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