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  Climbing for Cures by Geoff Tabin, M.D.


Medrokongga County, three hours north of Lhasa, is one of the poorest areas in Tibet, which is one of the poorest countries in the world. The main highway, a rutted dirt and gravel road, snakes along the mighty Tsong Po River. On both sides, the arid and desolate Tibetan plateau rises steeply into the jagged foothills of the High Himalaya. A few scattered settlements of bare-wood-and-mud hovels cling to the flat bed of land along the river. Buddhist prayer flags flap in the wind on top of each box-like dwelling, and yaks and goats graze on the sparse grass in the brown remnants of barley fields. Here, at 13,000 feet, the temperature drops below freezing every night in mid-September. There is no electricity or even firewood. Cooking is done over open fires of dried yak dung. Life is harsh, particularly if you are blind. And Medrokongga County has one of the highest rates of cataract blindness in the world.
Cataracts, a clouding of the lens of the eye, are responsible for the blindness of an estimated 200 people in this county of only 400 households. The 1987 Tibet Eye Survey revealed that, overall, blinding cataracts have affected nearly two percent of Tibetans between 40 and 49 years of age and more than half of those older than 70. This is the highest reported rate of cataract blindness anywhere in the world. Whether a genetic predisposition, high altitude, sunlight, diet, a combination of these, or other factors causes the cataracts is not clear. What is clear is that cataracts are a devastating problem in a land already ravaged by poverty and political turmoil.

Birth of a Passion: I first met Dr. Sanduk Ruit, a Nepalese ophthalmologist, during my fellowship year in corneal diseases and surgery at Melbourne University. An Australian ophthalmologist named Fred Hollows had brought Ruit to Australia to further his training in modern cataract surgery. Ruit and Hollows were both dedicated to improving the world through the elimination of blindness, and they both believed the best way to achieve this goal was by teaching local doctors. Hollows died of cancer in 1993, but his legacy lives on in the Fred Hollows Foundation and the Nepal Eye Project of Australia. The Hollows Foundation sent me to work under Dr. Ruit at a cataract camp in Jiri, a small town in the mountains of Nepal. Ruit is of Tibetan descent and was born in Nepal, in the remote foothills of Kanchenjunga, the world's third highest mountain. He was self-educated and had earned a scholarship to attend school in India, where he eventually went on to medical school. After graduating with top marks, Dr. Ruit completed a full ophthalmology residency at Delhi's All India Institute of Medical Sciences, the Harvard of India. Dr. Ruit not only became a master surgeon; he also perfected the delivery of inexpensive, high-quality surgery in remote regions. Every patient we operated on in Jiri was totally blind before surgery. When we removed the bandages the following day, all of them could see, many for the first time in several years. The atmosphere at our eye camp was like that of a religious revival meeting. The joy was infectious. I was a convert.

One Passion Leads to Another…: My interest in international medicine grew out of my passion for climbing. I was a dedicated rock and ice climber in college during the 1970s, with a focus on big-wall rock climbs. After graduating, I took my passion to mountain walls in Asia and Africa. I entered Harvard Medical School in 1980 but had no definite plans for my medical career. China was just opening its doors to outsiders, for the first time since the Communist Revolution, and granted a permit for the first American climbers to visit Tibet. I was asked to join a team, funded by National Geographic, climbing the unexplored East Face of Mt. Everest. I dropped out of medical school, against the advice of virtually every non-climber I knew, and went to Tibet. Six of my teammates made the summit of Mt. Everest after the first ascent of the Kangshung Face, via a route that is still considered the most difficult on the peak. I had a great trip despite not making the top. I spent the rest of the year climbing and exploring and then reapplied to medical school. I graduated from Harvard Medical School in 1985 and started a residency in Orthopedic Surgery. During my third year, I was invited to join a team funded to get the first American woman to the top of Everest. Everyone I knew, including most of my climbing friends, said, "You can't quit your residency!" Everyone thought I'd be ruining my career, if not my life. But I quit and went to Nepal where I became the token boy who reached the summit along with the first two American women. I then worked as a general doctor in Nepal and saw so much preventable or treatable blindness that I was inspired to seek a residency in ophthalmology. I had found my passion in medicine.

Training the Opthalmologists: Following my fellowship year, I asked Dr. Ruit how I could help his effort. He asked me to teach cataract surgery in Biratnagar, Nepal's second largest city. Cataracts are the cause of 70 percent of the blindness in Nepal.
I worked at Golchha Charity Eye Hospital, where two doctors provide the only eye care for 800,000 people. These "doctors" were more like butchers-they removed a cataract by slicing the eye in half with a large knife and ripping out the lens of the eye with forceps. They sewed the eye back together with sutures the size of those an orthopedic surgeon might use. The doctors worked without a magnifying microscope and did not even wear sterile gloves. Even after the operations, the patients had to use thick, Coke-bottle glasses in order to see. It was not surprising to me that the second and third leading causes of blindness in Nepal were complications from this type of surgery and the loss or breakage of the thick corrective glasses. My primary goal in Biratnagar was to teach cataract surgery with intraocular lens implantation, performed in a sterile manner under an operating microscope. The lens implants allow the eye to focus clearly without the aid of thick glasses after surgery. Within three months, both Dr. I.C. Biswas and Dr. D.P. Joshi were no longer "butchering"-they were performing superb sight-restoring microsurgery, removing the cataracts and replacing them with lens implants. Meanwhile, Dr. Ruit had been working to obtain permission to perform and teach surgery in Tibet. Before this was approved in 1994 not a single doctor in the entire country had been trained to perform cataract surgery under a microscope, and no patient had ever received a sight-restoring lens implant.

Eradicating Cataract Blindness
Rumors of our cataract camp began circulating in Medrokongga County almost a year before our arrival. Hundreds of elderly Tibetans and their families were already gathered at the county hospital when we arrived. Some had been waiting for months. Their gazes: a mixture of hope and doubt. No one here has ever been cured of blindness. The hospital has the sickly smell of many such Third World facilities. The acrid odor of stale urine combines with the pungent smells of excrement and antiseptic. The halls and tables are dusty. A welcoming committee of flies buzzes in every room. There is no heat and no power. As the microscope, portable generator and other supplies are unloaded, Dr. Ruit looks across the barren dirt courtyard and gives me a broad smile. Pointing at the blind crowd, he excitedly explains that everything is perfect: "This is where the people need us."
For the next three days, 12 hours a day, Dr. Ruit and I perform surgery side by side in a makeshift operating room without any high-tech equipment besides our microscope. When the generator fails, we continue using the microscope to work on eyes illuminated by flashlights, which our dedicated assistants hold. Technicians, whom Dr. Ruit and I trained, inject local anesthetic to numb the patients' eyes and prepare them for surgery. When an operation is finished, the patient is rolled off one side of the table and the next patient is rolled on. The new patient's face is painted with antiseptic and surgery continues. The turnover time between patients is less than one minute. Dr. Ruit has no trouble sustaining a rate of seven perfect surgeries per hour for a 12-hour operating day. For a cost of about $20, these patients get approximately the same surgery that was state of the art in America ten years ago. While patients need a month to recover fully and must wear mild glasses in order to obtain perfect 20/20 vision, in the first postoperative day they go from seeing only shadows to having ambulatory vision (roughly 20/80). In America, cataract surgery now costs several thousands of dollars, and patients often have excellent vision without glasses in less than a week.
"There is a new sky for my eye! I am free from the hell of darkness!" exclaims Sonam Detchen moments after we remove the white gauze patch from her left eye. Tears of joy stream down her bronze cheeks. Yesterday, the 63-year-old widow could not see the shadow of a hand moving in front of her face. Today she can see her family for the first time in five years. With no living sons, she had no one to take care of her, and she often fell into ditches and went days without eating. Sonam was certain she would die. "Now," she says proudly, "I will be able to take care of myself."
Dr. Ruit and I performed nearly 200 "miracles" in Medrokongga County in three days. There were no infections and no surgical complications. Most importantly, three Tibetan ophthalmologists, who had spent three months in Nepal under Dr. Ruit's tutelage, observed all of the surgeries. The following week, they performed 91 more procedures under our supervision in Lhasa, at the Lhasa City Hospital. They worked on patients for whom Dr. Ruit or I had already restored sight to one eye. When it was time for us to return to Nepal, we donated the microscope, surgical instruments and supply of intraocular lenses and medicines to the Tibetans.

leading the cause
Dr. Ruit and I formed the Himalayan Cataract Project to train doctors and nurses in microsurgery and lens implantation throughout the Himalayan region. Since then, our work has continued in Nepal, and we have expanded our efforts into Tibet, Sikkim, Bhutan and regions of Himalayan India and Pakistan, where no cataract care was previously available.
The bill for training a team of one doctor, one nurse, and one technician, bringing the team to Nepal, buying a microscope and surgical equipment, operating a cataract camp, and leaving lenses and equipment behind for the doctors to perform another 200 surgeries comes to about $12,000. Once a new surgical site has been established, we help it become self-sufficient by charging patients who can pay for surgery. Our main hospital, The Tilganga Eye Center in Nepal, charges $120 for cataract surgery. Approximately one-third of the patients are able to pay full price, one-third pay a lesser amount based on their income, and one-third receive free care. We expect this type of cost recovery to help sustain our efforts in Tibet. Since many of the blind Tibetans are young, a majority of the cataract patients can return to the work force or claim a useful role in family. We have now established an eye center in Lhasa and trained a total of 30 doctors in Tibet, as well as two doctors in Sikkim, India, one in Darjeeling, one in Northern Pakistan, two in Bhutan and 30 in Nepal. Doctors from three other international foundations have followed our lead and are teaching eye surgery in this region. Despite our efforts, local surgeons will still not be able to perform enough surgeries to keep pace with the growing number of people who become blind each year. The backlog of people awaiting surgery continues to build, but we hold onto the hope that, as we train more doctors and donate more equipment, we can eliminate cataract blindness by 2010.

Geoffrey Tabin, M.D. is an associate professor of surgery at the University of Vermont College of Medicine and co-director of the Himalayan Cataract Project. He is a former full time climbing bum who eventually graduated from Yale, Oxford and Harvard Medical School. Dr. Tabin is the author of "Blind Corners," an adventure book that covers his climbing the highest point on every continent.

 

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