It is the only mystery worth solving: the mystery of leadership. And here's the question that's wrapped around that mystery: Why is it that even leaders who have the most-beautiful intentions create projects and organizations that don't come close to resembling their original vision?
Between the idea and the reality falls a shadow. This obscuring cast has given us a graceless DOS, crappy cell-phones, brain-dead customer service, hollow-hearted TV programming, and idiotic airlines. Worse, it robs us of pleasure in our own work and lives. Settling for "good enough" makes us all feel small and mercenary.
What if it doesn't have to be that way?
There is a place you can go to find the answer: India. But don't go to the megacities of Bombay and New Delhi or to the newly minted software center of Hyderabad. Go to the wild, wild south, mystic cowboy country, where gurus roam the plains, and where a John Wayne western turns into a Mahatma Gandhi eastern soon enough. Climb into a beat-up 1980 Chevy Impala. Ride for seven hours with an eye doctor who is 82. Ask him to tell you the secret, to answer the question, to solve the mystery. Listen carefully to what he says. Watch everything he does. And learn.
You know he knows. He's an eye surgeon — a man of vision. He has learned how to deliver perfection, and to do it despite crippling obstacles. As a young man, a brand-new obstetrician, he contracted rheumatoid arthritis and watched helplessly as his fingers slowly twisted, fused, and grew useless for delivering babies. So he started over, this time studying ophthalmology. He managed to design his own instruments to suit his hands, and these tools enabled him to do as many as 100 surgeries a day. He became the most admired cataract surgeon in India.
Twenty-five years later, he confronted another potentially crippling obstacle: retirement. In 1976, facing the prospect of social shelving at age 57, he opened a 12-bed eye hospital in his brother's home in Madurai, India. Today, he runs five hospitals that perform more than 180,000 operations each year. Seventy percent of his patients are charity cases; the remaining 30% seek him out and pay for his services because the quality of his work is world-class. He is a doctor to the eyes and a leader to the soul.
If corporate leaders who have the best educations, the best consultants, and the best financial and technical resources consistently deliver projects that are dead on arrival, how does perfection emerge for the Chief, Dr. Govindappa Venkataswamy, Dr. V.? How does his execution so closely match his vision? How did his original hospital, Aravind Eye Hospital in Madurai, invent a service so perfect that it created its own market — and how did it do so without any significant resources, and with a paying clientele that represented far less than half of its customer base?
What is the secret of leadership that would let us actually do what we see so clearly in our heads? Perhaps a visit to Dr. V.'s hospital, halfway around the world from the comfort, wealth, and complacency of Western leadership, will improve both our vision and our capacity to deliver on that vision.
The Journey to Sight Begins with a Cyclone
On the surface, India is a mess: It has a population of 1 billion, raw sewage on the streets, and traffic that moves at 20 MPH. But if you can look past India's visual obscenity, you will see a country that is turned inside out. India is the new frontier of the new economy, and American business will have to become more innovative — not just technically, but humanly too — to reach this market space.
The map can't tell you what meridian this new frontier is on, but 911 sounds about right. In India, every minute is an emergency: Birth, death, life, and infinity rumble past the windows of your car. To see the future, you have to travel to the rough edge of experience. This ride is going to be a bumpy one. Dr. V. is ready; he loves a good emergency. And in India, your wish is the universe's command.
We are driving from Pondicherry to Madurai, which is a seven-hour journey. The Indian gods who govern every learning experience have provided us with a challenge: In hour five of the journey, the skies blacken. Rain lashes the windshield. "Cyclone!" yells Dr. V., picking up his mobile phone to call his sister Dr. Natchiar, 60, Aravind's joint director of business development, to report exultantly on the amazing weather.
Later, in one of Aravind's classrooms, I will see a sign: "If You Are Looking for a Big Opportunity, Find a Big Problem." But it seems that this problem has found us. Billboards, uprooted by the winds, fly through the air. What better time for Dr. V. to remember his last heavenly vision! He was 55 when he first saw the golden arches of McDonald's, and it changed his life.
"In America, there are powerful marketing devices to sell products like Coca-Cola and hamburgers," he says. "All I want to sell is good eyesight, and there are millions of people who need it." The idea for Aravind was born from that vision of McDonald's.
"If Coca-Cola can sell billions of sodas and McDonald's can sell billions of burgers," asks Dr. V., "why can't Aravind sell millions of sight-restoring operations, and, eventually, the belief in human perfection? With sight, people could be freed from hunger, fear, and poverty. You could perfect the body, then perfect the mind and the soul, and raise people's level of thinking and acting."
In the eye of the cyclone, then, we get our first glimpse of the answer to the mystery of leadership: Leadership is a personal quest you undertake, one based on a mission that troubles your heart.
An hour into the storm, the sky clears. The driver delivers us to Aravind Eye Hospital, on a wide, dusty street in Madurai. Vara, Dr. V.'s niece, is waiting to greet us. "How I envy you," says Vara, 45, to me, "seeing the hospital for the first time. The thrill you'll get." She's right, I'll soon find. The cyclone is nothing compared to this.
In India, the big word in health care is "OM," not "HMO"
It frustrates the folks at Aravind that Tuesdays are always slow. It means that they can't do all that they could do. "We will see maybe 400 patients today," says Dr. Natchiar. "That's because for Hindus, Tuesdays are not propitious days to begin a new venture, so the people here will be emergency cases." It means that in the work of spreading perfection, Aravind will be a little behind schedule.
How do you achieve perfection in the never-perfect and always-compromised world of business? It helps to have a service that you can't sell. That way, you have to give it away. Your toughest customers are always the people who don't need you. Many of Aravind's patients can't afford cataract surgery. Most don't remember what good vision is — and don't understand why it would offer any benefit. So Aravind has to keep educating them — and perfecting its own service.
"In the third world, a blind person is referred to as 'a mouth without hands,' " says Dr. V. "He is detrimental to his family and to the whole village. But all he needs is a 10-minute operation. One week the bandages go on, the next week they go off. High bang for the buck. But people don't realize that the surgery is available, or that they can afford it because it's free. We have to sell them first on the need."
It's 7:30 AM on a typically slow Tuesday. But a slow day at Aravind would drive most American hospital officials mad. A few hundred people fill the hospital's driveway — friends and families who have delivered the 400 patients who are already inside. They spill out of the waiting rooms and onto carpets, passing the time until they can take the patients home, back to villages hundreds of miles away.
The free patients, whose medical services (including food and room) are covered entirely by the hospital, have a separate building. Paying customers are charged 50 rupees (about $1) per consultation and have their choice of accommodations: "A-class" rooms ($3 per day), which are private; "B-class" rooms ($1.50 per day), in which a toilet is shared; or "C-class" rooms ($1 per day), essentially a mat on the floor. Paying customers choose between surgery with stitches ($110) and surgery without stitches ($120).
"You don't have to qualify for the free hospital," says Dr. V. "We never question anyone. We sometimes give rich people surgery for free, and we don't question them. I don't run a business. I give people their sight." The next clue to the mystery of leadership: To achieve perfection, it helps to respect money — but not to be motivated by it.
Since opening day in 1976, Aravind has given sight to more than 1 million people in India. Dr. V. may not run a business, but it's important to note that Aravind's surgeons are so productive that the hospital has a gross margin of 40%, despite the fact that 70% of the patients pay nothing or close to nothing, and that the hospital does not depend on donations. Dr. V. has done it by constantly cutting costs, increasing efficiency, and building his market.
It costs Aravind about $10 to conduct a cataract operation. It costs hospitals in the United States about $1,650 to perform the same operation. Aravind keeps costs minimal by putting two or more patients in an operating room at the same time. Hospitals in the United States don't allow more than one patient at a time in a surgery, but Aravind hasn't experienced any problems with infections. Aravind's doctors have created equipment that allows a surgeon to perform one 10- to 20-minute operation, then swivel around to work on the next patient — who is already in the room, prepped, ready, and waiting. Post-op patients are wheeled out, and new patients are wheeled in.
Aravind has managed to beat costs in every area of its service: The hospital's own Aurolab, begun in 1992, pioneered the production of high-quality, low-cost intraocular lenses. Aurolab now produces 700,000 lenses per year, a quarter of which are used at Aravind. The rest are exported to countries all over the world — except to the United States. (In order for Aravind to get its lenses approved for sale in the United States, it would have to pay for an FDA study and a clinical study, which the hospital cannot afford.) Aravind even has its own guest house, and students and physicians from around the world come to teach, study, observe, practice — and boost their training. Poles for stretchers? They're made from bamboo that grows in Dr. V.'s garden. "We also have the $5 pole, which is bright and shiny," says Dr. Natchiar, "but we prefer these bamboo poles."
They are proud of their fiscal conservatism, but this is not HMO-speak. This is pleasure in the knowledge that they are not seduced by money. "The health-care business is so bad," Dr. Natchiar says. Extravagant is what she means. "Alternative models are needed. There is a new machine used to help with surgery that recognizes the doctor's voice. It is egotistic. That's another $100,000, which the patient pays. You have to stop and think, Is this the best way to spend money? At our hospital, machines aren't doing the surgery; people are. We need technology, but medicine also needs the practices of the East."
When Dr. V. started, there were perhaps no more than eight ophthalmologists in all of India. Dr. V. saw a market in the 20 million blind of India, most of whom suffer from cataracts, which in India are caused mainly by the glare of the tropical sun, poor diet, and genetic factors. Today, Aravind is the largest single provider of eye surgery in the world. In 1998, its hospitals saw 1.2 million outpatients and performed 183,000 cataract surgeries. Dr. V.'s extended family visited 1,488 villages to run diagnostic eye camps. Paying customers support the free surgeries, and the sale of lenses abroad adds to the bottom line. Aravind accepts no government grants. The hospitals are totally self-sustaining. And Dr. V. lives on his pension. "There is not one rupee that he takes out of Aravind," says Dr. Natchiar.
Scissors and Thread and an Old-Master Painting in 10 Minutes Flat
"The surgery is an art," Dr. Natchiar says. "You work in such a tiny space, and if you create a beautiful job, the painting is worth so much money. You put pictures in people's eyes. You paint them stunning flowers, their children's faces, or lines that are clear and sharp."
11 AM: In pediatric surgery, a chubby, brown, five-month-old baby with double cataracts is fussing on the operating table. A surgical team begins to sedate the baby, massaging the infant's legs and arms, hovering, comforting. The head nurse tries to find a vein buried in the chubbiness. It's like trying to find a thread baked into a loaf of bread. After about five minutes of studious searching, she finds it and injects the first anesthesia. The baby settles a bit, and the nurse moves on to the other leg. The anesthesiologist attaches the breathing tube, and the infant's second surgery begins (the first having been done two days ago). The surgery itself is over in five minutes. "Babies' eyes are very soft, so the incision is very small," says the surgeon. After a few minutes, the baby is carried out to its mother and begins to wake up. This child is one of 2,500 whom Aravind treats every month.
Cataract surgeries are beautiful. Eyes never look old. From the TV monitors in the operating room, an eye looks like the globe of the bright blue earth, floating in a sea of white clouds. The doctors never make it more gorgeous. They only make it perfect; they do this by scraping out the film that clouds the retina. The eye turns brilliantly clear, the light pouring into it. An artificial lens is then positioned over the retina. There is no blood until the suture needle is inserted, then one thread of blood appears, as if the surgeon were sewing with this red line.
For the team in pediatric surgery, the morning has been routine, another brief, successful operation that will give sight to an infant. I, an outside observer, provide the morning's only unusual element. Dr. V. has assigned me my own private nurse, in case the sight of the operation makes me faint. I don't faint — I wet through my surgical mask with tears. The surgical team has never seen this reaction before. But what I have seen — five adults hovering over a tiny infant and light flooding into a once-blind eye — is a study in selflessness, tenderness, and art that I have never seen before.
You haven't seen until you've seen Aravind. Whether you're a patient or an observer, your eyes are opened. You see in new ways.
Who Is Dr. V.?
For Dr. V., leadership begins with the pursuit of self-knowledge and a vision bigger than any that can fit in the prospectus of a single corporation. All his life, Dr. V. has resisted smallness. Yet there is nothing egotistic about him. He asks himself, "How can my work make me a better human being and make a better world?" That question is at the heart of the mystery of leadership. And to answer it is to seek perfection.
"Two qualities for leadership are to be a visionary and to know execution," says Dr. V. "If I can go from consciousness to higher consciousness, then I'll be a leader."
Dr. V.'s work is to fight blindness in the world and in himself. The two missions are one. He realizes his destiny by his work. Helping people see is to achieve a new level of consciousness.
His philosophy derives from a difficult but ideals-driven past. Dr. V. was born to a farmer's family in 1918. There was no school in his village. In the mornings, he had to take the buffalo out to graze, and then he would walk nearly three miles to school. Years later, when a school finally opened in his village, there were no pencils, paper, or even a slate. The children collected sand from the riverbed, spread it smoothly over the mud floor of their thatch-roofed schoolhouse, and wrote in it with their fingers.
Dr. V.'s father was a follower of Gandhi and a man who believed in perfection. "We were not thinking of amassing money as our goal," says Dr. V. "We always aspired to some perfection in our lives." Perfection, as he defines it, is a means of following God or of pursuing a form of higher consciousness.
Gandhi's ideas of celibacy, nonviolence, and truthfulness appealed to Dr. V. In 1948, after three of his cousins had died of eclampsia (an attack of convulsions) in the last three months of their pregnancies, Dr. V. began postgraduate medical training at Stanley Medical College, in Madras, training to become an OB-GYN. Rheumatoid arthritis struck him soon after graduation, and he was hospitalized for almost two years. Severe pain began then, and it has never left him. "When I finally could stand," he says, "I felt as if I was on top of the Himalayas."
There was also the pain of a terrible conflict in his life. He had been schooled in perfection by his father, and now he was barely able to work. What saved him from despair, says Dr. V., was meeting the philosopher Sri Aurobindo, a rebel in the Free India movement who had opened an ashram in Pondicherry. From Aurobindo, Dr. V. learned meditation and found a purpose: He came to believe that man has not reached the highest level of evolution, but that evolution will continue for several more stages until a higher intelligence is created. "Even the body has to be more perfect so that a new creature will result," says Dr. V.
But spiritual teachings, inspirational and useful as they may be, still are not enough. "I am not an idea man," says Dr. V. "The task is not to aspire to some heaven but to make everyday life divine." When he switched to ophthalmology, he had to train himself to hold a knife and to perform cataract surgery despite his physical pain.
I ask Dr. V. a simple question designed to get him to talk about his unique vision: "What are your gifts?" I ask him. Dr. V. replies, "People thank me for giving them sight." This is no error of translation, no slipup of English. Dr. V. considers his gifts to be the things that he has given others, not what he possesses.
Here is another clue to the mystery: The reward for work is not what you get out of it but what you become from it.
Marketing That Reaches the Deepest Part of the Market: Your Soul
Aravind offers a service so good that it creates its own demand. In that respect, you could compare it to FedEx, the Gap, or Starbucks — but only if you didn't care about how ridiculous that comparison would make you sound. Part of Aravind's service package includes love, courage, and total care. "You identify with the people with whom or for whom you work," says Dr. V. "It is not out of sympathy that you want to help. The sufferer is part of you."
"Market driving," a term coined by Philip Kotler, a professor at Northwestern's Kellogg Graduate School of Management, refers to the creation of a need that didn't exist before. What all market-driving companies have in common is that they are guided by a vision or a radical idea rather than by traditional market research. These visions involve high risk — and unlimited upside potential.
Aravind has brought its market-driving vision to the world's boldest and largest marketing segment, the one that will define future markets: the poor.
India's poor never expected to regain their sight. A visit to the hospital is largely out of their physical, geographic, and economic reach. It's also totally beyond their imagination, outside the boundary of hope. How can you hope for what you can't even imagine? How can you imagine what is so far beyond your daily experience? It isn't easy to picture an active market existing in these villages, where buffalo roam freely amid huts that have just a cot or two under their roofs. Yet everyone in India is an entrepreneur, and there is great pent-up demand. The poor can afford products and services — ones that sell functionality over features.
Most companies tend to focus on selling to the rich and the super-rich — consumers who have an annual income of $50,000 to $100,000, or more. But there are billions of potential customers out there whose purchasing power is about $2,000 per year.
C.K. Prahalad, an award-winning author and respected professor of strategy at the University of Michigan Business School, argues that you need more sophistication and greater intellect to cope in these markets. How do you marry low cost with quality, sustainability, and profits — all at the same time — in such diverse markets as food, health, communications, personal care, primary education, and financial services ? Prahalad's answer: You imagine selling your service or product to the poor. In a lecture given last January, he argued that "the business opportunity in India is in servicing the poor, and servicing the poor is good business."
Dr. V. agrees with that analysis, but he hates the sound of it. "Consultants talk of 'the poor,' " he says. "No one at Aravind does. 'The poor' is a vulgar term. Would you call Christ a poor man? To think of certain people as 'the poor' puts you in a superior position, blinds you to the ways in which you are poor — and in the West there are many such ways: emotionally and spiritually, for example. You have comforts in America, but you are afraid of each other."
As a market-driving organization, Aravind has to educate its free patients. One of the ways that the hospitals accomplish this is through community work, which their doctors and technicians almost routinely undertake. First, a representative from Aravind visits a village and meets with its leaders. Together they do the planning necessary to organize a weekend camp. Then Aravind doctors and technicians set out for the village, sometimes driving for days. Once there, they work around the clock, examining people and working to identify those who will need to be taken to Madurai for surgery.
They put a pair of glasses on people for whom the purchase represents a day and a half's pay. "People can't believe it," says Dr. V. "Often they can see clearly for the first time in their lives. They usually say, 'Thank you,' and go away — with the glasses on. The next day, they come back ready to make the purchase. This is how we sell 1,000 pairs of eyeglasses per day."
Give people a new experience, one that deeply changes their lives, make it affordable, and eventually you change the whole world. And your customers become your marketers.
The New Age Group Is Alive and Well, and Meeting in India
I have never met a leader who even approached Dr. V. The stories about him are legendary. Here's one: Dr. V. is leaning unsteadily against a wall. Usha, his niece and fellow surgeon, runs up to him to offer help. "You can't help me," he says, "I'm supporting the wall."
Here's another: A new guard confronts Dr. V. at the entrance to the hospital: "Sit down, old man, you're blocking people." In walks Dr. Natchiar, who asks, "Dr. V., what are you doing sitting in reception?" "I was told I can't go in, so I'm waiting," he replies.
And another: Usha, who holds the record for most surgeries in a day (155), admits to conspiring with the nurses to send her more than her allotment of patients, a practice that Aravind doctors routinely engage in. On returning from a village camp running a fever of 102, she checks herself into the hospital. Dr. V. happens to arrive in the morning. "What are you doing here?" he asks. "I'm sick," she says. "My fever is 104," he tells her. "How high is yours?" She can't bring herself to say, so she climbs out of bed and goes back to work.
An industrialist from Delhi once came to Aravind and said, "I need to build a hospital, and I'm very much impressed with this one. Could you come to Delhi and start a hospital for me?" Dr. V. replied, "You have all the money you need. It shouldn't be hard for you to put up a hospital in Delhi." "No," the industrialist said, "I want a hospital with the Aravind culture. People are cordial here. They seem to respect more than money. There is a certain amount of inner communion or compassion that flows from them. How do you do it?"
Dr. V. admits that Indian families raise daughters and sons with a certain discipline and love. "At Aurolab," says Dr. Natchiar, "the workers are all farm girls. Most of them are in the big city for the first time in their lives. For them, this is a luxury. They are next to God, working in this environment, helping others. They come to work at Aravind because they want some human element in their work. They want to work under a different philosophy."
Many members of the hospital staff go to the Aurobindo ashram. Says Dr. V.: "We feel that the higher consciousness is trying gradually to give us a system. We are all aware of the parts of the human body as they work. We take in food; we like the taste of it. Part of it is absorbed here, part of it there. But we are not aware of it. The higher consciousness works in the same way. Slowly, your system is built around it, but not according to human nature. At the hospital, we are slowly building an organization that seems to be linked with the higher consciousness."
When Dr. V. said that he wanted to build hospitals, Dr. Natchiar was ready to do what he asked. He was her older brother. He had raised her, and he had been her teacher at ophthalmology school. Dr. Natchiar convinced her husband to study ophthalmology. His sister, in turn, convinced her husband, and on it went: Eventually, nearly the entire family got involved. Little by little, a dynasty was being built. The family is now in its fourth generation.
"We keep talking to the children so that they understand the early days," says Vara, Dr. V.'s niece. "Last Christmas, when half the family went to America, the other half, 13 children, were left home. Dr. V. suggested that they go on a trip of their own. It was then that he organized the New Age Group, as he calls it, a morning study group." Each week, Dr. V. asks them a question: Why are circuses so appealing? Why do balloons cost what they cost? The assignments are meant to be fun and to teach the children about organizations and the social order. The children and their parents meet on Sundays over breakfast, rising at 6 AM to read and discuss the answers to these questions. This is a New Age Group of prophets in the making: Their talk is the language of laughter and passion.
The Future of Perfection
Why do adventure-travel companies escort people to the heights of the world but not to its depths? Perhaps because it's easy up at the top of a mountain in Tibet or Chile to think that you're getting enlightenment. A visit to southern India, a true topological depth, takes spiritual endurance. It forces you to examine your comfortable notions about yourself and about leadership: Your soul is tested more in the depths than it is at the heights.
This is a place where eating an ice cream can threaten your life. The food and water are so corrupt that a Western traveler is almost guaranteed sickness. The Times of India reported last spring that patients were pouring into a hospital in southern India suffering from serious food-borne illnesses. The Indian government raided roadside food kiosks, destroying uneaten food, and cholera experts were brought in to investigate. The smell of centuries of burning flesh and piles of sewage burns inside you. It invades your sleep. A doctor staying at Aravind said she wished she had brought a chilled bag of her own blood, in case of an accident. The AIDS epidemic in India is second only to the horror in Africa. There are truck drivers who stop as many as six times a day to have sex with children as young as 10 years old.
When organizations and systems are weak or breaking, leadership reaches its pinnacle. You have to find another way to perfection. It's not strange that an Aravind exists in India.
"Had enough poverty for a while?" a friend asked me when I got back from this journey to perfection. While I was in India, he had gone to Canyon Ranch in Tucson, Arizona. He works hard at answering 500 emails a day. Like his peers in Silicon Valley, he is focused largely on himself, a flyboy who spends one-third of his life in the sealed-off first-class cabin of one airliner or another. His mantra: What I want, what I need. He is the center of the universe. The bad news is that his universe is no bigger than him.
We may not admit the poverty of our own lives, but we feel it. Soon we may even see it; economic shifts will thrust the reality of it in our face. We are headed for the cyclone, and if we are blind to our soul, we will be uprooted in this new world order.
"People at business schools talk about share price," says Dr. V. "I tell them that I gave sight to 180,000 people last year, and that doesn't mean much to them." But the Aravind model may come to mean a great deal as the map of power continues to shift relentlessly toward the East, and as perfection becomes less the mystery and more the essential job of leadership.
Harriet Rubin (Hrubin@aol.com) is a Fast Company senior writer and the author of The Princessa: Machiavelli for Women (Doubleday, 1997) and Soloing: Realizing Your Life's Ambition (HarperCollins, 1999). Contact Dr. Govindappa Venkataswamy by email (email@example.com), or learn more about the Aravind Eye Hospitals on the Web (www.aravind.org).
Sidebar: Dr. V.'s Perfect To-Do List
You can set the same challenges for yourself as Dr. V. does.
Understand the deeper principles of work as well as your purpose in the game. Becoming a clear instrument of these aims is a declaration of power, and it draws resources - money and people — to you.
Understand the poor, and market to them. This requires more imagination than does marketing to established markets. It requires expanding beyond the smallness of the self. It requires a shift in your view of economics and market forces. Everything you do for your personal well-being adds another layer to your ego — and in thickening it, insulates you more from perfection, happiness, and fulfillment.
Appreciate that we are not different from the poor. We have spaces in us that are empty and ravaged. We are on the inside what the people of India are on the outside. They are materially poor; we are spiritually poor. Indians are on the outside what we are on the inside: starving for meaning, not homeless but the next worst thing — directionless.
Learn how to sell water by the river. If you can become market-driving, not market-driven, you can create new arenas and go on to build a legacy. When we talk about new markets, we will have to call on new abilities within ourselves. We will have to acknowledge the least-developed parts of ourselves. That means going deeper than intellectual abilities to more-profound, more-basic human attributes.
Recognize that the great opportunity in world markets is to make a difference in the human sphere. Bring people things they can't imagine wanting. From this act, we too will be changed — and maybe even enlightened. Dr. V. teaches that work can be a vehicle for self-transcendence.
A version of this article appeared in the February 2001 issue of Fast Company magazine.