Akwaaba from Ghana!

Akwaaba! Greetings from Kumasi, Ghana! This update has been in the works for awhile but somehow through all the traveling and experiences, ideas have yet to meet paper.

It is hard to believe so much has happened since we last wrote – leaving Nepal, spending time in India (including an incredible Yom Kippur in Cochin), a brief layover in Egypt with enough time to visit the pyramids and Sphinx, and now we are a month into our 6 week stint in Ghana – it’s difficult to know where to even begin! When we last left you, we were nearly on our way to India. We spent Rosh Hashana with Chabad in Kathmandu (with roughly 300 other Israelis!) and spent our last full day in Nepal soaking in the markets, streets, alleyways, monasteries, and stupas that we had found and come to appreciate for the chaotic beauty that comprised Kathmandu. Having arrived not knowing what to expect, we left Nepal amazed and awed by not only its culture, history, beauty, and charm but as much with the initiative and incredible people we were fortunate to meet and learn from. 

We arrived in India after a full day of traveling with a bit more of an inauspicious start…our ride from the airport never arrived, the taxi driver wasn’t quite sure where we were going and we had no phone…than no one at the guesthouse seemed to know of our arrival and securing us a room was a longer process than necessary. It seems though that these few inconveniences gave us the good karma needed. The next two weeks at Aravind Eye Institute were simply incredible, both professionally and spiritually. I could write reams and reams about this eye hospital, the largest in the world – its founder, Dr. Venkataswamy who wanted to build the McDonald’s of eye care, and the unique worldview and vision he had to create an entire system dedicated to preventing and treating curable blindness. This place, where a phrase such as compassionate care is not an oxymoron with cost-efficiency (they are a non-profit but run in the black. All patient care services including building and development is self-funded), and where every member of the team, from housekeeping to unit heads, understands their role and that they are working for something greater, something simultaneously both incredibly human and divine. We’ll be talking about this place a lot when we come home, so I won’t go on too much here[1], suffice to say that we both left Aravind inspired, encouraged, challenged, and with a greater sense of peace and purpose than when we arrived.

Zvi spent his time at Aravind observing with Dr. Rathinam in her uveitis clinic. We had the pleasure of meeting Dr. Rathinam in July during the uveitis conference in Kathmandu. Despite her very busy clinic and research schedule, she welcomed both of us to Aravind, ensuring we were well connected and meeting people to learn from. We were also fortunate to meet her family (and her adorable grandson). I largely spent my time with folks with the LAICO (Lions Aravind Institute for Community Ophthalmology) Center – a major training institute that provides management and leadership training for professionals around the world. My time was spent learning about Aravind’s model and research, helping out on several small writing projects, learning from the outreach department, and soaking in the atmosphere as much as possible.

One last impression about Aravind to share was how open and transparent the entire hospital was. Though we were only there for 2 weeks (which were interrupted by Yom Kippur and other holidays), we had immediate access to anyone we felt we needed to talk to. We met and spoke with nearly all the remaining founding doctors of the hospital, the current CEO and chief administrator (A Michigan MBA alum!), the CEO of Aurolab – the hospital’s own intraocular lens factory, and so many more movers and shakers of this world. Not once were people hesitant to open their doors to us, spend an hour to discuss and share and learn from each other, or help us use our time at Aravind to its fullest….needless to say we are incredible grateful for our time there, and are trying to share what we’ve learned here in Ghana…

There is so much to write and share – about Madurai and South India, about our Yom Kippur in Cochin with the last remaining remnant of a Jewish community that traces its roots to the destruction of the 2^nd Temple (70 CE), praying in a 400 year old synagogue in a sleepy harbor town, spending our last week in India in Mumbai racing around to get our Ghanaian visas sorted out before Simchat Torah started and the relief after nearly a week of uncertainty of having those visas in hand before the holiday started, our amazing chag spent with a Bene Israel family in Mumbai and learning new songs and foods, feeling the rush and bustle and insecurity of Mumbai all around us, the amazing small kindnesses we experienced along the way, seeing a Bollywood movie in the flesh…there is simply too much to write! Though our time in India was short-lived and was ad-hoc (we had not originally planned on an India stopover), it is time very well spent…

The old saying , “Man plans and G-d laughs” sometimes can work out to your favor. We had booked our tickets to Ghana via Egypt Air with an initial 12 hour layover in Cairo. We know you are probably shaking your heads in angst as you read this and thinking, “Cairo? Who in their right minds would go to Egypt now, especially with a few Israeli stamps in their passports?” Well after hours of searching, these flights were the best deal going and so we resigned ourselves to spending that layover in the airport, though wistfully thinking how great it would be to see the pyramids or other amazing sights. On the plane from Mumbai, we could see the endless Sahara stretching out below us, the outlines of towns and gas lines stretching here and there. We arrived around 12pm and almost immediately were met by Egypt Air officials informing us that due to the length of our layover, we were entitled to a free hotel room, free airport transport, and meal vouchers. We also were met by Egypt Air’s own travel agency who assured us that the security situation was quite stable that day and they could arrange a private tour of the pyramids and Sphinx for us…so who were we to say no? Not only were we walked through the VIP immigration line, less than hour after landing we had our own private van and English-speaking tour guide to the Pyramids of Giza and Sphinx. Following an amazing tour and ride through the city, we were checked-in to a 4 star hotel, complete with sauna/steam room and enjoyed a few hours of rest and relaxation before heading back to the airport for our connecting flight. Driving around Cairo, we did see many people with protest signs and trucks filled with young men, and no we were not anywhere near Tahrir Sq. The day we spent in Cairo the streets were full, businesses were open, traffic its usual nightmare. We did not discuss the current situation with many people, though it was painfully obvious at the near silent pyramids that Egypt was suffering in many ways.  We left pleasantly surprised and thrilled that we got to add a second original Wonder of the World to our itinerary (the Great Wall of China being our first), though consciously aware of how fortunate we were to have the experience.

We have now been in Ghana for about a month, and it will probably take us ten times as long to process everything. We are working with the Komfo Anoyke Teaching Hospital (KATH), a tertiary referral center in the Ashanti Region of Ghana. Our sponsor, the Himalaya Cataract Project, has been working with the eye center here for the past several years and recently supported the construction of a brand new eye hospital with the help of USAID. Unlike the hospitals in Nepal and India, KATH is a government institution, which brings with it all the inefficiencies and bureaucracies that one might imagine. The Eye Unit currently has 4 residents and 6 full time ophthalmologists, along with 14 ophthalmic nurses, 2 optometrists, and any number of “staff nurses” (regular RNs who do not have further ophthalmic training), national service volunteers, administration, etc. As there are only roughly 50 ophthalmologists in the entire country, the eye unit is particularly well staffed. Regardless though, there are many challenges and opportunities here and it seems we keep uncovering or realizing more every day. Zvi has mostly been working with the residents, giving lectures on uveitis and also consulting on any uvietis patients that come in. Last week we attended an outreach at a local district hospital with two of the doctors, but mostly Zvi’s work has been in the general clinic. He has also been helping develop cataract surgery protocols and check-lists for the operating theatre. I have been working closely with the administrative staff, helping with visioning and developing strategic plans for the coming year. I’ve also been focused on the clinic systems and doing small studies on patient wait times and flow, and giving workshops on using data for decision making.

We are staying in Ghana’s second largest city, Kumasi – a green rather laid back city that has the amenities but none of the hussle of the capital. We are staying in the hospital guest house, with several other visiting American medical personnel, giving us a built in social life. Kumasi is also home to West Africa’s largest market – Kejetia. This market is a maze of stalls, food, vegetables, and stuff, from entire rows of stalls selling toothpaste to women making groundnut butter and rows and rows of dried fish, open air butchers, stalls selling fetish items such as dried chameleons, animal skins, turtle shells and more. We’ve gone several times now and are able to navigate to different areas fairly well. Words do not do this market justice, between the hundreds of women and children carrying items for sale or transport on their head, the open-air preachers stirring the crowds, small children following us into alleyways yelling “Obrunoi!, Obruni![2] Hi!”, the smells of dried and salted fish, peanut butter mingling with mud, vegetables, ginger, chili pepper, trucks overflowing with plantains and huge coco yams and cassava backing up to deliver their good in alleyways and bypasses crammed with people, animals, merchandise, the whirr and snip snip of the tailors’ row creating the brilliant dresses, vests, and pant suits that men and women wear here, the blind beggar’s we passed on the railway track rattling their coins in supplication…Sunday’s are quieter here, we went last week to buy fabric to make some clothes. Zvi noticed that the vendor we bought from had a hypermature cataract and encouraged him to come in to KATH. Though we haggled fiercely over the cloth, we parted with a hearty handshake and smile. The gentleman came in to the clinic this past week and he’ll be having surgery in a few days….just another day at the market… 

As with India, there is so much more to tell – from our Shabbat adventure out to visit the Sefwi Wiaso community, a group of Ghanaians that profess to be a “Lost Tribe”, the deeply religious nature of the country (there are signs everywhere for 3,5,7,14, or 30 day prayer/fasting events nearly everyday of the week), the morning singing and prayers at the eye unit before clinic starts, seeing the Ashanti King, swimming in a nearby crater lake where the water is warmer than bath water, participating in World Sight Day, watching French movies at the Alliance Frances cultural center, getting Kente cloth and other clothes made by local tailors, to watching Ghana’s pride, the Black Stars defeat Egypt 6-1 in a World Cup Qualifier match….

We are gearing up for our last few weeks in Ghana, they’ll be busy with work and another outreach camp. We can’t wait for Frayda to arrive and are sure to have more adventures to tell when we reach the US in a few weeks!

Keep in touch and can’t wait to hug and speak to you all in person,

Much love,

Jamie and Zvi

Past Post: Rosh Hashana Greetings!

A new year - a new country! Gmar v'chatima tova everyone - Happy Rosh Hashana. Zvi and I wish everyone a healthy and amazing year ahead. The end of our year has been truly a time of growth and amazement, professionally and personally for both of us. The month of August found us based in Dhangadhi, Nepal  at the Geta Eye Hospital. Dhangadhi is in Far Western Nepal  - an area that historically has been neglected by the Nepali government and was the scene of some of the worst fighting and atrocities of Nepal's recent civil war. Until just 10 years ago, this whole region would be virtually cut off from the rest of the country during the monsoon season with roads being washed out and bridges non-existent. A little over half a century ago, this region was jungle - dense, humid, malarial jungle. Few people lived in this plains region. With DDT and other technologies, malaria was virtually eradicated and the jungle was cut. People began moving down from the hills and snatching up as much land as possible. As Dr. Arjun told me - "Those who stayed in the hills were the rich folks 50 years ago, who now look to those "poor" folks in the plains for help." Indeed, while we saw very few other foreigners around Dhangadhi, on a brief visit to the nearby hills we saw cars and jeeps for Save the Children, UNICEF, CARE International, UNFP (UN Food Program) and more. Food security and inaccessibility to health services are major concerns in the hills region around Dhangadhi, and Geta Eye Hospital conducts ongoing community-based eye camps and screenings when possible. The hills around Dhangadhi are a different world altogether. We took a brief trip there to find it cold, wet, misty, mysterious - so unlike the hot and humid rice patties surrounding Geta. 

Geta Eye Hospital, as it stands today, is something of a jungle mirage. The new gleaming 3 story modern facility serves nearly 100,000 patients each year, with roughly 80% of its patients coming across the nearby Indian border. An eye examination costs Npr. 30/ (USD$0.28) and cataract surgery between $9.00-$25.00 depending on the complexity of the surgery and any subsidies a patient might receive. Patients can choose to stay in the shared ward or pay extra for a shared or private "cabin" for their stay after surgery. Patients tend to come with their whole family, especially the Indian patients. Families can opt for a private or shared room, however most are content to camp outside. Most bring cooking supplies and either purchase wood or bring a gas cooking canister. At night, - as August wore on, the rains slowed, Ramadan ended  and patient numbers began to increase - the hospital complex resembles a summer camp, minus the tents and counselors. Families sit quietly, children mill about staring at the pale foreigners. Those who already had surgery wear the "White badge of Honor" - the bandage protecting their new eye. During the busy season, there will be between 300-500 surgical cases a day. Fights sometimes break out in the evening, providing those camping out some entertainment beyond waving their homemade fans and perhaps dreaming of home. In the morning there'll be a mad flurry of activity as different doctors dash through rounds, nurses following close behind to make notes, put in drops, and send those with suspected infection or complications to the ward for further examination. Monkeys scurry about, recognizing the small pink bags that people receive from the canteen. Early mornings are primetime for monkey theft as people are quickly trying to eat, pack, and get in the registration line early. The monkeys make a mad dash and carry their booty to a rooftop sanctuary, dodging any thrown rocks or the canteen boys slingshot missiles. Tame spotted deer mill about happily munching on what they find and the ever present collection of dogs complete the picture. 

Over the past 6 or so years, Geta has hosted a revolving door of foreign doctors learning Small Incision Cataract Surgery (SICS). This was the main purpose for our stay at Geta and Zvi was not disappointed. Despite the rains and busy planting and festival season, he was able to perform over 130 cataract surgeries and close to 50 other procedures during his 5 week stay. The full time ophthalmologists - Dr. Deepak, Dr. Suresh, Dr. Arjun - all have thousands of cataracts to their credit and provided Zvi both guidance, mentorship, and many many games of chess in the quiet evenings. Zvi's subspecialty training in Uveitis continues to serve him well, and he has been consulting on cases in the outpatient department as well. Geta's nurses likewise provided Zvi and the other visiting trainees (Dr. Joyce from NYC and Dr. Vijay - a recently graduated Nepali ophthalmology resident) not just the support needed during the surgeries, they provided guidance, mentorship and could long spot complications and/or necessities before it was even vocalized by the doctors. The nurses, ophthalmologic assistants and other staff create a well-oiled machine that is helping what was once considered a Nepali backwater into a center of international ophthalmologic care…which makes Geta's history and its director, Dr. Bidiya Pant's story all the more amazing.

The history of eye care in Nepal is an incredible story. Nearly 30 years ago, it barely registered as a need. Even 10 years ago, the system was fairly limited to urban Nepal and not nearly so efficient or affordable as it is today. While many outside organizations, including our sponsor the Himalaya Cataract Project, are huge game changers in Nepal, the local initiative, vision, and determination of men and women like Dr. Reetha Gurung, Dr. Sanduk Ruit, and Dr. Bidiya Pant are what truly has made eye care in Nepal what it is today. If you're curious about eye care in Nepal, a new book about Dr. Ruit and HCP came out this past June - Second Suns - I haven't read it personally yet (despite lugging 10 hardcopies with us to Nepal for Dr. Ruit), but the reviews are good!   

Geta Eye Hospital is a smaller story - one that is much more personal, tangible perhaps because we have been there - perhaps because I have met other incredible, honest, humble people in my travels who simply saw a need, and decided they'll do something about it, no matter what. Thirty years ago, Geta Eye Hospital did not exist - it was a basic primary health care post in the jungle. Eye care in Nepal itself barely existed; the first ophthalmologic epidemiological study was first completed in 1984. A Swedish ophthalmologist and his wife began to organize Geta shortly after that study came out. 

Bidiya Pant was an ophthalmologic assistant from nearby, among the first to graduate with this new intermediate level certification. He joined the staff there as an ophthalmologic assistant. He worked there for 7 years - there was one ophthalmologist on staff, with occasional visiting doctors who'd come for a few months at most. Geta was drenchingly hot in the summer and humid, with not much relief in the winter. Electricity was spotty. Doctors simply didn't stay long. Yet the patients flocked there - they came from across the border, they came from the neighboring villages, they came down from the hills. Bidiya worked 6, 7 days a week, eventually performing surgery - a highly controversial move despite the lack of staff. The SICS technique had not yet penetrated Nepal, not for another decade, nor had interocular lenses widely arrived. The surgery Bidiya was doing was intense, and required significant recovery time and a lifetime of "granny glasses". While the center grew, Bidiya had a vision - this was his home region and he understood the potential. He realized as an ophthalmologic assistant though, his voice simply wasn't going to be heard so he decided to pursue an MD. 

Medical school in Nepal at that time was highly restricted to 30 students a year. It was 1992, the Iron Curtain had just fell and Russia was seeking foreign funds and students,"You just sent in your paper work and paid the tuition, they expedited your visa and I was a medical student."

The Swedish doctor - while recognizing Bidiya's drive and appreciative of his work ethic- did not approve of his plan. Bidiya left for Russia anyway, leaving his parents, wife and 3 children, and paying his own way initially. When he left, the Swedish doctor had to hire two people to replace Bidiya. The first year in Russia, Bidiya learned to read and write Russian. A decade later, he returned to Nepal a full MD. During those 10 years, the Swedish doctor saw what the importance of what Bidiya was doing and arranged for scholarships. Bidiya visited his family in Nepal during his 10 years abroad. Dr. Bidiya Pant returned and completed his qualifications to practice ophthalmology in Nepal. He returned to Geta as the senior Ophthalmologist in 2004.

"At that time I was the only full time ophthalmologists, others would come and once they learned what they wanted, they'd leave. I'd perform surgery late on Fridays, than head to the hills arriving at 1 or 2 am on Saturday. We'd do a screening and surgical camp all day, than I'd come home late Saturday night and begin work again on Sunday." 

During this time period, the SICS technique became mainstreamed through the efforts of Dr. Ruit. Intraocular lenses were being manufactured and produced in Nepal, the entire landscape of ophthalmologic care was rapidly transforming. Dr. Bidiya learned from other pioneers - Dr. Ruit, from Tilganga Institute of Ophthalmology. Partnerships were formed, and visions and dreams were becoming reality. Through a partnership with the Fred Hollows Foundation and the Seva Foundation, new structures were built at Geta. A modern clinical facility (no longer was the emergency department in an old mud and stick shack), operating theatres  were designed to specifics. Generators were acquired to cope with the frequent power outages, comfortable living quarters were built to attract doctors to stay. Support and nursing staff were sent to Tilganga and India for training as were management to learn how to create a well-oiled and efficient machine. Brick by brick Dr. Bidiya and his team built up the hospital. Another full time ophthalmologist joined in 2007 - Dr. Deepak Khadka, who remains as Geta's senior ophthalmologists and head of the training department. Other ophthalmologists joined and remain - today there are 7 full time ophthalmologists, who are often joined by visiting Nepali residents and international trainees. Progress continues both in terms of infrastructure - more patient wards and guest rooms are being built, a fountain and garden is being inlaid, additional staff quarters are nearly complete. A staff pool is functional to combat the heat (and no one is above air conditioning!) A workout room and library are also planned. Dr. Bidiya also is focusing on furthering the quality and availability of care, and staff are receiving sub-specialty training as well. Geta Eye Hospital intends to run their own residency program in the near future, and already is establishing their own satellite clinics in nearby border towns and in the hills. Daily dreams are made reality - the dream of sight, the dream of seeing home once more, the dream of offering a "second sun" to his community…

Meeting people like Dr. Bidiya (a quiet, soft spoken man you'd have to lean in close to when he spoke in English) is a highlight of this type of work. One of the main missions of Himalaya Cataract Project is to create more opportunities for local visionaries to have the tools they need to create change - hence the big emphasis on education. Local leadership allows for lasting solutions, and while there is a great deal of international collaboration and partnership in this story, there is also a Nepali man - a Nepali man who was once a boy and a young man and perhaps did not expect to become a doctor, a leader of his country, a pioneer. His vision and determination are inspirational since we perhaps can all find our own story within his, the chance meeting, the opportunity acknowledged to create and do and change. Looking back and writing about Geta's story perhaps makes it all seem so inevitable - Nepal's eye care is a success story but it took time and doubt, and some plodding along and belief and hope day after day to reach this point. It is perhaps too easy to point to other places (or even ourselves) and question why they are not Nepal, why haven't they achieved success, and where are the Dr. Bidiyas? In telling Geta's and Dr. Bidiya's story, particularly at the start of this new year and as we venture off to other countries, we can look back on this story and think, and smile and remember, and borrow a bit from these incredible visionaries, and say, "Why not here too?"

 

We are off to India next week and than to Ghana the end of September. We are filled with so much love and gratitude to everyone for their support and messages from home. A huge Mazel Tov to our brother Shmuel on his engagement to Yocheved Radnor - we can't wait to celebrate in November! Another huge Mazel Tov to cousins Marissa and John on their marriage! We're so sorry to have missed the wedding but are looking forward to many more celebrations together.

Gmar v'Chatima Tova - A happy and healthy new year! Come visit us if you can!

Much love,

Jamie and Zvi

Notes from the Canteen

We take nearly all our meals from the G. Eye Hospital canteen. It is a rough sort of place, though more 
couth than the usual street kitchen venue. A galley kitchen run on a single gas cooker, a traditional mud 
stove powered by fire. It is housed in the original Emergency and Inquiry department before the foreign 
lords of earth transformed this rural post into a modern center of medical excellence. Where the injured 
and sick used to throng, now sit doctors, assistants, visitors, and patients causally sipping tea and eating 
their meals.

Kitchen

When the power is on, a color television blares loudly the latest soap opera or Bollywood movie from India. It is always too loud and crowded with the canteen owner’s family and its workers, an old man and a pack of boys ranging from around 10-18 years old. The youngest boy claims he is 14 but looks about 10 or 11. I have a feeling he was told strongly, “If someone asks, say you’re 14!” We were told he is a boy from a nearby village – not related to the canteen family. His father brought him to work 
here since he was such a trouble maker. We call him “matzik” – a Yiddish term that roughly translates to rouge, a troublemaker. His eyes are always on the lookout for mischief and adventure; he’s continually roving the compound chasing dogs and other children, shooting rocks at monkeys with his sling shot and has a cheeky forward smirk always on his lips and a glint in his eye. He is most likely the bane of his village, the lovable black sheep…

These boys cause us no end of amusement and trouble for only one speaks enough English for us to communicate with, and the rest all have a glint in their eye that makes you question how much they
understand. Whenever we order, they repeat it as if it is the strangest request they’ve ever heard – dhal bhat! Heavens me, they’re ordering Dhal roti! We usually have to order twice and are never sure what 
will arrive until it is actually placed in front of us. A sort of truce has been declared at least for dinner
for they have decided that whatever we order, they’ll bring rice and roti. We have started a vocabulary 
exchange of sorts; however as the menu varies so little we will soon run out of things to point out to 
each other. 

In actuality the canteen serves about 4 different things. Dhal is virtually always available for breakfast or 
dinner. Sometimes breakfast will consist of dhal with a mashed up samosa, sometimes there are pigeon 
peas in a spicy sauce to go with your roti. Most folks tend to take tea and maybe a roll or dhal bhat.
They have become accustomed to our standard order of one coffee, one black tea, and chapatti and 
vegetables or eggs. Lunch is a simpler meal and woe be to those who try to order something nutritious! 

Matzik and Chef...

Lunch consists of either “noodles” or “chowmein”. Noodles involves a package of ramen noodles stir 
fried with some seasoning and vegetables. The brightly colored imported packages line the canteen 
shelves cheerfully announcing that they contain “No added MSG!”. Chowmain is a street food classic – 
egg noodles stir fried with cabbage, eggs and other vegetables and oil. They serve it on a small metal 
plate heaped high, often with a samosa. Asking for dhal causes all sorts of problems – first you are
looked at as if this food was never heard of before in the country. Then whoever is taking your order 
yells to the old man in the kitchen to see if there is any left. Than if you’re lucky, they’ll shrug their
shoulders and do the enigmatic head bob that Nepalis and Indians have perfected, and eventually they’ll 
bring you dhal bhat. The food comes on a quartered metal plate with one large section and three small 
sections. In the large section your rice or roti is placed, usually with a bitter gourd and potato dish. The 
bitter gourd is too harsh for our American palates; we pick around it for the potatoes. One small section 
contains “Achar” – a red spicy/sour tomato sauce to season your dhal. Sometimes pieces of onion and 
chili are also included. Another section has your small bowl of dhal (mung dhal here – good with a 
squeeze of lemon) and the last your vegetables – usually a potato curry. All this is yours for 45 Nepali 
rupees. Dinner rarely changes – dhal bhat, dhal roti or in our case, in order to be sure they covered all 
their bases, dhal bhat and roti. The food is good, tasty, and filling, they will refill your plate until you say 
otherwise. This can be a bit awkward if eating in the “doctor’s room” which is further from the kitchen. 
One of the boys will run across the road with the special bowl consisting of three bowls welded together 
only to be told that the trip was unnecessary. 

We usually eat with the other doctors or visitors – sometimes in the “doctor’s room” sometimes under 
the sloping eves of the main cafeteria. At night the power cuts in and out often forming a weird staccato 
with the television. The coveted table at the main canteen is the blue Pepsi Cola table right next to the 
fan. Benches and chairs ring it and it is usually the providence of doctors or assistants to sit there in the 
evening. Patients and their families who are not cooking their own food elsewhere sit at the long table 
with its backless benches. This table has a clear view of the television and a short trip from the kitchen. 
When the rain comes, it comes suddenly and it pounds on the corrugated tin roof. Huge lakes form 
under the eaves and mosquitoes dance about in heaven. The rain comes on suddenly and fiercely 
here. Often we must remain under the eves until it subsides to a gentle roar. The unfortunate who 
are caught out in it scramble for shelter, though they are drenched in minutes. The canteen boys sent 
on errands take a small umbrella and come back partially soaked. The hospital is quickly laying down a 
stones around the hospital and canteen to alleviate the mud. Laundry sits on the line for days as wave 
after wave of rain falls; it’s not worth the trouble to keep collecting it off the line. 

One night we sat at the Pepsi table, the doctors playing chess, all of us drinking tea. At the long table sat 
two old Nepali men dressed traditionally with Nepali topi hats and the long tunic shirts and linen pants. 
They each wore a vest as if chilled in the 90 degree humid night. They could have been brothers, both 
grizzled and thin, a day or week’s worth of stubble on their chins. One had an eye patched with white 
cotton – a surgical patient, most likely cataract. He still had a piece of cotton wedged in his ear from 
surgery to catch any fluid that may drip. It’s a bit unusual to see older men like them at the canteen – 
most people come with their whole families and cook for themselves. Perhaps the two came together,
alone without their wives. Perhaps they were widowers – they looked close to 90 but easily could have 
been 60. They sat side by side eating their chapatti and dhal. Every time the boys came offering more 
chapatti, they took one or two more. Across from them sat a younger man, a patient or a patient’s 
relative. He sat eating rice and dhal. All were silent, only grunts and snorts and other bodily noises of 
eating and belching that are not suppressed here. They ate quickly; nearly shoveling food into their 
mouths as if afraid the plate would somehow disappear in the time their hand migrated to and from 
the mouth. Later the canteen boys sat at the same place and also ate, ravenously as young boys do, 
in a hurried snatching way, having their fill until the plates were all wiped clean. The television blared 
its usual yelps and bangra. In the distance the generator whirled and the compound fell to its muted
reverie…only to begin again early the next day with the first cup of tea at the G. Eye Hospital Canteen.

Past Post: Greetings from Dhangadhi (Originally sent August 2, 2013)

The past few weeks have been incredibly busy and jammed with so many different experiences, emotions, adventures, and more that it has been difficult to keep up with regular updates. We have now moved to a more remote and southern region of Nepal where time runs a bit more slowly, the heat and humidity dulling the urgency to rush and see and do a bit so hopefully there will be more time to catch up, process and connect.

We tried to pack in as much learning and exploring as possible during our Kathmandu tenure, including some time outside of the capital. Outside of Kathmandu, Nepal is green, rural, and beautiful in the heartbreaking way that poor countries are so often are when their physical beauty masks the millenniums of history, culture, wars, and environmental challenges its citizens currently face. Of those we have encountered, Nepalis have been incredibly helpful and welcoming. The timeless scenes of women kneeling in rice paddies in their bright saris, the friendly smiles and “You are very welcome madam” and the eagerness to please and help betray this country’s struggles and triumphs, its ongoing challenges to make sense of the world as we all are and the rapid unending change that, globally, seems to threaten tradition, culture, and what people know and hold dear. This is a continual challenge for anyone traveling and/or working abroad – one that we particularly feel being in these countries for so short a time – to get a glimpse beyond the façade and to demonstrate, not that we understand, but at least acknowledge the struggle and challenges as we all move forward.

 We spent one weekend exploring the medieval kingdom city of Bhaktapur, beautifully restored and well maintained and also caught some glimpses of the Himalayas while Shabbating at Nagarkot, less than 30kms outside of Kathmandu. Traveling around Nepal is less about distance than about the mountains – traveling less than 20 miles outside of Kathmandu can take a couple hours on the winding zigzagging nerve jangling roads that lace the mountains. Nargarkot provided us a better glimpse of rural Nepal with its terraced hills of rice paddies and corn. Having geographically won the lottery, the village now has expanded into tourism and every weekend brings Nepali and foreign visitors to the cool hills to rest, hike, and see the Himalayas. While our views were largely obstructed by clouds, very early one morning we were lucky to get a glimpse of the snowcapped peaks.

Cooling off with our new friend...

While our updates and emails have been very travel heavy, there is work going on as well! As mentioned, our time in Kathmandu was largely for observation and learning how a well-run eye hospital operates on the ground. Zvi has been working with Dr. Anu in her uveitis clinic and also gaining surgical exposure on Small Incision Cataract Surgery (SICS), a low cost/technology procedure that is widely used in the developing world to provide high quality and high volume cataract surgery. Additionally, the end of our Kathmandu stay focused on the 2^nd National Uveitis Conference hosted by Tilganga, where Zvi presented on Ocular Manifestations of HIV. This was an incredibly well-organized and useful conference featuring top uveitis specialists from India, Nepal, Bangladesh, and the United States. The conference provided current general ophthalmologists and residents a much needed chance to gain exposure and share ideas regarding these diseases. The two day conference was a testament to how important exposure and opportunities to share information are, particularly for clinicians working in remote areas who are not often able to access resources as much as they would like. The polish and ease of how the conference was organized is another testament to Tilganga’s focus on efficiency and quality.

Our last full week in Kathmandu brought us a few visitors, Ema and Abba Kresch! Zvi’s folks were a bit jealous after our first email and decided to pop over for a visit. Staying with us at Tenzing and Dadoma’s, they filled their days with exploring the city, tracing our adventure to Bhaktapur and Nagarkot, watching Zvi present at the 2^nd National Uveitis Conference, and adventuring with us to southern Nepal. They have been as enthralled as we have with the cities many temples and religious sites, monkeys, streets, colors, incense and more. With Tenzing as our fearless driver, we went down together to Chitwan and Lumbini in Nepal’s Terai (plains) region in the southeast. The Terai is below the mountains and contain Nepal’s hot, muggy jungles. Successful malaria eradication programs in the late 1950s and 60s have seen the migrants flood the region and much of the jungle deforested for rice paddies. National parks have been established to preserve the jungle and its unique wildlife, including Bengal tigers, elephants, rhinos, wild boar, sloth bears, and more. The jungles here were once the hunting playgrounds of Nepali and British royalty, but now play host to tourists on safari. Together with Ema and Abba, we rode elephants into the jungle and visited the elephant breeding center to see the baby elephants. This being the monsoon season our encounters were limited, though we did see some wild boar, exotic birds and a rhino. 

The highlight for everyone was participating in the elephant bath time!  Around midday the elephant handlers bring the elephants to the river in Chitwan to cool off and scrub down. Participants ride bareback and after saying a few magic words to the elephants got a shower blast from their trunk! It was awesome riding these magnificent animals and also cooling off with them in the river!

A successful mountain flight

We decided to spend our final morning all together experiencing Nepal’s greatest geographical wonder, the Himalaya’s!  While timing won’t allow us a chance to go trekking, a mountain flight was the next best thing. Airlines in Nepal run “mountain flights” that take tourists to see the Himalaya Range and the peak of Everest. During the flight, the crew allows you to join them in the cockpit to take pictures of the range, and you can see the range from the windows. Together with Ema and Abba, two visiting Chabad rabbis, Zvi and I capped off our Kathmandu adventure by seeing the highest snow caps on earth!

Everest

A few hours later, we were back at the same airport for our flight to Dhangadhi, in far western Nepal. We are posted now at Geta Eye Hospital – a busy rural eye hospital near the Indian border. It currently is low season for patients due to the rains and planting time, but during “high” season, this hospital sees thousands daily and conducts anywhere from 300-500 surgeries 6 days a week. The focus here is for Zvi to gain more surgical exposure in SICS training, and I will be analyzing and compiling data I collected in Kathmandu. Hot, muggy and buggy, the hospital has its share of resident monkeys, dogs, spotted deer, and gigantic jungle bee hives that have sprung up near the guest room where we are staying in the hospital. Roughly 80% of their patients are from India (Indian and Nepali nationals can freely cross each others’ borders and the Indian rupee is used and accepted in this part of Nepal). Dhangadhi is the district capital and a city of about 100,000 people; the hospital is located about 10 km away from town. We explored town briefly yesterday and will continue to explore the surrounding areas over the next few weeks. Known as the far west, Dhanghadi does have a wild west feel to it – people here do not seem to be used to seeing foreigners around and we do attract a bit of reserved and polite interest.

Over the next few weeks we’ll be learning how to live in the heat and with the bugs and bees, as well as how a rural eye hospital functions.

More pictures and adventures to come!

Past Post: Greetings from Kathmandu! (Originally sent July 12, 2013)

Scrambling like billy goats up the Wild Wall...

Matt, Jamie, and Zvi on a clear day overlooking the Forbidden City

Wow! What an incredible few weeks it's been - hard to believe that it's been only 10 days since we left Detroit! Our first stop was to Beijing to visit my brother Matt and sister-in-law Elaine. Matt has been in China for over 8 years now, speaks fluent Mandarin, and is a true walking, talking "Google" about anything you might want to know about China. It was amazing to see the city as a "local" and get to see some sights that most visitors would never have been able to find. Any question we had, Matt had an answer for - whether it was about what year a particular temple had been built, the succession of the different Chinese dynasties, to where the best dumplings in town can be had. We had beautiful weather (no smog! no rain!) our first two days in town, and we took advantage by walking the city's old hutong houses, getting panoramic views from old temples, visiting Tienanmen Square, and so much more. Zvi discovered that the roof of Matt and Elaine's building is accessible, and so we had a beautiful Kabbalat Shabbat service on their roof, davening 30 stories up as the sun set behind the mountains and bustling city. Shabbat day was spent walking to the Dirt Market, Temple of Heaven park, and old famous pharmacies. 

Not wanting to tempt our luck, we decided to go a day early to our trip's highlight - Hiking on the unrestored "Wild" Great Wall of China. Matt and Elaine arranged for all of us to stay with a farmer in a suburb about 2 hours outside of Beijing. The air was cooler and the views were striking. We could see the wall from the farmer's drive way. Matt, Zvi and I took off for a "medium" hike up the wall that very afternoon. Unlike restored parts of the Great Wall with their hordes of tour buses (both Chinese and foreign), paved roads, flea market stalls of vendors hawking everything from kitchy gifts to dried fruit, and gondolas, here we were alone in the great wilderness of northern China. Only the small villages below (while benefiting from the influx of tourists to this part of the wall, were a bit perplexed why anyone would want to climb the darn thing) spoke of life, that and the rustling of wild chickens and cicadas. When they say Wild, they mean it - we clambered up and downs crumbling ruins, often teetering on the edge of what remained of this monster, trying to image how they built this centuries ago and if it really could have kept out the Mongols. We cut through brush that looked undisturbed for ages, being thankful that those bushes didn't contain thorns, snakes, or anything else unsavory. Tremendous kudos to Matt ( you know why - remember the Aussie hill? ;) ) 

The next morning Matt and Elaine decided to take it easy and enjoy the green and quite of the farm, while Zvi and I blasted off early for a long trek on the wall. We were too late for sunrise (4am) but it was tremendous to climb the wall together. We didn't see a single soul until about 4 hours into the hike, just rolling clouds, vistas and mountains stretching into mountains. We soon learned to spot how the bricks and stones changed as the wall had been built over different centuries. Little artistic touches here and there also gave the wall, some humanity and as rocks crumbled under our feet, we felt for those poor souls who had to lug them up in the first place....

A tremendous 6 hours together and back to Beijing! Our last day there brought rain and storms and was spent picking up last minute supplies, treating ourselves to a foot massage, and trying to figure out what to do since our flight was delayed and we'd more than likely miss our connecting flight in Malaysia. After some good-byes, we headed to the airport for our next adventure! 

Our flight was delayed but not enough that'd we'd miss our connecting flight completely if we were lucky (the next flight to Nepal was the following morning - I was looking up sights and places to stay in Kuala Lumpur...). Zvi spoke with the stewardesses on-board who rushed us off the plane as soon as we landed.  We made it!  But our luggage decided to detour in Malaysia.    frantic dash through the Kuala Lumpur airport and we made plane with 10 minutes to spare! 

Landing in Nepal is something else - much more than a "I don't think we're in Kansas" anymore feeling, we knew it was an entirely different world than Beijing (strange how they're both lumped together in Asia!). After getting our visa's and waiting for our luggage, and finally finding the small booth with a faded dated sign reading "Luggage Complaints lodged here" - it was clear our bags had made a detour as well.
 "Not to worry Madame, we have received a message that 2 will arrive tomorrow morning" 
"But sir we have 3 bags..."    
"Ah yes, well we know where 2 bags are, that third bag, we don't know. That is a problem madam, isn't it?"

(spoiler alert - all 3 bags arrived the following day as promised).

We were received by Mr. Tenzing Sherpa, one of the proprietors of the guest house where we've been put up. A cheerful, humorous man, he and his family run this guest house and a trekking agency. It is nearly always full with visiting doctors working at Tilganga. We stopped at Tilganga first and met a few folks, than to our guest house. Kathmandu is an overwhelming, dizzying, chaotic city of bright colors, temples around every corner, women in bright saris and salwar kazis, cows lounging randomly on the street, pathetic stray dogs everywhere, holy men dressed either in the Buddist maroon and saffron robes or the canary yellow clothes of Hindu priests, dust, mud, car and motorcycle horns, wild monkeys climbing buildings and rooftops, and so much more. Incense drifts in the air mingling with street food and garbage. Yet it is safe, comforting so. We are either ignored or if we look lost or are staring at a map, someone will approach us and try their English to give us directions. The biggest danger is from the motorcycles and the sidewalks that tend to turn into 6 foot cliffs into someone's cement back yard. 

Zvi and Tenzing

Our first afternoon, Zvi and I wandered downtown, map in hand from Tenzing. We went first to Thamel, the catacomb like tourist district full of trekking gear and curio shops, bars, restaurants, and guest houses. The streets are narrow and jam packed, wires are strung everywhere and hang down to bop you on the head as you walk past. They are sometimes decorated with prayer flags or ribbon. Walking through Thamel we suddenly emerged into a market place. "Oh you found Ason!" Tenzing later declared, delighted that we found the traditional market, with its central stuppa (temple) filled with worshippers, men and women everywhere selling vegetables, fruit, lentils, spices, coffee, tea, and more. Seven roads lead out of Ason to the rest of the city. I could stay there for hours taking in this bit of daily life...

Our first days at Tilganga have been filled with new faces, names we can't pronounce or remember well though eventually we link them together, tours of the hospital, and trying to explain who we are and why we're there. It's easier for Zvi - as a medical personnel, his job is much more easily defined. I've more or less dropped in to their Training department and am to review their many different training programs (more on that later on my other blog). 

We had the privilege to meet Dr. Sanduk Ruit today - the founder of Tilganga and a man who has given over 100,000 people back their sight! He, like all the Nepalese so far, was incredibly gracious, unpretentious, and welcomed us warmly to his hospital and country. 

We've been enjoying our guest house and the family tremendously. Our room has a private bath and a balcony where, when it's clear, we get a great view of the city and mountains (not Everest though). Tenzing and his wife Dodomina sit with us at dinner and we pummel them with question after question about Nepal. They have hosted so many doctors, and have stories about them all. They have 2 sons, the older busy with exams, the younger finally warming up and showing us his school worksheets about Nepal. 

More to come but first some housekeeping:

We're in Kathmandu until the end of July, and then head to somewhere south - details to come as we have them.

Much love! Shabbat Shalom!

Jamie and Zvi