As his stature in Nepal grew, Ruit continued turning down offers to endorse any particular faction of his country’s political leadership. But there was one invitation to visit with a part-time politician that Ruit was happy to accept. So happy, in fact, that he brought his parents with him.
“This is the woman who brought such a beacon of light into the world?” the man who’d summoned Ruit said. “Let me look at her!”
Kasang lowered her eyes shyly, unable to meet the gaze of the person she considered no less than a living god.
“What about your father? Let me at least shake his hand for raising such a man!”
Sonam was too overcome to reach for the outstretched hands. It was improper to stand face-to-face with the supreme leader of Tibetan Buddhism. He fell to his knees on the thick carpet, averted his eyes, and bowed his head.
The Dalai Lama settled for placing his hands on the heads of both of Ruit’s parents and chanting a blessing, wishing them long life and excellent health.
“Come, come, sit next to me, Dr. Ruit,” he said, patting an overstuffed cushion beside him in the reception room of his offices in Dharmsala, India. Ruit felt his mind bending in disbelief and endeavored to straighten it out. Could it be possible that the man on earth he revered most was speaking to him with such informality, such intimacy? Had he come so far from Olangchungola, achieved so much, that His Holiness was equally interested in him?
“We have so much to talk about and so little time,” the Dalai Lama said. “My secretaries will attempt to hurry us along. Come, come.”
Tenzin Gyatso, the Fourteenth Dalai Lama, has often said that if his karma had not been to spend his life as a Buddhist monk, he would have chosen a career in science. “He had so many questions about how we achieved our results,” Ruit says. “He knew all about the latest surgical innovations and asked how he could help bring them to all the far-flung regions of the Himalaya. I was surprised and humbled by the breadth of his knowledge, and I told His Holiness so.”
“But you humble me, Dr. Ruit,” the Dalai Lama said. “You humble me with your compassion. I’m just a simple Buddhist monk. I often wish I had some technical skills, so I could be of greater use.”
Ruit was watching the mouth of the leader of Tibetan Buddhism, the head of state of the government of Tibet in exile, and trying to take in his words. But in a separate chamber of awareness beyond language, he felt his attention drawn to his hands, to the way the Dalai Lama cupped them in his while they spoke, to the way they seemed to transmit an electrical current. “His hands were so soft and warm, like they were speaking their own language, passing on some of his inner strength,” Ruit remembers. “I don’t know how to explain it, but I was just so happy. Happy to be summoned to this meeting. Happy to meet with a man I admired so much. Happy to see my parents’ happiness in his presence. And happy for the confirmation he was giving me that I had chosen the correct path.”
As promised, his secretaries leaned into the room after fifteen minutes, subtly glancing at their watches, but the Dalai Lama dismissed them with a brief shake of his head, sending them away once, and then again, until he’d repeated his offer to help Ruit in any way he could and conveyed the message of gratitude he’d invited Ruit to Dharmsala to deliver: “You know, there are many kinds of Buddhas among us,” he said, pulling Kasang and Sonam up from the positions where they’d prostrated themselves on the carpet, looking at them directly. “Your son is a Buddha, too. He is our medical Buddha.”
“I don’t know how to explain it, except to say that His Holiness really brings the light,” Ruit says. “After I left him, I felt so full of power I felt I could accomplish anything.”
Ruit’s colleagues in the medical community concurred. After nearly two years of editing and peer review, the results of Ruit and Chang’s trial at Pullahari were published in the American Journal of Ophthalmology. The study documented the fact that one of the world’s best and fastest phacoemulsification surgeons had taken nearly twice as long to operate on each patient as Ruit had. It also demonstrated that one day after surgery, 91 percent of Ruit’s patients had normal vision, compared to 78 percent of Chang’s, an essential difference for people who often walked home over difficult terrain soon after the operation. The data equalized after six months, when there was no significant difference in the visual outcome of Chang’s and Ruit’s patients: 98 percent of each group had excellent eyesight. The results of the surgery Ruit was doing in monasteries, schools, police posts, and veterinary clinics—which the study referred to as SICS, for small-incision extracapsular cataract surgery—was comparable to the outcome patients could expect in modern American hospitals.
“I really wanted to do the trial,” Ruit says, “because some of our own colleagues that we had trained to do manual surgery were feeling inferior, like they couldn’t keep up with the West, with their latest, greatest phaco machines. So we wanted to make it little more sexy. We wanted to see how we compared, best to best. The results of the surgery were strikingly similar. But our turnover time was much quicker. That’s what our colleagues needed to know. And because of David’s good heart, we were able very vocally to say that SICS is the best solution for high-volume developing world surgery.”
After more than two decades of uphill struggle, Ruit’s renegade philosophy of bringing the best care to the poorest people in the most remote places had been vindicated in peer-reviewed print. He had a fanatically dedicated partner in Tabin and a powerful new ally in Chang, one of the thought leaders of his industry.
“What impressed me the most was that there was a magic in Ruit’s system,” Chang says. “And Sanduk had developed it on his own, without academic support. I was really happy that our study confirmed what he’d been fighting for for so long. But I felt like it was just the first step. Statistics can seem dry and distant. I didn’t think people understood yet the scope of the problem, the challenges people face in the developing world, and the courage they have to go on living despite obstacles that would stop Americans in their tracks. I came away feeling people had to know that there were heroes like Ruit and Tabin fighting to change the world. That this was a story that needed to be told.”
Clear Vision for Life
In time past, wrapped up in clinging blindness,
I lingered in the den of confusion.
—Milarepa
I stepped out of the taxi after the driver finally found Ruit and Tabin’s Hong Kong hotel. We’d been circling backstreets for twenty minutes before we’d located their modest lodgings: a narrow tower standing above a narrow street that specialized in the sale of toilets. Most of the doctors attending the World Ophthalmology Congress were staying in brand-name five-stars, connected by elevated, climate-controlled walkways to the Hong Kong Convention and Exhibition Centre. But the codirectors of the HCP, whose frugality with donors’ funds was too ingrained for them to even pay themselves salaries, weren’t about to spend $300 or more a night for hotel rooms.
After Tabin had gotten his teeth into me, I’d been trying to unearth and piece together the information to tell this story. And since seeing Patali Nepali’s sight restored by Ruit in Rasuwa, I’d begun traveling with Ruit and Tabin, trying to understand the forces that drove them. In June 2008 I joined them in Hong Kong, at a conference attended by thousands of their peers, to hear them make a case for why their approach to cataract surgery in remote areas of developing countries should become the global standard.
Walking toward the entrance, I saw Tabin through glass beaded with condensation, waving good-bye with his tennis racquet to a surgeon, an over-forty singles champion from Rhode Island whom he’d played a few sets with before the congress kicked off. Ruit sat in the far corner of the lobby, on a slender plastic chair that bowed beneath his weight, as inert as Tabin was animated, scowling as he edited a copy of the speech he planned to give the following morning. I pushed through the door, and Tabin’s face shone with the delight he directed at friends and acquaintances alike.
“Ni h
ao!” he yelped, hugging me to his sweat-soaked workout gear.
Compared to week-long treks through the mid-hills, our twenty-minute walk the next morning through the superheated streets of Wan Chai was more of an annoyance than a hardship. But it was enough to ensure that our small delegation, which included Ruit, Tabin, and six members of Tilganga’s staff, arrived sweating through our suits and saris.
We left the seething streets, where breakfast soups boiling in cauldrons added even more moisture to the air, and entered the bland, modern exhibition hall. In the whir of industrial-strength air-conditioning and the patter of slick-talking salespeople, we might have been in Phoenix or Houston. Ruit hurried ahead, nervous about a lecture he was due to give that would lay out his vision for combating cataract blindness worldwide. I walked with Tabin, and we slipped farther behind the fast-striding crowd every time he stopped to shout an enthusiastic greeting and hug a colleague he recognized.
We were about to board an escalator that would take us up to the exhibition floor and lecture halls when a well-dressed middle-aged Asian man fell to the floor and rolled onto his back, his chest heaving spasmodically. There were more than eleven thousand ophthalmic professionals attending the congress, and the majority of them were doctors. But the stream of purposeful walkers parted around the fallen man, everyone continuing on their way. Not Geoff Tabin. He dropped to his knees without hesitation and took the man’s hand. “I’m a doctor,” he said. “Can you understand what I’m saying?”
The man nodded.
“Can you breathe?”
He nodded again, then tried to sit up.
“Why don’t you just take it easy for a minute,” Tabin said, rubbing his shoulder so he would stay in place, and checking his pulse. Tabin squatted on his haunches, talking soothingly until a team of paramedics in neon-orange jumpsuits arrived. “I think he just had a panic attack,” Tabin told them. “No chest pain and his resting pulse is normal.”
We left him in the hands of the paramedics and stepped onto the escalator, now sure to be late for the beginning of Ruit’s speech. I said, “I thought you guys weren’t supposed to do that anymore, with the threat of lawsuits and everything.”
Tabin looked at me like I’d just denied the existence of gravity. “That’s just craziness,” he said. “I’ve never hired a lawyer in my life. If lawyers can scare us away from helping people, then the world will really be out of whack.”
We passed a lecture hall with a standing-room-only crowd. The signboard at the door said, LATEST EXCIMER LASER: VISX CUSTOMVUE VS. WAVELIGHT ALLEGRETTO. Knowing how nervous Ruit was when addressing large crowds, I hoped our late arrival wouldn’t make him even more anxious. But when we walked through the door of room 309, I counted exactly eleven people, apart from an equal number of Tilganga employees and HCP supporters, scattered across a sea of a hundred empty chairs.
Tabin and Ruit had come to the conference with several boxes full of Fighting Global Blindness: Improving World Vision Through Cataract Elimination, the textbook they’d written as a blueprint to help others replicate their success in the field. It included step-by-step illustrations of Ruit’s sutureless technique, lists of tools and materials needed to conduct cataract camps, and tips on the best way to organize medical teams planning to work in remote areas.
Tabin took a seat near the door, by the boxes of books, shaking his head. “Every leading cataract surgeon in the developing world is at this conference, and this is the turnout we get?” he said. “I guess they’re here to play with the latest toys so they can go home, say they’re familiar with the most modern equipment, and charge the most money possible for their services. Did you know that China has the largest population of untreated cataracts in the world? We’re in Hong Kong, and I don’t see a single Chinese policy maker or surgeon in this room.”
I was used to seeing Ruit in command, but he looked meek at the podium, reading haltingly from a prepared script and barely glancing up at his audience. “We estimate that there are upward of sixty million people who are severely visually impaired by cataracts,” he said. “And in many parts of the world, these people live very far from hospitals. International organizations that fly in for a week or two do more harm than good because they leave complications behind. You have to build trust with your patients not only by delivering excellent care but by being there to follow up when they need more.”
I knew how passionate Ruit could be on this subject. I’d sat with him during long drives, listening to emotion choke his voice as he spoke about the epidemic of unnecessary blindness, and much of the world ophthalmic community’s indifference to eradicating it. But there was no passion in his talk to room 309, only nerves, perhaps because the indifference of so many of his eleven thousand colleagues was so vividly displayed by the rows of empty seats. Still, Ruit soldiered on. “So what I’m really saying is this. You have to change your way of thinking. You have to change your concept. These are more difficult surgeries than hospital surgeries. You have to build a system and put it in place. You have to be more serious about training people in un-served areas and helping them put together high-quality teams who can attack cataracts with a production-line approach. We can teach you how to do this,” he said, regaining a little of his composure, knowing how solid the ground on which he stood was. He’d played a central role in transforming eye care across his country and much of the surrounding region. He’d done the hard work, created the model, and perfected it. Now, with Tabin’s and Chang’s help, all he had left to change was his profession’s attitude.
Ruit flipped to the key slide in his PowerPoint presentation; it showed two charts, side by side. The chart on the left documented the nearly 24,000 cataract surgeries performed in Nepal in 1994, the year Tilganga opened its doors—a time, he told the audience, when small-incision surgery was still rarely performed in his country’s rural areas. The second chart displayed the latest data available, from 2007, showing that Nepalese surgeons, many of whom Ruit had trained, had performed 167,000 cataract surgeries. “And by 2007,” Ruit said, “nearly hundred percent of those were high-quality microsurgery with IOL implantation.”
The small audience broke into enthusiastic applause, and I could see the Ruit I knew trickling back into the awkward figure at the podium. He raised his eyes, finally, from his text and made eye contact with the rest of us. “When we first started working in Nepal,” he said, “we faced lot of barriers. People told us it was too expensive to provide the best care to the poor. We’ve worked out how to get round most of that now. We have a model you can take to the underserved areas of the world. And we’re here to help you.”
Ruit’s speech had been designed to address his profession’s indifference to overcoming the global crisis of cataract blindness. The turnout had highlighted that indifference among far too many of his peers. But at least the eleven strangers in the room who’d listened intently had heard his call to action. Tilganga had been built on the trash-strewn site of a temporary parking lot for buses, I reminded myself. Surely revolutions had been started with fewer people.
The main exhibition hall of the 2008 World Ophthalmology Congress was dominated by flashy multimedia display booths built by pharmaceutical companies and medical equipment manufacturers. Doctors circulated through the booths, stuffing free samples into World Ophthalmology Congress tote bags they’d received at registration and gaping at infomercials made by the producers of half-million-dollar-plus excimer lasers, which boasted of the profits the doctors could earn by investing in next-generation technology.
I took the opportunity to try my untrained hands at a cataract surgery simulator. I pressed my eyes to the rubberized microscope eyepieces, like a submariner lining up a torpedo, and maneuvered a virtual phacoemulsification cutting tool toward a dense white cataract nesting at the center of an imaginary eyeball. Once I was in, I promptly made a mess of the cataract, pulverizing it with the application of far too high a burst of ultrasound waves, traumatizing the surrounding tissue, and guaranteeing
that, had my virtual patient existed in the fragile world of flesh and blood, they’d never see out of that eye again. I confirmed, as I had after watching the North Korean doctors struggling to learn Ruit’s technique in Rasuwa, that surgical artists like Chang and Ruit only made the procedures they’ve perfected look easy.
Tabin gave a talk to a crowd of seventy or so at the booth of Santen, a large Japanese pharmaceutical company he’d wooed, convincing the CEO of their American subsidiary to donate tens of thousands of dollars of medication and IOLs to support the HCP’s work. Under a banner that read, SANTEN: A CLEAR VISION FOR LIFE, Tabin delivered much the same speech as Ruit had the previous day. But he spiced up his PowerPoint with photographs of his mountaineering years, and seeing a bearded, wild-haired version of the man at the podium hanging from the Kangshung Face of Everest, many of the passing doctors took a seat and listened to at least part of his presentation, until the topic changed back to preventing blindness.
David Chang drew a much larger crowd. Striding the wide stage that his sponsor Alcon, one of the goliaths of the ophthalmic industry, had constructed, Chang spoke engagingly into a wireless headset while a blizzard of images and animations bombarded the translucent panels he paced along. Here was a $2,000 laser-etched intraocular lens, custom-cut to cure a patient’s particular astigmatism; there, a golfer grinning and giving a thumbs-up after his new Alcon lens allowed him to track his ball’s flight.
Corporate mission accomplished, Chang concluded his presentation by calming the storm of multimedia and turning to speak simply to the crowd. “All these technical advances I’ve been talking about are worthy achievements,” Chang said. “But tomorrow, Dr. Sanduk Ruit of Nepal—stand up, Sanduk, there you go—tomorrow, Dr. Ruit will be performing live surgery of the small-incision cataract technique he pioneered. If you go to one event at this conference, go to that. You have to see what Dr. Ruit is able to do with your own eyes to believe it.”
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