surgery is now technically appropriate for the hard case of white cataracts, and both solve the technical problem of long patient recovery times by utilizing the IOL as a complimentary technology. Community ophthalmologists choose to SICS versus Phaco for a variety of reasons.

6.5 Cost Recovery Requires SICS and Phaco

As demonstrated by their coverage at the Asia-Pacific Academy of Ophthalmology,

In a head-to-head comparison of phaco and SICS, with the techniques performed respectively by [U.S. ophthalmologist] David Chang, M.D., and Dr. Ruit to treat 180 “typical cases”—patients with hyper-mature cataracts in Nepal—SICS was comparable in terms of safety. It also showed a distinct advantage in terms not only of cost, but also of ease, time, and visual outcomes in these cases. About 70% of the Nepalese patients who underwent phaco in Dr. Chang’s hands achieved 20/60 or better vision; more than 90% achieved 20/60 or better after SICS with Dr. Ruit, (Anonymous 2010)

ophthalmologists in the autonomous global network to eradicate blindness discuss both the economic imperative and the scientific evidence for SICS. They really believe in its efficacy for resource-constrained settings. Reinventing SICS and adapting phacoemulsification for white cataract have put South Asian ophthalmologists in an enviable position: They are proficient in both surgical techniques and, therefore, are cognizant of the advantages and disadvantages of each. Community ophthalmologists believe both techniques are necessary for their social entrepreneurship model.

The scientific reasons for using SICS include the fact that SICS is safer for patients with white cataracts or complicating medical conditions. When I interviewed Dr. James Clarke (Crystal Eye Clinic , Ghana) at the Unite for Sight Global Health and Innovation Conference at Yale University in April 2011, he told me he preferred SICS because it did not require expensive sutures, was cheaper than Phaco, and also because, “SICS is a newer technology that has come in, it gives much better results at less cost …. The cataracts we see—they are very dense. We are not sure how well that Phaco will perform.” Similarly, Dr. Sanduk Ruit (2012) asked, “[h]ow to make Phaco a safer technology? Put it in the heads of Western ophthalmologists that Phaco cannot be applicable to all cataracts in developing countries… Without question that there are a lot of cataracts in small developing countries that you cannot use Phaco and SICS is superior.” In the 2007 expert clinical trial, Dr. Ruit and his colleagues found they had lower complication rates when they used SICS on white cataracts as compared to expert Asian-American Phaco surgeon Dr. Chang who used Phaco on similar white cataracts in Nepalese patients (Ruit et al. 2007). A clinical trial by Indians at a hospital in Pune, Maharashtra, India, also found SICS is better than Phaco for white cataracts (Gogate et al. 2005, 2007).

In Mexico, Dr. Juan Pablo Olivares (unpublished interview, 2012) discusses whether SICS or Phaco is better for hard white cataracts:

I think that for very hard mature or hypermature cataracts that SICS is a better technique when done by a properly trained surgeon. Why? Because there aren’t differences in visual acuity results as well as complication rates and the main advantage is that we spare the endothelial damage to the endothelial cells by not using Phaco; not using the ultrasound really helps with that. Hypermature or really hard cataracts are mostly seen in very old patients so the endothelial damage is already there; that would be my preferred technique for hard brown. [Dr. Ruit‘s SICS] technique was first described using an anterior chamber maintainer (using simcoe cannula to irrigate the anterior chamber constantly) and it is more difficult to perform. That technique has more complication rates than what Aravind does [for M-SICS]. With viscoelastic, even though it is more expensive the cost benefit to the patient is very good.

In the last week of September 2012, Dr. Olivares made a presentation at a congress for medical doctors based on the results at Sala Uno. When he or his team utilized M-SICS or Phaco both resulted in good outcomes for the patients and the same complication risk were the same. SICS/M-SICS has better one-day and one-week postoperative vision compared to Phaco (Ruit et al. 2007). As I previously pointed out, if there are any problems with Phaco, the surgeon must convert to ECCE or SICS.

Economic reasons for using SICS on white cataracts include its speed: At five minutes, SICS is faster than the fastest Phaco surgeon who typically takes fifteen minutes (Chang 2005a, b). It is also cheaper, as it is one-tenth to one-eighth the cost of Phaco (Chang 2005a, b). Being fast and cheap is excellent for addressing the backlog of patients who are blind due to cataract, but the fact that the technique is manual and does not require electricity (unlike typical phacoemulsification probes) is a definite advantage for low-income countries with poor electricity infrastructure. In addition to the economic and scientific reasons, there is the social justice reason, which has close ties to the high-volume practices discussed in prior chapters. Dr. R. D. Ravindran (2012) suggests SICS is best for resource-constrained settings in order to address the backlog of individuals with cataract. Yet, the cost recovery from user fees would be incomplete without utilizing both SICS and phacoemulsification. The eyes of patients for whom surgeons choose SICS versus phacoemulsification differ for both scientific and economic reasons.

Ophthalmologists commonly utilize phacoemulsification for immature cataractous lenses diagnosed in patients with early access to medical care; such patients are typically located in urban industrialized areas. While phacoemulsification has a transnational definition of “high technology” that assumes modern Western scientific knowledge is the best and most important, it was demonstrated as inappropriate for advanced stage white cataracts, which are typically more prevalent in less economically developed countries. However, ophthalmologists in South Asia have engaged in a process of adaptation on a transnational stage to develop special techniques and changes in the operating theater. These special techniques and changes facilitate successfully applying phacoemulsification to the hard case of white cataracts while further validating its standing as “high tech.” However, there are two reasons why the surgeon might convert from phacoemulsification to extracapsular cataract extraction (or SICS). The conversion is necessary if there are complications during phacoemulsification, or the patient has contraindications for phacoemulsification, such as high intraocular pressure, high blood pressure, or high blood sugar.

The scientific reason why one might prefer phacoemulsification is that, with its smaller incision, there is no astigmatism, thus there is no need for distance glasses (Dr. R. D. Ravindran, unpublished interview, 2012). The chief medical officer of Sala Uno in Mexico, Dr. Juan Pablo (unpublished interview, 2012), explains it this way:

I would also say that I would prefer Phaco for other types of cataract, for younger patients. [SICS is not as good as Phaco] [b]ecause of the astigmatism with a bigger incision. Younger patients in their forties are people who are still working; their expectation about the results is totally different than an 80-year-old person who is at home or watching TV or who does not have a very agitated style of living.

Dr. Khan (unpublished interview, 2011) in Kenya and Dr. Ravindran (unpublished interview, 2012) at Aravind make similar statements about the need for Phaco to satisfy white-collar or wealthy patients with their higher expectations for their post-surgical visual outcomes. Dr. Ruit (unpublished interview, 2012) agrees, saying that “Phaco is like a very committed fashion; there are a lot of MNCs interested there. It is a fantastic procedure.” Depending upon a patient’s social context and his or her surgeon’s proficiency in SICS versus Phaco, patients who undergo Phaco surgery are less likely to require distance glasses and therefore may be more fashionable. Scientifically, Phaco may be better for patients who might have other eye diseases. An ophthalmologist at Tilganga Institute of Ophthalmology (unpublished interview, 2012) prefers Phaco personally saying, “If you have to do other surgeries in the future, such as glaucoma, it’s a better surgery.”

Decreasing the phacoemulsification equipment costs will make the technique more viable for the global south. Professionals at Aravind and Tilganga plan to continue to produce technology locally to make phacoemulsification machines less expensive. For example, Aurolab already produces their low-cost Pegasus phacoemulsification machine—but only for sale in India (Williams 2012, July 21). In 2011, Tilganga announced its plans to make a low-cost, battery-operated Phaco machine for use in their outreach microsurgical eye camps in Nepal.

Using Phaco is important for cost recovery in community ophthalmology. Aravind’s model of social entrepreneurship requires the performance of phacoemulsification as distinctive because it is the “Western technique.” Ophthalmologists can therefore justify charging the wealthier patients higher prices for the latest Western surgical technique and for the use of the expensive phacoemulsification ultrasound machine—the latest Western surgical technology. This conspicuous consumption enables the sliding scale fee system where high-income patients subsidize services for non-paying and low-income patients.

An economic reason for NGOs and government hospitals to continue using Phaco in resource-constrained settings is to keep high-income patients who might otherwise go to the private sector, which would reduce or eliminate the sliding scale fee schedule in the Robin Hood model of cost recovery. At this chapter’s beginning, I discussed my confusion while completing 1.5 months of fieldwork at Tilganga in 2009. I wondered, why were they doing Phaco if they had reinvented SICS? Before returning to Tilganga in 2011, I posed this question to the ophthalmologists I interviewed at the Lions Eye Hospital, Loresho in Kenya. They answered that offering Phaco procedures is necessary to be competitive with other eye hospitals and clinics; in order to keep their rich patients, they had to offer the “laser surgery.” Laser surgery is the vernacular term some South Asian and Kenyan patients use for phacoemulsification, which involves an ultrasound probe. It should not be confused with the term LaserPhaco which involves a laser probe invented by African American ophthalmologist Dr. Patricia E. Bath (Davidson 2005; Program for the LaserPhaco Symposium 1988, March 27).

In 2003, Loresho ophthalmologists were among the first Kenyan doctors to offer phacoemulsification. Dr. Khan (unpublished interview, 2011) remembers that,

[b]efore we started offering phacoemulsification to treat cataract disease, there were only two other hospitals performing this Western technique [in Kenya]. High-income patients used to come to Loresho and ask, ‘are you doing the laser surgery?’ When the answer was no, they would go somewhere else to have their cataracts treated. Phacoemulsification was a necessity for survival; we were losing high-income patients to the private sector.

These high-income patients were necessary for their user fees to enable them to subsidize low-income patients. Now, Loresho claims to perform the most Phaco surgeries, corneal grafts, and SICS in Kenya.

Cost recovery requires conspicuous consumption resulting in fees from the rich subsidizing the poor. I saw a straightforward example of this when sitting in the waiting room of Dr. Jyotee Trivedy’s executive clinic at Loresho in Kenya. In her clinic, a female nurse (or perhaps a counselor) was trying to convince a family to purchase phacoemulsification cataract surgery with Alcon lenses for their older male relative, because “it is the best Western surgery.” Dr. Ruit (2012) explains that with “Phaco/SICS there is a cost differential. There is a lot of demand from the affluent community for Phaco. If you want to serve poor people you have to serve the rich people.” When my mother visited the optical shop at Loresho, she commented with surprise that there was no perceptible cost difference between the cost of eyeglasses from Kenya and those from the USA (2011). While this cost recovery is very positive because it provides free surgery for the poor, it has a negative aspect: After moving away from a double standard of ICCE/ECCE at the global level for low-income countries/high-income countries, it appears to advocate a new double standard of SICS/Phaco at the local level for poor/rich patients.

Eye hospitals in LEDCs focus on the cost-effectiveness of SICS; this is why they want to disseminate it further. Nonprofit organizations in India and Nepal have developed SICS and focused on its cost-effectiveness. As a result, many South Asian ophthalmologists are experts in both SICS and phacoemulsification—knowledge held by very few Western ophthalmologists. The equivalent efficacy with faster speed and lower cost makes SICS more viable than phacoemulsification for any nation-state trying to reduce the cost of cataract surgery (Anonymous 2010; Blumenthal 2002; Ruit et al. 2007; Wormald 2007).

6.6 Conclusion: SICS Is a Radical Innovation from Below

Community ophthalmologists have problematized the developmentalist (and exceptionalist) understanding that Western industrialized countries create sophisticated high technology and disseminate it to less economically developed countries. Community ophthalmologists are producing high-tech surgical science from a peripheral location in the world-system: South Asia. With its higher density of patients with advanced stage white cataract, South Asia was a propitious location to advance cataract surgical practice in order to make the surgical science viable for the physically hard case of white cataracts. Therefore, the re-invention of SICS by Nepalese ophthalmologist Dr. Ruit and the adaptation of phacoemulsification by Indian ophthalmologist Dr. Vasavada together serve as a physical and figurative hard case (Collins 1982, 142). Each example of appropriation demonstrates domestic experts who are citizens of a less economically developed country can produce sophisticated science that is novel and contextually appropriate. This production of advanced modern science and technology in the global south is a necessary step before it can be circulated. Therefore, these examples serve as further evidentiary foundation for conceptualizing innovation from below.

Scientific and technical experts in the global south were interested in distributional justice and epistemic sovereignty; their interests influenced them to produce innovation from below. Firstly, community ophthalmologists were interested in distributional justice, that is, who benefits from the science. Through reinterpreting, adapting, and reinventing ambulatory SICS, these Indian and Nepalese ophthalmologists configured the patient-users (Woolgar 1991) of sophisticated high technology; they reinterpreted patient-users from the urban white-collar rich professional to the poor rural subsistence agriculture worker.

Secondly, community ophthalmologists were interested in epistemic sovereignty (Healy 2003). They wanted to assert themselves as credible, inventive experts without relying upon knowledge and surgical practices from the West. After reinventing mini-nuc to create SICS, both Dr. Sanduk Ruit and Dr. R. D. Ravindran have suggested SICS (M-SICS) is best for less economically developed countries (Ruit et al. 2007; Anonymous 2010). South Asian community ophthalmologists are using the radical innovation of SICS to challenge the necessity and suitability of “the master’s tools” (Lorde 2003 [1983]) in the global field of ophthalmology, i.e., Western science and technology. This is on a global scale where local experts in resource-poor areas of the global south challenged the knowledge hierarchies separating them from foreign experts in wealthy industrialized countries of the global north (Nieusma 2007). Southern ophthalmologists reconfigured (Eglash 2004; Woolgar 1991) themselves by shifting their identities from expert-users to expert-producers of sophisticated surgical science.

Innovative users can produce advanced modern science and technology. While South Asian ophthalmologists upheld phacoemulsification as the gold standard for performing cataract surgery globally, they also became producers of scientific knowledge and high technology. They did so by proving SICS: has equivalent outcomes to Phaco, is safer than Phaco (for eyes with white cataracts or for patients with other complicating factors such as high blood pressure), and is better suited to the high-volume radical finance Robin Hood model to treat the backlog of patients needing cataract surgery.

In this chapter, I have demonstrated how medical scientists in LEDCs contributed to global modern science and technology in the field of ophthalmology. Utilizing scant resources, they have re-created two highly technical forms of surgery through “appropriation,” where they have moved along the spectrum of “users” from consumption to production (Eglash 2004).

6.7 Afterword: Interlocking Innovations

[T]he way it is done is multiple. You know, it is done through training, it is done through consulting process, (pause) giving of products, giving applications for software. You know, IOL … that’s a big part …. So I think it’s happened in multiple ways. (Thulasiraj Ravilla, MBA, Aravind Eye Care System, unpublished interview, 2012)

The hard case of white cataracts provides a stopping point for reflection about how outsiders challenge an incumbent socio-technical regime, and the relationships between science and technology innovations developed in appropriate technology niches . Community ophthalmology professionals are challengers to the incumbent Phaco-regime; they created SICS as a radical innovation and adapted Phaco for white cataract as an incremental innovation. These two surgical innovations could have been competitors in a technology substitution transition pathway. Instead of being solely competing surgical innovations, they additionally are useful in the global south as complimentary innovations in appropriate technology niches .

Making surgical science both high quality and low cost is not enough; the entire process of eye health care should be inexpensive. For cataract surgery, this necessitates low-cost surgical science and technology consumables. Producing low-cost IOLs in the Global South has had a global impact providing IOLs very inexpensively to the world. By 2012, at Tilganga, the Fred Hollows Intraocular Lens Laboratory (FHIOL) was producing high-quality intraocular lenses certified by the European Union. It was also providing 80% of the lenses used in Nepal and selling lenses in Africa, Asia, and Australia. From 1994 to 2012, Tilganga-FHIOL produced 2 million lenses that they exported to forty countries (The Fred Hollows Foundation 2012).

Likewise, in 2012 Aravind‘s manufacturing unit claimed 7% of the intraocular lens sales worldwide (this measure is by volume, not by income); earlier they had claimed 10% in 2005 (Oregon Public Broadcasting 2005). Aravind Eye Care System reinvests all revenues (Rubin 2001). Having initiated the local production of low-cost, high-quality ophthalmic consumables in less economically developed countries, it is now the leader among three manufacturers in India that produce more than 1 million intraocular lenses a year (Aravind et al. 2008).

This demonstrates both Aravind and Tilganga together have gone past the 5% of the market indicating an innovation is ready to breakthrough from niche to regime (Geels and Schot 2007, 405; Rogers 2003). They have made both ophthalmic surgical science and technology consumables less expensive globally. However, the ancillary costs for energy, personnel, and technology maintenance exceed the cost of new medical technology (Kressley 1981, 312–13). This is the nature of a socio-technical system: Instruments are connected to the regime’s other elements including ideology, flexible specialized labor, energy infrastructure, facility infrastructure, and expert labor. Inexpensive surgical science and cheap technology were both necessary, but the two alone were not sufficient. The result of South Asian community ophthalmology organizations using these radical and incremental innovations concurrently is that these fully developed innovations became linked together into interlocking innovations.

The socio-technical system transition (pathway no. 4) dealignment and realignment involve the co-evolution of multiple, complimentary, and sub-system innovations which, when linked together, make wider application possible (Geels 2005, 91, 97–99; Geels and Schot 2007). Typically, in dealignment and realignment, breakthroughs from the niche to the regime occur with multiple linked innovations, not just one singular artifact (Geels 2005, 98). This is because the multiple innovations relate to each other through positive feedback (Geels 2005, 97). Geels explores three ways positive feedback occurs among multiple linked innovations. I will add a fourth positive feedback mechanism to more robustly develop the concept of interlocking innovations.

The first way multiple innovations relate to each other through positive feedback occurs through cross-sectoral clustering. For example, changes in material science and the speed and frequency of communication, i.e., steel and the telegraph, influenced the technological transition in Europe from the sailing ship to the steamship (Geels 2005, 98). In this case, community ophthalmology professionals have, within the civil society sector, created innovations adapting from and participating in international development, industrial manufacturing, and hospital services sectors.

An additional mechanism by which multiple innovations provide each other with positive feedback is complimentary utility. Complimentary utility means a technology benefits from the presence of another linked technology. This benefit comes in at least two forms: (1) the newer linked technology creates a product or process that directly enhances the functionality of an existing or incremental technology; (2) an existing or incremental technology’s design and widespread adoption in the niche constrains the newer linked technology’s design in some manner. It becomes evident the complimentary utility of multiple linked innovations is related to rules of the socio-technical niche.

Above, I have demonstrated that, in the incumbent regime, Phaco could not become an ambulatory procedure until foldable IOLs were introduced; this demonstrates complimentary utility where the design of an incremental technology, the foldable IOL, constrained phacoemulsification’s utility. Furthermore, I have illustrated that, in the appropriate technology niches , SICS was enhanced by the adaptation of Phaco for white cataracts (providing both to patients helped Aravind and Tilganga continue using the Robin Hood model of cost recovery).

SICS, a new scientific innovation, thus became “the right tool for the job” of addressing the backlog of advanced stage cataract disease, but not in isolation. SICS has complimentary utility with intraocular lenses, a technological innovation, to restore sight to patients with advanced cataract disease. These intraocular lenses are produced through highly labor intensive and labor specialized processes at low wages at Aurolab and living wages at Tilganga-FHIOL.

Likewise, SICS had complimentary utility with high patient volume with its checklisted processes, standards, and benchmarks to routinize a high patient throughput and increase surgical volume in eye hospitals and eye camps (Prentice 2018). High volume constrained both SICS and Phaco. Without high patient volume, the eye unit could not fulfill the first cognitive rule that is deeply entrenched in the autonomous global network: to eradicate and control blindness. Subsequently, high volume became a formal rule in community ophthalmology organizations such as Aravind, Tilganga, Loresho, and Sala Uno.

A third way that interlocking innovations contain positive feedback is through a sub-system innovation. Incremental innovations have accumulated over time and are hierarchically organized to form a sub-system that altogether improves overall performance (Geels 2005, 99). One example of a sub-system might be the clean laboratory for manufacturing biomedical prosthetics. Such clean room infrastructure typically includes special uniforms and protocols to reduce air particulate counts, vent hoods, computer numerically controlled lathes, other machines, magnifying glasses, microscopes, linoleum flooring, and positive pressure air ventilation systems. The users, processes, scientific knowledge, and technological artifacts which compose a “clean room” sub-system are quite complex with their own interdependencies (Mody 2005). This sub-system innovation was pivotal to endogenous production of intraocular lenses at low cost, which again supports the guiding principle of eradicating and controlling blindness.

A shared ideology is the fourth way that interlocking innovations contain positive feedback between multiple, linked, complimentary, and sub-system innovations. The radical ideology which helped shape the appropriate technology niches subsequently has influenced the formation of the interlocking innovations. This radical ideology can be represented by Gandhi’s concept of sarvodaya or good for all (see Chapter  3). This ideology serves as a foundational building block upon which the many other innovations have been built. For instance, it is incorporated into the problem-sequence for surgical science (see above) and the development of management standards and health services benchmarks in eye camps (see Chapter  4). Therefore, this ideology serves as an early and important cognitive rule in the appropriate technology niche that influences the formation of the interlocking innovations and is carried along with them wherever they travel.

This was a practical building block for appropriate technology activists challenging the incumbent regime. Since their economic ideology strongly differed from the incumbent regime’s practices and approaches, this economic ideology served as a point of commonality between persons of different cultures and geo-political origins interested in eradicating blindness. The financial innovation that emerged from this radical economic ideology was also important since the appropriate technology niches themselves were not attractive to the typical investors in the incumbent regime who might otherwise support technology niches.

By extending Geels’ work, I define interlocking innovations as the multiple, complimentary, and sub-system innovations providing each other with positive feedback through a shared ideology. In this example, community ophthalmology professionals, working within their appropriate technology niches, have created interlocking innovations which are: a novel constellation of context-appropriate processes (or products) in science, technology, and management connected to each other by a shared economic ideology and other guiding mission (or cognitive rule).

The complimentary utility between the multiple innovations comprising an interlocking innovation means one innovation cannot breakthrough from niche to regime without the others (Geels 2005, 98). Innovations are first produced inside niches as separate, singular knowledge and artifacts. Once these multiple complimentary and sub-system innovations are linked and black boxed, they then circulate outside the niches. Altogether, these scientific, technological, financial, and organizational innovations, shared ideology, and rules are necessary to scale-up sophisticated surgical practices to address the eye healthcare needs of the rural poor at a low cost.

In Chapter  7, I discuss how Aravind and Tilganga train other community ophthalmology professionals in their interlocking innovations. The multiple and complimentary innovations created by Aravind and Tilganga are packaged and sold to other eye units. Selling low-cost interlocking innovations provides additional revenue and helps fulfill the larger mission of eradicating and controlling blindness. Domestic NGOs addressing avoidable blindness inside and outside of South Asia send their employees for training in both the surgical techniques and the management practices. Such training can enable them to then create cost recovery models similar to those of Aravind and Tilganga.


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© The Author(s) 2019

Authors and Affiliations

  1. 1.Logan Williams Consultancy Services, LLCCumberlandUSA

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