Tabin paused outside the swinging doors to the operating room, and Nkurikiye and I caught up to his entourage as he consulted with one of his trainees, Chris Kurz, who was completing his cornea fellowship with Tabin at the Moran. He and Tabin reviewed a recent corneal transplant Kurz had performed, a far more complex procedure than a cataract surgery, which Kurz said had gone well, except he’d had to sponge away more blood during the operation than he’d expected.
Tabin turned to face the rest of us, aiming his question toward the knot of students with pens and notebooks at hand. “Do you know how to tell, with one hundred percent certainty, if a plant is poison ivy?” Tabin asked.
No one ventured an opinion.
“Okay, you take a handful of the reddest leaves you can find and rub them on the thin strip of skin between your testicles and your anus. Then you wait two to three hours. If you experience extreme itching and discomfort, the plant is definitely poison ivy!”
There were a few embarrassed chuckles, and the pens hovered motionless over open notebooks.
“Likewise,” Tabin continued, “if Dr. Kurz is operating on an eye, how does he know if he’s cutting corneal tissue? The cornea, the clear surface at the front of the eye, is unique. It’s the only tissue in the body that draws all the oxygen it needs from the air, not a network of capillaries. If Dr. Kurz cuts and it bleeds, he’s cut not corneal tissue but the sclera, the tough white outer wall that covers the rest of the eye,” Tabin said, driving his point home neatly, setting the students’ pens in motion.
I imagined that during all the cramming they’d have to do one day for their medical boards, few of them would struggle to remember this particular lesson.
Tabin backed through a set of swinging doors and bent to a set of double sinks to scrub in. Four support staff lounged in front of crisp, flat-screen displays, calibrating equipment or browsing the Internet. From the ceiling, an octopus-like PrismAlix lighting array, with dazzling halogen discs held at the end of each tentacle, lit the adjustable chrome operating table brighter than a tropical beach at noon. Tabin, swaddled in a crisp green paper smock that had been tied behind his back by a nurse, took his place on a Stryker Surgistool, calibrated by a technician to the precise millimeter of height and forward lean the doctor preferred. The chromium stool, a mobile wonder of shock-absorbing arachnid legs, looked fully capable of jettisoning boosters, landing on Mars, and collecting soil samples.
I thought of the single 60-watt bulb taped to the ceiling over Ruit’s plywood operating table in Rasuwa.
Travel frequently enough, dislocate yourself often enough at jet speed, and your culture shock mutates into something else: not the shock of the new or the unknown but the unsettling juxtaposition of the present and the very recent past. Here you are. But there you were. And all too often that contrast points, in my experience, to a gulf between meager resources and material excess too wide to comfortably accept.
Evidently John Nkurikiye was thinking along the same lines. “All of this for one patient, for one rather simple procedure,” he said, shaking his head as a woman was wheeled through the double doors by orderlies and positioned before Tabin’s gloved hands.
That made six medical staff in the room, and seven observers. Tabin’s scrub nurse took no notice of me as she began to lay out surgical tools. But as soon as the operating theater manager confirmed Tabin’s choice of jazz over soft rock for the sound system, she glanced in my direction. I looked away and turned toward Tabin’s elderly patient. The day before, while I’d been watching Tabin remove a cataract at the VA hospital near the Moran, a nurse whose name tag read M. BIGWOOD had called me over for questioning. He was a large man, unsmiling. It might have been my inexpertly tied surgical mask; knotting a mask behind your head is like tying a bow tie behind your back, and I’d yet to fasten one convincingly. Or perhaps he’d simply chosen that moment to conduct a random pop quiz.
“Tell me,” the man had asked, “how long has cataract surgery been practiced?”
I tried to recall fragments from the background reading I’d recently begun.
“Since about 2000 B.C.?” I said, fairly confident I had the right date.
“Excellent,” he said. “They called it ‘couching,’ poking at the cataract with a needle. Not very helpful, and you can only imagine the infection rates, but they might have seen a bit of light after that, a little improvement.”
I tried to peer over his large shoulders to watch Tabin work, but M. Bigwood wasn’t done with me. “Where does the material for a modern IOL come from?”
My ability to recall precise details was degrading as I strained to see. I floundered for a moment, then said, “An airplane windshield?”
“What airplane?”
He had me there. I shrugged.
“A World War II Spitfire,” he said. “Military surgeons noticed that shards of Spitfire windshield shattered by gunfire didn’t react with tissue when they were embedded in pilot’s eyes. So they knew the eye wouldn’t reject lenses manufactured from the stuff. Intraocular lenses have been made of a similar material ever since.”
Now I watched Tabin perform surgery on the elderly woman, taking care not to make eye contact with the female nurse in charge of the Moran’s operating room and prompt questions from her. I looked everywhere but in her direction.
My eyes strayed to a flat-screen monitor at one of the technicians’ desks. I noticed an article he was browsing through, titled “The 10 Most Stressful Jobs.” Surgeon and anesthesiologist led the list, followed by smoke jumper and industrial deep-water diver. Tabin had told me a story the previous evening about a Boston surgeon who’d jumped to his death from the roof of a hospital after accidentally removing the uncancerous eye, the one healthy eye, from his preteen patient.
On the largest of the variously angled monitors mounted on the walls behind his head, I watched the sharp end of the modern tool Tabin was wielding to break up his patient’s cataract. It was called a phacoemulsification device, or phaco for short. Tabin inserted the phaco tip into the capsule of the eye. Rather than coaxing out the cloudy lens of the eye whole, as Ruit had in Rasuwa, Tabin used phacoemulsification to pulverize the cataract with precisely directed ultrasound waves, then draw out the fragments with suction so that he could insert a foldable IOL through the tiny wound he’d created.
“Hey, you’ve got to see this,” Tabin called to me. I joined Nkurikiye and the scribbling students ringing the operating table. A nurse handed Tabin an injector that tapered to a needle-thin point. Magnified on the monitor, it looked as thick as the neck of a beer bottle. Tabin fed the tip back up the tunnel he’d carved, depressed a plunger, and a translucent lens unfolded like a sea creature across the width of the eye, spreading thin arms, called “haptics,” that held it in place.
Even I could tell how clear the patient’s eye now appeared, projected many times the size of life across a bank of monitors, staring placidly at all the cardinal points, like the Buddha eyes I’d seen painted on nearly every smooth surface atop the temples of Kathmandu.
“That went just textbook!” Tabin said after nearly half an hour, which included a delay of fifteen minutes when his patient interrupted him from beneath her draping to ask for another injection of anesthesia. I noticed the light sheen of sweat on his forehead, and condensation on his rimless glasses. I pictured Tabin a few hours earlier, hanging from the ceiling of his attic by his fingertips. Those same fingers had just restored a woman’s sight. What sort of adrenaline jolt, I wondered, did that provide to his system?
Assistants peeled off Tabin’s paper surgical gown, cap, and mask, throwing them into a trash container along with his latex gloves. He dialed a series of contacts on his iPhone, trying to line up a partner for a late-afternoon rock climb, hoping to inject a few more hours of fun between the end of his workday and the beginning of the evening’s festivities.
Nurses tossed the surgical tools and the mostly full bottles of IV fluids into the garbage, then stuffed in the disposable drapes t
hat had covered the patient. Nkurikiye and I stood next to a trash can piled as high as my waist with the detritus of a single operation.
In Ruit’s operating theater, all the surgical tools were sterilized and reused. IV fluids were consumed until the containers hang empty from their racks. Drapes and surgical gowns were laundered and boiled in autoclaves again and again until they disintegrated.
Nkurikiye stared at the trash, shaking his head.
“I know this is America, but this seems too wasteful even for a country as rich as yours. Do you know what those instruments cost? Do you know how hard they are for me to get in Rwanda? I’d jump into that can and steal them if it wouldn’t land Dr. Geoff in warm water. Do you know I could treat one hundred patients—more!—with the contents of that trash?”
I knew. Or, rather, I was beginning to know, which, I realized, is not at all the same. Here you are. There you were.
Burn the Day
More and more I want to write about people who cannot modify themselves to reality, whose life looks like no one else’s, people who stain your life.
—James Salter
“Here we are,” Tabin said, inching through a knot of admirers at the auditorium door, shaking hands, exchanging email addresses, and promising to look at résumés of those who hoped to work with him, before jogging down a sloping aisle toward the lectern.
I had spent a few days watching Tabin work by then, and had attended a specialized lecture he’d given to ophthalmology students, which had reinforced how little I still understood about the technical challenges required to cure blindness. It had also demonstrated just how often Tabin tended to dance along the border of socially unacceptable behavior. He’d begun by accidently projecting the wrong slide. Everyone in the classroom had gasped at a photo of an enormous naked man, lying facedown, presumably dead, on an urban sidewalk. “Whoops,” Tabin had said as he’d fiddled with the cursor on his laptop, “wrong Powerpoint! That’s from a slide show I mostly do for climbers. I used to call it ‘Why fat people shouldn’t bungee jump,’ but people kept telling me that was in bad taste.”
Tabin’s noontime talk the next day was open to all the students at the University of Utah School of Medicine. His work with Ruit had been attracting increased media attention, and that had made Tabin a prominent figure on campus. The packed lecture hall was evidence of the Utah students’ curiosity about how he’d managed to forge a career of world-changing work beyond the mainstream of medicine.
As a technician fiddled with his laptop, until a facsimile of his overcrowded desktop loomed on the screen behind his head, Tabin crackled with energy, rocking from foot to foot in a pair of trail-running shoes still speckled with red dirt from a single-track mountain bike ride the previous afternoon. He’d changed into khakis and a well-worn, pale blue short-sleeved button-down that appeared to have been cut from material the precise shade and texture of the scrubs he’d worn into surgery. From where I sat, next to Nkurikiye in the third row, I could see threads protruding where his shoulder seams were separating.
“We’ve got a lot to cover, so let’s get going,” Tabin said. A file folder bloomed open, and an image of a stark, black-banded mountain filled the screen, spindrift blowing from the summit. “I was in the middle of my first year at Harvard Medical School when I was invited along by a team attempting the last unclimbed face of this. I sent my academic adviser a postcard, telling him I was off to Mount Everest, and to hold my spot,” Tabin said, and the crowd laughed. “I don’t recommend you try anything like that if you want to have a career in medicine. I came back from an unsuccessful expedition to find myself out of Harvard.”
Tabin clicked through a few dozen more slides of mountains and the scruffy groups of climbers, whose tribe, it was clear from his enthusiasm, he had joined just as proudly as he had the medical community. The photos of bare-chested young men posing on glaciers or dangling from overhanging ledges on slender ropes were full of bravado. And unlike so many public figures who are required to repeat canned speeches, Tabin evinced a pleasure at sharing snapshots from his former life that seemed anything but forced, especially when he paused on a two-decade-old slide of himself, bearded, obviously exhausted, his oxygen mask pulled aside to reveal his triumphant grin on top of the world.
“I shouldn’t do this,” he said, caught up in the moment, and in the palpable buzz of appreciation he’d extracted from his audience. He flipped to a photo of Everest taken from a distance, towering above the neighboring peaks, and explained that his team, which had succeeded in putting America’s first female mountaineer on the summit, had trekked toward it, through deep mud, during the monsoon. “We wore these nylon tights, not so much to get in touch with our feminine side and bond with our female teammates, but to keep off the leeches. There’s a poem I wrote. It’s rather good, actually. It’s called ‘Leech on My Dingus.’ Would you like to hear it?”
A few of the students hooted, urging him on.
“On second thought, I probably shouldn’t perform it in front of a full audience,” Tabin said, and as he hit the brakes, I was relieved to see that there were some borders of bad taste he had the sense not to cross. “But if anyone wants to stay after the lecture, and promises not to be offended, I’ll give a private recitation.”
Then, with no change in tone or intake of breath, Tabin executed another one of those conversational swerves at freeway speed. With Everest’s granite pyramid still hovering over his head, he detailed the extent of blindness worldwide: The latest survey from the International Agency for the Prevention of Blindness had concluded that 40 million people in the world were blind, unable, even, to count fingers at a distance of ten feet. If you included people who were severely visually disabled, the number leapt to 161 million. Three out of four of them, Tabin said, could easily have their sight restored if only they received the kind of medical care people in countries like America take for granted. He switched to a pie chart depicting leading causes of preventable blindness worldwide. “As you can see,” he said, “more than half of the preventable blindness in the world is caused by cataract disease, which is simple to treat. But there’s a problem with my profession,” he explained. Most ophthalmologists are more interested in the latest high technology than in curing that massive backlog of blind people. “Why?” he asked, before answering his own question. “Because most of those blind people live in poor countries. And even if millions of them are so disabled by their blindness that they can’t work, they can’t walk on uneven ground, all they can do is sit in the corner of their homes, hoping to be fed, it’s a lot more profitable to charge people in wealthy countries thousands of dollars for minor procedures like cataract surgery or Lasik, so they can drive a bit better at night, or follow the path of their golf ball a little better, than to provide life-changing care to those who need it most.”
Tabin’s passion was infectious, or would have been, had dozens of pizzas not just then been placed on a table ten feet in front of his lectern. But he was oblivious to their arrival. He was staring at the crags and contours of the mountain of information he was trying to convey, and losing his hungry audience. I stood up and drew his attention to the steaming towers of cardboard boxes. When everyone except Tabin had inhaled a few slices of cheese or pepperoni, he resumed his talk.
He spoke of returning from the top of the world, of meeting a surgeon named Sanduk Ruit, who’d been born among Nepal’s high peaks but now lived in Kathmandu. He spoke of Ruit’s determination to focus on conquering the backlog, case by case, of the world’s needlessly blind. “What if I told you that Dr. Ruit pioneered a simple way to do cataract surgery,” Tabin said. “That he’s able, in about four minutes, to do a high-quality procedure, with results just as good as the outcome I can achieve here, for about twenty dollars a patient?” There was a murmur throughout the lecture hall. “Well, it’s a fact. And I believe, dollar for dollar, it’s the single most effective medical intervention on earth. After Dr. Ruit taught me this amazing thing was possible, I kne
w I had to dedicate my life to working with him.” Tabin presented a slide of Ruit at an eye camp in rural Nepal, grinning Buddha-like as he untaped the bandaged eyes of a woman who squinted up at him, hopefully. “So this man here’s become my partner in everything I do.”
Tabin talked about the organization he founded with Ruit, the Himalayan Cataract Project. He spoke of the 500,000 low-cost, high-quality surgeries the HCP and the organizations it partnered with had already performed in some of the world’s poorest, most isolated communities since 1995. He detailed the HCP’s emphasis on training, saying they had taught Ruit’s technique to hundreds of surgeons in the developing world. He presented flow charts and maps, but almost everyone’s eyes remained on the small man with the outsized forearms, his chin nodding vigorously as he made each fresh point from the podium, as if underscoring the foolishness of disagreeing with such obvious truths.
He said that the few ophthalmologists in developing countries tended to live in cities, but that most blind people were subsistence farmers and laborers in remote rural areas. He said that other ophthalmic organizations were doing excellent work for the poor of the developing world, and he declared that the HCP’s greatest innovation, and challenge, was streamlining and simplifying surgical procedures, so they could effectively organize mobile outreach efforts to remote areas in two dozen countries, from Tibet to North Korea to Ethiopia and Rwanda. Finally, Tabin laid out the lofty goal he and Ruit had set for themselves, a goal that involved more sustained effort and logistical intricacy than any expedition to the world’s high places. They were attempting to cure preventable blindness. Everywhere on earth.
After the applause had faded, and most students had shuffled off to labs or classes or insomniacal hospital shifts, I wondered how many who had listened to Tabin’s speech might be swayed to choose less lucrative fields of medicine. How many would forgo late-model German sedans and second homes in the world’s beauty spots to assume challenges that would take them to the world’s dustier posts and away from the guaranteed payday of practicing in affluent cities. At least a few, it seemed, judging from the number who’d remained to hear Tabin’s poem.
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