Return to Samaro

A few weekends after returning to Dembi Dollo from the Gambella eye camp, I journeyed with the girls who live with the Daughters of Charity back to Samaro.  The four girls who were there for the summer- Anane, Senna, Ayantu, and Letu- had all either lost their parents or left homes where their parents either neglected or abused them.  We ventured first to the district of Anka, which Sister Evelyn had dubbed "the end of the world," since it contained a wide, elevated plateau from which one could see Samaro, Addo (location of the podo clinic), and other towns even further out.  From there, we headed down the steep drop-off past the plateau, down to the road which led to Samaro.

Alex, the Irish permaculturist, had long since left the million dollar fields, but Sister Kaffa still oversaw the kindergarten, animal life, and plant life in Samaro.  We stopped by the chicken coop and picked some mangoes, but sadly missed out on visiting the young calf, which had recently died due to lack of milk.  At the day's end, we slowly trudged our way back up the mountain to the sisters' compound despite six year old Letu's worries that we might not have enough energy to make it.  We returned rejuvenated and revitalized from the agrarian paradise we had had the opportunity to enjoy.

Letu with her "umbrella"

Sight

"When you restore sight, you restore hope."

-Dr. Samuel

What is it like to become blind?  Over the week of the Gambella eye camp, I had ample opportunity to ruminate on this question.  I can only imagine the gradual loss of vision which occurs with the more common causes of blindness, and the hopelessness that ensues as the darkness slowly creeps in.  With glaucoma, one loses vision from the outside in, first being unable to see out of the corners of the eye until eventually one can no longer see anything at all.  When a nuclear cataract first develops, one's reading vision actually improves to the point where some people no longer need to use reading glasses.  This joy quickly turns into worry, however, as the nuclear cataract matures and gradually blocks out all sight.

I tried to grapple with the emotions which the blind experience- the depression from realizing that you will never be able to see the faces of your children again, the loss of self-worth from being unable to work or do any meaningful activity, the complete and utter dependency of being reliant on someone else to help you perform even the most basic functions.  We even heard stories about some blind people who would cry out at the top of their lungs for help because they desperately needed to use the toilet but had no way of finding it and no one to help them do so.

One morning, a young man wearing a UCLA t-shirt pulled me aside.  His ten-year old brother, he told me, needed to be seen by Dr. Samuel.  His brother had been born blind in one eye, and had recently become blind in the other and desperately needed help.  As Dr. Samuel came down the line screening patients for operable cataracts, he reached the young boy and gave his verdict- the boy had extensive corneal scarring from trachoma which could not be reversed with cataract surgery, or any surgery available in Ethiopia.

In desperation, the young man grabbed me again.  "Have him recheck!" he burst, unable to believe there was nothing to be done for his brother.  I calmly re-explained Dr. Samuel's diagnosis, trying to avoid my own conflicted feelings about the boy's case.

As the young man and his little brother dejectedly collapsed on the benches along the hallway, I sat down with them.  A wave of hopelessness washed over me as I felt the despair and anguish of the brothers sitting next to me.

"We tried to get him an appointment in Juba, we tried to get him an appointment in Khartoum," the man wailed [Juba is the capital of South Sudan, Khartoum is the capital of Sudan].

The tragedy of this boy's blindness was compounded by the fact that even though they had sought medical care earlier in three different countries, there simply were not enough doctors available to treat everyone who needed care.  The young boy's life had been irrevocably altered because of this simple fact, and he was relegated to a lifetime of blindness.

Yet there was still hope amidst the tragedy.  Anne-Berit brought up Shashamane school for the blind, which Larry, Sean, Joey, and I had visited near the beginning of the trip.  I strongly urged the young man to visit the school with his brother and family- they had the resources to help his brother get an education and could help him live his life to the fullest, despite his visual limitations.

The disappointment of being unable to aid many of the patients was outweighed by the joy of witnessing patients from the previous day regain their sight.  As we arrived at the hospital each morning, forty to fifty patients who had undergone cataract surgery the day prior sat in the courtyard just outside the operating room.  We would slowly make our way down the line, removing the patches covering the healing eyes and distributing post-op medications, while Dr. Samuel checked the eyes for any complications and, most importantly, for restored vision.

Dr. Samuel checking visual acuity

Patients typically didn't react immediately once the eye patches were removed, but as they began to look around and as the realization that their sight had returned crept in, smiles erupted on faces all over the courtyard.  Some patients would point at their grandchildren, finally seeing their faces again, and a few even belted out worship songs and shouted prayers of thankfulness to God.  Mario and Sean followed one elderly patient named Gideon back to his house, where his pastor presided over a ceremony and his church choir offered up songs of praise for the transformation in Gideon's life.

One woman who had had her sight restored grabbed my hand and gestured toward the sky, saying something I couldn't understand.  "She is saying, 'I thank God for you,'" my friend Jango explained.  "I didn't even do anything!" I laughed.  I suppose I should be thankful none of the patients licked my hand, which was an experience that befell Sean when an overjoyed woman wanted to express her gratitude.

a post-op patient

 family and friends gather excitedly around a man who has regained his sight

At the end of each day, despite being drenched in sweat, despite being covered in mosquito bites, despite having to eat meals covered with flies, despite the fatigue of 12-hour days, despite the frustration with argumentative patients or the inefficiencies of Ethiopian healthcare, I felt this unshakeable sense that somehow- somehow -it was all worth it.

Manual Small-incision Cataract Surgery

Cataract surgeries performed at the Gambella eye camp:  276
Highest number of surgeries performed in one day of the camp:  49
Cost of each cataract surgery:  $50 US dollars (cost to patient is free)
Average duration of a single cataract surgery at the eye camp:  < 15 minutes

 Dr. Samuel's notes explaining manual small-incision cataract surgery

The manual small incision cataract surgery (MSICS) procedure which Dr. Samuel regularly uses reflects the incredible resilience of the human body.  To perform the operation, the surgeon essentially cuts open the eyeball, replaces the lens, and patches the eye- without sewing or suturing the cut in the eyeball!  After one day, the eye actually heals itself and the patient has his or her vision restored.

Of course, the details of the procedure add additional layers of complexity.  A step-by-step guide to MSICS-

Prep- Dilation, Sterilization, and Anesthesia

Before the operation can begin, the patient's pupil must be dilated in order to give the eye surgeon the largest possible area in which to work.  Because the lens lies behind the iris, the further the pupil is dilated, the less the iris will obstruct the exit of the lens.  We used a mixture of tropicamide, cyclopentolate, and phenylephrine to achieve dilation.

As with any other surgery, the surgical field must be sterilized prior to operation- at the eye camps, Dr. Samuel uses a povidone-iodine mixture.

Finally, the eye must be numbed and rendered immobile.  This was accomplished with a lidocaine-adrenaline injection.  The adrenaline works by delaying the absorption of lidocaine, the anesthetic, into the body so that the numbing effect can continue throughout the duration of the surgery.

Step 1- Conjunctival Dissection

eye as seen from the side

Once the patient is lying on the operating table, under the eye of the ophthalmologist's microscope, the real fun begins.  The ophthalmologist grabs hold of the outer layer of the white of the eye (the conjunctiva) and makes a careful horizontal cut a few millimeters above the iris.  Though this step is referred to as the conjunctival dissection, it is technically a dissection of two layers- the conjunctiva and the layer of the eye below it, called Tenon's capsule.  In dark-skinned people, such as those in Gambella, Tenon's capsule is much thicker, and sometimes the ophthalmologist must make a second cut to dissect Tenon's capsule instead of taking the two layers out with one blow.

After pulling away an area of the conjunctiva and Tenon's capsule, the surgeon then seals (or "cauterizes") the blood vessels he or she has exposed.

Step 2- Linear Incision

eye seen face on

Next, the ophthalmologist makes a careful horizontal cut in the sclera, the layer underneath the conjunctiva and Tenon's capsule.  Some surgeons prefer the "smiley face" cut or the "frowning face" cut, but Dr. Samuel's incision of choice was linear.

Step 3- Scleral Tunnel

eye facing up as seen from the side

Thirdly, the eye surgeon creates an upward sloping tunnel from the incision he has just created all the way to the area in front of the iris (the anterior chamber).

Step 4- Capsulorrhexis

Now that the ophthalmologist can reach the lens, he can peel off a circular area of the front part of the "bag" (or capsule) holding the lens.  In other methods of MSICS, doctors peel off the front of the bag in other ways, such as in a "V" shape.

Step 5- Hydrodissection

 eye as seen from above

Once the front of the capsule is removed and the nucleus (or center) of the lens is exposed, the ophthalmologist shoots a stream of water at the nucleus, rotating it about 180 degrees to completely detach it from the rest of the lens.  


Step 6- Nuclear Extraction

 eye as seen from above- pulling the nucleus through the scleral tunnel

Next, the surgeon can reach into the capsule and pull out the nucleus of the lens.  Dr. Samuel's preferred technique was to use a fishhook, which he created by reforming the needle of a syringe into a hook shape.  Not all nuclei are created equal, and there was a huge amount of variability in the consistency of lens nuclei at the eye camp.  Dr. Samuel deemed the fairly mature cataracts "delicious," as they were solid, hard, and dense, and relatively easy to extract.  Hypermature cataracts, on the other hand, have progressed further than mature cataracts and are also known as Morgagnian.  In Morgagnian cataracts, the outer part of the lens (the cortex) actually turns from solid to liquid though the inner part of the lens (the nucleus) remains solid.

According to Dr. Samuel, the nuclear extraction step is the hardest part of the operation, as the lens is in danger of falling further back into the eye.  To me, this seemed like the most exciting part of the surgery, as the removal of the lens from the eyeball was almost like the delivery of a baby (albeit a tiny baby that you throw away immediately after the surgery).


Step 7- Aspiration

Since the lens is composed of both the center portion (nucleus) and the outer portion (cortex), even after the nucleus has been extracted, the less rigid peripheral portion of the lens remains.  Typically, the surgeon aspirates or suctions out the cortex using a device called a Simcoe cannula, essentially vacuuming behind the iris to pull out the strands of lens remaining.  Sometimes, fragments of cortex remain behind the iris on the same side of the eye that the incision was made.  In this case, it is impossible to reach the last pieces of cortex, so an additional incision must be made about 120 degrees counter-clockwise from the initial incision.  From there, the ophthalmologist has the perfect angle from which to suction out the last of the lens.


Step 8- Inject Viscoelastic

Normally, the space behind the cornea (the anterior chamber) contains a water-like liquid called aqueous humor which, among other things, helps to maintain a sort of pressure equilibrium in the eye.  During MSICS, this equilibrium is disrupted and thus the ophthalmologist injects a similar (but synthetic) material called viscoelastic to help restore the appropriate pressures.  The surgeon can choose between dispersive and cohesive viscoelastic.

Cohesive viscoelastic, as its name suggests, tends to clump together, making it easier to remove.

Molecules of dispersive viscoelastic, on the other hand, separate from each other making removal more difficult.  The benefit of dispersive viscoelastic is that it coats the inside of the cornea (endothelium), providing a nice protective coat.


Step 9- Lens Implantation

 inserting the new lens through the tunnel and under the iris

Finally, the ophthalmologist inserts the new lens into the spot where the old lens used to sit- behind the iris and within the "bag" (capsule).  Two curved prongs on either side of the new lens called haptics ensure that the lens hooks snugly into the capsule.  To my understanding, the viscoelastic helps create the right pressure in the front of the eye so that the surgeon has an easier time placing the new lens.

artifical lens with hooks (or "haptics") on either side

Step 10- Removal of Viscoelastic


When the surgeon removes the viscoelastic using the vacuum-like tool called a Simcoe cannula, he can also use the opportunity to "polish" the newly inserted lens along the patient's visual axis.  This helps to lessen any blurriness the patient might otherwise experience.


Step 11- Closing the Wound

applying water pressure to the incision to seal it

Finally, the ophthalmologist fills the space behind the cornea with water to restore the pressure lost after the removal of viscoelastic, then shoots water along the linear incision he made in Step 2.  If all has gone according to plan, when the surgeon lightly taps the patient's cornea, no water leaks out of the incision because a flap of eye is holding it shut.

Throughout the surgery, the ophthalmologist must make numerous decisions as he goes.  If the surgeon senses the patient is tense, he will typically make his initial dissections further from the intersection of the white of the eye and the cornea (the limbus), thereby creating a longer scleral tunnel.  Tense patients are at greater risk of their irises leaking out through the incision, so creating a longer tunnel helps prevent this.  Patients who have a condition called pseudoexfoliation, in which protein deposits appear in the iris and/or lens present as riskier surgical cases because the strands encircling the lens and holding it in place (zonule fibers) are more fragile.  Thus, the ophthalmologist must be especially delicate in his surgical actions.


After drying the eye and injecting an antibiotic mixed with a medication to reduce inflammation, the patient's eye is patched up and he or she is sent home to rest until the next morning, when- if all has gone well- the patient will regain sight.

Operating Room Haiku

Iodine stained walls

Rhythmic click of fan above

Sight returning soon

Days in Gambella

walkway at the Baro Gambella Hotel

Every morning at the eye camp we would rise early in the morning for an egg breakfast at the hotel before heading out to Gambella Hospital where the day's work would take place.

 the group at breakfast

 

bajajs we rode to the hospital one morning

 setting up in the operating room

When we arrived at the Gambella hospital that first Saturday, we found to our dismay that the hospital lacked running water.  Our only option to remedy this problem was to transport plastic yellow jerry cans full of purified water from the church down the road to the hospital.  Rolling blackouts were not uncommon, and occasionally Dr. Samuel would have to close up a patient's eye halfway through surgery until electricity returned to the operating room.

 tree full of bird's nests outside the operating room

fallen bird's nest

During the times I was not in the operating room or assisting the patients waiting outside, I would spend my time helping out in the eye clinic, where patients were readied for the surgery.  Those who wore a piece of tape above either eye indicating an operable cataract would enter the clinic, where we would perform keratometry and biometry to obtain a measurement of the patient's eye.  From these measurements, we could determine what size lens Dr. Samuel would need to insert during cataract surgery.  During this time, we would also clip the eyelashes of the eye to be operated on, and take the patient's name and age.  Though the cataract surgery was free for all patients, we charged 50 birr (about $2.70) for the medications patients would use after the operation.

performing biometry on a patient

If anyone believed that all Ethiopian women were oppressed, one need look no further than Sister Kaffa, a Daughter of Charity in her early 20's, as an exception to that rule.  With a big personality, a big voice, and a big smile, Sister Kaffa would not hesitate to speak exactly what was on her mind.  Her intolerance for disorder and noncompliance was matched only by her sense of humor and love for Ethiopian pop star Teddy Afro.

Sister Kaffa's primary role at the eye camp was intake- registering patients' names and ages, and collecting their money for medications.  Since the patients' names were typically in Nu'er or Anuak, languages as foreign to Sister Kaffa as they were to me, her attempts to record patient names often turned comical.  After a patient would calmly state their name, Kaffa, having never heard these names before in her life, would incorrectly repeat the name back to the patient.  Across the room, an eavesdropping nurse would overhear Kaffa's mistake and repeat the patient's name a little more loudly.  Still struggling to understand, Kaffa would restate the patient's name incorrectly a second time.  Finally, the kids poking their heads through the clinic window to observe the happenings inside would all shout the patient's name in unison, at which point Kaffa would understand and, with a big laugh, would record the patient's name correctly.

If obtaining a patient's name seemed difficult, however, it was a walk in the park compared to figuring out a patient's age.  Many elderly Ethiopians never had a birth certificate and thus had no way of knowing their true ages.  One patient with graying hair stated he was 10 years old, while another young-looking patient claimed he was 120!  Still others saw the question as a sort of trivia game in which they were the hosts and we were the contestants, replying with such cryptic answers as "I was one year old when the Italians invaded."

In the meantime, the rest of the clinic would be no less chaotic.  Dragonflies would find their way inside, zipping back and forth as they crashed into patients and staff alike until finally getting knocked out by the spinning fan above.  Some of the blind patients would often get confused or just impatient and start pushing the other blind patients around them, leading to full-blown fights between blind people which required us to intervene.

 view from the hospital

Some of our younger patients provided some much needed comic relief.  One twelve year old boy came to us telling us he couldn't see the board in class and wanted his eyes checked.  Yet upon visual exam, his vision came up 20/20.  It turned out that his mother was having a baby in the maternity ward across from the operating room where Dr. Samuel was performing cataract surgeries, and he had grown bored while waiting and figured he would get his eyes checked to pass the time.  Another day a crazy three year old boy wearing a pink hoodie and no pants ran back and forth through the hallways doing karate moves and mugging for no one in particular.

One of the strangest and funniest conversations I had with two teenagers waiting outside the clinic went as such-
Teenager:  "What's up?"
Me:  "Not much.  What's up with you?"
Teenager:  "You don't know what is up because you are doctor.  We know because we are nigs."

***

One day a local news crew, having heard about the eye camp, came to the hospital to interview Dr. Samuel.  Dr. Samuel characteristically declined, since doing an interview would rob him of time he could be spending on additional patients.


***

Our first day in Gambella, we also had the chance to visit the town of Abobo, 20 miles south of Gambella.  Though we had gone to scope out possible future camp locations at the clinic there, we culminated our visit with a trip to the Abobo dam.  For some reason, officials were worried that if they allowed pictures of a certain bridge in town or of the dam at Abobo, terrorist attacks would ensue, and thus photos of these structures were illegal.  We quickly snapped some shots anyway.

***

One morning as I went down the line of patients waiting to undergo cataract surgery, I came across a small elderly woman who was missing the piece of tape above her eye which would indicate which eye was to undergo cataract surgery.  As I motioned back and forth between her eyes to ask her which eye had the cataract, she eagerly grabbed my hand and pointed my finger at her left eye.  The woman's daughter, standing nearby, reacted with a mixture of amusement and embarrassment, laughing and putting her hand to her face, in a manner which reminded me more of American mannerisms than Ethiopian.

The daughter, who spoke English well, turned out to be a worker at a dispensary far out in a remote corner of the province of Gambella, and had also brought her husband and young son- a fan of John Cena and aspiring wrestler- to the eye camp.  She said she worked alone at the dispensary and that things were often slow because visitors needing medication could be few and far between.  Still, it struck me that without people like this woman, who was perhaps the only healthcare provider the people in her area would ever meet, medications for an array of conditions would be entirely inaccessible.  It dawned on me that sometimes it's the unknown people doing the least glamorous work that are the true heroes.

The Man from South Sudan

In the midst of our breakfast one morning at the Baro Hotel in Gambella, a tall man with the characteristic horizontal forehead scars of the Nu'er people and clad in a black suit approached our table.  "Good morning," he said in a jovial manner.  "My name is David and I am the ambassador from South Sudan to Ethiopia."

It turned out that one of the Nu'er men who had joined us at dinner the previous night had spotted David at the restaurant and explained the goals of the eye team to him.  "My son is also from America, visiting here with his mother," David explained, gesturing to the young boy sitting at the table next to us. "This is his first time in Africa and he hates it here," he laughed. "He's asking for hamburgers, complaining about the heat, and refusing to eat his food because there's so many flies on it."

All was not well with the two-year old nation of South Sudan, which David reminded us was the youngest country in the world.  Though Ethiopia and many other countries were supporting her, the new country lacked the necessary infrastructure to achieve anything resembling stability.  After living through decades of fighting, the South Sudanese people knew the culture of war better than the culture of peace and couldn't fully comprehend the needed shift in mentality to build South Sudan into something prosperous.

As we later found out, conditions deteriorated even further in the weeks after our meeting with the ambassador- land disputes and historic rivalries between people groups in the eastern South Sudan province of Jonglei, the province bordering Gambella, eventually led to mass violence and the displacement of over 100,000 South Sudanese from their homes into the wilderness.

And shortly thereafter the president of South Sudan fired his entire cabinet in what was interpreted to be the final move in a power struggle between him and his vice president.

Amidst the discussion of political issues, Dr. Samuel piped up.  What was the level of medical services available in South Sudan?  Inadequate, came the answer.  The capital city of Juba possessed decent but insufficient medical services, and the rest of the country fared far worse.  As we headed out, a few members of the group asked for David's contact information.  David assured us he would stop by the eye camp at the hospital later that day and provide the information then.  When night fell at the hospital we realized David hadn't made an appearance.

Perhaps he got caught up in his official business, or perhaps he never truly intended to visit us at the hospital.  Nevertheless, the figurative door was open.  South Sudan was in need of ophthalmic services, and Dr. Samuel and team were only too ready to serve should the opportunity arise.

The Restorer

Dr. Samuel (far left) checks the vision of a patient after cataract surgery 

Dr. Samuel Bora Imana projects such an air of tranquility that if I didn't know he was a Christian, I might think he was a Zen Buddhist.  Soft-spoken, patient, and wise, he's one of the most laid-back ophthalmologists I've ever met, which, if you know any ophthalmologists, is saying something.  Born to humble origins in Aira, Ethiopia, to farmer parents, he excelled in school and gained acceptance to Ethiopia's top medical school, Addis Ababa University.  Though he initially trained as a general practitioner, he later became an ophthalmologist after witnessing how transformative ophthalmic surgeries could be, and is now one of the 80 or so ophthalmologists in Ethiopia, a country with a population of nearly 90 million.  When he was offered a position to teach at Addis Ababa Medical School, he declined in favor of working with Tropical Health Alliance Foundation and the Daughters of Charity, which allowed him to fulfill his desire to provide services to the poor.

Dr. Samuel has been called "the best ophthalmologist in Ethiopia" by the former ophthalmology division chief at the Loma Linda VA, but he's also the kind of doctor who will apologize for reaching past you to empty a syringe mid-surgery even though it's actually you, not he, who is in the way.  He's the type of person who prefers the simplicity of the farming town of Aira to the urban sprawl of Addis Ababa, and the type of doctor who will pause for five minutes to explain a teaching point with illustrations even though he still has thirty patients left to see.  His intention was always to practice medicine in Ethiopia, not in higher-paying countries like many of his classmates intended, and his prayers always include the patients he will be treating.  The very rare occasions when he raises his voice are, in his own words, to use it as his only weapon during surgery to a patient who refuses to hold still, thereby risking the integrity of his or her eye as well as the outcome of the procedure.

Dr. Samuel with his last patient at the Gambella camp

Arriving at the Gambella hospital each morning during the eye camp gave me a small taste of what it may have been like to live during the time of Christ.  Hundreds of people who had been waiting since the early morning would turn and watch Dr. Samuel and our team as we entered, gazing expectantly, in hopes that we would be able to cure their optic ailments.  Some would cry out to be examined, or even reach out their hands to tug on our clothing.  For many, because of their limited access to any healthcare providers, this could be their one and only opportunity to regain sight, and many had traveled hours, days even, for the chance.  Being treated almost like a god could go to many people's heads, but astonishingly, Dr. Samuel maintained his humility despite the extreme reverence afforded him.

I've observed that the people who achieve greatness in one sense of the word are driven as if by some invisible force.  These people accomplish superhuman feats stemming from a sense of urgency not to build up themselves and their own reputation, but to fulfill some sort of need in the world.  For Dr. Samuel, that motivating force seems to be the millions of Ethiopians who lack access to eye care.  This same force also seemed to carry him through 276 cataract surgeries in one week, almost as many as the typical Ethiopian ophthalmologist completes in one year.  "If we have one more lens left, I feel we need to use it," he said. "If we return home with unused lenses, I will think to myself that there were more people who could have been able to see."