When facing two paths, if you are strong enough, always choose the hardest one.
—Nepalese proverb, repeated to Sanduk Ruit by his father, Sonam
I woke, rubbed the dust out of my eyes, and studied the soldiers blocking our way. Their Kalashnikovs were slung over their shoulders. They wore fatigue pants, blue windbreakers with red ironed-on hammers and sickles, and plastic shower sandals.
When Ruit rolled down the tinted window and showed his face, they stepped respectfully aside and opened an iron gate. After the solitude of the road, we pulled in to the courtyard of a concrete building where a crowd of expectant patients had gathered. Ruit said we had arrived in the village of Kalikasthan, at the heart of the Rasuwa District. I saw no buildings other than the one in front of which we parked. Rutted dirt trails led away from it into sparse eucalyptus and pine forest. The two-story cinder-block structure was a gift from Seventh-Day Adventists who had built it as a clinic, Ruit explained. The Maoists admired the solidity of the construction. They waited until the builders hung the fluorescent lights, bolted dentist’s chairs to the concrete floor, and installed Western toilets. Then they liberated the building by force and turned it into a makeshift military post.
“The Maoists have a bad reputation, yet they’re not so unreasonable,” Ruit said, climbing out of the Land Cruiser. “They don’t like religion. But they appreciate architecture.”
A few months earlier, being an American in Rasuwa might have been awkward, because the Bush administration had branded the Maoists terrorists after 9/11 and had supplied weapons to the government they were trying to overthrow. But while I was with Apa, Maoist candidates had successfully appealed to the long-suffering majority of the Nepalese people and swept the national elections. They’d fanned out across the country, even appearing in the high villages of the Khumbu on foot, carrying microphones and speakers powered by car batteries, and had given fiery speeches promising the 81 percent of the country’s citizens who labored as subsistence farmers a better life if they were in charge. Though they’d yet to hammer out the fine points of governance, the Maoists now ruled Nepal. What had started in the western district of Rolpa and had then spread to Rasuwa and other rural areas as an armed rebellion to free peasants from a powerful and wealthy Kathmandu elite now had to reinvent itself as a national party capable of improving the lives of the poor. Perhaps that’s one reason why they’d allowed Ruit to turn their military post into a temporary eye hospital.
Ruit left to scrub for surgery, and I picked my way through the crowd of women in red and orange saris and men in topis and turbans, gripping hand-carved canes. On the unlit second floor I found Ruit’s advance team hard at work processing a long line of patients, who shuffled forward with varying degrees of vision. I saw not only elderly people but children as young as five, their arms extended for balance, slowly groping their way along.
In wealthy countries, cataracts, the clouding of the clear lens of the eye, typically affect older people. But in the developing world, poor nutrition, exposure to unfiltered ultraviolet rays, and the numbing range of physical traumas afflicting those who live at the subsistence level, compounded by a lack of basic medical care, all combine to make cataracts the leading cause of preventable blindness among the world’s poor. That was who filled the second floor of this temporary hospital: the world’s poor. The line of patients inched politely onward, oblivious to any Western notion of personal space, the chest of one person pressing into the bony shoulder blades of the next. The cloying smell of body odor and infection clung to many of the patients like the patched and sun-faded clothing most of them wore. Their battered hands and feet were maps of hardship. Though most had walked hours on rocky trails for the right to wait in this dank cement room, many were barefoot.
As they cleared the line, Ruit’s staff prepped each patient for surgery. A female medical technician gently trimmed eyelashes with a pair of tapered scissors. Others simply scrubbed Rasuwa’s red dust from patients’ faces.
Beside a door leading to the operating room, a small video monitor sat on the floor. On the screen, with a clarity I hoped the visually impaired patients couldn’t discern, a crescent-shaped blade pierced a large, unblinking eyeball.
The Nepalese waiting their turn beneath that blade stared calmly at the screen for a moment or two at a time, or chatted with their neighbors. Ruit told me that when he began working in rural Nepal, more than two decades earlier, rumors that he practiced enucleation— that is, removing the entire eyeball— had frightened prospective patients away. “I put the monitor there so my trainees can watch, but also because it relaxes the patients,” Ruit explained. “They see that cataract surgery is in fact a very simple procedure, and they know what to expect.”
I squatted next to two boys, nine and thirteen, who couldn’t be anything but brothers. They were both squinting at the monitor and leaning their heads together while the younger boy, whose cataracts were less mature, described the surgery. With Ruit’s daughter Serabla translating, I asked them their names and ages. Birbahadur, the thirteen-year-old, interrupted to ask why we weren’t speaking Nepali.
“You see, his cataracts are so advanced he can’t tell you’re a foreigner,” Serabla said.
Voices raised in alarm drew my eyes to a thin, stooped woman wearing a ginger-colored silk blouse and a long, pink floral guneo, clothes noticeably finer than most of her peers’, who stumbled as she was called to the eyelash station. She clutched at the air in front of her wildly and would have fallen if her husband hadn’t rushed to steady her and lead her carefully across the room. The woman walked with the painful, jackknifed posture of someone with osteoporosis and clutched his arm like a life preserver.
Her name was Patali Nepali, she said, inclining her head in the direction of my voice. Her hair was long and dark, silvered with age, and tied back neatly with a ribbon. I looked into her eyes. She would have been beautiful if not for the pale, milky orbs the size of marbles where her irises would have been. I could see myself reflected on the blank surfaces, squatting in front of her. She wore an orange tikka at the center of her forehead, which Hindus believe stimulates the growth of the third eye. Certainly, her other two weren’t doing her much good.
Wheezing asthmatically as she spoke, Patali said that she came from a village well over an hour’s walk away, in a range of hills visible to our west. I’d assumed she was elderly, but she told me she was fifty-six and had spent most of her life as a seamstress. She’d worked until a year earlier, she said, her skills steadily deteriorating, until she was forced to admit she could no longer see well enough to sew. With the family reduced to one income, they tried to live on her husband’s earnings as a woodcutter and hired laborer; they were Damai, members of one of the lowest, the untouchable castes, and owned no land themselves. They’d been forced to sell off many of their possessions, including their only cow, to feed their five children.
“This last year,” Patali said, “I can do nothing useful. My own children have to wash me like a child. So we have been hungry. I eat only in the morning, but still there is never enough for my family.”
A few weeks before our conversation, their eldest son, a seventeen-year-old on his way to Kathmandu to look for work, was injured in a bus accident. He’d been riding in the cheapest seat, on the roof, when the bus collided with a cement truck. Her son was more fortunate than some. He was thrown clear of the wreck but broke both his legs. “I was obliged to sell the last fine thing in my home to pay his medical bills,” Patali told me. “My sewing machine.”
I asked her husband how he had brought Patali to Rasuwa. “We took a taxi,” he said. I realized how few vehicles I’d seen on the climb to Rasuwa and wondered if a village tucked even farther into these hills was reachable by road. “Basket taxi,” he said, laughing, pointing to his strong woodcutter’s back. “I’m the taxi!”
Ruit’s team had done their best to turn a filthy military post into a sterile operating theater. They’d slit open black plastic trash bags and taped them over broken windows. Next to extinct fluorescent fixtures, bare lightbulbs hung over the two operating tables from extension cords cleverly taped to the ceiling. Cables snaked past medical equipment crowded into the room, toward a generator outdoors. The generator also powered the most critical equipment, two Zeiss surgical microscopes that had been delicately transported from Kathmandu.
Behind a mask, in a green gown and white latex gloves, Ruit seemed even more intimidating. But when he saw me, he waved me over warmly. “Come here, stand beside me, David,” he said. “This is a rather challenging case.” I stepped over a tangle of cables and balanced behind Ruit’s left shoulder, my feet pressed together on a small patch of clear concrete, between a rusty fan plugged in to a power strip with bare wires and a bucket full of blood-soaked things I didn’t want to look at too carefully.
I tried to meet the one functioning eye of the elderly-looking man on the table, but he couldn’t see me. He was thin and grizzled and wore a necklace of heavy amber beads smoothed by time. In one socket, only a scarred blue-white mass remained from a youthful farming accident. The other eye was blinded by a large cataract. When I read his chart, I learned that Thulo Bahadur was fifty-two, another lesson in the way hardship can sculpt human features. Ruit asked me to remove the man’s orange-and-pink cotton topi. When I did I saw how rarely, except to sleep, he must have taken the cap off. The skin on Thulo’s forehead was several shades lighter than his browned and deeply lined face.
I’ve always loved watching any physical task performed flawlessly. I’m mesmerized by a gas station attendant who can clean a windshield with precise, confident strokes, or a woodsman capable of splitting fire-wood with a single clean blow. But Ruit was in another class altogether. He painted bright orange sterilizing solution briskly around the man’s right eye, propped the lids open with a wire speculum, and whipped a surgical drape over his head, leaving the large cataract exposed through a perfectly aligned hole. As he delicately lowered the lens of the Zeiss and picked up his crescent blade, I felt a shiver of appreciation for the grace and economy of his movements, the flawless choreography of his instruments in motion.
Ruit beckoned me forward and encouraged me to watch the surgery on a monitor connected to the microscope. I leaned forward to look. Through the high-powered Zeiss, the moon-bright cataract, orbited by a faint ring of translucent cornea, looked more like a planetary body than part of a human. “This is a very, very, very large cataract,” Ruit said. “This fellow would only perceive light and no light, but no forms. So we’ll just get it out of the way.”
Ruit urged the point of his blade gently upward into my field of view, piercing the outer surface of the eye, which flexed before tearing, and then carved slowly, from side to side, expanding his point of entry. “This is the wound construction,” Ruit murmured. “I’m actually making a tunnel. You must make the passageway large enough to deliver the nucleus. The nucleus is like the yellow of the boiled egg, you know?” When he was satisfied, he inserted a Simcoe cannula, a combination probe, suction, and irrigating device. With the tip of the probe, he separated the spherical, cloudy lens of the eye from the filmy capsule that enclosed it. And using the cannula to direct a jet of sterile fluid at the orb, he succeeded in loosening the cataract until it spun in place, like a marble ball on a decorative water fountain. “This,” Ruit said, with the reverence of a Buddhist monk chanting morning pujas, “is the ‘hydro-dissection.’
“But now comes the little bit tricky part. Normally I would make a slightly smaller wound, but this fellow’s cataract is so . . . ” he trailed off in mid-sentence, concentrating. I would come to know these silences, and the difficult tasks they enveloped, intimately. Ruit fed the cannula back through the wound. It was scored with fine textural lines, like a file, allowing it to grip the cataract’s smooth surfaces. He worked it under the cataract in tiny increments that seemed too precise for human hands to direct. He was humming, something catchy and minor key, unmistakably a tune from the subcontinent, perhaps from a recent Bollywood film.
When he had caught the cataract with the probe, he drew it slowly into the wide end of the funnel-shaped wound. I saw the clear tissue along the pathway bulge as he urged the cataract through the narrowing tunnel he’d designed. Ruit stopped humming, and I could feel him holding his breath as he coaxed the cataract completely out of the wound, which puckered shut after delivering the hardened tissue into the humid air of the operating room. “Perfect,” Ruit said happily, gathering the cataract in a fold of gauze and flicking it toward the bucket at my feet. “But he won’t be able to see until we insert an artificial lens.”
While prepping patients for surgery, Ruit’s technicians had measured the shape of each person’s eyes with a device called a keratometer, so he could insert a lens of the correct power, a lens that would ensure that the patient’s vision was as precise as possible after the cataracts were removed. A nurse held out a small plastic tray, and Ruit plucked an intraocular lens about the size of a child’s fingernail from it with a miniature set of forceps. He slid it briskly through the wound until the lens was centered under his patient’s dilated pupil. When I leaned forward to look at Thulo Bahadur’s eye, it appeared clear and clean as a freshly washed window.
“So this is what we’re calling sutureless surgery,” Ruit said, the pride in his voice unmistakable. “The wound will seal itself and heal without stitches. And tomorrow the patient should see very, very well.”
As Ruit folded and discarded the surgical drape, and the nurse taped a plastic eyecup over Thulo Bahadur’s repaired eye, I glanced at my watch. The entire operation had taken seven minutes. For an unusually challenging cataract surgery. Seven minutes to restore a man’s sight. My spine tingled like it was connected to the generator.
I watched a dozen cases more, some lasting only four or five minutes, until the patients were led away to a recovery room by Maoist soldiers who’d been assigned to help. Ruit handled his instruments with such ease and precision that the surgery began to seem simple, something that anyone, even I, could attempt. Then I stood behind the room’s second operating table, observing Dr. Kim and Dr. Kim, two North Korean surgeons Ruit was training to bring his method to their banished country. Their instruments jerked and sawed with such relative violence that I could barely stand to watch. When they finally completed their single case, more than forty-five minutes after they’d started, I leapt at the chance to find a few breaths of fresh air.
By mistake I walked through a door that led not outside but into a room as hot and wet as a sauna. On a table cobbled together with two sheets of carpet-topped plywood and supported by cinder blocks, four patients were lying on their backs, receiving injections of local anesthesia, waiting for surgery. Along the opposite wall, two autoclaves, which I mistook at first for huge cooking pots, hissed and rattled over propane rings of flame, sterilizing surgical equipment.
Into this steam room, an unsteady Patali was led by her husband. Patali’s thin legs were shaking, and I had Serabla ask him if he wanted me to find some food for his wife. “They already gave us dal and such,” he said cheerfully. “Today, she is not suffering hunger, only fear.”
Fortunately, Patali couldn’t see the anesthetist’s long needle as it approached her eye. After she felt the sting, her hands fluttered and twitched at her sides, like sparrows trapped inside the building. “I have to go!” she cried toward the spot where her husband had been standing, but nurses had already shooed him back to the waiting room.
“I think you should stay,” I said, taking one of her hands. It felt tiny and cold despite the heat from the autoclaves. “Tell her Dr. Ruit is a good surgeon,” I said to Serabla. “Tell her that when the bandages come off, she’ll be able to see her children again.”
On the operating table, Patali clutched my hand throughout the surgery on her left eye. Five minutes later, when I helped her sit up and repositioned her so her right eye faced Dr. Ruit, she was calm enough to release my hand. I stepped behind him, skirting the bucket now brimming with medical waste. Ruit had removed his hiking shoes, and his wide, bare foot lay on the pedal of the microscope, controlling fine focus. As he set to work on Patali’s second eye, I leaned forward to watch, my fingers resting lightly on his shoulder.
“Don’t touch me!” he barked.
I jumped back, accidentally kicking the microscope’s power cord out of the socket. “Daayviid,” Ruit said, his voice now low and singsongy, the voice of someone calming a startled animal. “This lady would like to see out of both eyes, eventually. Do you think you might be good enough to plug my microscope back in?”
On the roof of the temporary hospital, Ruit’s team had set up camp. Six tents were duct-taped to the concrete, lines of drying surgical scrubs hanging between them. Exhausted nurses and technicians sprawled on sleeping bags or darted inside to change into jeans and T-shirts. The esprit de corps of Ruit’s team was obvious, and I was struck by the confidence of the professional women, compared with the meekness of most of the female patients I’d met. At dinner, one particularly sassy scrub nurse wore a tight T-shirt that declared, in bold letters: shut your mouth when you talk to me.
I sat inside a low, open-ended mess tent across a camp table from Ruit, beside three Chinese Australian donors who’d come to determine what sort of investment they were getting for their money. I mopped the last of my dal and aloo gobi from a metal plate with my second freshly baked chapatti. Ruit swallowed his last bite and sighed contentedly. “It’s important,” he said, “to feed your army really, really well.”
The crowns of eucalyptus trees rose just above the roofline of the building, stirring in the slight breeze. They flavored the dusk with herbal currents. Once it became fully dark, the cook’s assistant removed our plates and replaced them with candles, which lent the glowing interior of the tent substance, separated it from the dim evening air.
The two North Korean surgeons were both named Kim, but they couldn’t have been more different. One was small, shy, and bespectacled. The other was strapping, outgoing, and as handsome as a soldier on a Soviet-realist propaganda poster. When I was introduced as an American journalist, they found an excuse to slip out, and returned a few minutes later properly equipped. They had each fastened a pin depicting Kim Jong Il, the “Dear Leader,” to their shirts.
Ruit reviewed the day’s surgeries with them, drawing diagrams of the interior chamber of the eye on a page ripped from my notebook. He had performed forty-four perfect surgeries over the course of the afternoon. Between them, the Kims had struggled to complete seven. “The secret,” Ruit said, sketching the ideal wound construction, “is to go slowly, slowly, slowly until you’ve mastered the technique, you see. You’ll need to do about two hundred cases each before you really get the hang of it.”
“How many cases have you done?” I asked. “More than two hundred, I imagine?”
“Oh, a few more,” Ruit said, reaching for the bottle of rum he’d brought from Kathmandu.
“By his own hand, more than eighty thousand,” said Nanda, the keeper of her husband’s flame. The scale of what Ruit had achieved and what he was attempting struck me then, for the first time. One man had already restored sight to the equivalent of a football stadium’s worth of people. Yet more than one hundred million people around the world who needed an ophthalmologist’s services were still waiting. Beneath us, sleeping on mats in a recovery room, were fifty-one people who, if all went well, could no longer be counted among that number tomorrow. And when the Kims returned to North Korea, they would bring Ruit’s technique with them and pass it on to their colleagues in one of the world’s most isolated places. He was seeding not only Nepal and North Korea but much of the poorest ground in Asia with enthusiastic young surgeons like Kim and Kim. It was visionary.
Ruit poured a healthy splash of rum into each of our mugs, neatly quartered a bowl of limes with a sharp knife, and squeezed fresh juice into each of our drinks. Then he raised his mug. “What we do is hard,” he said, with something like glee. “If it was easy, someone else could do it.” Everyone sipped the citrusy rum, and we traded toasts in the half dozen languages of those assembled around the table. The Kims looked elated. The breeze picked up. Guttering candles threw sparks of light off our tin mugs, onto the canvas walls of the tent, and I felt something rare, something important, being kindled.
Early the next morning Ruit looked fresh in a crisply ironed white polo shirt and black trekking pants. Though we’d had only a few hours of sleep, he practically skipped, clear-eyed, toward another long day of surgery.
The fifty-one postoperative patients were gathered in a courtyard bordered by low stone walls, waiting with bandaged eyes, squatting on packed dirt with the same heartrending patience as the bus passengers stranded in the slow-moving Trishuli. Ruit conferred with his camp logistics manager, Khem Gurung, making sure the day’s new cases were properly organized. Khem was one of the dozens of younger, clean-cut medical technicians who cheerfully endured the hardships of traveling and working with Ruit.
“I have to eat something and scrub in,” Ruit told me. “Stay and see these bandages come off. You might find it interesting.”
The day had a peculiar yellow cast. Shafts of storm light broke through scudding clouds to pick out individual potato and turnip fields on the laboriously terraced hillsides, and made certain stands of scrub pine smolder like they were about to ignite.
Patali had dressed for the occasion in a style befitting a master seamstress. She wore a crimson-colored silk blouse of her own design, and she had brushed her long black hair so thoroughly before tying it back with a matching silk ribbon that her silvered strands looked like reflections rather than evidence of age. Her husband waited outside the courtyard with the other family members, leaning anxiously over the stone wall. He murmured something reassuring, and her head tilted toward his voice like a plant tracking the sun’s passage.
Ruit’s team didn’t wear uniforms. Most of the male staff favored polo shirts, like their leader. But what set them apart was their brisk efficiency, movements that must have been modeled on Ruit’s. Khem Gurung’s shirt was lime green, and his manner with patients mirrored Ruit’s almost exactly. Khem knelt to peel off the first patient’s bandages, then examined his eyes in the bright beam of a handheld slit lamp until he was satisfied the surgery had been a success. Thulo Bahadur blinked in the sunlight. Then he began to laugh.
“How many fingers am I holding?” Khem asked.
“Two,” Thulo said, waggling his head dismissively, as if insulted to be asked such a simple question. “Two fingers. I can see that perfectly well.” He looked across the courtyard, past the fifty other bandaged patients, toward the stand of eucalyptus; then his eyes focused on the battered cane he held clutched in both hands. He pulled himself up by it until he was standing and dropped the stick in the dirt by his bare feet like something unclean.
Nurses followed Khem down the line of patients, handing out eye-drops and instructions for keeping the wounds clean until they healed. The two young brothers squatted, stunned and motionless, after their bandages came off. Then Birbahadur saw his mother, a worn-looking woman in a red head scarf and heavy brass earrings, waving outside the wall. He waved back at her shyly. She covered her mouth with both hands and burst into tears.
I squatted in front of Patali with Khem. Ruit’s initials had been neatly printed on her bandages with a felt marker. Khem peeled both bandages down until the blue plastic cups that had covered her eyes were dangling from her cheekbones. Patali blinked and blinked and didn’t react at all. Her eyes were deeply bloodshot, and I feared the surgery had been a failure. Then her mouth widened into a grin at the vision kneeling before her; a sweaty, unshaven foreign journalist pointing a camera at you can’t be the most inspiring thing to see at the moment you regain your sight. But she didn’t seem to mind.
“If you can see clearly, why don’t you touch his nose,” Khem said.
Patali reached out with her forefinger and placed it squarely on the tip of my nose. All three of us laughed when she found her mark. “Wait,” I said, scrambling over to her husband. I put out a hand and helped him over the wall. He squatted beside his wife and straightened his plain brown topi on his head. Patali studied his lined face.
“So, how does he look?” I asked.
“The same,” Patali said. “Still handsome.” Then she threw her thin arm over his solid shoulder. I watched Patali take in the world surgery had returned to her. I saw her gaze alight on a distant ridgeline, where a shaft of morning sun brushed the tips of terraced hills with a warm caramel color. They were only the dusty mid-hill ranges of Nepal, one of the poorest vistas the country could conjure, but she looked toward home as tenderly as Apa Sherpa had during our trek when we’d crested a ridge and he’d first sighted the distant summit of Everest. “Oh,” she said, leaning against her husband, smiling fully for the first time since the bandages came off, “Look at the hills! Do you see how they shine?”
I watched Ruit’s staff perform a few dozen small miracles more. The oldest patients seemed the most overwhelmed by the gift of second sight. Their joy was sudden and unfiltered. One elderly man, wearing a white turban and a shabby suit coat that hung to his knees, danced circles around his walking staff, singing to himself, drawing protests from patients whose feet he was too entranced to avoid.
All fifty-one of the previous afternoon’s surgeries had been successful, Khem explained when he finished his examinations. Kim and Kim’s patients had a bit more swelling and postoperative trauma, but for beginners their results were excellent, he said.
I watched 114 new patients being led into the hospital for the second day of surgery, many hunched over and staggering as unsteadily as Patali had the previous afternoon. Patients streamed past them out of the compound, dozens of the formerly blind hiking away toward their homes, navigating the uneven dirt trails that radiated out from the temporary hospital without the aid of the relatives who accompanied them.
Walking toward a rusted gate, I saw someone who looked like Pa-tali. But this woman was standing straight up and striding confidently beside her husband. Her back hadn’t been bent by osteoporosis at all, I realized, but by her sense of helplessness, by the weight of blindness. The transformation was startling, almost more than I could reasonably believe one day after seeing her squatting timidly on the concrete floor of the hospital, waiting for surgery.
I fumbled in my pockets for rupees, doing the math. Not enough. I scrounged through my camera bag, finding a thick wad of bills I’d saved for an emergency. I ran to the gate before she could begin the long walk home and pressed the money into her hands. “For a sewing machine,” I said, unable to meet Patali’s eyes.
On the roof of the building, leaning against a railing, Sanduk Ruit was watching his patients. He stood with one arm over the shoulder of Serabla, who looked on proudly at her father’s handiwork. I pointed Ruit out to Patali, told her that the man on the roof was the one who had restored her sight. She bent low toward him, her hands clasped together in gratitude. “Thank you, Doctor dai,” she said, even though we were much too far away for Ruit to hear. “Thank you.” Then she took her husband’s arm and they walked together up a dirt trail that led toward a pine grove, his basket immeasurably lighter. I watched until they entered the shade and were swallowed by shadows.
I looked up at the figure on top of the building, silhouetted against a borderless sky. Though his pitch had been full of self-promotion and bluster the night we’d had dinner, Tabin hadn’t overstated the importance of his work with Ruit. The man on the roof was still a mystery to me, but I wondered if there was a single person on earth doing more measurable good for others.
The line had been cast in Salt Lake City and the hook set in the mid-hills. I had come to Nepal, lost one book on the trails of the Khumbu, and swerved, finding another. I felt the weight of the mostly empty notebook in my shirt pocket. “Well,” I thought, flipping it open to a clean, blank page, “well.”
Excerpted from Second Suns by David Oliver Relin. Copyright © 2013 by David Oliver Relin.
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