Clouds roll north through the low Himalayas, as seen from the road to Okhaldhunga.
A garish freight truck’s breakdown on a high gravel pass temporarily blocks the road, as well as the team’s progress.
The first hour of waiting was just a blur of impressions: the morning fog peeling off the nearby Bagmati Bridge; the bus driver tightening down the dashboard with his screwdriver; and Sunam placidly repeating “Time is not fixed in Nepal” like a mantra. The trip to Okhaldhunga is, ideally, a quick flight due east from Kathmandu with a short trek following, but the planes are booked for the Dasain festival. Two lanes quickly become six on Kathmandu’s Ring Road. Our 15-passenger bus actually seats 18 this morning, and our original plans for a one-hour flight have been replaced by a two-day overland ordeal that demands at least 10 hours of bus time today.
The mountain road beyond the outskirts pummels the bus’s undercarriage. The ride is laughable, but that doesn’t necessarily translate into enjoyable. Ear-splitting, polyphonic horns sound at every potential delay; brakes scream in protest at every turn; and, once we enter the heat of the central Terai, sweaty neighbors leave outlines on the cloth seats. There’s something really humbling about bus travel, likely due to the complete loss of control you experience as a passenger.
Today, the discomfort dissolves when I wake in the full reality of this place: the immense valleys, broad rivers and mountains shouldering down to the flatlands in a tumbling mass of Asian green. The hem of clouds along the western horizon poured sunset over the patchwork of rice paddies near Janakpur, verdant stretches disturbed only by the blazing scarlet saree of a woman tending her fields in the fading light. You knew that all of this travel was worth it just to give this display back to someone.
Travelers encounter cost/benefit questions frequently, as do medical students. Eight years of school, innumerable hours of study, substantial financial investments, two months in Asia, 19 hours of bus travel, and a trek over the Koshi River tomorrow—and it’s all worth it for that first patient who removes his eye patch to look out at the Himalayas again.
When we reach the village of Gurmi, on the banks of the Dudh Koshi River, we are forced to leave the bus behind and cross the river by footbridge, our equipment carried by a horde of porters, the most veteran of whom bear a mid-scalp bald patch worn hairless by the coarse straps used to carry their loads.
On the eastern bank, an hour’s wait produces a local bus for the final leg to Okhaldhunga. The bus is aged (and not gracefully), but the driver—unfortunately—is not. Above the marijuana-print handkerchief that circles his neck, there’s no hint of the anxious wrinkles to assure me of a veteran driver. This one can’t be more than 23, lolling across the driver’s seat chewing a mix of tobacco and lime, and the question of his age only complements my doubts about this cliff-side road we’re about to traverse. With a cough and burst of miasmic brown smoke, the driver rouses the bus, and we limp down the deeply fissured road to the cliffs ahead.
Throughout this day, I’ve seen one consistent question in the faces peering from roadside houses and vendors lining the hill in Gurmi: How did he get here?
I ask myself the same thing. Shouldn’t I be tucked into a textbook somewhere, studying for the boards or working on residency applications? Or, if anything, shouldn’t I be seeing patients?
But this is one of the strongest metaphors I’ve known for the true context of healing. The care of another’s health cannot be viewed rightly as some stand-alone moment, detached from the rest of her life. And if it takes a three-day camp set within a four-day road trip to teach me that, then I count it a happy—though tiring—lesson.
After two days of exhausting anticipation, we descend a footpath that opens up to a wide field, where a host of our patients stand. On a short ridge is the school that will serve as our hospital for the next three days.
Our team divides quickly. Chansi goes to the community health training, Gopal to pre-op, Pemba and Dr. Kishor to the tarp-lined operating theater. And I go to an awkward spot in the middle of the courtyard. After hours of planning and expectation, I am utterly lost. Just as this place broke into the well-rehearsed dance of vision screening and pre-op treatment, I realized that I don’t know a step. Sheets of Nepali break over me in a storm of incomprehensibility.
This initial vertigo past, I hit upon the patent realization that you don’t need any more than my primitive grasp of Nepali to fold drapes, enter surgery data and give a few retrobulbar blocks. And, though I absolutely ache to be a surgeon, every minor contribution I make here is quietly connecting me to the greater whole: the hands and minds screening hundreds of patients in the morning and removing the first 25 cataracts that afternoon.
It’s a wonderfully decentralizing moment when you realize that the place you occupy in this business of healing is a privileged invitation. Once rid of all delusions of rights and wages here, you become a guest at one of the richest tables, pulling up a chair to some of the most coveted offerings of human interaction: the stoic chins of the elderly held steady in my palm as I examine their eyes. The dazzling afternoon sun plays on the gold loops hanging from the noses and ears of women waiting in the surgical line. Somber, unchanged faces permit me to pass a needle behind their eyes with no more than a slow “mathi hernus”—“look up.”
The next morning, there is a change even before I’ve passed the school’s gate. A rarified air of eagerness and anxiety moves in the space between doctors, patients and onlookers. One by one, patches are peeled back and the flare of a flashlight brutally delivers a newly opened world to the eye. Some patients are impassive, submitting quietly to a whir of slit-lamp exams, antibiotic instillation and post-op instructions. Others give a flush of emotion that shines with holy simplicity. One man, with just a hint of a smile at the corners of his mouth, simply points slowly from Dr. Kishor to me and back again.
The Nepali team flits over the line of patients with the attention and pride of mothers with children, and—though these cases stand in a line of thousands that have been performed through Tilganga—team members haven’t tired of snapping photos of every smile that comes in the wake of “Thik chha?” (“It’s good?”) and a quick finger-count exam. It’s infectious. A wave of expected success tumbles over each case—but that wave also pushes aside any hint of failure. I feel it in myself as well, a temptation to eschew poor results and photograph only the happy cases. In any endeavor like this, when medicine blurs into spectacle, when pride and expectation are invested, there is an easy gravity that pulls you from altruism. It’s simply evidence that, in spite of all its glory, this remains a human endeavor—a tangle of hopes, egos and intellect that passes from clumsy hands to injured bodies and back again.
The following afternoon’s lassitude stands in stark contrast to the activity of the past two days, but it’s a good break, especially for our two surgeons. They have managed 108 cataract surgeries, perched on broken office chairs over sterile-draped wooden desks. The day ends with a celebration of the eye camp at the district government office: introductions by all present, a prolonged speech, and a concluding banquet of Nepali fare and orange soda.
Just that morning, one of the bilateral cases—the man who had pointed between Dr. Kishor and me the day before—was asked about removing the other cataract after the success of the first operation.
“I’d rather not,” he said.
“Why not?” asked Dr. Kishor.
“I can see now, so I can take care of the children,” he replied, indicating a small boy and girl behind him. “It is good enough.”
“But this cataract will burst in your eye!” Kishor said.
“Let it burst. It is good enough.”
It is a sobering reminder on our last day of what is at stake here—that the lines being drawn by our work cut across the borders of basic human functioning, removed from questions of comfort or convenience. Where we saw standard-of-care, odds of success, and likely prognosis of nonintervention, this patient saw only children to whom he could now tend.
I’m reminded that we treat patients here not for a mass of data detailing visual acuities and post-op complications, but for children who can be cared for by their grandfathers, for mountain trails walked without stumbling, for faces recognized and loved ones seen again. All this, no matter how often I lose sight of it, is the reason at the heart of true medicine, and though I didn’t have to come to this remote part of Nepal to be reminded of it, I am terribly glad that I did.
Dr. Benjamin Thomas is a preliminary medicine resident at Mount Sinai Hospital in New York. In July, he will start his ophthalmology residency at the Bascom Palmer Eye Institute in Miami.