Second Suns

by David Oliver Relin

  Tabin had stepped off the ledge and taken the leap. And this time, though he wasn’t turning somersaults, tethered to a cord, swinging at the mercy of unpredictable winds between granite canyon walls, the sensation was no less exhilarating.

  Load Shedding

  Though born in a dark age, I am very fortunate.

  I may be unworthy, but my guru is good.

  —The First Jamgon Kongtrul, instruction to his new disciples, to be repeated aloud when facing obstacles

  The twelve corneas traveled on dry ice, in a white Styrofoam box sealed with duct tape. The box, carried under Geoff Tabin’s arm, was plastered with stickers, alerting authorities that it contained human tissue. Customs officials at Tribhuvan airport had delayed one of these deliveries before and had been unlucky enough to face a furious Ruit, warning them that their actions might prevent blind people from regaining their sight. In a culture where karma factors into so many decisions, no one wanted such a potent black mark ticked against them for eternity.

  After a cursory glance at the bleary-eyed foreigner, they waved him around the line of people waiting to load their luggage onto scanners. In the arrivals area, Tilganga’s new driver, La La, greeted Tabin with a slap on the back and plowed a path through the shouting touts, toward Hilda. In the passenger seat, with the box cradled in his arms, Tabin saw that Tilganga’s vehicle had a large “H,” for hospital, affixed to the windshield with blue painter’s tape. “Everything okay, Dr. Geoff?” La La asked. “The trip was good?”

  “Waaayell,” Tabin said, “it was a bit long.”

  He’d been traveling for more than thirty hours since the corneas that had been FedExed to Vermont from eye banks across the country had arrived. He’d slept for a few hours on a padded bench in the Bangkok airport before boarding his flight to Kathmandu.

  “Going to be little bit longer,” La La said, laughing apologetically. “We’re having bandh.”

  “A what?”

  “A bandh. I think you can call this thing ‘strike’ in English.”

  “Why’s that?” Tabin said.

  The driver answered with a shrug. The explanation was beyond his limited English. Even in Nepali, people could tie themselves in knots trying to talk about the Maoists and what motivated them. As Hilda pulled away from the airport, Tabin saw that the streets were thronged. The city always seemed to contain about twice as many people as it was equipped to support, but something was different this time. The stream of slow-moving traffic hit a human dam. Most of the protesters were young students, wearing red headbands painted with hammers and sickles.

  Hundreds of them had surrounded a long black sedan a few vehicles ahead of them and were shaking their fists, chanting something over and over, and rocking it from side to side. It was dusk, and Tabin couldn’t see the passengers through its tinted windows, though he could imagine their panic.

  “What are they yelling?”

  “They say, ‘No corruption in the new Nepal,’ something like that.”

  “Who’s inside?”

  “The rich person,” La La said. “Maybe government man or family of king.” He rolled down the window, waved over the nearest head-banded boy, and began speaking rapidly, pointing to the blue “H” on Hilda’s windshield. Suddenly they were moving, the mob parting with unlikely organizational discipline, and Hilda was waved through the gauntlet. Protesters had blocked the main route from the airport into Kathmandu with a cross-country bus covered in red banners. It spit diesel smoke and backed up precisely enough to let them pass.

  “What did you say?” Tabin asked.

  “I told them we worked with Dr. Ruit,” he said as they accelerated past Pashupatinath. “I say some poor people need to see and we carry them a box of brand-new eyes.”

  Twelve corneas meant, if they made no mistakes during surgery, that twelve people would have a second chance at sight, courtesy of American cadavers. The quality of donated corneas is measured by the number of functional cells remaining in the tissue when it’s removed. Some of the corneas Tabin had procured from American eye banks had cell counts too low to be considered optimal and had missed the cut for use in U.S. hospitals. But in Kathmandu, where donated corneas were as rare as uncongested streets, viable but imperfect tissue was a treasure. Whenever possible, Tabin brought a batch to Ruit.

  Fresh corneas degrade rapidly once they’re harvested. The sterile solution they’re packed in can preserve them for only five days. And each hour, more of the corneas’ functional cells die. So they would operate into the night.

  “Ready to work hard?” Ruit said, throwing an arm over Tabin’s shoulder.

  “Do I have any choice?”

  “None,” Ruit said merrily. “None at all.”

  Tabin downed two weak cups of instant coffee, then, considering the surgeries he had ahead of him, stirred up two more, hoping they would counteract his jet lag, and scrubbed in. Reeta allowed herself only one cup of black tea, so her hands would be steady.

  In Tilganga’s early years, Ruit had been the only surgeon qualified to transplant corneas. But Reeta, like Ruit, was relentless about learning the latest advances in her chosen specialty, and she’d quickly surpassed Ruit as a corneal surgeon. She’d returned from the fellowship in Vermont that Tabin had arranged for her so skilled that Ruit’s surgical burden at Tilganga had been dramatically lessened, and he’d begun to leave the most difficult corneal cases in her able hands.

  Ruit had been refining his skills, too. “It seemed like every time I returned to Nepal, Ruit had tweaked his cataract technique,” Tabin says. “I’d gotten a lot faster, but he kept making so many innovations, it was impossible to keep up with him.” Ruit had switched from the common practice of sitting by the top of the patients’ head, and operating over their forehead, to sitting beside their temple and performing his surgeries from the side of the eye he was working on, which created less scar tissue and decreased postsurgical astigmatism. This way, he was able to have his staff bolt two operating tables together and prep one prone patient while he worked on the other, shaving valuable seconds off the time it took to slide his next patient into place. By the time Tabin arrived in 1996, Ruit had succeeded in carving unusually small tunnels in the side of his patients’ eyes, no wider than the diseased cataracts that needed to come out. These wounds were so tiny that they allowed the eye to heal itself without needing to be sewn shut.

  Ruit stayed long enough to make sure Reeta and Tabin had the supporting staff they needed; then, thanks to the blockade, he rode home through quiet streets to spend the rest of the evening with his family.

  Tabin blew out his breath and bent to his work. The traumatized portion of his first patient’s cornea, the clear tissue at the front of the eye, had to be excised in such a way that the shallow cavity he would cut into the surface would precisely match the disk of donor cornea he planned to cut, then sew into place there. His scrub nurse lifted the donated cornea out of the solution of sterile liquid that had been preserving it and placed the flap of clear healthy tissue, about the thickness of grape skin, onto the center of a punch, then slid the device onto a stainless steel tray in front of Tabin.

  He made sure the cornea was properly lined up, then pressed down hard on the punch with the heel of his hand. Despite its appearance of fragility, corneal tissue is surprisingly tough, and a surgeon must use a fair amount of force to cut through it cleanly. He picked up the disk gently with tissue forceps and draped it over the hole he had prepared. The fit was perfect, and after rotating it a few degrees so that it was optimally aligned, he began suturing the graft in place.

  After several careful stitches ensured that the transplant was firmly affixed, he snuck a glance at Reeta, who had finished her first case and started her next. When Tabin tied off his last suture, his patient’s eye looked as good as new, except for a cat’s cradle of fine black filament encircling the graft.

  Tabin pushed his stool away from the operating table and asked Reeta to confirm that he’d done as well as he
believed he had. Holding her gloved hands carefully away from the microscope, she leaned in to look through the eyepiece, inspecting his work. “Tissue looks lined up well,” she said. “Stitches are neat and tight. I’d say it looks perfect, Dr. Geoff.”

  Tabin was just beginning to stitch his next cornea into place when Tilganga’s operating theater went dark. The dim emergency lights were just bright enough for him to avoid poking the healthy portion of his patient’s eye with his suturing needle.

  “Load shedding,” Reeta said, in a calm, resigned voice that betrayed none of the stress she surely felt in the dark, with a patient’s open wound waiting for her attention. “Nowadays it’s become so common you can practically set your clock by these power cuts.”

  “Do you think the power will come back soon?” Tabin asked.

  “That’s rarely the case,” Reeta said. “But our staff will be tinkering with the generator presently, and we should have lights then. That is, if the bandh hasn’t blocked our petrol supply.” They sat quietly in the dark, and in Reeta’s serene company, Tabin permitted himself to relax. All he could hear, other than his breathing, was steam escaping from the propane-fueled autoclaves boiling their instruments in the adjoining room. Then the motorboat throb of the generator started up outside, and the light in Tabin’s microscope flickered, then flared back on.

  The next morning, Ruit arrived at work well rested. He found Reeta and Tabin slumped in the tea room next to his office on the second floor, sipping from chipped china mugs, working to wake themselves. They had been up the better part of the night and had completed eight transplants. Having snatched four hours of sleep, they planned to finish the rest shortly. Eight patients were settled in recovery rooms. And if their bodies accepted the foreign matter, and the corneas knit themselves into their patients’ tissue and remained clear, all twelve would be given a second chance to see.

  “You know,” Ruit said, “this is ridiculous. We can manufacture all the artificial lenses we need. But we have to go to such great lengths to acquire these corneas, and there is an unlimited supply just the other side of the river. The question is, can we collect them?”

  After completing his morning rounds, Ruit tried to cross the airport road where it spanned the Bagmati River. Growing impatient, he held out his arms, trying to slow the endless stream of traffic. He dodged a speeding Bajaj motorcycle, telling himself to take care, and sidestepped down the steep embankment to the Bagmati. He was on his way to speak to a cremator, not to become kindling for the man’s fires.

  The fuel that sent Nepal’s most fortunate dead on their journey of transmutation was stacked higher than Ruit’s head, in piles calculated to consume an average corpse. Ruit walked between the human-sized towers of hardwood for hundreds of yards, until he emerged from this forest of final transmission at the ornamental brick gates of the temple complex.

  Hindus argue about the exact number of gods in their pantheon, since many appear in multiple guises. Some scholars poring over the ancient scriptures of the world’s oldest religion, the Vedas, Upanishads, and Puranas, count as many as 330 million. Many Hindu sects consider them various manifestations of a single supreme being; others consider them separate deities. But all Hindus agree that Lord Shiva is a god among gods, the creator and the destroyer, an ultimate arbiter of life and death. Pashupati is one of Shiva’s many names, and the temple built sixteen hundred years ago in his honor is the holiest Hindu site in Nepal. Hindus in the kingdom aspire to end their days by the banks of the Bagmati, believing that a cremation at Pashupatinath might lead them toward the gates of paradise, or at least to reincarnation in the most appealing form possible.

  Ruit strode through the sprawling temple complex, admiring the statues of Shiva in his various guises: as Pashupati, lord and protector of animals, holding a deer in the palm of his hand; as Sadashiva, a fierce five-headed figure holding a trident and a snake; and as all-seeing Talagaon, an imposing anthropomorphic pillar covered with one thousand eyes and endowed with unblinking watchfulness, a god it was impossible to deceive. The task ahead of him was tricky, and the pitfalls for a Bhotia at Nepal’s holiest Hindu site were numerous.

  Ruit found Krishna Thapa, Pashupati’s chief cremator, at Bhas-meshvar Ghat, stacking firewood around the corpse of an emaciated woman shrouded in homespun white cloth. Thapa, too, was dressed all in white—a short white dhoti and a long, flowing white shirt, appropriate for both the solemnity of the death rituals and the warm work his position required.

  Ruit kept a respectful distance while the woman’s family members clung to each other in their grief and Thapa placed rice on the funeral pyre, so her soul wouldn’t face hunger as it traveled, and chanted prayers, speeding her to her next incarnation. He covered her with straw, to shield her from the final indignity of having her family watch the details of her disintegration, then poured clarified butter from a golden urn through the thin shroud covering her face, into her open mouth, until it overflowed and spilled down her cheeks. Thapa gave her son a lit candle and guided his hand to his mother, lighting the holiest human spot first, in the traditional manner, until flames leapt from her burning lips like last words.

  When the fire spread to the straw, Thapa left the mourners in the hands of his assistants, who would be sure to tend the pyre until, ideally, only ashes and fragments of bone remained, ready to be swept into the river.

  “May I speak with you for a moment?” Ruit said. Standing face-to-face with Thapa, he saw what a tiny man he was, barely larger than a boy, with delicate, birdlike bones. Ruit started to explain who he was and why he’d come, but his growing prominence in Kathmandu made an introduction unnecessary.

  “I know who you are, Doctor,” Thapa said. “We all know about the work you do on the other side. I’ve heard people say when you make their eyes, you tear out the eyeballs entirely and sew in new ones. Is that the case?”

  “That’s what I wanted to talk to you about,” Ruit said. “We do no such thing. To cure the most common kind of blindness, cataract disease, we make a tiny cut and insert a small piece of plastic, no larger than your fingernail. To cure the next most prevalent sort, corneal disease, we take a small scraping from the eyes of the dead and use that to give sight back to the living. When you’re free, why don’t you come across the road and see for yourself?”

  They agreed on a time the following morning, and Ruit left Thapa to his next task: joining his fellow shepherds of the dead in carrying the shrouded remains of a man so corpulent, it took four cremators to escort him to his point of departure. The supply of corneas at Pashupatinath was limitless, Ruit thought, as numerous as the cords of wood waiting to consume them. Walking along the trickling Bagmati toward Tilganga, Ruit saw packs of dogs rummaging in the shallows, fighting for unburned bits of flesh. “I can fight for scraps, too,” he thought.

  “We already had an eye bank at that time,” Ruit says, “but we had very little tissue coming in. So the next day Shanka Twyna, the eye bank director, gave Krishna a very VIP tour. He put him in a sterile suit so he could see the lenses being cut and polished in our laboratory. I had him stand beside me during cataract surgery, and sometimes that can be a problem. I’ve had government ministers or big rugged mountaineers pass out cold the first time they see me make a tiny incision. But you can imagine Krishna wasn’t shy about human flesh. He’s Chhetri,” Ruit explains, “the caste who’re allowed to touch the dead. He’d been handling corpses since he was a boy. So he had no problem watching me work. Then I had him observe Reeta doing a corneal transplant. He was amazed that it took such a small flap of tissue to complete the surgery. Twyna and I walked him through the recovery rooms and let him watch blind patients weep with joy when their bandages were removed. It’s a powerful thing, you know. It catches me up every time I see it, and I’ve seen it so many thousands of times. But Krishna was unusually touched. Maybe because in his work, he only saw people going one way, down, and he saw the possibility of helping bring others back up. After that, he was devoted to cre
ating a partnership between Pashupati and Tilganga.”

  With one foot in the crematory door, Ruit launched a campaign to convince Kathmandu society to donate the corneas of their dead. “I’d made a study of our practices of dying,” Ruit says. “At first I was convinced Buddhists would be the answer, because I knew I could convince them that the dead, who are no longer inhabited, should be of use. But Buddhists keep the bodies of their relatives at home until a day they consider auspicious for their cremation, and corneas have to be harvested quickly. So I shifted my focus to Hindus, because they cremate ASAP.

  “We put up signboards at Pashupati, saying, IT’S NICE TO DONATE YOUR CORNEAS. WHEN YOU DIE YOU CAN GIVE TWO PEOPLE THE GIFT OF SIGHT, and such like that. And that year, I think it was 1998, we started filming commercials for television, telling people donation was the right thing to do. This upset some powerful people. The head royal Hindu priest summoned me and said, ‘Young Doctor,’ even though I was in my forties, ‘don’t you ever take any eyeballs!’ But I don’t mind a fight,” Ruit says. “You have to get brushed a bit, you need a little resistance, before you can get stronger, you see? So I ignored his threats and pushed on. We had a really uphill battle. We had to break a big taboo in our culture that you don’t defile the dead.”

  Ruit had assembled Tilganga’s board of directors carefully, so that its members came from diverse castes and careers and had influence on many sectors of Nepalese society. The popular comedian Hari Bamsha Acharya was the board member Ruit selected to sway public opinion. Even before the rise of the Maoist revolution, his comedy had begun to cut increasingly close to the bone, skewering the corruption of the old regime. He filmed a public service spot mocking those who thought modern eye surgery meant yanking out eyeballs, and announcing that he planned to donate his corneas when he died.