Second Suns

by David Oliver Relin

  But it was Krishna Thapa, unknown to most Nepalese until their final hours, who was most helpful obtaining corneas, in reliable quantities, for Tilganga. “Coming from his mouth as he counseled families about to say farewell to their loved ones, it meant more than anything we could do,” Ruit says. “He told them they would be giving a gift not only to the blind but to their relatives, because of the merit the dead would acquire on their way to their next life.”

  In the early days of their collaboration, Krishna would call when he’d convinced a donor’s family, and technicians would rush across the river and harvest the corneas right on the burning ghats. But the pace of donations picked up so dramatically that Tilganga acquired a small office in the Pashupatinath complex where the fifteen-minute procedure could be done under more sanitary conditions. They now had an on-site eye bank, staffed twenty-four hours a day, ready to collect tissue whenever their partner across the river called.

  In 1998, the year they launched their campaign, the number of locally harvested corneas Tilganga received grew from a handful to 240. In 1999, it rose again, to 547, requiring Tilganga to train a second corneal surgeon. At a time when the word “sustainable” was not yet in fashion, Ruit had reached across his country’s holiest river and set in motion a mutually beneficial exchange of resources with no end in sight.

  Ruit had become so accustomed to swimming alone against his profession’s mainstream that he struggled to let go of any responsibilities, though he knew it was necessary. The lineup of patients waiting on benches by Fred Hollows’s portrait grew longer each morning, and Tabin, Rex, Reeta, and members of the board pressed Ruit to hire more staff.

  For years, Ruit had kept his eyes on Nepal’s most promising medical students, nurses, and technicians. He knew he should hire some of them, bring in others who could help to shoulder his load, but he’d run Tilganga on limited funds since its launch, and his frugality had become ingrained. He didn’t know any other way to operate, other than trying to squeeze the work of two staffers out of each Tilganga employee. But with Tabin proving a dedicated fund-raiser, Ruit finally began to relent.

  Khem Gurung was one the first significant new hires Ruit approved. Gurung’s father had been a regional governor in the mid-hills, and when he came to Tilganga with a fresh degree as an ophthalmic technician in hand, Ruit asked him why he wanted the job. “I’ve seen too much corruption. I want to work someplace free from corruption.” Gurung’s resourcefulness and easygoing attitude would overcome many obstacles, Ruit judged. And his wiry fitness and willingness to trek to Nepal’s most difficult terrain would free Nabin Rai, who was less enthusiastic about roughing it in rural areas, to concentrate his duties at Tilganga, where he could became the hospital’s roaming troubleshooter and its resident public health advocate, plotting out where to build rural clinics and devising the most effective means of reaching the largest number of rural Nepalese.

  For years, Ruit had rebuffed most of the potential employees his board had suggested. “I can’t take just anyone,” he’d tell them. “I’m growing my staff like a crop. Many of them are still in school.” By the millennium, that crop was finally coming in. With some money still arriving each year from the Fred Hollows Foundation, and modest but reliable funding from the slow-growing HCP, Ruit was able to do something he’d never imagined possible: offer competitive salaries to the candidates he wanted most.

  Tabin, too, was struggling to adapt to new circumstances. He and Jean bought a large white Victorian house in a neighborhood of old shade trees near the campus of the University of Vermont. Every time he walked up the drive after work, and saw the manicured lawn and the wraparound porch, he couldn’t believe he was rooted someplace so solid; a few years earlier, he’d been living out of a duffel bag. But it was the strong, opinionated women who inhabited this home that made him realize how radically his life had changed.

  Livia, the eldest of Jean’s children, was a standout student applying to elite colleges. Emilia, the middle child, was an athlete; she joined Tabin in jogging early-morning laps around slumbering Burlington. Ali, Jean’s youngest, had embraced climbing and was ready at a moment’s notice to join her father on a sprint to New Hampshire’s granite pitches. The first child they’d had together, two-year-old Sara, was currently a mobile force of chaos, scattering toys throughout the house and sweeping Tabin’s academic papers off tables where he’d left them carefully stacked. Jean had become pregnant with another child, Daniel, after she and Geoff had agreed that Sara would be happier with someone closer to her own age in the home.

  Hyperactivity has its advantages. Especially when you’re trying to work full-time as a surgeon, give your growing family enough attention, and raise money to combat a global health crisis most people in wealthy countries have never heard about. Still, Tabin felt the tyranny of time; there weren’t enough hours in the day for him to devote himself properly to his family, and his long absences added to the burden. At first, Jean and the girls accompanied Tabin on trips to eye camps in Nepal and Bhutan. “I loved the travel,” Jean says, “and getting to see Geoff in action. But I underestimated the difficulty of having both teenagers and toddlers. The frequent absences from school created all kinds of problems. So I decided I needed to be there for my kids. That meant staying home and making sure their lives weren’t always interrupted. Geoff wants to have everyone along with him all the time. This is sensitive stuff; Geoff and I really love each other, but it’s put a lot of stress on our marriage.”

  John Frymoyer, the dean of the University of Vermont’s College of Medicine and the CEO of its hospital, understood the pressure Tabin felt, and the multiple lives he was trying to lead, and allowed university staff to create HCP promotional materials and send out letters soliciting donations. Tabin organized fund-raisers, which, in typical Tabin fashion, he dubbed “fun-raisers,” twisting the arms of famous climbing friends to give slide shows, trying to sweep up donors in the romance of the world’s highest mountains and the needs of the people who lived among them. “It was a lot of work,” Tabin says. “I had to keep records of every five-dollar check and write thank-you notes to every donor. But I don’t want to overstate my role. It’s not like Ruit wouldn’t have survived without me.”

  As the balance of the HCP’s bank account slowly grew, Tabin phoned Ruit nearly every day, discussing how they could make the most of the funds and planning their upcoming trips. Tabin was especially keen to raise the skill level of Tilganga’s staff by training a full roster of subspecialists, doctors who were able to treat retinal disorders, care for glaucoma, and practice pediatric ophthalmology, so the hospital would be qualified to care for any eye condition. They also talked about purchasing excimer lasers, so Tilganga could recover at least part of the cost of providing free care to the poor by charging Kathmandu’s upper class for high-tech procedures like Lasik surgery.

  Ruit and Tabin discussed creating a network of community eye centers in Nepal, so they wouldn’t have to depend solely on eye camps to reach rural areas, and so patients with urgent conditions wouldn’t have to travel for days by bus to Kathmandu. Tabin wanted to recruit a corps of dedicated young doctors, drawn from both America and Asia, send them to Tilganga for training, and unleash them on the region’s hot spots of preventable blindness.

  After five years of operating beyond its capacity, Tilganga was beginning to show the strain. A hospital designed for twenty-five surgeries a day was doing double that, and the building didn’t have room to train more than a few foreign doctors at a time. Tabin and Ruit began discussing an expansion of the facility onto a vacant plot of land, uphill from the hospital, that Tilganga owned. “That would take money,” Tabin says. “Lots more money than we had.”

  In the meantime, Ruit and Tabin worked on ways to expand Tilganga’s influence throughout the region. In the fall of 1999, they designed a seminar to teach Ruit’s technique and invited Himalayan eye-care leaders to Kathmandu. At a dinner they held at the Yak and Yeti to welcome attendees, Tabin’s name c
ard was placed beside Ruit’s, but he kept jumping up between bites of food, introducing himself to surgeons and health care officials around the long table, clapping them on the back and shaking their hands warmly in both of his.

  “Over the years, Geoff has surprised me many times,” Ruit says. “And that evening I saw something clearly I’d failed to properly appreciate. Geoff’s personality drew people to him. I realized you could put him on an airplane, or at a fund-raising event, or at a table of doctors we were trying to convert, and in five minutes, he’d make friends with everyone, right, left, and center. I can’t do that. I’m not so out-reaching. And I was glad to have him as my partner. Behind all of his naughtiness, I realized, he really cared. He had a golden, compassionate heart.”

  One of the doctors who’d come to Kathmandu that day was precisely the sort of person who could help them expand their outreach. As the tiny kingdom of Bhutan’s first trained ophthalmologist, Kunzang Getshen was largely responsible for the eye care of his entire country.

  Getshen had short-cropped hair, graying at the temples, gracious manners, and an incongruous laugh that barked out of him when he was titillated by something Tabin said, which was often. But he was dead serious about improving eye care in his isolated kingdom, and once Tabin identified the flame that burned in him, the terrier was all teeth.

  Getshen told Tabin about the challenges facing him in Bhutan. He had recruited an Indian ophthalmologist to work with him and had begun training a second local eye surgeon, but he had virtually no funding or infrastructure. In a country where health care is free but doctors are few, Getshen was forced to send his most serious cases to surgeons in India.

  “I’d love to visit you in Bhutan,” Tabin said. “I’ve studied your rates of blindness, and together we could really bring them down.”

  “I’d be delighted to have you as my guest,” Getshen said, in erudite English that he seemed to construct, a paragraph at a time, before he spoke. “But every major development in my country must be approved by the royal government. And His Majesty wants to concentrate on removing primary obstacles for my people, such as providing basic medical services and building roads and schools.”

  “I’d argue curing blindness is about the most primary thing you can do to improve people’s lives,” Tabin said.

  “Of course I agree,” Getshen said. “I’ve prepared an eye-care plan for my country. Perhaps you could take a look at it and give me your suggestions? As the chief ophthalmologist for seven hundred thousand Bhutanese, I have less time for such things than I’d like.”

  By the time he was home in Vermont, Tabin had read Getchen’s plan and completed a proposal of his own for an HCP-led initiative in Bhutan. He contrasted Bhutan’s rising rates of blindness with Nepal’s, which had been steadily falling in the years since Ruit had moved home from medical school in India. He compared the modest cost of cataract surgery with the income lost to a country’s economy when blind people, and the caregivers they require to have a decent quality of life, are banished from gainful employment. And he detailed how Bhutan’s eye-care system could be transformed, providing he could find the funds. He sent the document to Getshen, hoping it would help pry open the door for the HCP to work in Bhutan.

  With one of the lightning bolts of luck that have struck Tabin almost too many times to be believed, he received a call from an old friend and fellow Marshall Scholar at Oxford, Mark Haynes Daniell. Daniell had been hired by Mitt Romney to work at Boston’s Bain & Company and had done well enough to eventually leave and launch his own investment firm in Singapore.

  Daniell, who’d been contributing modestly to the HCP’s general fund for a few years, told Tabin he’d been following the HCP’s work with admiration. “But I don’t want to give indiscriminately anymore,” Daniell told Tabin. “I’ve benefited from some investments, and I’d like to make a targeted donation that could begin to turn back blindness in a single country. Can you think of any place where, say, five hundred thousand dollars could really make a difference?” Tabin knew that Daniell had long been fascinated by the small mountain kingdom and its protected Buddhist culture. “I believe you’re familiar,” Tabin said, “with a country called Bhutan?”

  In a place often called the “world’s last Shangri-La,” Jigme Singye Wangchuck, the fourth Dragon King of Bhutan, relished the role of gatekeeper. K4, as he is affectionately known to his people, was less than a year older than Tabin, and as close to universally beloved as any head of state could be. He refused to throw the doors of his mountain kingdom open to the corrupting influences of the West, setting a slow, cautious course toward modernization. He denied visas to backpackers and limited tourism to high-paying group travel, mandated that his citizens wear traditional clothing to work, and banned television. He, too, had been educated in Britain, where he’d learned about the excesses of capitalism and the pervasiveness of poverty, even in so-called wealthy nations. In London he had swum briefly in the waters of the modern material world, before deciding to protect his people from it for as long as he could.

  The king had attracted media attention when he’d announced, in 1972, shortly after ascending to the throne following his father’s sudden death, that Bhutan would swim against the tide of simply accumulating wealth. He’d declared that “gross national happiness” was more important than gross national product, igniting a firestorm of both admiration and derision among foreign academics, who’d debated whether he could shelter his people from the realities of the twentieth century. Now the government of this monarch who’d worked so hard to keep foreigners out of his pristine mountain kingdom had invited the HCP in.

  With Daniell’s money, Tabin was able to launch the HCP’s first major expansion beyond Nepal and Tibet. Where he and Getshen wanted to begin was by giving teachers and basic health care workers throughout the country simple training, so they could identify those who might benefit from eye surgery. Simultaneously, Tabin and Getshen would select a group of the nation’s most promising medical students and send them to Tilganga for training. It would be a complex process, Tabin told Getshen, but in a country with such good governance, and a population of only 700,000, they could effect change quickly.

  “The idea that Geoff would take a hands-on role was very important,” Daniell says of his decision to donate the money. “This ensured the funds were well spent and the operating procedures and equipment well suited to the objectives of both an international eye-care standard and the country’s stage of development.”

  In the winter of 2000, at the Queen Mother’s invitation, Daniell traveled to Bhutan and pledged $100,000 a year for each of the next five years to transform eye care in the country. Afterward, Tabin flew in, met with the minister of health to discuss implementing the plan he’d honed with Getshen, and signed a five-year memorandum of agreement with the royal government, giving HCP staffers freedom to work in every far-flung community of the mountain kingdom.

  Five years to turn a nation’s entire eye-care system around. It wasn’t a lot of time, but Tabin felt sure they could do it. Since the day five years earlier when Tabin had taken Ruit’s hand and pledged to form the HCP, he’d relied exclusively on Ruit’s judgment about who they would work with in Asia. Now Tabin had helped open a new front in the battle against blindness and had forged a partnership with one of the world’s most reclusive monarchies. It had been a long time coming, but he was finally learning to shoulder his own load.

  Burn the Old House Down

  Even the bravest warrior with the sharpest eye who finds himself in a dense forest on a moonless night is unable to see and may soon be lost. The world, so rich in bright promises of happiness, is in truth, Oh King, such a forest. By night it becomes black. Love becomes brutal selfishness, wisdom becomes calculation. Prosperity becomes rabid greed, and justice, a means of oppression. This kingdom will rise and fall a thousand times. Even your own wisdom and power will wax and wane. There is no moment at which great exertion is not required.

  —The Warrior
Song of King Gesar, an epic oral legend about the royal leader, believed to be a reincarnation of Guru Rinpoche, who unified the warring principalities of the Himalaya

  “How are you doing, Doc?” the king asked. “Is everyone in the family well?”

  “Very well, Your Majesty,” Ruit said. “Now let’s have a look at those uncooperative eyes of yours.” King Birendra Bir Bikram Shah Dev slid his chair toward Ruit’s slit lamp and removed his glasses. He was familiar with the process after years of regular visits to Tilganga so that Ruit could monitor the pressure in his eyes, which might lead to glaucoma.

  “The king always spoke to me in English,” Ruit says. “He was a thoughtful fellow who didn’t want to be stiff with me. He knew that if we spoke Nepali, I’d have to use lot of formal words, archaic language specially for royalty, so I’d be groveling to him like serf to master.”

  “How does it look?” the king asked, leaning back in his chair.

  “You probably won’t go blind today or tomorrow,” Ruit teased. “But we need to keep an eye on your pressure. I’ll need to see you in another three months.”

  “Okay, Doc, you’re the boss,” the king said, and he changed the subject to a topic he found more interesting, a topic everyone in Nepal was discussing: the Maoists. Birendra asked Ruit if he’d met any of their leaders. Ruit admitted that he’d had a look at a few of their eyes in the line of duty, adding that the leaders he’d encountered had seemed reasonable enough. Not as radical, certainly, as the students in the street.