The head of a three year old is surprisingly heavy. I position Kuna’s limp neck over my lap and cradle her blue-black face in my gloved hands. Moving the harsh circle of the operating microscope’s light over her unblinking eyes, I focus on the white pupils filling my view. Kuna is blind from cataracts.
“I would like to operate this patient, Dr. Rose. I can give her sight.”
“How would you operate on the eyes of this patient, Robert?”
“I can make her see. Why I should not do that?”
“What is your plan, Robert? She is only three years old. She is malnourished and in poor health. She could die from complications of sedation. You must operate only as a last resort.”
“But I will do a good job.”
“She may be blind forever if the surgery does not go well, or be in chronic pain. Bleeding, infection…”
Robert chuckles. “Oh, Dr. Rose, I don’t think much about that. I can do it. Teach me how she can be fixed most well.”
I work against the clock to operate on both of Kuna’s eyes before she wakes. Ketamine, a tranquilizer commonly used for animals, is notorious for causing muscle spasms and nightmares, but it’s all we have. Robert is a non-physician eye surgeon in Liberia, West Africa, and in the absence of better-educated surgeons, he’s nearly all they have, too. I’ve volunteered to teach him how to improve his skills—despite deep reservations about both the ethics and the efficacy of doing so.
My nose and eyes sting from the disinfectant that permeates the stifling room. Tiny spiders crawl on the walls where strips of surgical tape hang in preparation for Kuna’s postoperative dressing. Rain pounds down on the corrugated roof and rivulets of sweat slowly worm their way down my back. I feel the heat radiating from Robert’s eager face as he leans over my shoulder to watch every detail. The patient on the adjacent table is so close he could touch us.
At Kuna’s feet sits a nurse who administers sedation by way of an intravenous in her foot. Supplemental oxygen, basic monitoring, and emergency supplies are not available should she stop breathing or need heavier sedation. I feel like a time traveler, transporting medical expertise to a previous century.
A faint grittiness at my fingertips confirms the intended depth of my initial incision. I think of Kuna’s mother, who had placed Kuna into my arms saying, simply, “Now.” We stared at each other for a moment that felt timeless; white to black and black to white, parent-to-parent, but across a universe. “Now. You fix my girl.” Robert inhales as I enter her eye.
Nearly forty million of the people alive today are blind, and almost six times that many are severely visually impaired. The vast majority of blindness occurs in the developing world, due largely to cataract, the clouding of the lens within the eye. Home in Connecticut, I can cure cataract blindness with a painless operation that takes mere minutes to perform.
But here in Liberia, healthcare is essentially nonexistent, transportation poor, electricity intermittent, and clean water rare. When you’re blind, the statistics are grim: 80 percent of blind infants die by the age of two. If you’re older, the folk expression sums it up: “A blind man is a mouth with no hands.” Society cannot support those who cannot support themselves.
Who can serve those in need? There is a chronic shortage of medical practitioners throughout the developing world. Funds are lacking, and the process of training physicians is lengthy and expensive. Educational facilities are meager, expertise rare. Young doctors from the developing world lucky enough to train abroad rarely return home to work, and those who do almost never serve in the rural, impoverished regions where they are needed most. Patients are sicker, the work is harder, resources are slimmer, remuneration is lower, and burnout is endemic.
To help fill the desperate shortage of doctors throughout the developing world, trainees such as Robert have begun to receive enough rudimentary medical training to practice general medicine, general surgery, obstetrics, orthopedics, and anesthesia. This is a subject rarely discussed outside of public health circles, for it hides an uncomfortable truth: Complication rates deemed unacceptable in the industrialized world are tolerated when there are no other solutions at hand. Most physicians who are sophisticated about global medicine have come to condone the practice, although the vast majority of Western doctors still find the idea anathema.
Should non-surgeons perform eye operations, as well? Among the surgical subspecialties, the precision and manual dexterity required to perform ophthalmic procedures is unparalleled. For that reason, the concept of delegating eye surgery to non-physicians remains especially unacceptable to most doctors, despite a 1999 World Health Organization initiative to eliminate avoidable blindness by the year 2020—in part by training non-physicians to perform cataract surgery. I am torn on the issue: The status quo is obviously intolerable, but I am not convinced that non-surgeons can function in place of doctors. Robert finished his training a year ago, and it is to measure his capabilities that I sit here with a child’s future in my hands.
The next several minutes go well. I show Robert several techniques for the removal of pediatric cataracts. Working within the transparent fluid of her eye’s front-most chamber, I tear a perfect circle in the outermost membrane of her lens and gently suck out its cloudy contents with a modified syringe. Then I polish the one-cell-thick membrane that will support the artificial lens to be implanted. This is folded, taco-style, in preparation for insertion. The heavy wooden table upon which Kuna lies is poorly designed for microsurgery. My legs awkwardly straddle the wide corners as I attempt to manipulate one foot pedal for focus, and the other for magnification. My neck aches. I concentrate on positioning the lens implant as it begins to unfold, shimmering with reflected light within her eye.
Suddenly Kuna jerks her head, violently. “Oh no!” Robert shrieks—far too loudly. Operating room protocol strictly prohibits such exclamations, even if they perfectly express everyone’s reaction, and especially when the patient is rousable. Outbreaks such as Robert’s shred the illusion of control required when performing surgery. Kuna is regaining consciousness while instruments are engaged within her eye, and this is a particularly bad moment for this to be happening. Delicate tissue can easily rip, causing complications I don’t have the equipment to manage. The pupil is distorted into a vertical slit, like a cat’s eye. I can neither reverse nor avoid this crucial stage of the operation.
Soothing Kuna with my voice, I attempt to brace her flailing head with my wrists while stabilizing the instruments that hold the twisted implant. I lift my gaze from the microscope for a fleeting glance at my co-workers. Robert is sitting this one out so he can concentrate on observing. The scrub nurse sorts instruments with a detached air, while the nurse anesthetist stares distractedly at the floor. What kind of teamwork is this? I think. I state the obvious through clenched teeth: “We… need… more… sedation.”
I lull Kuna back to sleep despite the blinding light in her face, which is covered with a drape. Braced for her next lurch while willing my muscles to relax, I delicately dial the glistening lens into its intended resting place. I aspirate the surgical gel from inside the eye, tear a circular opening in the center of the remaining membrane that holds the implant, and confirm that the pressure is neither too low nor high. I am close to finishing the first eye and am just beginning to close the incision when—bang, an earsplitting boom. My view darkens to nearly black as the operating microscope cuts out. The pit of my stomach registers a free fall. Holding suture material a fraction of a hair’s thickness, my eyes are glued to the barely distinguishable image that lingers in the eyepieces. “I am so sorry, Doctor Rose,” Robert says. “The generator, it has broken.”
Rendered without useful sight myself, I cradle Kuna’s lolling head and coax the curved needle through its arc, guided purely by the instinct of long experience. Except for my fingertips and the slowly expanding bands of sweat that soak my cap and mask, I am entirely immobile, remotely conscious that furious activity surrounds me. This is a silent inner space, devoid of thought, accompanied only by Robert’s breath in my ear.
Kuna’s head finally relaxes, and as I close her incisions, returning the pupil to round and cleaning away the blood, the natural beauty of her eyes is restored from the violation of surgery. Trimming and burying the suture knots, I realize that at some point, without my notice, Robert has illuminated the surgical field with a hand-held flashlight. It is deeply gratifying to feel I’m not alone.
I peel off the sodden drape that clings like a death mask, dark with sweat and reveal a face of innocent and classic beauty. I close her long lashes before applying bandages. Kuna will slowly emerge from her drug haze and enter a land of blackness, guided only by her mother’s voice. I vibrate with the thrum of adrenalized blood in my skull, thinking: Tomorrow when her bandages are removed, she’ll see her mother. For the first time. But I can’t avoid a second thought: What if Robert had been on his own?
I first met Robert in Ghana seven years ago, when he was assigned to help me screen a village for treatable eye disease. I liked him from the outset. Energetic and determined, he exhibited more skill than I expected from his training as an ophthalmic nurse. We bonded, surrounded by strutting chickens and dancing school children, the beating of drums, and the ubiquitous red clay of rural poverty.
I remember his face illuminated only by the occasional oncoming car as we navigated the bumpy road back to Accra. On that trip, Robert described surviving fourteen years of unspeakably brutal civil war as a child in Liberia. He fled its burning capital after witnessing the Hieronymus Bosch-like carnage of the streets: rebel troops eating the hearts of presidential loyalists right from their freshly split chests; marauding soldiers parading in wedding dresses and wigs; public executions and torture. Robert dreamed of further training, and whispered with deep resolve about returning to Liberia some day as a surgeon, to help his ravaged nation.
Six years later, I bumped into him while presenting a paper at an international conference. “I am now practicing as a non-physician eye surgeon in Monrovia,” Robert told me with quiet pride. But he had a request, as well. Staring at me intently, he implored, “Can you help me become a better surgeon, Dr. Rose?” I hesitated.
By 2013 I am heading back to West Africa, to help Robert become a better surgeon. I watch my fellow passengers wait for the flight, in Brussels. I see distinctions: Whites seem to brace themselves within a zone of “me” and “mine,” surrounded by their carry-on luggage and flight survival basics: pillow, travel snacks, socks, earplugs, eye mask. They monitor the passage of time as if it depended on their management. They recheck their documents, plug in their earphones, or bury their heads in books, fortifying their headspace as they depart the familiar.
By contrast, West Africans seem to have a fundamentally different relationship to time and space, allowing themselves to just… be. Swaying and dipping with languorous ease, they own the space they inhabit. Children sleep on the terminal floor, their limbs cozily intertwined. Women bear their dignity with regal deportment, heads and bodies wrapped in cloths of pulsating color and clashing geometric patterns. Dozing men drape themselves over chairs and parcels, spreading their arms and legs widely. Wafts of powerful cologne compete with eye-watering body odor. It’s a sensory assault.
I watch with a combination of attraction and envy. Greetings begin with an explosion of glee; arms extend over a wide, slow arc to meet with the smack of the palms, a luxuriant glide into a shake, grasp, and a slide away—ending in the satisfying snap of the middle fingers as they part. Salutations are theatrical: the lilting, syncopated prosody of native tongue punctuated by an incredulous, falsetto “Oo!” It’s utterly infectious and I feel myself beaming. Yes, Robert is not the only one I’m doing this for. Heading back to Africa fulfills something unexpressed in me.
Descending into the capital of The Gambia, I see clusters of color emerge from the smoky haze, like photographic images in a chemical bath. Robert has traveled here from Liberia to meet me, and we hug each other’s damp bodies in the airport with mutual excitement. All my senses scream: Africa. It smells like cooking meat and urine and petrol and citrus. The streets of Banjul, capital of The Gambia, are filled with sand and lined with shuttered buildings. Billboards peel in the oppressive heat, congratulating the president on his birthday, or declaring: “Do not hate yourself for not voting for Jammeh for president in 2011!” Women squat along the roadside, delousing their wide-eyed silent children. Men crouch together, watching the squeal and groan of traffic, fingering prayer beads.
Robert and I meander through the marketplace. The stink of huge, sand-covered sea snails denuded of their shells leaches into the back of our throats. Tables sag under the weight of giant, muddy angelfish, dried sea rays, and piles of sticky, red snapper. Our sandals crunch over hills of dried scales as we skirt overflowing pails of fetid fish entrails. Around the corner, Halal-butchered beef and goat hang on rusting hooks. Strands of glistening intestine drip their syrup. Severed cow heads buzz with feeding flies. Stripped of skin, the eyeballs stare out. Catfish smoke and sizzle over beachfront fires. Idle young men slouch on makeshift chairs, their knees at ear-level, sprouts of facial hair at the edge of their jaws aspiring to Islamic-style beards. Hello how youuu? they whisper as we pass. Turning to make eye contact, everyone is looking elsewhere.
A friendly local, one who can clearly use some source of income, goes out of his way to make our acquaintance. After a few words of greeting, it is silently, lazily understood that he has become our guide. Moses is unemployed and desperate for funds. He is like nearly everyone we meet during our stay in The Gambia: Regardless of professional training, fluency in languages, or numerous skills, people cannot find jobs. He tells us about his family as we walk, and his walking pace is indescribably slow—West African slow. As he shows us the waterfront of The Gambia River, once legendary for its slave trade, it occurs to me that one cannot actually walk more slowly. Amid the gray, choking moistness of smoking fish and diesel exhaust, a sense of torpor dulls my jet-lagged brain. Time assumes a hallucinatory, slow motion quality. Insects buzz and the air pulses with the occasional blast of a truck’s horn, a seagull’s cry, a child’s scream. Moses walks alongside and says little. I am glad for his presence in this dream.
After some hours, Robert and I say goodbye to Moses and crowd into a communal van crammed with the clammy, jet-black flesh of sixteen other souls, not counting several flaccid babies who lie on their mother’s laps, as if in a stupor. We lurch back and forth, slowly navigating the dunes of sand that fill the road. Squeezed against the burning, mud-caked window, I am captive to an endless parade of boarded up storefronts advertising holy products and plumbing fixtures, electronics and shipping services, in Arabic, French, and English. I spy glimpses of the great Atlantic between buildings. Long, hand-painted fishing boats bob up and down listlessly. Discharged at last, we stagger, nauseous and lightheaded, into the feverish blast of mid-day Banjul. At a Lebanese market, we pick up a stack of Shwarma bread, a bag of pistachios, a dozen filth-encrusted eggs, a few dusty tins of sardines, and some dried limes. Finally, we arrive at the cool, dark oasis of the Sheikh Zayed Regional Eye Training Center, its curtains drawn against the heat.
I’ve made the trip here to understand how Robert was trained. For decades I’ve taught other physicians in underprivileged countries. We share a common medical education and a commitment to understanding the body in health and disease. But I can only guess at where to begin teaching a non-physician surgeon until I observe the gaps and strengths of his education, gauging his depth of knowledge and then getting a sense of his breadth of experience.
That trained eye surgeons are urgently needed is obvious to any newcomer to this part of the world. Old and young blind people are led through the marketplace grasping the shoulders of the sighted. Blind twins clench each other’s shirts as they dare to cross a busy intersection. A middle-aged man grasps a branch tenaciously, the other end pulled by his impatient elderly mother, who must guide him. Because the nature of blindness is shy, I know that the majority of it is hidden from view.
The Sheikh Zayed Center was founded through a charitable donation by Sheikh Zayed bin Sultan Al Hahyan, the principle driving force behind the creation of the United Arab Emirates. Established more than a decade ago for the purpose of training non-physician eye surgeons, it has so far recruited students from sixteen countries throughout Africa. They can be found working in fourteen sub-Saharan African countries, serving roughly 251 million people. The training period to turn out a non-physician eye surgeon lasts only nine months.
This comes as a shock to me. I’ve directed Yale University’s residency program for eye physicians in the States, and know that ophthalmology is a substantial undertaking. The visual system is the most complex in the body, and the knowledge base in our field doubles every several years. After four years of medical school and an internship year, applicants undertake a three-to-four-year residency program in ophthalmology. Under the tutlelage of expert subspecialists, they study the intricasies of the visual system in health and disease: applied optics, physiology, pathology, microbiology, pharmacology, anesthesia, and the arts of microsurgery. Following residency, many elect to pursue another year or two in subspecialty fellowship training, which include refractive surgery, cornea and external disease, oculoplastics, orbital disease, ocular oncology, uveitis, glaucoma, vitreoretinal disease, pediatric ophthalmology, and neuro-ophthalmology. It’s a long road, and I can’t fathom condensing even rudimentary training into nine months.
Robert introduces me to those who run the Center with obvious pride. They are told about the purpose of my trip: I have travelled from America to learn about the education provided here, and will then accompany Robert for the purposes of equipping, mentoring, and supporting his practice in Liberia. Robert presents me as a trophy, and I’m caught off guard. But the director is most gracious, inviting me to present lectures during my stay, and arranging a meeting with other principals at 10 a.m. the next morning.
At 11:30 a.m. the next morning, Robert and I sit and wait. Smiling shyly as he watches me fidget, he jokes, “African time, Dr. Rose!” The air conditioner whines on its highest setting, and staff members secure loose papers against the blast of additional fans, brought in for what I can only imagine is my intended comfort. It’s common knowledge that the white man has never flourished in The Gambia.
Dr. Winston Ceesay is the first to arrive. He is the only ophthalmologist in The Gambia, a country of 1.7 million people. A model of clinical detachment, his long white coat and slender build accentuate his austerity, and his formal bearing is betrayed by his relative youth. I am prepared to admire him from the start, but he greets me with studied remove. Robert shakes his hand enthusiastically, but Ceesay merely nods to his former pupil. Next to arrive is Ansumana Sillah, the National Eye Health Project Manager, a non-physician eye surgeon with a Masters Degree in Community Eye Health. He shakes my hand with both of his, and Robert’s with mild irritation.
Chastened but ever hopeful, Robert positions himself at the head of the table with pen in hand, poised to take notes. The four of us make a caricature study in contrast: Robert sports designer jeans with ornate, white stitching; a Hugo Boss shirt with a wide spread collar; pointy dress shoes; and a bright green vest. He’s flying high as my self-styled protégé. Sillah, a portly government man who appears most comfortable in the world of bureaucratic matters, wears a flowing, handwoven, orange grand boubou (a caftan), and taqiyah (a Muslim style head covering). Ceesay examines his cell phone with great concentration. I wonder how I look to them, and what I must represent: a medical humanitarian, a neocolonialist, or perhaps simply the recipient of a lifetime of privilege?
We settle in as medical people do, discussing patients and patient care, work concerns and challenges, and day-to-day issues. What emerges is a mosaic of what it is like to live and work in such a place. I am told about a thirty-seven-year-old blind Islamic woman who rejected surgery because her husband did not approve, and about the president’s ban on any form of private or public political discourse. Some of the students at the Center this year seem to show great promise, they tell me, while others need work. Electricity is reliably unreliable; mail intermittent. Supplies in all areas are lacking, and corruption (euphemistically termed “inefficiency”) is rampant. And another challenge: As in all of Africa, there is significant competition for patients from traditional healers, who not only discourage modern practices, but also ignore the tenets upon which it is based, such as sterile technique, anesthesia, and basic science.
The Gambia is the only permanent location for West Africa’s Regional Eye Training, and I inquire about its political stability. The location of the Center was decided several years ago, it is recited, “in large part due to its continual stability among West African nations.” We all know that stability in West Africa is a relative concept, however. Extremist and militant elements, including al Qaeda in the Lands of Islamic Maghreb (Elements of AQIM), Ansar al-Dine, the Movement for Oneness and Jihad, and other groups continue their activities in northern Mali; AQIM are active in Mauritania; Guinea-Bissau experienced a recent coup-d’état; Northern Nigeria battles Boko Haram weekly, and so on. I elect not to pursue this subject.
The teaching curriculum for non-physician surgeons is made available for me to study. While it is fairly comprehensive, there are some glaring gaps. No training or services exist for the nine different ophthalmic subspecialties. On a didactic level, this represents a huge educational gap. On a practical level, it translates to an inability to recognize and treat many diseases and complicated cases. Nevertheless, given the monumental challenges, scarce resources, and the fact that only one physician runs the show, I am impressed by what the Center seems to have accomplished. Students coming through the program get a brief overview of several important conditions in our specialty.
I am surprised and delighted by the openness of our conversation. Still, it becomes clear that there is a quid pro quo in effect: In exchange for receiving facts and figures about the program, details of training, and student demographics, I am asked to consider regular donations of time and resources. The Sheikh’s period of support expired several years ago, and so have those of the other non-governmental organizations that followed. While it has been repeatedly projected that funds generated by surgery would cover operational expenses, the government continues to heavily subsidize each and every procedure due to cost overruns. Times are hard, I am told, and the financial existence of the Center is threatened. I may be able to play a helpful role.
At the end of a long day, Robert and I decide to find a restaurant for dinner and celebrate our reunion. This requires the services of a cabbie, and Robert bargains aggressively with one named Azik to see whether he might be suitable. This is business as usual and I always enjoy the ritual, which is why I’m caught off guard when Robert suddenly raises his voice. “You are trying to take advantage of me, Azik. You are a dishonest man!” he screams. “The fare was lower when I lived here two years ago.”
His neck veins bulging, Robert leans into the taxi, insulting the cringing driver with mounting anger. I interrupt to suggest we find another; there are many drivers around the corner, after all. But apparently this has become a point of pride and I am ignored. Berating Azik even after he acquiesces to the reduced fare, Robert bullies him throughout the awkward ride to the restaurant, demeaning his intelligence, growling that he doesn’t “even know how to drive properly.” When we reach our destination, Robert orders him to wait during our meal—“no matter how long we may be. Fetch us quick-quick when I call you!” Robert is verbose and jubilant during our meal, loudly relishing his orange soda and barracuda. This is a celebration for him.
An unwitting spectator to the sport of social domination, I am again captive to the driver’s continued humiliation on the drive home. “I am your favorite passenger and your good friend now, yeah Azik? Tell me how much you are liking me!” When I start to give Azik a tip, Robert gently places his hands over mine. “I will call you tomorrow, Azik,” he states gravely. “You will be ready for me.”
Crickets screech in the night heat as the day’s dust settles. Robert uses an entire large can of insecticide, and then another, to spray for mosquitoes in our shared apartment. “You do not want malaria like I had once!” he cautions. I ask him to stop when he opens the cupboards and sprays our dishes. “Mosquitos may live there, Dr. Rose!” he implores. “Enough,” I say. A look passes between us through the sweet fog that hangs in the air. “Sleep well, Dr. Rose.”
Word has spread quickly that a visiting professor will give a series of lectures, and students from all of the Center’s programs are waiting for me the next morning. Robert struts in like a peacock, wearing a freshly pressed pair of trousers and a deep blue dress shirt. The students wear native dress from Sierra Leone, Cameroon, The Gambia, Mali, Senegal, Guinea Bissau, and Zambia. Today’s group includes community ophthalmic nursing students, refractionists (who measure for spectacles), optometric technicians, and surgical ophthalmic nurses.
I enjoy teaching, and I start by challenging their static concept of a surgeon as a mere manipulator of tissue. Providing examples of unforeseen challenges that might pop up at any moment during common operations, I stress the importance of cultivating both fluidity of motion and ready responsiveness. I point out that this requires flexibility of mind and body, innate caution, and no small degree of courage, as well. We discuss the importance of formulating intra-operative “escape strategies” in preparation for the inevitable complication, and alternative techniques that can be employed in the heat of an operation gone wrong. The students are challenged and excited by this unfamiliar style of teaching, and their probing questions reveal a hunger to learn. Robert is noticeably silent. I sense that he is overwhelmed.
After the lectures, Robert and I are given a tour through the Center’s clinical facilities. The hallways are full of patients with various conditions, including trauma; children with bulging tumors, or hugely deformed eyes from congenital glaucoma; adults with parasitic infections of the lids. It is so crowded that men in taqiyahs and brightly colored boubousstand in vacant spaces behind doorways. Others in Western dress overflow onto the poured concrete patios that surround the buildings. A group of long-necked women sporting elegant wigs and tribal jewelry lie in the shade of trees, while Muslim women covered head to foot according to conservative dictate congregate in the baking heat of the sun.
The Center is a buzz of clinical activity. Like every facility in which I’ve ever worked in the developing world, the concept of privacy is wholly irrelevant. Observed by extended family, elders, and sometimes even village chiefs, several examinations take place in each room. I make notes on disease prevalence, testing methods, treatments offered, patient flow, and the interaction between staff and patients. I hear Robert fall behind, engaged in animated chitchat with medical staff from his past, and eventually I lose him altogether. There’s too much commotion for people to take much notice of me, and I watch without disrupting the flow of the clinic.
Not so when I step into the operating “theater” (as it is called throughout the former British colonies), where staff members become instantly self-conscious. As the only white visitor in the basic but adequate facility, it’s a naïve attempt to go incognito. Dr. Ceesay acquiesces to the universal collegial courtesy of being observed in action. I compliment several operations performed by him and his students. They are performed satisfactorily and I’m relieved that, unlike many similar sites I’ve visited elsewhere, principles of sterile technique are carefully respected.
But much of each student’s practical training takes place away from The Sheikh Zayed Center in Banjul. The next day, to gather an impression of this experience, Robert and I are driven out to the site of the eye clinic and leprosy/TB station in the city of Brikama. Endless piles of garbage line the crowded road there. A good 50 percent of the construction we pass is unfinished: Discarded cement blocks and piles of timber lie in various stages of neglect and decomposition. Along the way, our driver points to The Gambia’s only golf course, which, like so many vestiges of post-colonial Africa, seems highly out of place. I can spot only a collection of impressive termite hills in a field, and several trees featuring large vultures.
For many kilometers we crawl behind a truck stuck in first gear that belches black smoke. A jolly workman Robert dismisses as a “cretin” stands smoking a cigarette on the flatbed, engulfed in fumes. Every minute or two, momentarily unveiled, he peers around the truck’s side and enthusiastically motions us to pass. Each and every time he indicates safe passage with a double “thumbs up” and a broad smile that reveals four remaining teeth, several cars whiz by in opposing traffic.
The Brikama Eye Clinic sits within a fenced enclosure surrounded by the raucous bustle of a typical West African town. As we enter, Robert is welcomed back by his old instructor, another non-physician surgeon. The two of them smack palms, guffaw, and swap long stories with great hilarity, oblivious to the throng of patients who wait silently, waving away the flies.
The electricity goes off and on in the single, poorly lit room that constitutes both the examining and waiting areas. Equipment is sparse and threadbare. I wander into an adjacent inpatient facility that consists of a single large room with a dozen iron cots against the wall. The sounds of babies squealing and motorcycles revving their engines penetrate the iron-barred windows, and the overhead fan takes a full twenty seconds to complete a revolution. What must the quality of teaching be like, given the endless number of patients? There is clearly no time for instruction. Yet six months here will constitute the majority of each student’s clinical experience before they graduate and assume full care of their own patients.
On the morning of our departure from The Gambia, Robert and I head to the airport, hours before the sun has risen. Dark forms trudge past shuttered buildings and locked gates in the sooty darkness, and the occasional truck rumbles toward neighboring Guinea-Bissau. Called “The First Narco-State” by Time magazine, it has become a key hub for the international drug cartels. We are stopped at numerous checkpoints “manned” by wide-eyed boys in uniform who appear unsettled by their own authority. Barefoot and sleepy, they stare unabashedly at the white man sitting in the rear of the Sheikh Zayed pickup truck.
I’ve had problems carrying donated medical equipment and pharmaceuticals through customs in many locations throughout Africa and Asia. Robert is barred from joining me when I’m “invited” in to a private room for inspection. The Gambian security people stare at me like a space alien. Whispering to each other in hushed tones, the customs agents examine each of the hundreds of medication-filled syringes and intraocular lenses I’ve brought for Robert’s use in Liberia. Micro-incisional blades, lens loops, and cannulas are fingered with fascination. But after an interminable wait and the eventual nod of a senior officer with a dirty tie and bare feet, smiles widen. The goods have been released and no “cash money” has been demanded. Congratulatory pats on the back are offered all around and the next thing I know, I am passing through a receiving line of jolly, West African handshakes. “You are most welcome in The Gambia!” they say, ushering me to the departure lounge.
Now that I’ve seen how and where Robert trained, I have a far clearer understanding of his background, and feel better equipped to embark on helping him “become a better surgeon.”
In June 2013, after a typically roundabout intra-African flight itinerary—one that takes fourteen hours by way of Sierra Leone, an overshoot to Ghana, then Cote d’Ivoire, and back to Liberia—we finally arrive in the Liberian capital of Monrovia. It’s my first time here, and while it still feels very much like West Africa, it is more reminiscent of Harlem or South Chicago. Or so it appears on the surface. Many young people wear Western clothes, and sport “ghetto garb”—neon sneakers, low slung pants, chains, hats turned sideways, stylish sunglasses, and lots of bling. Christian symbols and quotations from the New Testament adorn every surface: buildings, walls, vehicles. As we drive toward the center of the city, billboards advertise banks, telecoms, and churches. Others promote HIV/AIDS prevention, or admonish against rape and family violence. Foreign aid agencies and NGOs line the streets, and U.N. soldiers patrol in their distinctive white jeeps and helmets. To the throb of street music, child vendors hawk combs and candy, padlocks and papaya.
Robert points out a dozen topless women smeared in dried clay walking along the side of the road near the airport. “Do you know the Sande Secret Society, Dr. Rose?” “The Sunday Society?” I ask. “No-no. San-de. These young women go to the forest for some months, learn the ways of the female, become fertile, and have their circumcision, too.”
Black American citizens who wished to form a colony for former slaves established Liberia in the mid-nineteenth century. Transporting their southern American belief in the superiority of Protestantism and European culture to the shores of Africa, they became frustrated by their unsuccessful efforts to “civilize” the native population through evangelization and education. These “Americo-Liberians” rapidly instituted their own form of slavery, placing themselves at the top of an imposed social hierarchy of the indigenous population. While never constituting more than five percent of the population, they have maintained nearly all positions of power and social privilege for more than a century. This has led to repeated internal uprisings from the native peoples, and eventually set the stage for the brutal civil wars of 1989-2003.
A huge building originally slated for ex-president Samuel Doe’s Defense Ministry looms on the horizon, gray and skeletal. President Doe was dismembered in 1990 and, according to local legend, his remains were cooked and eaten in the street the next day. Prince Y. Johnson, the Budweiser-drinking opposition leader who supervised Doe’s torture and death (available on YouTube), is now a senior member of the Liberian senate, and serves as the chair of its Defense Committee. Charles Taylor, an escaped convict from a U.S. jail, assumed power from Doe until his own forced resignation from the presidency in 2003. In May of 2012, President Taylor was found guilty of “aiding and abetting… some of the most heinous and brutal crimes recorded in human history” by the international criminal court near The Hague. Never tried for atrocities committed in his own country, he was found guilty of crimes committed in neighboring Sierra Leone.
Liberia has a population slightly exceeding four million, and is the fourth-poorest country on earth, according to the World Bank. Nearly 200,000 Liberians are blind and there are only three working ophthalmologists in the nation—one of them “on loan” from China. This is typical for Africa, where the ratio of ophthalmologists to patients is roughly 1:1,000,000 (It’s 1:10,000 in the U.S.). Robert’s New Vision Eye Center is our destination. It is down the street from Lucky Pharmacy (“For Life-Saving Drugs”) and the “No Bad Days Business Center” and across from a ramshackle dwelling spray painted “GodGift Production.”
New Vision Eye Center sits on a small, muddy lot next to a stream clogged with weeds and trash. A mixed cinderblock and thatched-palm construction, it is jammed with patients who rest on plastic chairs and long wooden benches, heavy-lidded yet alert for the sound of their name in the oppressive heat and humidity of the rainy season. And rain it does, drumming down on the corrugated tin roof to Wagnerian effect.
Cheery “Merry Christmas!!!” pennants featuring a rosy–cheeked Santa Claus, and a prominent hand-lettered sign, “You are Wellcome Dr. Aron Rose in Liberia,” greet me at the entryway. Robert mumbles an offhand greeting to his staff without making eye contact with any of them. They line up to introduce themselves shyly, and a welcome tour is hastily commenced. Just inside the loosely hinged screen door, a privately owned shop—more like a large closet with a display case—does a brisk business selling medications and dressings. Patient registration and checkout take place in the same room as consultations, a dark ten-by-ten-foot space crammed with desks and chairs that must be continually moved to accommodate staff, patients, and their family members. The remainder of the clinic is a meandering hallway that is used for both patient screening and waiting. It is illuminated by a single bulb and the occasional ray of light that enters through the gaps between wall and ceiling, casting chicken wire shadows upon the indistinguishable forms that slump and cough and wait. In the back of the building sit Robert’s consultation room and the operating theater, which doubles as a storage room. There’s far too little room to do too much work on too many patients.
Many aspects of the operating theater trouble my practiced eye, and nose. It smells overpoweringly of mold, and tiny insects are everywhere. The room measures fifteen by fifteen, and is spectacularly overcrowded. Two heavy wooden tables hold piles of disposable and reusable instrumentation necessary for the dozen or so surgeries that take place on a typical operating day. To reach the operating tables, staff members must navigate patients, including blind ones, across a tangle of wiring that covers the floor while avoiding all sterile surfaces, like the precisely positioned, rickety Chinese operating scope. The coup de grâce is the air conditioner. Minimally effective, it essentially serves only to recirculate warm, muggy air around the room with vigor, defeating several principles of operating room sterility in one fell swoop.
I express my concerns to Robert. “Do not wor-ry, Dr. Rose,” he responds, touching me lightly on the shoulder with a grin. “All will be very fine, you will see.” Sensing my skepticism, he elaborates. “Late in the night before surgery, the staff will wash the theater with bleach, and the instruments will be boiled in pots of water in the hallway. You will see. You will be very happy.” The majority of the staff Robert refers to consists of volunteers who work twelve-hour shifts without pay. They do so in the hope that funds may someday materialize to employ them.
The next morning, Robert has “collected a few difficult patients” for me to see in consultation. A large stack of medical records is placed on the desk for my review. These are the toughest cases from the last few months and include those with complications from his previous surgeries. Others have suffered severe injuries, or have rare/recalcitrant infections. Looking over the charts, I suspect that Robert does not know how to recognize advanced ocular manifestations of serious systemic or neurological disease. Those nearly blind from other disorders make up the remainder of the pile.
This is essentially what I have been waiting for. I can quickly assess another clinician’s level of care when asked to consult on their difficult cases. Reading Robert’s medical records will tell me about his powers of observation, his deductive reasoning, fund of knowledge, and his ability to make timely decisions. His microsurgical skills can be appreciated in detail. It is a great starting place for teaching.
However, it becomes rapidly apparent that there are big problems ahead. Robert’s records are meager, and they reveal an absence of any methodology. Examination findings are haphazard and incomplete. Assessments and plans—the organizational heart of the medical record—are entirely absent, and so are operative notes and records of key postoperative findings. The problem is clear: There is a fundamental lack of appreciation for the utility of organization. Was it not taught in The Gambia, or has over-scheduling led to rushing and poor documentation? Either way, introducing and stressing the practical importance of ordered observation will be a far greater challenge than teaching operative technique. Robert’s pride may be at stake, but so is the wellbeing of his patients.
Unfortunately, though, there’s little time to reflect on all of this. Patients fill the clinic and its grounds, and it is rumored that many have traveled for days to be seen by the American.
The first is an eight-month-old boy who was carried by his grandmother more than 500 miles—from Grand Kru County near Cote d’Ivoire, a trip that has taken her nearly two weeks. He has the light brown hair of the malnourished and his skin lacks elasticity, a sign of dehydration. His corneas are the color of diluted milk and his pupils are white with cataracts. The eyes wander directionless from chronic lack of stimulation to the optic nerves—a bad prognostic sign. They are also huge, a condition referred to as “buphthalmos,” from the Greek words for oxen and eyes. Congenital glaucoma (or raised pressure in the eyes) has caused enlargement of his eyeballs and damage to the optic nerves. His grandmother volunteers that others in her tribal village have also been born blind, and I suspect that this syndrome is most likely the result of intermarriage within the family.
The boy’s mother stands silently in the corner during the entire examination. She looks fourteen, but claims to be twenty-one. I gently tell her that it is not possible to make her baby see. I do not explain that in my part of the world he would require the seamless teamwork of numerous subspecialists who share access to the latest technology and drugs. The costs would be astronomical.
Her child’s prognosis is met with no acknowledgement that it has been heard, and I turn to Robert for assistance. He confirms that the mother and grandmother both understand all I said, and have no questions. He murmurs to me that they arrived convinced that the baby’s condition was caused by spirits; the result of sorcery and witchcraft. A long silence follows. Impatient that no treatment will be taking place, Robert calls the next patient while guiding them out the door.
A teenage girl brings in her sad and beautiful six-year-old sister. She is named Wonlay, which means “tired,” a name given to a girl whose parents have lost several children in either childbirth or childhood. “Where Ma and Pa?” Robert barks. “Pa not well,” the older sister mumbles, head down. “Where Ma?” he demands. There is no response. Dismayed by his interrogatory manner, I step in to obtain a history, only to learn that the child has never received any medical care. We must, in effect, gather all clues from scratch.
Both corneas are scarred from previous infection. I point out to Robert that the pupils are deformed, signifying that inflammation has infiltrated the eyes. The lenses are cloudy, which means that the inflammation was profound, and probably chronic. It may be possible to save Wonlay from total blindness, but only if she receives treatment quickly, as her visual system’s development is nearly complete. Robert tells the teenage sister to bring the patient back in three days for pre-op screening by a nurse anesthetist. She nods, barely. Before the two girls have left the room, Robert states, “We will not see this child again.” “What makes you say that?” I ask. He smiles, as if to say that he doesn’t know where to begin. “We will see, Dr. Rose.” But time proves that he is right.
Twenty-four-year-old Rebecca enters the room next. She sees double and has been blurry in one eye since her boyfriend punched her repeatedly in the face. “Are you in pain now?” I ask. “Small pain,” she whispers, wearing the expression of utter worthlessness so common among abused women everywhere. Battered women are a common phenomenon throughout the developing world, and are currently the focus of significant media attention in Liberia. Perhaps that’s how she found the courage to venture here for care.
I show Robert that Rebecca, when asked to look up, can elevate only one eye. This signifies a “blowout” fracture of her orbital floor, which has entrapped one of the muscles that move her eye. Scars around the lids are well healed and there is no swelling, indicating that her injuries are not recent. This also means that her double vision will be permanent until repaired by surgery. The floor of her orbit (the skull cavity within which the eye sits) must be recreated with a synthetic plate once the muscle has been freed from the restricting bony fragments. No one in Liberia has the expertise or equipment to do this relatively straightforward procedure.
I ask, How do we book an anesthesiologist, Robert?
“We have no anesthesiologist in Liberia, Dr. Rose.”
Rendered mute by shock, it takes me a minute to gather my thoughts. I never realized that all operations in this country must be performed with only sedation, and not general anesthesia. Must patients rely on their own willpower to suffer the unimaginable pain that “breaks through” sleepiness during surgery? Do doctors routinely risk the complications that follow from their patient’s uncontrolled blood pressure, wildly beating hearts, and insufficient oxygen levels? Are they forced to restrain them on the table lest they jerk away at an inopportune moment?
I refer Rebecca to an ophthalmic colleague in Ghana who might manage a charity case at my request, but she has no funds for travel there. Robert tells her to return to his clinic in one month, his routine directive for patients with no hope of improvement. I wonder if this a demonstration of Robert’s compassion, allowing patients to gradually accept their plight without feeling abandoned. Or is he, too, in the dark?
Joseph is next, a big man, but bent and haggard. He enters the room on his brother’s arm, looking like a defeated warrior. Having vomited for days in excruciating discomfort, he sits down uncomfortably and admits that he is ready to die. Despite weekly visits to Robert, he has gone nearly blind in the left eye while suffering unremitting pain, boring deep into his skull.
It takes only a moment to make the diagnosis. I show Robert how a flashlight and the tips of his fingers are all that are necessary to detect an attack of narrow angle glaucoma. But like so much of clinical expertise, the classic medical school turn of phrase “Out of mind, out of sight” summarizes the real problem here: Robert sees only what he is trained to look for. He’s not prepared to make clinical observations that are “off his radar,” or that require diagnostic thinking. A sound medical education lays the foundation for making diagnoses, which requires step-by-step analysis based upon thorough history taking and examination. Joseph’s case exemplifies Robert’s fundamental weakness: These skills are nearly absent. His medical thought process is disorganized.
Joseph’s pupil is dilated and unresponsive to light. His cornea is opaque and his eye hard as a rock. I pull Robert out of earshot and gently remind him that each of these basic findings should have been noted at the initial stage of any ophthalmic examination. It is obvious that they were simply skipped. I did not need to emphasize that Joseph’s sight would have been saved (and enormous suffering averted) if Robert had been methodical in his approach. He is silent. Whether this is pride or shame I can’t tell, but I hope that my message sinks in. Plans for emergency surgery the next morning are made.
Next, a father tenderly lays his two-year-old daughter on the table before me, and looking at the floor, steps back wordlessly to let me work. The contents of her right eye bulge through a laceration of her cornea, contained only by a balloon of clotted blood and iris. This child has a ruptured globe, inflicted the day before by her abusive mother’s belt. I arrange a tetanus vaccine, antibiotics, sedatives, and an eye shield in preparation for repositing its contents and repairing the wound first thing in the morning.
After seven hours of continuous, complex examinations, and patients who continue to arrive from distant locations, we take a break. The staff of New Vision crowds into the consultation room and the door is closed. Equipment is covered with paper operating drapes, and everyone digs into stewed fish with potatoes in spicy tomato sauce and boiled plantains, all prepared by Caroline, Robert’s pregnant wife. There’s some small talk, but attention is primarily directed at the primal, unabashed joy of replenishing energy. “Why do patients continue to arrive as it gets later?” I ask Robert and his staff. “Aren’t appointments spaced throughout the day?” This elicits a pause of incredulity, followed by hoots of laughter, the slapping of thighs and the wiping of tears. “Oo!” they all chime, expressing surprise and delight. “This is not your first time in Africa, yeah? You know African patients do not come when they are called. They come when it suits them!” The joke’s on me, and we all laugh.
Wherever I work in the developing world, there’s a glorious sense of camaraderie that forms among hardworking medical personnel. The nature of the work is utterly exhausting, but exhilarating, too: We combine our efforts, giving our all to those in need, creating deep bonds that transcend that which otherwise separates us. Those who know me well know I’m happiest when I am depleted and enriched in this extraordinary environment. I give myself over to the rhythm of it all—the exertion, shock, concentration, dread, and delight. And what a privilege; what a view! I have a unique perspective on the endlessly variable cycle of the human condition—suffering, hope, courage, and heartbreak. I savor the quality of this sweet fatigue as a fresh volley of rain pounds down.
Break is over; there’s much more work to do. A roll of toilet paper passes among us to wipe our faces and fingers, sticky with palm oil. The door swings open and a very long queue of patients awaits us, many craning their necks to peer inside. At the very front stands a proud woman, eyes closed, tears streaming down her face. Sarah has made the long trip from Maryland County, desperate for help. At forty-two and after a brief illness, her corneas began melting, like ice on a pond. Now her brown irides protrude through the thinnest spots, leaking intraocular fluid. Sarah can see only shadows in the periphery of her vision. Her beet-red eyes ache and tear so constantly that she can’t keep them open for more than five seconds at a time.
As is the case with each of the patients Robert has brought back for me to see, he does not greet Sarah. Nor, breaching medical protocol, does he either summarize her medical history or offer the courtesy of explaining why my opinion is being sought. Is he trying to distance himself from the care he’s delivered, or does he want to avoid appearing the student in front of others? I realize that I’m beginning to resent his passivity. I’ve taken pains to advise Robert all day in private, and make a show of complimenting his work in front of patients and staff at each opportunity. Why, I suddenly wonder, have I been examining so many of his patients in his absence? And why am I doing the lion’s share of the work in his office, writing medical records, directing his staff, writing prescriptions, and booking cases for the operating room? Sarah whimpers, miserably. I focus my attention on piecing her story together as I flip through Robert’s slipshod notes.
Robert treated Sarah several months earlier with chloramphenicol, an older antibiotic that is popular in the developing world due to its low cost, easy availability, and general effectiveness. It is rarely used in the West because of a poorly understood side effect: an “autoimmune reaction” that has caused Sarah’s immune system to actively reject certain parts of her own body as foreign, including her eyes. Usually in such cases, powerful anti-inflammatories are used to turn off the body’s faulty immune response, but doing so in Sarah’s case would be dangerous. Weakening her immunity and sending her home to poor village hygiene would be an invitation to serious infection. Should such an infection enter her vulnerable eyes, the consequences could extend beyond total blindness, and even prove fatal.
Sarah and her husband are desperate, and do not have the funds to travel to Ghana, Nigeria, or Kenya for eye treatment. They reject the option of my sewing at least one of her eyes shut in an effort to protect it from further damage and save it for future rehabilitation. As Robert looks on impassively, I give them a private supply of powerful antibiotic drops I’ve brought with me from the States. We all understand that not only Sarah’s vision but her existence is at stake. She can neither contribute to the livelihood of her tribal community nor her family; she can’t function as a mother or a wife. She grasps each of my hands tightly in her own, chin up and eyes tightly shut, wordlessly imploring. I close my own eyes and squeeze her hands back, long and hard. I’ll study her chart and investigate all other possible treatment options tonight.
There’s not a moment to reflect or gather my wits. A boy named Joy comes in next, searching in front of him with outstretched fingers despite a parent supporting each arm. He was a normal, playful sixth grader until some six months ago, when he lost the vision in both eyes after contracting measles, the most common blinding condition of children in the developing world. Joy stands in front of me wearing a look of raw anguish, nostrils flared and mouth frozen with the terror of the recently blinded. His sightless eyes scan left to right, up and down in the futile hope of seeing anything at all, but blood vessels have already crept over his whitening corneas.
Joy’s parents dutifully followed their village healer’s instructions. As Dr. Ceesay and Mr. Sillah said in The Gambia, traditional healers are present everywhere, propagating folk cures that sometimes cause significant harm. These include the routine use of unsterile plant and animal products as medications: twigs and leaves, toxic sap or plant infusions, ground cowrie shells, and urine-containing solutions. Joy’s parents took turns forcing his eyes open as they were instructed—lovingly and for days, despite his screams of excruciating pain. This desiccated his corneas and hastened his eyes’ demise.
I look to Robert for some semblance of professional commiseration, but he is, as usual, expressionless. There’s little to be done for the boy at this point other than protecting him against secondary bacterial infection and corneal perforation. Theoretically, it’s possible to search for facilities in other countries willing to perform heroic operations once he is stable, but realistically this is beyond a long shot. The costs of transportation, numerous highly complex procedures, expensive post-op medications, and years of careful follow-up care, are prohibitive. The chances of surgical failure are also very high, even if powerful anti-rejection drugs and local expertise were available, which they are certainly not.
Tragic endings are all too common in such situations. It is likely that Joy will be consigned to a lifetime of blindness, eventual social marginalization, and extreme poverty. One can only hope that his family will be able to continue supporting him long term; doing so will be an enormous financial and practical burden on all members of their village. In the world of ubiquitous superstition and extreme poverty that constitutes so much of Africa, it is likely that witchcraft will be blamed for Joy’s infirmity. This, in its own way, weighs on me as an added defeat.
By the time clinic finally ends, I notice that Robert has discarded the bookmarks I’ve placed for him in his texbooks, and returned them to their shelves. Weary and depleted, I say nothing. I decide to bring him out to a restaurant so we can discuss the day’s cases while they are still fresh. Shortly after arriving there, Robert lashes out at the waiter for being too slow, not opening his bottle of apple juice to his liking, and leaving the paper napkin stuck to his glass. Insults quickly escalate to threats, and before long the waiter literally shakes with fear. “Go away, quick-quick!” Robert growls. I initially try to distract him, and eventually ask him to stop, but he only sends me an eerie smirk. When the check arrives, Robert interrogates the waiter ruthlessly about each and every item, and, after verifying its accuracy, demands to see the manager to complain about the shoddy service. As I pay the bill, Robert tells the manager that he should be ashamed of his restaurant’s poor quality.
Robert drops me off at the Lutheran Guesthouse, where he has me staying. Deeply fatigued, I enter the common room to a small group that sings Amazing Grace after their late meal. The wind howls off the Atlantic. In my room I hear a haunting wail and look out the window. A lone woman runs as fast as she can, mouth open, down the narrow street, enclosed on each side by high walls, topped by shards of glass. What she’s fleeing I can only imagine, but it’s an image of pure terror that makes me feel vulnerable to forces I cannot define. For the first time, I allow myself to feel fear.
I try to review the day’s cases, one by one, considering how each can be used for teaching purposes, but the electricity flickers, dies, and resumes every few minutes. Well past midnight I give up, and fall asleep with difficulty. My nightmares teem with images of ignorance and torpor, suffering and sorcery. A pre-dawn crack of thunder wakes me up.
Before I came to Liberia, I clearly stipulated that Robert must limit the number of surgical cases in order to allow me to teach and observe without rushing. If need be, I would operate in a case or two, but only to demonstrate technique. Yet when I arrive at clinic the next morning, more than thirty patients await surgery. Most have been told that I will be their surgeon. Robert has planned to operate on others simultaneously on an adjacent table. This fundamentally undermines the express goal of my trip, and infuriates me. But cancelling poor and desperate patients who have traveled for days, purchased expensive medications, and mentally prepared to place themselves in the hands of the “expert,” is out of the question. He has trapped me. I make as many changes as the schedule allows, while Robert assiduously reorganizes the contents of his briefcase, eager to avoid my anger.
As we begin our day’s work, my mood darkens further. Several changes I’ve insisted upon have been made, but serious breaches of sterile technique persist. The ineffective air conditioner still blasts through the overcrowded room and a single scrub nurse hands cross-contaminated instruments to the two of us, operating simultaneously. Staff members continually open the door with questions about clinic matters. Patients and staff members brush up against sterile surfaces, while crusty microsurgical instruments are prepared for re-use without proper cleansing, and only gloves are changed between cases to avoid the expense of additional paper gowns. To top it off, ear-splitting gospel and “Hipco” ringtones reverberate through the room every few minutes. This is the antithesis of operating room protocol.
Coming from a high tech and affluent society is often poor preparation for work in the developing world, and I’ve learned that attempting to transport advances of twenty-first century medicine to the developing world is a highly improvisatory art.
Hosts never disclose their full panoply of needs, either out of embarrassment or simple unawareness of their own deficiencies. A delicate balance must be struck between the need to set standards, and the diplomacy necessary to effect change.
My challenge is to figure out what must be changed right now, and what can be dealt with later, step-by-step. One counterintuitive lesson is that local modifications to modern protocols are often wise adaptations, best left alone. For this reason, I’ll leave many of the current systems in place. But because issues of sterility cannot be compromised, I insist on some basic changes before we continue.
It’s another long and arduous day. But nearly all of our patients do well, and Robert is triumphant.
By the end, I have taught him how to operate using both his dominant and non-dominant hands simultaneously—a breakthrough achievement. He adds several procedures to his surgical repertoire. His technique becomes more fluid, and I admire how quickly he acquires facility. The day’s satisfactions are diminished, however, by Robert’s non-stop abuse of Habib, the circulating nurse throughout the eleven hours we operate. This man easily does the work of several people without complaint or mistakes, but Robert insults his intelligence and viciously criticizes his perceived inadequacies. I’m disgusted by his treatment of Habib and his obliviousness to the fully conscious patients being operated upon, who hear every word.
As the rain sizzles on the aluminum roof and the days in Liberia pass, I program software and start an outcome study at New Vision Eye Center that will enable us to identify, analyze, and track Robert’s performance together. Newer microsurgical instruments are ordered, and unsalvageable and dangerously worn ones are destroyed. Changes in procedure are made: Mobile phones are turned off during operations, and non-essential messages held. Improvements in scheduling are instituted to control patient flow in the clinic and maintain sterility in the theater. I teach the staff how to use the new examining instruments I’ve donated. Each of them gets a defined job description, so they know what is required of them. Examinations slowly but surely become more methodical, and proper charting is emphasized at each step. Robert and I even begin planning a new office space and operating theater.
Patients return the day after their surgeries, bathed in the euphoria of new sight. I catch them praising Jesus, shaking their heads slowly from side to side while munching their white bread and mayonnaise sandwiches. My heart expands.
Surgical training in the United States is rightly famed for its quality, but it’s too lengthy, expensive, and laborious a process to replicate in most of the developing world at this point. A non-physician eye surgeon in West Africa receives only three months of classroom training, followed by six months of hands-on clinical exposure with another non-physician surgeon in a rural outpost, such as Brikama. They learn to perform many common eye procedures, and are prohibited only from performing operations on one-eyed patients and children under ten. I strongly doubt this holds in practice. Patients never question the credentials of their “doctor” in underserved areas. They generally won’t know the difference, and are grateful to receive care of any kind.
When I accepted Robert’s request to help make him “a better surgeon” in New Haven the year before, I embarked on a journey into unanticipated territory. Starting in Banjul to evaluate his education, and ending in Monrovia where I would assess and improve upon his skill set, I was repeatedly forced to plumb my own professional growth in order to identify and convey the most important lessons I’ve learned along the way to becoming a better caregiver.
Teaching Robert to become a better surgeon required me to define concepts essential to medical thinking, and distinct from operative technique. I tried to show him some important intangibles entirely off his radar: That care begins from the first moment of patient contact; that our patients’ stance, speech, affect, complexion, bearing, and many other physical and mental characteristics help us figure out not only what ails them, but who they are as individuals; that our care extends beyond their “condition” into a longstanding and near sacred pact of trust between patient and caregiver.
Robert is untroubled by his spotty ability to select appropriate treatment, and shows little concern about past mistakes. I try to impress upon him that this is a far more difficult skill to acquire than operative technique, and utterly essential to become a better surgeon. It requires much more of an educational foundation, and then maturation: breadth and depth of knowledge, experience, and acquired wisdom. None of this is possible without a commitment to continual study, and his apparent lack of interest makes me worry whether he has the capacity for this kind of professional growth.
The “steps” of an uncomplicated procedure are the easiest skills to master, but strategizing to avoid potential complications and escape evolving ones is the secret to a consistently successful procedure. I spent a great deal of time encouraging Robert to think about the scope of his intended actions and their consequences, both immediate and long term.
Toward the end of my visit, Robert and I have a frank discussion that focuses on our expectations of each other as teacher and as student. I tell him that he can depend on me to advise on any professional matter at any time, and should consult me on any difficult patients. I will continue to make educational materials available in the form of videos, books, and journals. I will assist him in designing a new clinic and operating theater, help him select and obtain instruments, and support his professional growth.
In return, I expect that he will study ophthalmology, learn about unfamiliar diseases, read material I send him, remain consistent and uniform in examination and documentation technique, and commit to deepening his knowledge within the field. Robert responds with a hesitant smile. “This will be difficult,” he says, looking away. “Help me understand,” I say. “We are very lazy this way, Dr. Rose,” he responds.
This troubles me deeply. There is a cultural gulf between Robert and me: In his world, learning for its own sake is unnatural; One does not acquire knowledge in order to find out what a thing is, but merely what a thing does. How do I explain to Robert that this job requires far more than he seems able to perceive?
I am concerned that his limited education has prevented him from cultivating a mind fertile for intellectual growth. So far, Robert does not seem to value the benefits of scholarship. Unless and until this can be achieved, his professional development will be limited to advancing his manual skills, and sadly, his care of patients will remain only partial.
Other cultural gaps may pose further problems: I suspect that Robert considers my emphasis on timeliness and precision in record keeping impolite, as it undermines our togetherness. Traditional African society stresses the paramount importance of unity at every level, and social etiquette frowns on most forms of disagreement. When I point out his clinical gaffes, does he feel that I’ve made a social one? Also, my “scientific training” and method of inquiry defies his African belief that the universe is a chain of forces empowering and depowering each other. My belief that causes can be isolated is entirely foreign to him. When interviewing a patient, Robert asks why they think they don’t see. “Did a stick hit you? Were you witched by someone?”
Robert is far more interested in doing than thinking. He is proud, and equates self-reflection with doubt and weakness. Will his cultural makeup allow him to embrace the primacy of humility in clinical practice? Can I teach him professional prudence? More fundamentally, is someone like me the best one to teach Robert, or will he inevitably come to resent the irreconcilable injustice of our differing life circumstances?
And then there’s this: I’m concerned about Robert’s incapacity for empathy and compassion. In clinic, he routinely missed the opportunity to demonstrate compassion toward any patient or family member. While complex anthropological factors make it difficult for me to judge some aspects of his behavior, the repeated attacks I witnessed on those of lower social station were all unprovoked and sadistic. I also know what I do not know. As in much of Africa, tribal politics play a central role in Liberian culture. Robert started from nothing and is rapidly gaining prestige in a society infamous for its unforgiving power hierarchy. He was raised in an environment that taught one lesson in no uncertain terms: Power equals survival.
A highly placed official in the American Embassy in Monrovia puts my concerns in not just cultural, but historical context. “Liberian society is ill,” she said. “Engineers are being taught by apprentices, and buildings fall down because they are not properly constructed. Our teachers are taught by those who, at best, may have finished high school, and our medical students are taught by non-physicians. A lack of education pervades Liberian society—because a generation has been lost by nearly two decades of savage civil war. Many of today’s parents, you see, were yesterday’s child soldiers.”
Yet: Is Robert good enough for the large patient base he serves? The unfortunate answer is that he must be—at least until adequate numbers of physicians can be trained. Non-physician surgeons like Robert can help relieve the surgical backlog in the developing world by performing uncomplicated cases, leaving the more difficult ones to medical doctors, if and however they can be found. The alternative is a return to a complete lack of any patient care for a huge portion of the world’s population: tens of millions of lives broken by pain and suffering that could have been alleviated.
And there are victories. At this moment, Sarah—the woman with the melting corneas—and another desperate case from Liberia are receiving free, sight-saving operations that I’ve arranged in Connecticut.
And nine months after I return home, Robert and I are reviewing the plans for a new clinic and operating theater by email. He’s told me that the work we did together continues to benefit his office organization and the care of his patients. Still, he has not consulted me on a single patient, nor used me for any professional development since my return. I’ve yet to receive any data from the outcome study I put in place. My offers of support and requests for further information from The Sheikh Zayed Center in The Gambia have also gone unanswered, after an initial correspondence confirmed mutual enthusiasm.
Robert has asked when I’ll return to Liberia, and wants me to accompany him on an outreach mission “up-country.” I’m still waiting to see whether he upholds his end of our mentoring agreement.
Then, out of the blue, Robert sends me a short video, without comment. It renews my hope. It reminds me what this is all about.
The video was taken inside a poorly lit mud hut somewhere in the Liberian countryside. A bright-eyed, three-year-old girl I recognize waves her hands in glee and runs toward the camera. Then, magically, she catches a ball and screams with pleasure. I hear Robert laugh.
“Good girl, Kuna!” he says. “Now run with me, girl!”
This story was originally published at The Big Roundtable.