The job paid nothing, but the rewards were great

The job paid nothing, but the rewards were great

Grateful patients made up for the incredibly crude conditions this ophthalmologist experienced as a volunteer in rural India, where millions are blind for lack of treatment.

By Antonio F. Viñals, MD
Ophthalmologist/New York, NY

I spotted the boy with a "lazy" eye at the entrance to the Sri Meenakshi Temple in Madurai, India. His father was the attendant there, guarding the shoes visitors removed before entering.

I pulled out my examining penlight and did a few eye motility tests on the child, who was about 5.

"Are you a doctor?" asked the dad, one of the many Indians who speak English.

"Yes, I work at the Avarind Eye Hospital," I replied. The hospital had been founded in 1976 to perform free eye surgery for the people in this impoverished area of the Tamil Nadu state. I was there for 10 weeks on a volunteer stint arranged by my residency program.

"Something wrong?" the father asked.

"His right eye is turned inward. If he doesn't have surgery, he may never develop useful vision in that eye."

"That would be terrible," the man exclaimed. "But I cannot take him to a doctor. I work every day."

"Please take him to the hospital. I will help," I said, giving the father 200 rupees (about $6), which was probably equal to at least one week's salary. The man listened attentively and promised to bring his son to the hospital.

Barefoot in the OR

I still vividly recall that en-counter, but it was just one of many memorable moments during my sojourn in India in 1997. It was a privilege to help reduce what seems to be an insurmountable health problem. India has about 1 billion inhabitants and only about 10,000 certified ophthalmologists, most of whom practice in or near large cities. In rural India, where I worked, people go blind from treatable conditions such as cataracts. A World Health Organization survey conducted in the late 1980s showed there were more than 12 million blind people in India, with cataracts causing 80 percent of that blindness.

My daily routine at the hospital began at about 6:30 am, with re-examination of post-op patients. As the sun rose and morning prayers boomed from loudspeakers in the town center, the patients sat quietly in a large room, waiting for their names to be called. They'd all slept at the hospital overnight on bamboo mats, many accompanied by family members. After their exams, the patients often bowed, even knelt before me, and said "Nandri! Nandri!" ("Thank you! Thank you!") Their gratitude was unlike anything I'd experienced in the US.

After examining the post-op patients, I typically headed to the OR, where conditions were rudimentary, to put it mildly. The rickety operating table was a throwback to the '50s, and my scrubs and cloth mask were washed in a disinfectant that smelled like formaldehyde. A nurse would pour sterile soap onto my hands, and another would rinse it off with boiled water, practically scalding me. She'd pour it from a cast-iron basin while I stood at the huge concrete trough that served as a scrubbing sink.

The hospital supplied no surgical gloves. Luckily, I'd brought my own, as had other foreign doctors. The local doctors, though, just operated without them. We all worked barefoot, because most shoes were covered with animal dung, mud, and bacteria, and the hospital had no surgical booties.

The hospital had no scalpels, either. I'd brought some with me, but mostly we used and reused razor blades. We'd break each one to create a fresh edge, then sterilize it. Because as many as 20 doctors would perform 100 or more cataract operations a day, six days a week, every resource had to be maximized—even the operating rooms, where two operations often took place simultaneously.

Most afternoons, I examined new patients, many of whom had advanced bacterial or fungal infections and required corneal transplants. Unfortunately, donor corneas are hard to come by in India; often, the most we could do was supply high doses of antibiotics.

Waiting for the lights to come on

As I settled into my work, I was soon doing five or six cataract operations every morning.

We used the old-fashioned technique, making a long cut in the eye and squeezing the lens out. The modern method is to make a small, stitchless cut and use a phacoemulsification unit to remove the lens. But in this bare-bones environment, that equipment was a luxury we didn't have. So my Indian experience didn't add a lot to my surgical technique.

Still, I learned plenty, starting with how to operate under less-than-ideal conditions. I didn't meet my patients until right before the surgery, so I knew nothing about them. The OR temperature often soared as high as 120 degrees when the air conditioner was shut off to conserve power. The occasional mosquito landed on my nose during surgery. Power outages occurred daily.

The first time I faced a power outage, I was in the middle of surgery. But a nurse pulled out a strong flashlight, and I managed to continue suturing. Another time, I was in the middle of expelling the cataract from an eye when we lost power, rendering the operating microscope useless. "Don't worry, sir, the light will come back soon," said my assistant nurse.

"Oh, yes," added the Turkish surgeon working next to me. "This will happen every day. Do not worry. It will be fine." Sure enough, after three or four minutes, which seemed an eternity, the lights and operating microscope came to life, and we were able to finish the operation without complications.

We faced other drawbacks. The equipment was old and sometimes didn't work. When the operating microscope broke down, I didn't have a great view and had to make assumptions as to when to push or pull. We didn't have any viscoelastic, which we normally insert in the eye to keep it from collapsing, so we had to use air. I had to operate quickly, because of the greater chance of infection.

After 10 weeks, I was thoroughly battle-tested. By comparison, surgery in an American OR would be a piece of cake. But never in America would I feel such great satisfaction.

Payment that can't be counted

The patients I operated on lacked the means to pay for their surgery, and many traveled for days to our hospital. Despite our limited resources, we were providing a wonderful service.

Everyone I worked with in the country was highly motivated and enthusiastic, and I was soon caught up in this feeling. The staff and townspeople knew that we Westerners were there to help them, and they were friendly and appreciative. The local doctors entertained us. They made only about $20 a week, but they thought life was grand. They knew you don't have to make a million dollars to be happy. A sense of goodness abounded. It was like stepping back in time.

In the US, reimbursement problems and lawsuits create a negative environment in medicine. My experience in India was a pure form of medical practice. I was helping people and expecting nothing for it except their appreciation.

And that I surely got. During my last week at the hospital, I ran into the father of the young boy I'd examined at the temple. "I brought him in," the man said, "and they will operate on him soon. You saved his eye. Nandri! Nandri!"

That, alone, made my Indian sojourn worthwhile.

 

Doreen Mangan. The job paid nothing, but the rewards were great. Medical Economics 2000;7:114.