Sunny Days That I Thought Would Never End

For all its green-scrubbed glory and ceaseless, smile-lit tides of recovery, eye care can have its depressing moments. Down here, it’s easy to soak in the sun of our successes. After all, cataracts and pterygium and allergic conjunctivitis and other mild ocular prey comprise a Texas sized portion of the cases we see. Ophthalmic nurses probably have “book her for cataract surgery” and “tetra and gutt. chlor” (ointment and drops)  tatooed to their tongues by now because they are the remedy to nearly every case seen on outreaches. For weeks now we’ve seen treatable cataract case after treatable cataract case, flecked with a few glaucoma, corneal scar, and pterygium (a net of broth-colored phlegmish tissue crawling from the corner of the conjunctiva toward the pupil) to keep the crew on its toes.

Blindness, we were told, was lurking in and around these rural chiefdoms; Ali often reminded us that we must fight blindness with “machine guns” and blast its insidious mercenaries out of their foxholes. Not to contradict General MacArthur, I used to think, but the stuff we’ve seen is hardly insidious. The sluggish cataracts, the pterygium slouching like snails toward a pupillary Bethlehem, the conjunctivitis that EVERYONE (and I do mean everyone on account of the unrelenting dust) had—it all seemed so insipid, feckless, senior citizens brandishing walkers at Green Berets. With a good surgeon on board, we could wipe it all out while brushing our teeth before bed.  

            Then there was a patient who I will call Niya. She wore a green school-issued skirt and flitted around the consultation room like the white furs on a dandelion. Her mother followed behind her with an infant no older than 10 months yoked to her back by an overbearingly technicolored shawl, the child’s trio of tight ponytails sprouting like black vines from the mothers nape. For all of her wildness and excitement, Niya turned out to be a wonderful patient. As Dr. Wanye collected patient history from the mother, a few of us took turns examining Niya’s eyes through an oscilloscope and listening as the mother described the “shiny thing” she saw in her daughter’s pupil. This is not nearly as innocuous or “oooooh, interesting!” as it sounds. A glint in the eye, particularly in the pediatric eye, is the first lead for retinal blastoma. Retinal blastoma is a highly vascular, cancerous growth on the retina that, if untreated, expands, explodes, and metastasizes to the brain through the optic nerve. And sure enough, as each of us closed in on a circular slice of the retina, we saw it, bulbous and opaque with raspberry arteries sprawling from its center, a set of pumping highways converging in a dull white cloud. Standard protocol for treatment is chemotherapy and, depending on the size and nature of the tumor, surgical measures to excise what is otherwise a highly lethal pathology. Dr. Wanye explains this to the mother as her daughter wanders near the black and white examination device, stretching her fingers toward its gadgetry only to have them slapped away by a nurse whose wound braids must carve canyons into her scalp.  Wanye tells the mother to go to Accra, explains the treatment options softly, VERY softly because the usual recourse for an American child with RB is quite different from that of a Ghanaian child with RB. The unfortunate truth is that chemotherapy is expensive, wildly expensive, and yet all that expense can be repackaged and forcibly shrunk given a proper insurance policy. This family, the mother and her wonderful daughters, had no such insurance policy, making monthly payments on chemotherapy a practical impossibility. And Unite For Sight can’t cover it either, since we don’t raise and allocate funds for retinal blastoma treatment. So we go to option number 2, which surely can’t be much worse than option number 1, but it is. The only way to keep an untreated blastoma from spreading to the brain with any level of comfort is to remove any tissue that could potentially play concierge to the cancer’s metastatic desires. This includes a large segment of the optic nerve, the retina, and, as one would naturally, but regrettably predict, the orbit (eyeball). Option three is do nothing, to observe the cancer’s slow spread through the optic nerve, across the chiasm into the other eye and the brain, until it kills her. Option two it is, then. By bloodless, lugubrious default.

For all the machine guns we wield to fight blindness, the war at our door is at times miles out of our league. Typically this is not the situation, but as in Niya’s case, we are not exempt from feelings of futility. The more pervasive scenario that grinds our gears as healthcare providers is the one where the war doesn’t meet us soon enough. My first day in Karaga, a village outside of Tamale, we saw a young woman blinded by absolute glaucoma—had she visited four years earlier when the symptoms became apparent, we could have started treatment and saved both eyes. Yesterday I saw a kid no older than my brother carrying the grotesque result of an untreated corneal laceration. The wound was left untreated for months and in that time much had changed about the eye; the cornea had melted off, the iris had prolapsed like a misshapen bead, and the sclera had turned meat red with inflammation. There was nothing we could do to save the eye and without an evisceration of the bad eye (the scooping out of the iris, pupil, sclera, etc. to prevent infection), the other eye would become sympathetically infected as well. Had we seen him immediately, we would have repaired the corneal laceration and sent him on his way. Oftentimes we find victims of a procedure whose outrageous price is only outdone by its incredibly frustrating result: couching. Sparing the gory details, the practice of couching (falsely) claims to ameliorate a patient’s cataract by poking the lens out of place and into the back of the eye.  This can present a very real difficulty to cataract surgeons, especially if the lens is not pushed fully out of place and sits cockeyed like a phase of the moon peeking out from the pupil. How these ignorant charlatans, no more skilled than a pub regular twirling a toothpick, are not immediately wiped clean from village premises is beyond me. But they’re not and sometimes they get their first and botch any shot we have at resolving the most resolvable medical dilemma in the optic world (aside from farsidedness in adults). The list of clouds floating over our sun keeps growing the longer I stay here­—patients with blinding infections from local “eyewashes,” patients that disregard post-operative care and needlessly end up with infections, the number of patients that refuse surgery because some “taboo” was spread throughout their village wagging a finger at Dr. Wanye and his pragmatic, secular approach to fighting blindness. Easy to get pessimistic over, that’s for sure. And yet, I’ve learned here that medical situations aren’t perfect, that our patients are not perfect, and that we certainly are not perfect either. That is the reality of a profession that demands constant, predictable results in a storm of chaotic causes. Atul Gawande once said that it is not assumed nor expected that a doctor be perfect in his profession—“only that he strives to be.” And though I saw it first in Gawande’s book, the guiding phrase is taking on a much deeper meaning here with every sun-lit day that passes.  

The Unflinching Vivacity of Our Man Ali

He sits at the head of the table, his head laughing, careering on its glabrous swivel. “Ya, masa,” he calls to the waiter of the empty restaurant, “we do not want break-delay...we want breakFAST!” The laughing continues and he gets bigger-eyed than before, his pupils expanding like oi slicks pooling on twin drifts. Suddently, the power goes out and the pulse of the ceiling fan  flattens to nothing. We can hardly breathe, swallowed up in the convection rushing in like a stampede from the outside . Ghana can lay it on thick, hot, and heavy; thankfully, Ali buoys us, the languor-stricken and hard-to-mollify, with his jokes. “So, how much ah we go-een to chahge for dem to look at these ladies?” He fans both arms across the table to encompass the four girls—Lynn, Poy, Ebony, and Laiyin—and tap dances on us all with glistening eyes. “Because dees four gals ah very special, they belongs to me so I will not let dem look at da face free of chahge.” Glowering now, distributing smarting glances among our expatriate family, “I will take no less den 500 tousand for dem to look at deez gals, not even dee docta will look at da face witout paying me for dem!”

Then in an instant, his demeanor turns smoothly on its ever-spinning axis. Delivering a cheek-creasing smile, “I like dis, I am very hahppy.” We laugh. “Ebony, you ah eating so well for me today. You make me so, so happy” he continues, gesticulating his syllables with a conductor’s flare. He swiftly nabs an unbridled bone from my plate, eyes it hastily, and delivers it to his indiscriminate mouth. The girls say ew; the guys leak smiles; Ali says “what is hahppenin?” and follows up with an “offer” to Lynn, our resident ballerina. “Leeen,” he shouts from two feet away, “you ah going to dance wit me please” and offers her his two hands, fresh from clearing the remains of our meal. Lynn shakes her head, but Ali insists, “One dance, Leen, please, why you will do a very much dancing in the State, but when I say ‘you like to dance,’ you will not do it. AH-ah!” This last sound, AH-ah, lies somewhere between a turntable scratch and an animal yell.  

Ali is considered by many, foreign or otherwise, to be a typical Ghanaian. Beside both sides of his nose are vertical tribal scars— pocked, tobacco colored wells no longer or wider than a blade of grass—that he often attributes to a ravaging case of diptheria he endured as a child (never mind that scarring isn’t a symptom associated with diptheria). He lives in a spavined pink flat locked in a horseshoe with five others just like it. The red lawn is covered with black rubbers, thin tufts of saw-grass, and breathtaking children that clean dishes outdoors and assemble in a cluster along the street when cars arrive and depart, as though welcoming a heralded bus at its main terminal. They are all his children, as he says, since in Ghana your neighbors are literally considered an extension of your nuclear family. His clothing is recycled and pregnant with a fowl, but forgivable odor memorializing two or three weeks of unlaundered use. Money is tight, time stops and starts as he pleases, and everything, and I do mean everything, is a worthy subject of his GI tract. Typical Ghanaian, yes; typical human—hardly. Ali is unflinching in his dedication to our cause.  He picks up every volunteer from Accra and lugs them 13 hours to Tamale, where he has already made his or her living arrangements, he coordinates all medical outreaches and outreach living arrangements and culinary accommodations and transportation and sundry requests like laundry and fan repairs and bottled water, and then he has to take the outgoing volunteers all the way back to Accra every ten days, only to turn around on a dime to meet us back in Tamale—not to mention the hundreds of eye exams he conducts on a daily basis and the handfuls of surgeries he books and oversees year round. He is tireless, more so than anyone I have ever seen, and embraces his life with unabridged alacrity.

There are people that sluice our spirits like profligate floods, and there are those that visit and leave us just as naked as we came, and there are those so ostensibly packed with goodness or energy or whatever you would like to call it that they are tacitly obliged to share it with others.  And then there is Ali, a man who urgently, forcedly injects us with his zest and alchemizes from our womb-weary, trembling curiosity in this beautifully abstruse land a harvest of confidence and comfort.

“When we live dis way, it is not that we should be hahppy,” Ali says, “It is dat we MUST be hahppy if we ah to keep living dis way.” Word, Ali.

The Surgeon Man Cometh

Dr. Wanye arrives on Ghanaian time, two hours after we take breakfast near the clinic in Karaga. It is 10:30 Am when I see him first, strolling in black loafers and a tucked oxford toward the plastic chairs, his bowling ball head sprayed with morning light and thin arteries of sweat.

“Hello, hello, good to see you again,” he greets. The doctor extends a gentle, steadied hand hip-height and relieves our group from visual acuity tests, a full, symmetric smile preserved as he rotates and shakes, rotates and shakes. For a man of his responsibility—he is the only ophthalmologist for the 2 million people in the Northern Region of Ghana- he exudes a seasoned serenity, as though he has already rehearsed the surgical cases for the day and trusts his hands to cut and hold and tie mindlessly into the darker hours of the evening. There are 30 something surgeries to be performed today, 30 more the following day, and an overflow to be dammed up on Sunday when the stragglers and last-minute consenters rush to reintroduce their eyes to vision. Dr. Wanye performs cataract surgeries with a swift, itinerant motor, incising a dense organ of colorful gowns and sweet, leathery faces one after the other, cleaning the next patient’s eye before the previous one has left the theater.

Surgeons are often conjured up to be the doctor kings of the healthcare profession. Publicly perceived, they are the smartest, fiercest, most unshakeable healers we have, thoroughly adorned with rafts of instruments and machines and supporting staff to carry out our most sacred of medical rituals: the operation. But this is not Wanye, poised over a microscope with surgical scissors, clipping his eigteenth conjunctiva of the day, then slicing through to the sclerotic tissue and cracking the anterior chamber of a glazy cataract, only to slide in a limpid lens the size of a snowflake. He talks with the single nurse about the punctuality (or lackthere) of lunch and occasionally voices a staggered narration of the procedure. “Usually...the iris sags downward in the eye...and it opens up the incision...further...so that we can reach the anterior chamber with...relative ease.” Over and over, he cleans and clips and slices and injects and implants and sutures. No barking at frantic nurses for pharmaceutical x or instrument y, no spurting blood soiling his scrubs or disposable mask, and there is no monitor pealing out like a dial tone when the phone drops off the hook (and it never does in our operating room).

Wanye is a medical soldier, a factory physician even, not a cowboy. He has no interest in such dramatics. Atul Gawande once observed that the best surgeons are not the most naturally gifted or deeply ambitious, but rather the best versed in there respective operations. It’s not about genius, Gawande explains, it’s about who is boneheaded enough to practice the same thing over and over and over again until it becomes a fluid recitation, an indelible routine, a habit of the body as automatic and impregnable as breathing. Sometimes hospitals here lose power and running water; Wanye continues to operate with a flashlight illuminating the field and whatever bottled water he can scrounge for. His repertoire is that far engrained. As a lowly, aspiring physician, it is humbling and awe-inspiring to witness a master in his element, flexing the muscles of his craft with the grace and eminent prowess of an acclaimed musician or headlining athlete. Being inches away from the patient’s pupil, like a black umbrella against a fresh white cloud, I was entranced—with the surgery, with the anticipated result, with my own excitement crystallizing as the surgeries went on and on. “We are almost ready to call it a day,” Dr. Wanye says, 28 cataracts deep and kicks a pitch of blood-smudged cotton near his feet. We have 30 more surgeries tomorrow, 30 more practices to add beneath the doctor’s belt, and, most importantly, 30 more patients who will reunite with sight. 

A Lofty, Liberal, and Typical "Save The World" Post

Currently writing from a small village called Karaga, where the people are soft-spoken, the food is dense, and the flies are starving. We've just returned from an outreach inside the village, where we examined nearly 220 patients, dispensed hundreds of drops and antibiotic eye ointments, and booked 50 patients for free cataract, pterygium, and glaucoma surgeries to be done this Friday. Personally, I am finding the work extremely rewarding and vocationally corroborative-- that is to say, I am beginning to see myself as a doctor more and more as I examine patients. I've learned a bunch of phrases in the local language, Dagbani, and wield them flaccidly, but at the very least I can assess how the man is ("agbira"), ask him to cover his eye for a visual acuity test ("poma nimbla") and tell him that we will do our best to eliminate the problem (much too long to type and I still need a translator for some parts of this mini-spiel).

Seeing patients down here can be as thrilling as it is heartbreaking. At times, we find people no older than 50 with mature cataracts or full blown pterygium, and knowing that we can provide surgical treatment is very satisfying. At the same time, I saw a woman yesterday, 22 years old, with absolute glaucoma, meaning we have no effective surgical or medicinal treatment that will resolve her issue. Objectively, our solution is to hand her eye drops that will slightly reduce the vitreous pressure in the eye, but tacitly, among ourselves, we are certain that she will completely and irreversibly blind by years end. I read about this type of stuff in books and journals and visually observe all sorts of medical phenomena on TV. Somehow, seeing it in person unwraps it all for you, makes it crawl into your brain and say, "this is real, people actually go blind here for no reason." I met one woman today with immature cataracts and severe conjunctivitis, so severe that her left eye appeared as a membranous duct, running with a sickly yellow discharge, preventing her from telling me how many fingers I was holding up from five feet away. These pathologies-- glaucoma, cataracts, conjunctivitis-- are scoff-worthy here in the United States, controllable and swiftly corrected. So they should be here, these pathologies, so invariably squelched that no one should go blind from them as a result. We are plagued by the "lack"--of knowledge, of access, and of locally trained professionals-- in Ghanian eye care. Back in the states, many people told me of Ghana's beauty-- the lush plains gushing with verdant leaves and wild flowers, red dust roads slicing the heart of the north into bucolic chunks, and the warm, tactile-obsessed population, trying desperately to populate those around them with happiness. And it is beautiful, for those that can see it. For those that cannot see the thatched adobe lining the savannah like sunbaked ornaments or witness their children growing and walking and changing, Ghana is still a wonderful place--everyone takes care of everyone here. But if people are to have full agency here, to be employed and to parent and to take care of others when they are in need, then these pesky, resolvable pathologies must be eradicated. 

So. That is my blindness spiel. Now that it is out of my system, you can expect less lofty, less liberal, more interesting reflections in the future. My next post will center on our shepherd and infinite source of inspiration, Ali. Until then...