Second Suns

by David Oliver Relin

  Tenzin Yongdu, one of the monks living at Pullahari, perfectly exemplifies the fusion of East and West the Jamgon Kongtrul believed would flower on this ridgetop. When I visited the spot where Chang and Ruit faced off, Yongdu gave me a tour of the grounds. Biologists estimate that there are nearly seven thousand species of flowering plants in Nepal, and it appeared that most of them had taken root in the soil surrounding Pullahari, luring a visitor’s eyes from the sacred buildings to sprays of orange, magenta, and crimson blossoms mimicking the colors of the quietly strolling monks’ robes.

  The monastery’s main structure, the imposing Rigpe Dorje Institute, stands apart, even in such a landscape. It rises from a grand ground-floor shrine room that’s been painstakingly adorned with grinning skulls and wildly colored murals painted by master artisans, depicting each stage in the endless cycle of samsara, the Buddhist wheel of life. Then it narrows, like clarified thought, past simple, wood-lined spaces devoted to study, and tapers to a modest residence on the roof, topped with slim golden spires.

  Tenzin Yongdu, a white-haired, blue-eyed monk formerly named Harold Rolls, had retired to Pullahari after working as an architect in New York and Vermont, when the monastery was still a simple cluster of whitewashed dormitories. He’d taken a Buddhist name and prepared to spend his remaining days living a quietly contemplative life. But his fellow monks had other plans for him; they wanted him to design the building the former Jamgon Kongtrul had hoped would become Pullahari’s beating heart. “They started in on me,” Yongdu says, “after they found out I had been an architect. They were wildly excited, talking about the sacred geometry that should guide the building’s design. I told them I had no idea what they were talking about. Then they all started laughing and slapping me on the back. ‘Even better,’ one of them said. ‘Divine inspiration!’ ”

  Rather than trying to re-create the classical monasteries of Tibet, Yongdu settled on something more modern, a design he felt reflected the Rinpoche’s intentions. “I’ve learned to sacrifice my ego but not my intelligence,” Yongdu says. “And I tried to summon all the intelligence an old man had left. I wanted the building to be a launching pad for thought, not removed from the world but viewing it clearly, like the Rinpoche did. That’s why I made it spacious and bright, why I wrapped it in windows, and why I made the library and classrooms the soul of the structure, so it would be a place of engagement, not escape.”

  When Chang drove through Pullahari’s gate, he was relieved to see how orderly and manicured the monastery’s grounds were. But he was intimidated by the prospect of performing surgery there. “I was going, ‘Wow, we’re not in a hospital, we’re in the middle of nowhere,’ ” Chang says. “It’s sort of like if I went over to your house and we started operating on you in your living room.”

  “I may have had some spiritual home field advantages,” Ruit says. “So I tried to do everything possible to make David’s operating theater feel homely.”

  Chang had convinced AMO, the manufacturer of the Sovereign Whitestar model phacoemulsification machine he used in his California practice, to ship the same $100,000 ultrasound device to Nepal. He would use it during the clinical trial and, with AMO’s blessings, donate it afterward to Tilganga. Ruit had entrusted a technically sophisticated engineer he’d hired, Ajeev Thapa, to disassemble the $52,000 Zeiss microscope the HCP had purchased, a five-hundred-pound piece of equipment similar to the scope Chang used in California, and transport it up to Pullahari, where Chang found it perfectly calibrated next to his familiar phaco machine, in a large classroom converted to an operating theater on the second floor of the Rigpe Dorje Institute.

  Ruit had also enlisted the monks of Pullahari to serve as orderlies. They had sterilized each surface in the classrooms where they ordinarily gathered to study rolls of Buddhist scripture and empty their minds of the white noise of modern life, making the marble floors and wooden walls gleam like the center of the cloudless sky their meditative practice trained them to visualize.

  “The way Ruit incorporates civilians, if you will, into his work is incredible,” Chang says. “We had these armies of monks helping us, which I can only liken to eager Boy Scouts. They were so hardworking and helpful. And I needed that help because a trial like we were attempting had never been done before.”

  The gold standard in medical research is a randomized trial. In practice, this means that rather than collecting data from work that’s already been completed, for the most credible results, the reseacher designs an experiment from scratch and randomizes the flow of the patients, so there’s no possibility of infecting the results with bias. Tilganga’s screeners had gathered 108 patients with mature cataracts; they waited, eyelashes trimmed, eyes sterilized, in the monastery library, among sacred scrolls and classics of Himalayan literature that the literate among them would be able to read, once again, if the surgeries were successful.

  After the Tilganga staff anesthetized them and gave them a retro-bulbar block, an injection temporarily paralyzing the muscles that control movement of the eye, monks drew black or white Ping-Pong balls randomly out of a plastic bucket and sent the patients, depending on which color of ball had been picked, to Chang’s or Ruit’s operating room.

  “Right away, I was pressed to the limit of my ability,” Chang says. “At home, the cataracts we’re operating on are much less advanced. As a cataract matures, it hardens from the texture of Styrofoam to something more like mahogany, and it’s much more difficult to remove. In the U.S., you might see one case this tough a year.” Chang activated the ultrasonic tip of his phaco device, trying to balance the force it took to carve apart the calcified nucleus of his patient’s diseased lens with the delicacy required not to traumatize the surrounding tissue.

  Meanwhile, Ruit had finished his first case and started on the second.

  “In America,” Chang says, “we usually operate one or two days a week, get a lot of rest the night before, and make sure we don’t drink coffee that morning so our hands are steady. Then many ophthalmologists do four or five cataract surgeries a day, tops. A lot of us dread that one difficult case we know we have coming up in two weeks, so we have plenty of time to plan for and worry about it. But each of these cases was that one worst case. And it was an assembly line; they just kept coming!”

  In his operating room, Ruit sat comfortably on his stool, humming a Bollywood tune, his bare feet fine-tuning the focus of the $9,200 portable Zeiss microscope he now took on trips to the field. The surgical instruments he needed for his manual procedure—the speculum, scissors, forceps, crescent blade, and irrigating cannula he used for hydrodissection of cataracts, which he’d had manufactured to his specifications in India—cost just under $80 for a complete, reusable set.

  “How are you doing, David—do you need anything?” Tabin asked, looking in on Chang after he’d watched Ruit complete his fourth surgery while two monks guided his fifth patient to his table.

  “I’m fine,” Chang said, keeping his eyes trained on the inner capsule of his first patient’s eye, where his phaco machine’s ultrasonic probe had nearly finished pulverizing the opaque lens. “How many has Ruit done?”

  “Ruit’s speed was incredible,” Chang says. “But I was pretty sure that my patients would have better results. Pretty soon, I began picking up my pace and finished a few cases I felt pretty good about. It was sort of like being a contestant on Iron Chef. You have a limited time, people scurrying around and watching, and a camera over your shoulder while you’re … cutting up the beef.”

  Tabin darted back and forth between the operating rooms, making sure the patient selection was truly randomized and that every step of the assembly line was running smoothly. He leaned in to watch Chang, admiring the expertise with which he pulverized every crumb of hardened tissue before inserting a late-model foldable lens with the sort of grace and speed Tabin associated with Ruit. “Do you have any questions, David?” Tabin asked. “Anything I can do for you?”

  “When do I get to use the toilet
?”

  “Waaayell,” Tabin said, laughing, “that depends who you ask.”

  When Chang returned, he stretched his back and strolled over to observe Ruit. Then he began revising his opinion about who would prevail, once all the postoperative data was collected. “I was open-mouthed, watching him work,” Chang says. “You just don’t see something like that every day in my profession. That combination of efficiency, grace, and speed. After that, I wasn’t sure who’d win the day, but I realized that Ruit was just a master, master surgeon.”

  After their second day of surgery, Chang, Tabin, and Ruit sat on a west-facing terrace, watching the sun set over the mid-hills.

  “Tired, David?” Ruit asked.

  “Oh, a bit,” Chang said. Actually, he felt like he’d barely survived a day of hand-to-hand combat.

  Early the next morning, Khem Gurung led the Tilganga staff as they prepared patients for their postoperative exams in a red sandstone amphitheater facing the shrine hall. There was no worry about disturbing the monks, who had been up before first light, completing their prayers at the time they considered the most spiritually charged portion of the day, when darkness gives way to the faint glow of dawn. They stood on the balconies of their dormitories, their scarlet robes burning in the low-angled sun, as bright as the blooms in Pullahari’s gardens.

  Ruit let his staff remove the patients’ bandages while he hung back and contemplated the magnitude of what he’d just been able to prove. He was certain that he’d held his own against one of the West’s finest surgeons. “We photographed and noted the degree of trauma in the eyes of each case,” Ruit says. “I was quite sure that both David and I had done a laudable job. We wouldn’t be able to compare our results precisely until our staff did follow-up examinations. But I suspected our trial would prove that David Chang, with his latest machines, had done well. But no better than I, with just a few needles and knives.”

  In the summer of 2005, when Tabin returned to Burlington, he began packing up his office, placing framed photos from Asian cataract camps into cardboard boxes. John Frymoyer, the dean who had first championed Tabin, had left the University of Vermont. His successor, Dr. Joseph Warshaw, had also been a firm supporter of Tabin’s, until he’d been diagnosed with terminal multiple myeloma. But the team that took over the medical school after Warshaw’s departure “micromanaged my practice and limited my time away,” Tabin says. “Every time I came back from a trip I felt a little bit less welcome. It was death by a thousand cuts.”

  The cut Tabin found intolerable had come several months earlier. He’d returned from another trip to Nepal, walked into his office, and found a memo on his desk that enraged him. “It was this long, officious list of things I was no longer allowed to do, like make HCP-related calls from my office phone or use university copying machines, printers, and secretarial staff to prepare HCP materials,” Tabin says. “That memo made it clear I needed to find a new home for the HCP. Jean and I had a great community in Burlington, and we loved our house, but I knew if the HCP was going to survive, I had to find an institution that would support my international work.”

  Before leaving Vermont for the trial at Pullahari, Tabin began searching for other jobs, and when the University of Utah’s John A. Moran Eye Center presented him with an ideal opportunity, Tabin seized it. Dr. Randy Olson, the Moran’s director, had grasped, instantly, the importance of Tabin’s international work and the luster his presence could add to a facility already considered one of America’s leading eye-care centers.

  “Geoff was doing entire surgeries for less than we spend to drape a single patient,” Olson says. “I’d always been told there would be more people going blind from cataracts than there would be surgeries available, but Geoff was proving that didn’t need to be the case. Most American doctors working in the third world were still stuck on the old model: do twenty surgeries, make your trip into a little vacation, and leave complications behind. He and Ruit had created a whole new paradigm.”

  Olson offered both Jean and Geoff places on the University of Utah faculty and promised to create the sort of position for Tabin that he had fantasized about—director of the Division of International Ophthalmology. His salary would be considerably lower than those of his colleagues who worked year-round at the Moran, but his trips overseas would no longer be considered unpaid leave. They would be the heart and soul of his job. And as a sweetener to the offer that Tabin already found impossible to resist, Mormon-dominated Salt Lake City was populated by another spiritual community whose zeal he shared: mountaineers, obsessed with scaling the rugged peaks that ringed the metropolitan area.

  By 2006, Ruit was facing fundamental changes, too: His success in reducing the number of Nepal’s rural blind was making him famous. That year, he was named the recipient of the Ramon Magsaysay Award, often referred to as Asia’s Nobel Peace Prize. The citation praised Ruit for refusing to accept “the absence of medical care [that] condemns [people] to darkness.” In 2007, Asian Reader’s Digest, the continent’s largest publication, anointed Ruit its “Asian of the Year.” “In the last 23 years,” the magazine wrote, “Dr. Sanduk Ruit has personally conducted nearly 70,000 cataract surgeries, often saving more than 100 people a day from blindness.… As Ruit spreads new techniques to … many hundreds of others, hope grows that one of the great public health challenges of the 21st century can be overcome.”

  These accolades didn’t go unnoticed in Nepal, whose appearance in the international press was often limited to reports of new atrocities in the ongoing war between the government and the Maoists. By 2006, 12,800 people had died in Nepal’s civil war, and more than 150,000 had become refugees in their own country, fleeing from the worst spasms of violence.

  International monitors like Human Rights Watch alleged that thousands of captured Maoist fighters were “disappeared” by government forces. The same monitoring groups also reported an organized reign of terror directed against supporters of the government in the Maoist-controlled countryside, where rebels, sometimes leading squads of child soldiers they’d pressed into service, would overrun police posts, killing or kidnapping whomever they found inside.

  Ruit says that the country’s competing powers, the Maoists and the Congress Party, each asked him to serve as their minister of health. He rebuffed both, telling them he preferred to remain where he was most useful, working where a powerful politician and a subsistence farmer received exactly the same standard of care in his clinic.

  There was one life-changing move that Ruit felt compelled to make, for his family. Lisa Ling, before departing for Mustang, had filmed Ruit in his apartment. “Where do you think the most famous doctor in Nepal would live?” she asked as her cameras panned around the Ruits’ dingy apartment. Ruit was pleased that Ling’s focus on his modest home showed how he’d shunned the corruption that afflicted so many influential Nepalese, but Nanda was embarrassed by the film’s implication that they lived one step above the poverty of Kathmandu’s streets.

  Each day, Ruit’s elderly parents left their apartment in the center of town and transferred between three buses so they could make a morning pilgrimage to Swayambhunath. Ruit found their daily, traffic-choked journeys increasingly intolerable. For years, Ruit’s relatives, who had preceded him to Kathmandu from Olangchungola and had built a successful business selling Tibetan antiques and carpets to collectors in the West, had offered to help Ruit find and furnish a house of his own, in a better location.

  Ruit’s family was proud of its most famous member and felt it was improper for a doctor of such renown to continue living like a student. “He could work anywhere in the world, but he chose to stay here for his parents and the people of his country,” says his cousin Tenzing Ukyab. “One day Kasang was in a bad crash, when a three-wheeler she’d transferred to from a bus on her way to Swayambhunath smashed into a transport vehicle and turned over. Sanduk had to stitch up his own mother’s face where it was torn.” Ukyab told Ruit that enough was enough, that it was time to move. If h
e was reluctant to accept his family’s help, then he should do it for his parents’ sake. Let them live near the temple they revered. Neither Tabin nor Ruit had ever drawn a salary from the HCP. And Ruit says his wages at Tilganga, combined with work he did after hours in his private clinic, amounted to only $32,000 a year. So it was with real trepidation that Ruit decided to use an uncomfortable portion of his savings to purchase a house commensurate with his standing in Nepalese society. “For all he’s done here, the Nepalese government should have built him a palace, but they’re goons who can’t take care of their own people,” Ukyab says. “We were delighted after so many years of encouraging him that he finally agreed to move.”

  Ruit bought a house near the base of the hilltop temple that would allow Sonam and Kasang to make their daily pilgrimage by foot. It was a three-thousand-square-foot brick structure with a prayer room on the second floor and a window framing the golden spire of Swayambhunath. Inside the house’s gated courtyard, a riot of purple bougainvillea blossoms climbed the brick walls.

  The place seemed palatial to Ruit, especially after twenty years in a tiny apartment. But seeing the way Nanda’s eyes shone at the prospect of moving up so dramatically in Kathmandu society pleased him. He took out a mortgage that made him as anxious as his father had been when the family had first moved to Kathmandu, and accepted his cousins’ offer to fill the large, echoing building with comfortable furniture. Ruit hung the Ramon Magsaysay and the Asian of the Year awards on the walls of his expansive new living room, and allowed himself a flicker of pride for the way he’d been able to steer his family’s fortunes. No one could doubt any longer that he was well matched with a beautiful Newari woman from Kathmandu’s upper class. He’d managed to install his parents safely upstairs in their last home, a place they’d never have to leave, as they’d been forced to flee Olangchungola. What other blessings, he wondered, would this chapter of his life bring?