Second Suns

by David Oliver Relin

  Since I’d arrived in Hong Kong, Ruit had been especially prickly and unapproachable. He was willing to speak about the technical challenges of his work, but he fended off most of my personal questions. I tried picking my spots during meals, when he was most relaxed, with little luck. I attributed some of his reticence to the strain he felt from fighting for attention at the conference. I had come to believe that his story, twined with Tabin’s, was even more extraordinary than I’d imagined that day in Rasuwa when I’d watched him surveying his patients from a rooftop and had decided to write it. If I was to do justice to the journey they were taking together, I had to get Ruit to reveal more. It had taken Tabin years to win Ruit’s trust before they’d developed a close working relationship. I didn’t have the luxury of that sort of time, so I asked Tabin for advice.

  “Ruit’s tough,” he said, speed-walking toward the exhibition hall on the last muggy morning I’d spend at the conference. “There are no shortcuts with him. I’m afraid you’re on your own.”

  We entered a theater that had been arranged for the live surgery. Organizers had removed sliding partitions so the space could be enlarged. Perhaps one thousand people filled the rows of movie-style seats, including close to one hundred of the Chinese surgeons Ruit hoped to convert to his system. I sat between Tabin and David Chang, but technical problems delayed the start of the program and Tabin left to pace the aisles of the theater, stopping to network whenever he recognized a face.

  As I watched the screen, waiting for the show to begin, the room thrummed with the expectant atmosphere that fills an arena just before the opening tip of a basketball game. Instead of uniformed players, a live feed from a local hospital appeared on the screen, and a world-renowned surgeon strode into the frame, holding his sterile latex gloves stiffly in front of him as he approached his patient. He was the head of the ophthalmic department at a prestigious medical school and attempting the same SICS cataract surgery Ruit would shortly perform.

  From the moment he made his first incision, I knew something was wrong. His movements seemed fitful and tentative. He severed a blood vessel, until the image projected three stories tall was streaked with crimson gore. Expert panelists sat on a podium in front of the screen, commenting in hushed voices like broadcasters at a golf tournament. David Chang leaned toward me and whispered, “Surgery is stressful to begin with, but live surgery is off the charts. I’ve seen superb surgeons who can’t handle the pressure and really blow it. He can hear the audience’s reaction and everything critical the panelists are saying. That makes it even tougher.”

  The surgeon narrated his procedure as he struggled to control the bleeding he’d caused, and his voice, which had started out authoritative, began to quiver with the strain. He sawed with his blade to enlarge his wound, and again the audience gasped. “He’s gone too deep and punctured the iris,” Chang whispered. “That will take some time to repair.”

  Tabin wasn’t able to remain as reserved.

  “This is outrageous!” he said loudly, hopping up from the seat behind me where he’d momentarily come to rest. “I wouldn’t let one of my first-year residents make a mess like this!” For the first time since I’d watched Ruit operate in Rasuwa, I began to feel truly queasy, observing the enormously enlarged metal tools probing the patient’s thirty-foot-tall bloodied eye. I had seen my share of eye surgeries by then, somehow insulated from my natural squeamishness by the fact that though they might seem a bit gory, they were part of the process of improving a human life. But as I watched a surgery go wrong, and worried that a man’s eye was being damaged, the insulation suddenly wore thin. I covered my face with my hands.

  When I was finally able to peer through my fingers, Chang whispered that the surgeon had been able to coax the prolapsed section of iris back, so the patient was out of danger. Now he was cleaning up the mess he’d made and preparing to insert an artificial lens. The problem, Chang said, was that the conference had allotted an hour for the three surgeries and the first had already taken almost thirty minutes. He didn’t know if Ruit would get his chance to operate.

  The second person who appeared on the screen was a highly respected female surgeon. She, too, struggled under the pressure of live surgery, and though her work wasn’t as bloody, it stretched on for twenty minutes. As the seconds slipped by and she fumbled with her tools, Tabin picked up the speed of his pacing in the aisle behind me. “We’re trying to convince this audience that manual small-incision surgery is a simple procedure that should be widely practiced,” he nearly shouted. “And now she’s making it look so hard she’s scaring off half the surgeons in the room.”

  With ten minutes left in the program, I saw a familiar face appear larger than life, and a pair of dark eyes above a blue surgical mask, shining with confidence. “With proper training,” Ruit said, “small-incision cataract surgery is a very simple procedure, the solution to cure the millions of patients in poor countries who need our services. This,” he said, holding up a curved metal tool scored with fine lines like a file, “is a Simcoe cannula. To a cataract surgeon it’s what a rifle is to an infantryman: the one essential tool.”

  An elderly female patient lay prepped on Ruit’s table. His poise as he prepared to operate, as he faced a complex physical task to perform, rather than a simple speech to deliver, was absolute. Technicians played a short video highlighting Ruit’s surgical innovations. At one point, I was confused, because he seemed to be operating out of order, sliding an artificial lens into the eye before removing the mature cataract, and at that moment, the surgeons in the audience applauded wildly. “That was brilliant,” Chang whispered. “The integrity of the patient’s eye was too fragile for Ruit to remove the cataract without it collapsing, so he put the IOL in first and used it to keep the shape of the eye intact while he removed the clouded tissue.”

  “Have you ever seen that done before?” I asked.

  “Not in exactly that way,” Chang said. “I would make the analogy to a pro golfer. When the ball is sitting on the fairway, we all know what to do. What really separates Tiger Woods from the rest of us is what happens when the ball flies into the trees. They have trick shots to get out of that. For the rest of us, when our ball goes there we go into a death spiral. That’s what it is for a master surgeon. You have to have that mental toughness. You have to be able to react instantly and creatively.”

  The screen switched back to a live shot of the operating room. “Dr. Ruit, I’m afraid we only have five minutes before our feed is cut off,” one of the panelists said.

  “Five minutes? Have little bit of mercy! I’ll see what I can manage,” Ruit said, bending swiftly to his work. But I could sense the smile spreading behind his mask, could hear him humming faintly as he made his first incision, the tip of his blade creating a small opening, then widening his wound, propelling his tool forward with graceful side-to-side strokes, like a speed skater’s blades cutting into a pristine oval of ice. In another moment, he had the scored tip of the cannula under the hardened cataract and was drawing it steadily through the funnel he had created, until the woman’s eye was clear. In went the artificial lens where the cataract had exited, and, as it slid into his patient’s eye, with its promise of lifelong clarity, I looked at my watch. The entire operation had taken just under five minutes.

  The audience stood and applauded. Ruit removed his mask as the patient was wheeled away, and I didn’t need to imagine his grin anymore. It was there for all of his peers to see, three stories high. He began to say something just as the feed was cut and the screen went dark. But his hands had spoken eloquently enough.

  The knock on the door of my hotel room later that night interrupted me as I was writing furiously in my notebook. I put my pen down with some annoyance and answered it. Ruit stood there, holding a bottle of Johnnie Walker Green and two tumblers in his right hand. He sailed a DVD of the live surgery to me like a Frisbee with the left. “A souvenir,” he said. I placed it on the desk beside my notebook.

  “Now, my
dear,” Ruit said, putting his arm over my shoulder. “Why don’t we have a drink and discuss some of those questions you’ve been pestering me with?”

  The Singing Bowls of Swayambhunath

  Still the world is wondrous large—seven seas from marge to marge—

  And it holds a vast of various kinds of man;

  And the wildest dreams of Kew are the facts of Khatmandu

  —Rudyard Kipling

  I hiked up through the dark, winding lanes of Kathmandu, from my hotel toward Swayambhunath, whose golden, spotlit stupa guided me in like a lighthouse. Street dogs snarled from construction sites, where they’d retreated for the night, and near-naked sadhus slept, curled against the cold, on the concrete floors of small roadside shrines. I arrived at the Armed Police Force base where Ruit and Tabin planned to play badminton and waited by the locked gate as instructed. I looked at my watch: 5:00 A.M., exactly.

  An instant later Ruit and Tabin materialized out of the dark from the direction of Ruit’s house. Ruit rattled the gate until a sleepy soldier answered it, but the soldier said that due to the upcoming elections, security on the base was heightened and the athletic facilities were closed to civilians.

  Ruit had looked forward to throttling Tabin in my presence; he’d boasted the night before that he’d never lost a match to him. Now he sighed, adjusting the ski cap he wore tugged down over his ears, and cast about for another way to get his morning exercise before we left on a seven-hour drive to southern Nepal. “Shall we climb Swayambhu?” he asked.

  I was pleased by the change of plans. I’d spent a week two decades earlier, laid up by amoebic dysentery, in a cheap Thamel guesthouse. I’d climbed up to Swayambhunath after I’d recuperated, and ever since, I’d thought of the hilltop temple, with its visual cacophony of shrines to competing gods, as a symbol of well-being. I hadn’t had an opportunity to visit in years; my hours in Kathmandu were tied to Ruit’s schedule.

  Ruit chose a wooded route, bushwhacking up a steep slope on the back side of Swayambhu Hill, weaving through trees strung with prayer flags as monkeys chattered at us for disturbing their sleep. As we climbed, I remembered the advice Ruit had received from his father as a child: “When facing two paths, if you are strong enough, always choose the hardest one.” Ruit was certainly strong enough. Though he was a decade older than me and overweight, I couldn’t keep pace with his stride, so I jogged as I tried to keep him and Tabin in sight. We climbed to the temple mount but bypassed entirely the tikka-smeared shrines and golden stupas I’d hoped to see. Ruit was out for exercise, not inspiration. After cresting the hill, he didn’t pause to admire the view of Kathmandu at dawn; he set a winding course through a grove of pines on our descent, steering us clear of every point of interest.

  By the base of the temple’s great staircase, several female vendors rose from the blankets where they’d been sleeping among their wares, trying for an early sale. They struck their hammered brass bowls like bells to get our attention, then dragged sandalwood sticks along the bowls’ rims, making them sing mournful notes, long, wavering cries that rose and fell like the protests of petulant children, a sound that matched my mood precisely.

  Rex Shore was at the wheel of Hilda. Keeping our tires on the muddy track took all the skill he had accumulated during his twenty years of driving in the former kingdom. Hilda’s odometer had stopped working, and her white lace headrests had grayed with age, as had Shore’s blond hair, but driver and vehicle were still a formidable team.

  In Nepal, there were roads and rumors of roads. “The road is coming” was a phrase I heard often, as if new highways were descending from the hills of their own will, like tarmac-topped glaciers. More often than not, probing new routes that appeared on maps as confidence-inspiring solid lines revealed rutted, muddy tracks. Ruit was always attentive to news of roads that could cut the distance his surgical teams had to travel. We were headed south to an eye camp celebrating the opening of his second full-scale Nepalese hospital, in Hetauda, between the capital and the Indian border. The two paved roads between Kathmandu and Hetauda were so jammed with truck traffic and so frequently blocked by the political demonstrations known as bandhs that Ruit asked Shore to test a new shortcut that had just been bulldozed through the mountains. If the road proved passable, we could save a few hours. I had been assigned to the test vehicle while Ruit and Tabin took the traditional route in the comfortable new Land Cruiser, which the Tilganga staff had decided to nickname the White Elephant.

  One of the most obvious by-products of Nepal’s bad governance was the country’s lack of roads that didn’t force those traveling them to risk rearranging their internal organs. Only six thousand miles of tarmac existed throughout the entire country of widely scattered cities and settlements. Compare that with Switzerland, where, despite similar topography, legendary efficiency has led to forty-tour thousand miles of paved roads in a country a quarter the size of Nepal.

  I rode in the back of Hilda with Alan Crandall, a colleague of Tabin’s at the Moran. Crandall, sixty, was sandy-haired and solidly built. Tabin had bonded with him immediately after discovering that Crandall was one of the rare American eye surgeons who shared his commitment to working in the developing world for more than a week at a time.

  “Bump!” Shore shouted.

  We bounced over a boulder, and both Crandall and I hit our heads on the roof. “Not the smoothest road,” Crandall said in his laconic cowboy drawl. Growing up, he’d worked on his father’s sheep ranch and quarterbacked Utah’s state-championship high school football team. He had since endured several potentially debilitating knee and back surgeries. The latest had come after an injury he’d sustained in Ghana in 2006; he’d taken Tabin there to introduce him to the work he’d been doing in Africa. As one of the world’s leading practitioners of phacoemulsification surgery, Crandall had been testing prototypes of phaco machines compact enough to transport to remote areas. The one he’d brought to Ghana was a scaled-down version of the machine he used in Utah, about the size and weight of a suitcase packed with books. While they’d been riding from a surgical camp, their bus had hit a fallen tree, blown a tire, and lunged into a ditch. Crandall’s phaco machine had shot off a rack over his head and slammed into him, fracturing his neck. Crandall had flown home from Ghana after his work was done, phoned Utah during a layover to schedule an MRI for himself, and, despite excruciating pain, conducted a day of surgeries at the Moran before enduring spinal-fusion surgery.

  “Talking to Alan,” Tabin says, “you’d never know what a badass he is. A lot of elite surgeons have attitudes to match their abilities. But Alan just has this easygoing approach to life that I really admire.”

  “Bump!” Shore shouted again, and we braced our hands against the roof. He chain-smoked most of the way along the cliffside route to Hetauda, taking his hands from the wheel only long enough to light another reeking Nepali cigarette. “Can’t say as I’d call this a bloody shortcut,” Shore complained, six hours later, when we rolled back onto the paved road only a few minutes ahead of the White Elephant.

  Hetauda was a small hill town near the confluence of the country’s north–south and east–west road systems, an ideal gathering spot for patients who lived below, on the densely populated plains of the Terai. Its proximity to the Indian border had also turned it, and its neighbor Birganj, into smuggling and banking centers; wealth had accumulated in the hands of the corrupt few and made the towns regular targets of Maoist attacks.

  After a decade of armed struggle, the Maoists had done what Ruit had originally suggested: sign a peace treaty and reinvent themselves as a political party. King Gyanendra’s plan to preserve the monarchy by force had blown up in his face. In April 2008, Maoist candidates had dominated the national elections. Prime Minister G. P. Koirala was swept out of office, though not out of power; he continued to wield considerable influence behind the scenes.

  Maoist leaders declared the king a relic of the country’s feudal past, and on May 28, the Maoist-led government
ordered him to vacate the palace within fifteen days. Gyanendra reluctantly handed over his diamond-and-ruby-encrusted crown and scepter. Then he and his entourage drove out of public life on June 11, 2008, through Narayanhity Palace’s pink gates after dark, in a convoy of black Mercedes limousines, officially ending 239 years of Shah dynasty rule and Nepal’s status as a kingdom.

  Two months before we rolled into Hetauda, the Maoists had formed a ruling coalition in Nepal’s parliament, allying themselves with more moderate political parties. They’d renamed the country the Federal Democratic Republic of Nepal and elevated the leader of their revolution, known by his nom de guerre, Prachanda, to head of state, making him the new republic’s first prime minister.

  Hetauda’s dusty, unremarkable appearance was diminished, slightly, by attractive rows of dense green Ashoka trees, their lower trunks painted white, that lined its main road. The banks, fabric stores, and snack stands that formed Hetauda’s core were little more than cubbies in the low-slung, hastily built shophouses that made up most of the settlement.

  The new hospital stood in a neighborhood of muddy vacant lots half a mile outside Hetauda’s commercial center. The land had been bought, and the construction and running costs of the hospital were largely financed, with HCP funds, as well as a donation of $200,000 from a Buddhist organization named All for Charity, based in Australia and Hong Kong, that had become enamored of Ruit’s work after Reader’s Digest named him Asian of the Year. The money appeared to have been well spent; the gleaming, three-story brick hospital looked like a newly constructed science building at an affluent American college. The only clue that it stood in one of the world’s poorest countries was a multicolored tent, the sort you would find at a large Nepalese wedding, that had been set up, temporarily, in the hospital’s courtyard to house the five hundred cataract patients Ruit, Tabin, and Crandall planned to operate on for the hospital’s official inauguration.