Before the formal speeches began, Ruit walked hand in hand with the prime minister, giving the man who’d fought so unflinchingly for the rights of their country’s poor a tour of the spacious new facility that was now so well prepared to treat them. Ruit, wearing a sober black jacket and a plain black topi tailored not only to fit his enormous head but to match the prime minister’s own hat, sat on a specially placed couch, surrounded by the prime minister’s security detail, and observed one of Tilganga’s brightest surgical stars, Dr. Govinda Paudyal, at work in one of the institute’s sparkling new operating theaters. Paudyal had become Tilganga’s speediest cataract surgeon; he had set Tilganga’s record the previous year, when he’d completed 204 cataract surgeries in a single day, during an outreach he led in Uttar Pradesh, India. As the prime minister watched, Paudyal whipped through several cases to demonstrate Tilganga’s increased capacity, removing diseased cataracts and inserting artificial lenses in three minutes, less time than it would take to walk from the new hospital building to the laboratory where the first-world-quality IOLs had been manufactured by an entirely Nepalese staff.
Heintz stood watching the head of the new Tilganga Institute and the nation’s leader, two former rebels who had risen to improbable heights, chatting happily on the far side of a piece of plate glass that had been installed so large groups of students could observe surgeries that transformed the lives of Nepal’s citizens, regardless of caste, class, or social standing.
“This is one hell of a dance,” Heintz remembers thinking. “I was struck that we’d actually achieved the goal we’d set. We built and equipped the place, and we did it all in a period of civil war, total chaos, limited leadership from the local government, and almost no support from the U.S. embassy. And I was thinking, mostly, about the ripples that would reach around the world from the powerful factory we’d built for good.”
Ruit had a new headquarters in a state-of-the-art medical facility on the hill above the lot where pilgrims’ buses once parked, and a new title, medical director of the Tilganga Institute of Ophthalmology. But just like Tabin after receiving his award from the Dalai Lama, he was in no danger of relaxing and savoring his accomplishments. Shortly after the inauguration, Ruit set out on one of the most ambitious surgical outreach expeditions he’d ever undertaken: a three-week trip across much of the eastern Himalaya, stopping to operate at four separate eye camps in Bhutan, Kalimpong, and Sikkim.
Along with failing to govern effectively, Nepal’s leaders had also failed to complete the long-planned road from Kathmandu to the country’s eastern border. The current route, which swerved south to the plains, took twenty hours of driving. Ruit had heard another “road coming” rumor; this one said that if it didn’t rain and the rivers ran low, it might be possible to head east and, navigating a tangle of dirt tracks and dry riverbeds, reach a stretch of pavement that had recently been poured from far-eastern Nepal to the Indian border.
We set off before first light. In the countryside, oxcarts still outnumbered motorized vehicles, and thousands of small, fiery red chilies left to dry on tin roofs glowed as the sun’s first rays ignited them, like coals too hot to touch. Just before we turned off on a dirt road, we rolled by a large billboard that read, in English, for maximum prestige: VISION SUPER-DELUXE WHISKEY—MANAGE YOUR DREAMS! It seemed an odd brand name for a drink that could get you blind drunk. I pondered this unimportant mystery drowsily as we followed the south bank of the Kosi River, the White Elephant lumbering gently along, rocking me back to sleep. When I opened my eyes we were in the middle of the river, with water rising so high along both sides of the Land Cruiser that we cut a wake. Manbhadur, another of Tilganga’s professional drivers, was at the wheel, and he looked perfectly relaxed, as if he were at the helm of a pleasure craft, rather than a Toyota with an exhaust system that could easily flood.
We bumped up onto the riverbank, and Khem Gurung and Manbhadur, riding side by side in the front seat, slapped their hands together in victory as we turned onto two tire tracks cut through a floodplain of reeds. We didn’t see another vehicle for hours, which was fortunate, since the narrow “road” we were traveling on was little more than an elevated dike between flooded rice paddies. The gauge on the White Elephant’s dashboard said the outdoor temperature was ninety-five degrees. We drove with the windows closed to keep out the dust, and with the air-conditioning off to save gas. Ruit didn’t care much about comfort, but his time was valuable. He could fly to Bhutan in two hours while his staff brought the supplies he needed for surgery by land. I asked why he didn’t. “Well, as you know,” Ruit said, “I’m not so fond of flying. And these trips give me lot of time to think straight and plot out the future.”
“What are you plotting now?”
“I was considering how best to adapt phaco for work in the bush. It’s the coming thing. There’s no use denying it. SICS is still the best solution in most cases. But people will think they’re getting second-rate surgery if we can’t offer phaco to them, even in the villages. So I’m wondering just how much we can push the manufacturers to make the machines smaller. If we can get them down to about the size of a briefcase, that should do.”
“Aren’t phaco machines too expensive?”
“Not if we can get the volume really up. My goal on this trip is to work out how to do ninety to one hundred phaco surgeries a day, so we can transfer that process to Thailand and China and such. That’s not being done anywhere in the world. And I’m going to establish this. In urban China now, surgeons are doing twenty a day. Maximum. If we can do hundred a day in the places we’ll be working, which is much harder, I’m sure we can pull it out anywhere.”
Woozy with heat, I’d mistaken Ruit’s silence for relaxation. As with Tabin, I suspected, there was a switching yard up there in Ruit’s oversized head, with trains of thought running, day and night, on multiple tracks, chugging toward destinations a decade in the future.
Eight hours after we left Kathmandu, we saw the new road switch-backing down from a spur of Himalayan foothills. On pavement, we made better time toward India, but still cut only two hours off the twenty the other route would have taken.
At the Indian border post the following morning, an agitated, energetic man with close-cropped graying hair was waiting for us. “Come, come, come!” Kunzang Getshen said, steering us through a mob to the jeep he’d brought down from Bhutan. Manbhadur remained with the White Elephant while customs officials slowly unloaded crates of medical gear strapped to its roof rack and scattered their contents on the ground. We hoped we’d see him in time for surgery the next morning. Indian police with long truncheons began beating the food vendors whose carts blocked our vehicle until they moved their paan and samosa carts out of our way. “This is India, a mad, mad mess of a country,” Getshen said apologetically. “Courteousness won’t get you far.”
As we rolled toward Bhutan in the jeep, Getshen greeted Ruit warmly. Since he and Tabin had helped pry open the door to the kingdom, Ruit had driven through it each year, performing eye surgery and checking on the progress of the Bhutanese staff who’d come to Tilganga for training. In many ways, Getshen’s history mirrored Ruit’s own. He’d been born into a traditional Buddhist family in a small mountain kingdom, and his relatives had debated whether to send family members abroad to receive an education. “At that time, we had no electricity, no services, and scarcely any schools in my country,” Getshen said. “To pass on messages to the outside world, we relied on strong men who would run for days from the capital to the nearest telegraph office in India. Many Bhutanese believed that if we came down out of the mountains to seek an education in India, we’d die of malaria, cholera, and other lowland diseases.”
As Sonam Ruit had, Getshen’s grandfather consulted the birds. “He went to the mountaintop to pray and put out buckwheat cakes for the crows,” Getshen said. “But they didn’t touch them. So he was opposed to sending any of us out. But my father insisted. He was in the first group to leave, walking all the way to Kalimpo
ng. And when he didn’t die, and returned after taking his exams in Darjeeling, he paved the road for the rest of us.”
We sped across the flat Indian plain, past the wrecks of head-on collisions that had been picked clean of salable parts, and by a series of billboards urging drivers to control themselves. SPEED THRILLS AND ALSO KILLS was followed, a few miles later, by LIFE IS SHORT. DON’T MAKE IT SHORTER, which was topped, just as the mountains of Bhutan came into view, by IF YOU ARE MARRIED, DIVORCE SPEED!
We were enveloped by the lush, rolling landscape of a large tea plantation, and, slouching in my seat, I thought it looked like we were fording another river, with green waves of new growth cresting and lapping at our windows. “We used to have a lot of lands like this,” Getshen said. “A lot! But the British chased us up the slope in colonial times and took them. Now our nation begins at the base of those mountains. It’s a tragedy,” he said, grimacing to emphasize his point, before his default sunny expression returned. “But it’s what we have.”
The ornate gate to Bhutan looked otherworldly after the trash-filled streets of Jaigaon, the settlement on the Indian side of the border. Serpents and dragons crawled up its freshly painted pillars toward a plinth topped with a slim golden spire. “My father designed this town,” Getshen said. “Before we were pushed to the base of the hills, there was nothing here. My king made him something like the magistrate of this region and told him, ‘We need a place for the people who’ve lost their farmlands and have to live here, so draw it up and build it,’ and he did. We lived here during the construction, but it’s so hot down here.” Getshen flashed his theatrical grimace. “I’m always relieved when I return to the mountains.”
Getshen’s father had done an exemplary job of city planning. Bhutanese wearing dress shoes and knee socks along with the traditional ghos, which looked like bathrobes, strolled uncrowded sidewalks. The streets of Phuntsholing were washed and swept; I couldn’t see so much as a candy-bar wrapper blowing across the town’s wide and orderly main boulevard, which canted up toward a vista of misty foothills. And the buildings that lined it had been designed in a similar high-Himalayan style, resembling the classical temples of Tibet.
Ruit’s team operated for three days in Phuntsholing’s large, newly built hospital. In Africa, fully a third of our patients had been children. Even in the surgical outreach camps I’d visited in rural Nepal, a significant portion of the patients were middle-aged or younger. But in Phuntsholing, nearly every patient was elderly. When I asked Ruit why, he said, “Because of our victory here. Kunzang can give you facts and figures when we reach Thimphu.”
On the winding five-hour drive up to Thimphu, Bhutan’s eight-thousand-foot-high capital, I rode between Getshen and one of the first protégés he and Tabin had selected for training at Tilganga, Dr. Dechen Wangmo. She was in her mid-thirties, wore her hair in a fashionable spiky crop cut, and spoke in the clipped cadences of the English-standard school she’d attended. Wangmo’s husband had also risen through merit in Bhutanese society and now served as a lieutenant colonel in the Royal Bodyguard, where he was personally responsible for the king’s safety. She was determined that their two daughters hit the books as hard as she had. “I don’t want them to dillydally and waste their time obsessing about Western pop stars,” she said.
At Thimphu’s National Referral Hospital, a large, harmonious butter-yellow building that loomed above the center of the town, a fusion of Eastern timelessness and Western science, patient intake was remarkably orderly; the separate queues for royals, monks, nuns, and ordinary citizens all moved briskly. But in a courtyard outside the operating room where Ruit, Wangmo, and their peers would be performing eye surgery for local residents and treating complex cases transported from the most isolated villages of the kingdom, chaos reigned. Wangmo looked at the crowd of patients straining to cut the line and then cocked her head at me. “I always tell my daughters, ‘Common sense is very wrongly named,’ ” she said. “Sense is, in reality, very uncommon.”
“Okay!” she shouted to the crowd. “I don’t know why you’re jostling like cattle. Everyone here will be seen and attended to. We need a smart young person to help organize this mob.” When no one answered, she singled out a shy-looking teenage boy in a bright green T-shirt who’d brought his grandfather in for surgery and was avoiding her gaze, his eyes fixed on his white tennis sneakers. “You!” she said. “Are you volunteering? You look like a sensible enough young man. I want you to tell all these people to take a seat on the benches we’ve thoughtfully provided. They’re well shaded from the sun. It shouldn’t be too much of a hardship for them to wait there. Nurse! This very good person will call out the names of the patients and bring them to you. You can manage that, can’t you?” And without waiting for an answer, she pushed through the crowd to scrub in for surgery.
Yes, I thought, Tabin and Getshen had certainly chosen their troops well.
Inside Thimphu Hospital’s operating room, Ruit was working with the same type of portable phaco machine that had fractured Alan Crandall’s neck. He asked me to time his surgeries, and I told him they were averaging ten minutes each. “I’ve got to get quicker,” he said, and retreated into the silence of extreme concentration.
The next morning, Getshen gave me a tour of his clinic while his staff screened candidates for the day’s surgeries. “Before Dr. Geoff came here, I had a quieter sort of life,” he said. “I had time for lunch, time to go out and play at archery if I liked. It was nice. But now it’s always like a railway terminal in here, and I’m rarely able to leave.”
In the nine years since the HCP had begun working in Bhutan, Getshen’s staff had grown to include seven ophthalmologists and forty-nine technicians. With Tabin’s help, Dechen Wangmo had traveled to the Moran, to do specialized training in pediatric ophthalmology before gaining invaluable experience in the high-volume crucible of Tilganga. Another Bhutanese ophthalmologist, Dr. Nor Tshering, had also traveled to Utah, where he’d worked as Tabin’s fellow, learning the latest techniques in corneal surgery, before spending three months at Tilganga putting them into practice.
Along with fully outfitted surgical facilities in Phuntsholing and Thimphu, Bhutan now boasted two HCP-funded eye-care clinics in the country’s isolated eastern provinces. Each year since the HCP had begun working in Bhutan, tens of thousands of the country’s children had been screened for eye disease, first by teachers Getshen’s staff of outreach workers had trained, then by technicians in regional eye centers. Since 2000, some 340,000 students had been screened for correctible eye conditions in a country with a total population of only 700,000, and HCP-trained staff had conducted more than 5,500 cataract surgeries. HCP-funded outreach workers also made sure that every child in Bhutan received enough vitamin A, to prevent the increased incidence of blindness that a deficiency can cause.
It had taken more than five years from the time Tabin signed his first working agreement with the royal government of Bhutan, but the country’s eye-care system had been transformed. Mark Haynes Daniell had gotten his money’s worth; Bhutan was a model of unmitigated success that the HCP could advertise when it sought future donors.
There was still one prominent failure in Bhutan, a single uncured patient whose condition was driving Dechen Wangmo crazy. “I wonder if you can help me,” Wangmo asked me in a conspiratorial whisper one morning. “My own auntie is blinded by cataracts. She lives in Thimphu with my cousin, but he believes she’s so old and frail there’s no point putting her through the operation. I’ve tried everything. We’ve grown so accustomed to seeing old people with cataracts, it’s difficult to convince Bhutanese anything should be done for them. I’ve told him, ‘If you’re so worried about transporting her a few miles to my hospital, I’ll send a horse and carry her myself.’ But he keeps refusing. You see, my cousin is a justice on our high court, and he can be quite stubborn. I wonder if you’d be willing to interview him, and perhaps, together, we can convince him to let his mother see again.”
Wang
mo telephoned her cousin to tell him I was eager to interview him, and the following morning the judge and his mother met us at Thimphu Hospital. He was a formidable-looking middle-aged man wearing a checkered gho and a neat salt-and-pepper mustache. I asked him a few cursory questions about Bhutan’s recent transformation from an absolute monarchy into a parliamentary democracy, and he answered with the brisk forthrightness that had characterized most of my conversations with the Bhutanese. Then I turned my attention to his mother, sitting cross-legged on a hospital bed and shivering under a blanket.
She was certainly old. She had white hair shaved as short as a Bhutanese nun’s and a deeply lined face. I asked my questions slowly and phrased them simply, not sure how responsive she would be. I’d underestimated how much fiery spirit still animated the old woman. “What’s my life like now?” she said. “What life! They’re kind to me, but my mind is shriveling up. Even when I’m in a room full of my family I feel alone. How would you like to live like that?
“I’ll tell you what,” she said, aiming her face directly at her son, who sat in a chair by the foot of her bed. “If you’re wondering how long I’ll be here, you won’t have to wait much longer. No one wants to stay alive just to live like this. I’ll die sooner if I stay blind!”
The judge had doubtless heard many closing arguments in his day, but I imagined few had hit so close to home. He gave consent for his mother’s surgery.
Dechen Wangmo performed the operation herself. The next day, I joined her in a private hospital room as she unwound the bandages from her aunt’s eyes while the woman sat up in bed. After a few minutes, her aunt blinked and shook her head, as if to clear the fog of so many years of blindness. “Can you see me, Auntie?” Wangmo asked. “Can you make out my face?”
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