Second Suns

by David Oliver Relin

  That’s often meant answering the phone late at night, whenever Tabin has a flash of inspiration. “Even when he’s doing something else,” Matt told me, “Geoff’s brain is always sifting through a sea of facts, looking for the little kernel that will make the HCP a bit more effective. I can’t tell you how many times he’s called me at midnight, from some concert, with reggae or whatever blaring in the background, to talk about some technical detail that will make our next trip to Africa more successful. It comes from a place of incredible compassion, but it can wear on people. He’s got twice as much energy as anyone I’ve ever met. I don’t think Geoff even knows what a freak of nature he is.”

  During 2008 and 2009 Tabin was expending that energy to flit around the globe so frequently, on so many working trips, that I had trouble deciding where and when to accompany him. After signing the HCP’s first five-year agreement with the king of Bhutan, Tabin and Ruit had traveled to that country every year to operate, help Kunzang Getshen create a countrywide network of eye care, and oversee the training of a new crop of Bhutanese ophthalmologists. Rates of preventable blindness were dropping so steeply in the kingdom that Bhutan had signed a second five-year agreement, asking for the HCP’s continuing assistance.

  Tabin’s Unsung Heroes award was also a misnomer, of sorts. Since he’d moved to Utah to head up the Division of International Ophthalmology at the Moran, Tabin’s profile had been steadily rising, and his praises were increasingly being sung in the media.

  The outdoor equipment company North Face, which had long donated gear to support Tabin’s work, funded a film crew that accompanied him and Ruit to eye camps in the Everest area. Called Light of the Himalaya, the movie North Face made attracted outdoor-oriented supporters to a cause they could believe in. Outside magazine did a feature story on the HCP and the making of the film, which added new donors to the organization’s growing database. And Lisa Ling remained so enamored with Ruit’s work that she followed him to North Korea, documenting his sight-restoring surgeries as well as his ongoing training of doctors in the world’s most isolated country for another National Geographic special. Producers framed the film as more of a glimpse inside the secretive nation than a documentary on Ruit’s work. Inside North Korea was timed to air during the first ever bilateral meeting of U.S. and North Korean diplomats, when news of the country’s nuclear menace was splashed all over the American media, and drew another wave of donors to the HCP.

  The reason I found myself in Ethiopia with Tabin was that his work had attracted the attention of Jeffrey Sachs, a Columbia University economist and public health advocate. Sachs had written in his best-selling book The End of Poverty that “Africa’s governance is poor because Africa is poor.” He argued that with properly targeted investment and intelligent development, extreme poverty could be eradicated throughout Africa within twenty years. As a founder of the United Nations Millennium Villages Project, Sachs set out to prove his premise in 2005 by choosing several of the poorest villages across the continent and attempting to turn them into showpieces of sustainable development by radically improving their agricultural practices, educational institutions, and health care systems.

  Two years later, Sachs’s project had made significant progress, but he was under intense pressure from critics and competing development experts to show measurable improvements in the villagers’ quality of life. And few improvements were as demonstrably transformative and cost-effective as restoring a blind person’s sight. He approached Tabin and asked him if he could complete a survey of one of the villages—Bonsaaso, Ghana—for $25,000 of the money that Sachs had raised for the project.

  “With that much money, I’ll not only survey every person in Bonsaaso, I’ll survey everybody in the surrounding area and cure every case of treatable blindness that I find,” Tabin told him.

  Then, in August 2007, with Huckleberry Holz, a surgical fellow studying with him at the Moran and four nurses and technicians from Tilganga led by Khem Gurung, Tabin did it. His team screened 4,600 people, performed 160 cataract surgeries, and prescribed 1,100 pairs of eyeglasses. Sachs was so enthusiastic about Tabin’s results that he asked if he’d do the same in the other eleven Millennium Villages.

  Tabin offered to go Sachs one better. “I said, ‘Let’s not just do an intervention. Let’s transfer our knowledge, train local people, and create centers of ophthalmic excellence that can change eye care in Africa.’ ” To demonstrate the results a few well-trained surgeons could achieve, Tabin proposed holding the largest eye-surgery camp in Africa’s history, in the place where blindness is perhaps most widespread on the continent: Ethiopia.

  In December 2008, Tabin began calling me three or four times a day, trying to persuade me to come with him. He was particularly enthusiastic about the country, where he had held a small surgical outreach program the previous year. He raved about the beauty of northern Ethiopia. “Like Moab but more amazing,” Tabin said. “We’ll climb up to incredible rock churches carved into cliffs. We’ll drink the best coffee in the world, go dancing every night, and push the fun-o-meter into the red.”

  At least he was right about the coffee.

  Inside the unventilated halls of Quiha Zonal Hospital, with the sun beating down on the roof, we were pressed close to patients being prepped for surgery. There were eight foreigners: six medical professionals and two journalists, whose skills seemed suddenly vague. The photographer Ace Kvale, Tabin’s friend and climbing partner, had come to document the work and, with Tabin, scale sandstone pinnacles in the desert north of Quiha. Between the front door and the operating room were three long corridors where Ethiopians in sweat-grimed white wool dhotis sat packed together on benches, clutching their dulas, long shepherd’s staffs that curled at the top. They propped these in front of their sightless eyes like question marks.

  “God!” said Ann Bagley, an ophthalmic technician from Salt Lake City, cupping one hand over her face and stumbling forward. “It smells like beef jerky.” It couldn’t have been more than a hundred yards from the door to the operating room, but negotiating that gauntlet, trying not to step on bare, callused feet, skirting assorted open wounds, inhaling the very essence of poverty while staring into all those blind eyes, was one of the longest walks I’ve ever taken.

  In a utility closet transformed into a makeshift changing room, Tabin had already pulled on scrubs when the rest of the team arrived. He was joined by three other American medical professionals: Alan Crandall; Alan’s wife, Julie, an ophthalmic nurse; and Ann Bagley, Alan’s sister. This small group had to summon a remarkable quantity of optimism; they had to believe they were able to help every member of the crowd, growing larger every moment, outside the door. Tabin’s team was also tasked with training a dozen Ethiopian technicians and nurses, as well as Dr. Tilahun Kiros Meshesha, one of only two ophthalmologists available to more than six million residents of northern Ethiopia. Fortunately, the HCP had brought two secret weapons: Sarita Paudel, a veteran surgical nurse from Tilganga, and Bal Sunder Chansi, a driven young technician whom Ruit had chosen as Tilganga’s training coordinator.

  It was Chansi who would be in charge, determining how many surgeries to do a day and deciding when the doctors were too exhausted to continue. I asked him if it was possible to cure eight hundred patients in five days. He answered with the subcontinent’s most distinctive gesture, the head waggle, a response that confirmed that he’d heard my question but was too wise to offer a definitive answer.

  “All we can do is try,” Chansi said, tying on a mask.

  Hunched over a surgical microscope, with his iPhone blasting Howlin’ Wolf through cheap speakers, Tabin worked his thirteenth case of the day. The patient, Lam Lam Berhar, was a fifty-five-year-old woman with large, milky cataracts obscuring both eyes and a case of trachoma, an infection that can cause the eyelashes to turn inward and scar the cornea, which had required a course of antibiotics before she could have surgery. Berhar had traveled a day on foot and eighty miles by bus from her village to reach
the hospital. She said her husband was also blind but they could afford only a single bus fare. Berhar’s vision had degraded to the point that she could make out only light and dark.

  I asked how quickly trachoma leads to blindness. “Not as fast as masturbation,” Tabin said, holding out his gloves for Sarita Paudel to rinse with a sterilizing solution.

  With Paudel assisting, Tabin made an incision in each of Berhar’s anesthetized eyes, using a diamond blade that had been built to Ruit’s specifications. Delicately, he worked each cataract-clouded lens out of the tunnel he’d constructed through several layers of the eye and flicked it into a bucket by his feet. Next he inserted a synthetic lens manufactured at Tilganga in its place. The process took him ten minutes. “Think of the eye like a peanut M&M,” Tabin explained, “with the candy shell as the outer chamber of the eye, the peanut as the lens, and chocolaty goo holding the peanut in place. My job is to take out the peanut, clean out the cortex, the chocolaty mess, and insert a new peanut, an artificial lens. It’s the single most effective medical intervention on earth, a little miracle. Tomorrow, she should see twenty-twenty.”

  Chansi drove the doctors hard the first day. They broke once in the early afternoon to use the bathroom and swallow a protein bar each before they tied their surgical masks back on. At 9:00 P.M. after 114 surgeries, Chansi pulled the plug. We all wedged into a Nissan Patrol for the short drive to our hotel in the town of Mekele. I wondered just how much energy Tabin would have left for the dancing he’d promised. He slumped sideways and began to snore. At our grim hotel, most of us skipped dinner and fell asleep in our clothes.

  At 7:00 A.M., the Patrol arrived to take us back to work. Before scrubbing in, the doctors inspected the results of the previous day’s surgeries. The line of squatting patients with bandaged eyes stretched along one entire wall of the hospital, around a corner, and halfway down the side of the building. Local priests with long beards and flowing gabis circulated through the crowd, comforting anxious family members. They held carved wooden crosses in one hand and horsehair flyswatters in the other. Say what you will about the efficacy of the crosses, but the flyswatters looked righteously useful.

  It was difficult, staring at the six or seven hundred people gathered at Quiha, not to feel that the Ethiopians had won the genetic lottery. Their café au lait complexions glowed in the early light. Women wore their hair in elaborately plaited shorubas, piled high over imperious foreheads. And the eyes of those who were able to see pinned you in place with striking intensity.

  Tabin crouched in front of Lam Lam Berhar, peeled back her bandages, and shone his climber’s headlamp into her eyes. Berhar, like many women in the second-oldest Christian country on earth, had a black Coptic cross tattooed in the center of her forehead. “Perfect,” Tabin said. “Crystal clear.” He waved at her. For a moment, Berhar’s face remained perfectly blank. Then her hand fluttered up to touch the cross on her head and she focused on Tabin’s grinning face. Berhar jumped to her feet, threw back her head, and ululated. Her cry was contagious. As the doctors moved down the line, dozens of other women who’d regained their sight stood and added their voices to the trilling chorus. Sometime in my life, I may hear a sound that expresses joy more purely. But I can’t imagine when.

  All day long buses and carts arrived at the hospital gate, unloading streams of the sightless. They walked unsteadily into the compound with staffs or were led forward, clutching the hem of a son or daughter’s long, trailing dhoti. The crowd grew to well over a thousand souls. Families, unable to find solid shade, squatted in the latticed shadow of thornbushes. The swelling crowd illustrated the toll blindness took on a developing country: Not only were the functionally blind unable to support themselves, but those who cared for them were pulled from the workforce as well.

  While Tabin operated, Dr. Meshesha practiced the small-incision technique he’d been perfecting since Tabin’s last visit. In the 1990s, when China offered twenty of the country’s brightest students scholarships, Meshesha jumped at the opportunity. Despite not knowing a word of Mandarin when he arrived, Meshesha completed an ophthalmic fellowship in a Chinese medium. When he returned to the region where he’d been born—Tigray, in northern Ethiopia—as only the area’s second ophthalmologist, he realized he could spend the rest of his life operating as he’d been taught and hardly make a dent in a population suffering so much from preventable blindness.

  After reading a medical paper Tabin wrote about Ruit’s technique, Meshesha concluded that SICS offered the best chance to serve the greatest number of patients. But without access to Ruit’s specialized tools, he had to improvise. Meshesha took a long, narrow-gauge needle and bent it to a shape that approximated the illustrations that accompanied Tabin’s article. Then, with a tool that cost three cents, he taught himself to perform credible SICS surgery.

  In 2006, Meshesha told Tabin what he’d achieved. “I was so amazed by his passion and the progress he’d made on his own that I arranged for him to spend six months with me at the Moran,” Tabin says. “Now Tilahun is one of the finest cataract surgeons in sub-Saharan Africa.” But no amount of talent could keep pace with the need of the millions of northern Ethiopians who required Meshesha’s services. Nepal had a population of twenty-seven million, and its doctors did more than 170,000 cataract surgeries a year. “There are eighty-two million Ethiopians,” Tabin said. “I bet Ethiopian docs did fifteen thousand cataract surgeries last year, tops. And most of those were in Addis [Ababa]. We need to create a system around Tilahun and get him more support, so he can get his numbers up.”

  On the lot next to Quiha hospital was a small general nursing school built by a Spanish charity that had run out of funds. It turned out a few ophthalmic technicians and nurses a year. The HCP planned to expand it into a full-scale ophthalmic training center, and to add facilities that could support two more surgeons at Quiha hospital.

  In the meantime, Tabin followed Ruit’s philosophy of asking all motivated staff members to test the limit of their abilities. When we first arrived and I met a nurse named Tekeste Negusse, I presumed he was Quiha’s surgeon. A tall man in his mid-thirties with a trimmed mustache, Negusse carried himself with an air of authority. As one of the few medical professionals available during the 1998–2000 war between Eritrea and Ethiopia, he’d been pressed into service as a battlefield surgeon. Tigray had been pounded by Eritrean artillery and fighter jets. “Medically, my trial was by fire,” Negusse told me as he watched Meshesha operate. “Despite the fact that I had only recently completed my training as a nurse, I had to do amputations, chest wounds, everything, because there were no other trained personnel at the front.” Tabin, hearing of his history, suggested that Negusse learn small-incision surgery on the spot and operate on some of the simpler cases when Dr. Meshesha took his breaks.

  “Tabin and Ruit are doing as much as anyone to improve the delivery of health care in the developing world,” says Al Sommer, a former dean of the Johns Hopkins Bloomberg School of Public Health and honorary chairman of the HCP’s advisory board. He likens the state of the American medical system, with its dependence on hospital emergency rooms rather than prevention, to the dysfunctional state of medicine in many of the African countries where he has worked. “With blindness,” Sommer says, “it all comes down to numbers. Last I checked, there were about five hundred ophthalmologists in San Francisco. But how many are there in all of sub-Saharan Africa? Not many more than that I’d guess. If you’re ever going to defeat cataract disease, there simply aren’t enough doctors. You have to train nurses and technicians to do the surgery.” He adds, “Ruit has made the process so simple, I don’t see why it couldn’t be done.”

  Between patients, Tabin stood up from his operating table in Quiha hospital, offering pointers and checking on the progress of Nurse Negusse’s surgeries. “Not great,” Tabin told me when I first asked about Negusse’s results. Tabin felt he was treating the delicate tissue in the eye’s inner capsule too roughly. But by our third day, Tabin had al
ready revised his opinion. “He’s doing much better now,” he said. “And he has surprisingly good surgical hands!”

  Alan Crandall handled the most complicated cases. They were generally children who had been born with cataracts or had suffered an injury to their eyes—from thornbushes, knives, or any of the other objects that frequently inflict wounds on subsistence farmers.

  The titanium plate that stabilized Crandall’s neck made hunching forward on a surgical stool uncomfortable, but with Ann and Julie assisting, he operated for fourteen hours on our second day, straightening up only to take a single bathroom break. First thing the third morning, he prepared to operate on a five-month-old. She had a tuft of curly hair on top of her head, huge eyes, and congenital cataracts that rendered them useless. To complicate matters, she also had acute glaucoma, high pressure in her eyes that could injure her optic nerves. Crandall had to not only remove the cataracts without creating scar tissue that would damage her growing eyes but construct tiny vents to release the pressure. He pressed his own eyes closed. His hands, in white latex gloves, rehearsed the movements he planned to make, like a ski racer reviewing the contours of a course before heading to the starting gate. “I’ve never seen him this nervous before,” his wife, Julie, said.

  “It’s just that in the U.S., you have so many resources,” Crandall said. “Here, there’s no backup. If you fuck up, this beautiful little girl is blind forever. Her life is literally in your hands.”

  In this case, that was a good thing. Crandall operated with the encouraging calm of a veteran pilot bringing a damaged 747 in for a safe landing. “That went fine,” he said after two and a half hours, his blue surgical gown striped with sweat, as the bandaged, unconscious girl was placed in her mother’s arms. “I think we might have a small victory here.”