Last Days in Zambia

Some last shots of some of the quirkier parts of Zambia-

Missed my chance to load up on this juice at the Pick N Pay supermarket near the hospital

Not as disappointed I never got to try this sauce

The sink drain in my bathroom at the hospital always reminded me of a Boston keratoprosthesis (artificial cornea)- see below-

My second to last day there was Women's Day, a holiday celebrated throughout most of the world though oddly not in the US.  Both women AND men working at Lusaka Eye Hospital got the day off, so the Yoos took us to Lilayi Lodge, where we swam, relaxed, and tried some new cuisine.

 Our one day of luxury- relaxing at Lilayi Lodge

Zachariah, the classiest baby in Zambia

Flying monkey

Zebra meat with fries and vegetables

Eating zebra

Picture with zebras

Days at Lusaka Eye Hospital, Part 2

Dr. Celestin:  "Are you Seventh-day Adventist?"

Me:  "No I'm Christian but not SDA."

Dr. Celestin:  "But you look like you are SDA."

Me:  "How's that?"

Dr. Celestin:  "You look like a small preacher."

[I'm not sure what that meant either]

Dr. Yoo and her patient, the former Zambian ambassador to the US (and graduate of Cal Poly SLO)

One day Dr. Yoo let me put in a suture in a patient's eye who had had corneal trauma.  It was incredible getting to do something "hands-on" with a patient's eye rather than watching as I usually do.  I realized that I've watched so many good ophthalmologists who make things look so easy that I didn't realize how difficult the procedures actually are.  I hadn't taken into account that I would have to adjust my depth perception to the microscope and that the tear film covering the eye would adhere to the suture, causing it to stick to itself and tangle before I could get a good grasp on it.  Overall, it was much more difficult than I thought it'd be but I was really glad to be able to get to use some tools under the operating microscope.

Dr. Celestin (to little girl needing her eyes examined):  "What kind of food do you like?"
Little girl (smiling):  "Nothing."
Dr. Celestin: "Nothing?"
Me: "Do you like candy?"
Little girl:  "No."
Me: "Do you like nshima?"
Little girl:  "No."
Dr. Celestin:  "Do you like pizza?"
Little girl:  "YEAH!!"

I also had a chance to see Dr. Yoo use a glycerol graft to treat a patient's Mooren's ulcers, a type of corneal ulcer with unclear cause with a higher incidence in Africa and India than in other parts of the world.  Glycerol grafts are a really cool option for corneal surgeons in the developing world.  The grafts are human corneal tissue preserved in glycerol, which allows the tissue to last up to 5 years.  To my understanding, fresh cornea grafts can be very difficult to access in the developing world due to a number of factors.  For one, most developing countries lack any sort of eye bank system where corneas can be harvested from cadavers and provided to patients needing transplants (although there is one in Ethiopia!).  Additionally, transporting fresh corneas from a country with a robust eye bank system, such as the US, can be difficult as the fresh tissue must be kept at a certain temperature and used within a short amount of time before it becomes nonviable.

A glycerol-preserved cornea that Dr. Yoo has transplanted

Enter the glycerol graft.  Dr. Yoo gets her glycerol grafts from an eye bank in Alabama, which sells them for a low cost.  As mentioned above, these grafts can last for up to 5 years, much longer than the life span of a non-preserved cornea.  The downside is that these grafts are rather opaque and do not allow the recipients much visual acuity, though Dr. Yoo said she has had glycerol graft recipients who can count fingers at 3 meters after surgery which is pretty remarkable!  The benefit of these grafts is that they can work as a "patch" for corneas damaged by conditions such as ulcers or erosions that would otherwise be severely threatening to the corneas and eyes.  And to me one of the most remarkable things was that these grafts can be used as a "placeholder" of sorts, as they can be removed and replaced with fresh corneas, should those corneas become available.

The work being done at Lusaka Eye Hospital was exciting and inspiring, and I'm glad to have had the chance to observe and learn from the ophthalmologists there.

Interview with Argent Moonga

Argent Moonga on right (Dr. Celestin on left, me in middle)

What is your official title?

I am a cataract surgeon.  It may not be common to other countries, probably something more common to African countries.  It is where a non-medical doctor- so in my case I've done clinical medicine which is a diploma- can still go further in a specialty, ophthalmology.  First we do what is called clinical ophthalmology, which is a two year program.  Then we do another two years of cataract surgery.  But in my case, after doing the two years in clinical ophthalmology, I did one year of cataract surgery because I already had the background.  So I had just to go straight into the second year of cataract surgery.  

I did it in Moshe, a very well known institution in Tanzania.  Actually that's where Dr. Celestine [the Rwandan ophthalmologist at Lusaka Eye Hospital] trained and most of the ophthalmologists we have in Zambia.  They have the patients, they have the facilities, they have more advanced technology than we have, they have a school.

But I did my attachments at a different hospital, a non-governmental hospital where they have a lot of patients.  But in a day in the outpatient department [there] you can see up to 100 patients!  They can do up to 100 surgeries in one day, of course with different surgeons, so maybe there will be six [operating] tables.

Where was this?  You said it was your attachment?

In Dar-es-Salaam, in Tanzania.  It's a hospital called CCBRT.  It is sponsored by CBM, Christian Blind Mission.

And the attachment- is that like your residency training?

Yes, where you do the hands-on training.

How did you decide to do ophthalmology?

Well I developed a passion when I was a student doing general clinical medicine.  We had a program where we rotated through the hospital.  We had just an orientation to the eyes, ears, the different specialties.  So when I came here [to Lusaka Eye Hospital], there was an eye surgeon who actually initiated the whole program.  Even the hospital, actually, is like his brain child.  So he was the medical director then at this hospital.  So when we went into [the operating] theater, he gave us some homework to do.  "I want you to look at this and this and this," he said.  So I started reading and started getting interested.  When I came back, he said, "I think you have a passion for this.  Why don't you start thinking about doing ophthalmology when you finish your training?"  So from then I started developing that interest.  I applied at this hospital and was picked!  Before I even did any ophthalmology training.  And this hospital sponsored me to do clinical ophthalmology here for two years before I went to Tanzania for cataract surgery training.

What do you like most about practicing in ophthalmology?

Ophthalmology is a very interesting field because- especially in my capacity as a cataract surgeon- here come these patients who cannot see for years, maybe two or three years.  Then I do an operation on this eye and the next day they are able to see and are jumping up and down.  That gives me so much joy.  I feel so happy when I see somebody who was not seeing then after a fifteen minute surgery, the following day they are able to see.

What do you think are the biggest challenges in your job?

I think the biggest challenges have to do with equipment.  We are just a developing country.  With the limited resources, we are able to do our best.  But IF we had the up to date equipment, I think we could do a tremendous job.

What are your career goals?

There are some barriers in terms of career progression.  If I want to do something higher it means I have to divert a little bit because there's no straight path to go and do a master's or anything.  So it means if I want to go and do something higher in ophthalmology I need to do public health, primary care...

Oh, administration.
...administration, that sort of thing.  So I'm planning to still remain in my practice but I may do something that will do with administration.  I still have the passion to have the hands-on with the patient- that's what I enjoy most.

Did you grow up in Zambia?
I was born in Zambia, grew up in Zambia.  Of course I've gone to a few African countries, like Zimbabwe, Tanzania, Congo, Angola, but Zambia's home.

A few random questions- how many people are in your family?
I have a daughter and a wife.  My daughter is six years old.

What's your favorite food?
My favorite food is rice.  Rice and other things you can mix it with.  Of course nshima is our staple food but I think rice is my favorite- rice with beans, rice with chicken, there's a lot of things you can add to it.

What's your favorite thing to do in your free time?
I like nature walks.  I just go walking around, enjoying nature.  I like watching these National Geographic channels where they just show animals.

Thanks, those are all the questions I have.
Thank you so much.

Restoration

"As long as the Lord grants me the hands and courage to continue, I will continue to do this work."

- Dr. Samuel Bora

Dr. Samuel Imana Bora seems as if he were created to do cataract surgery.  He appears to perform the surgeries effortlessly, never appearing to struggle, as he makes fine, ultra-precise maneuvers with his fingers in order to remove the cataractous lens impairing the patient's vision and replace it with a new synthetic lens.  He has now done over 15,000 manual small incision cataract surgeries (a type of cataract surgery commonly used in the developing world), and can even complete the most straightforward cases in less than 5 minutes!

"In order to do something you must first visualize it in your head," he told me.  Dr. Samuel was actually never trained in the manual small incision (MSICS) procedure he uses for cataracts.  During residency, he had been trained in a similar technique, called ECCE (extracapsular cataract extraction), which he used as a foundation from which to learn MSICS.  He watched videos and poured over other resources to teach himself how to perform the procedure.  "I pictured myself doing it over and over in my head before I really operated on a patient's eye."

"Sometimes people think you are a small god after you do surgery on their eyes but you have to remind them you are not," he laughed. "One man after I did surgery on his eye told me, 'You are my father.'  I was so touched."

Dr. Samuel and his wife had their third daughter, named Lensa, last year.  I joked with him that he loves cataracts so much he named his daughter after the "lens" he removes in cataract surgery.  "Actually, it's a traditional Oromo name," he told me. "We gave my first two daughters, Ruth and Deborah, Biblical names.  My second daughter Deborah chose the name Lensa for her sister."

Dr. Samuel spends one week a month working for the eye camps, one week working at Aira Hospital in western Ethiopia (the town of his birth), and the remaining two weeks in Addis Ababa, spending time with his wife and 3 daughters and working half-days doing cataract surgeries.

I feel that Dr. Samuel, as well as Sister Evelyn, set the tone for the eye camp team.  There's an intangible quality about the team such that I can only describe them as a family.  They laugh, joke, tease, even bicker with each other, but at the end of the day you know they have each other's backs.  Much of this I would attribute to the calm and reserved caring which Dr. Samuel demonstrates as well as the exuberance and warmth Sister Evelyn radiates.  It was good to reunite with Dr. Samuel, Sister Evelyn, and the team, and difficult to leave, but I have a sneaking suspicion that sometime in the future we will meet again.

Much love for these friends

Eye Camp, Round 2

By 10 am the first morning of the eye camp, Dr. Samuel was finishing a cataract surgery under the light of a flashlight I held about a foot above the patient's eye.  The electricity had gone out and with it the microscope and light typically used for the surgery.  Rather than leave the patient's eye open, Dr. Samuel had elected to finish under the rudimentary illumination.

Patients waiting to be seen

The clinic was a frenzy of activity as Mitiku and Tamene evaluated and treated patients for their eye conditions, Ato ("Mr." in Amharic) Getahoon prepped patients for surgery, Challa and Sister Almaz dispensed medications and collected payments, and Desi ran back and forth from the "operating room," collecting surgical equipment to be sterilized and returning clean equipment.  All the while, the pressure cooker serving as sterilizer emitted a high-pitched hum from the corner of the clinic.

Meanwhile, in the makeshift operating room next door, Dr. Samuel pumped out the cataract surgeries while scrub nurse Ebise stood for long hours assisting Dr. Samuel and circulating nurse Sehai prepped any and all surgical materials necessary.

A patient with a lipoma in his cheek being prepped for cataract surgery

Desi prepping the surgical equipment for sterilization

Ophthalmic nurse Mitiku evaluating a patient for glasses

The eye camps are a collaborative effort made by Dr. Samuel- a Mekane Yesus (Ethiopian equivalent of Lutheran) ophthalmologist from Ethiopia, the Daughters of Charity- an order of nuns focused on serving the poor who had historically been responsible for much of the eye care in western Ethiopia, Dr. Larry Thomas- an American doctor who raises awareness and support for Ethiopia/the eye camps, and Dr. James Guzek- an American ophthalmologist practicing in Washington.

Removing eye patches the first day after cataract surgery

Dr. Samuel evaluating a patient's eye the day after surgery

Putting in post-op eye drops

Dr. Samuel putting eye drops in an albino patient's eye after surgery

Ophthalmic nurse Tamene and Sister Almaz putting drops in patient's eyes after surgery

Mitiku telling patients "Praise God" for successful cataract surgeries and giving instructions on post-op eye drops

Tamene evaluating patients for operable cataracts

Luke screening patients for cataracts

Mitiku evaluating the eye problems of an anxious baby

People crowding the door to the clinic to try to be seen

By mid-day/afternoon, after spending a few hours waiting in the heat patients would be pushed up against the door of the clinic, eagerly waiting to be seen and evaluated.

The crowd of patients waiting to be seen never seemed to decrease

I spent most of my time in the operating room, soaking in everything Dr. Samuel explained about his surgeries and the variations required for each patient's eye.  In between, we chatted about everything from ophthalmology, Ethiopia, my future, his family, and our faiths.

Watching Dr. Samuel perform cataract surgery

A man who had been blind for many years smiling at his restored sight

There was no hand-licking at this camp as there had been at the camp I had attended in Gambella, but there was singing and a good deal of smiling and laughing when patients came to the realization that they could see again.

Luke and his "son" who followed him everywhere

One of Dr. Samuel's most challenging cases was a woman with bilateral cataracts who also had psychiatric issues.  While lying on the operating table, she refused to keep her head still, and Dr. Samuel feared that if he opened her eye the worst case scenario would be vitreous and retina (contents of the back of the eye) coming out!  I was sweating bullets as I struggled to hold the patient's head still, and her son pinned her arms down so she couldn't touch her eye.  Thankfully, Dr. Samuel was able to complete the surgery successfully and the next morning found that she had a good visual outcome.

The patient with psychiatric issues on the first day after surgery- she swore that the previous day I had been a black man who was smoking cigarettes

At the close of each day, after all the cataract surgeries were finished, Dr. Samuel would see and evaluate the patients whose cases Mitiku and Tamene were unsure about.  Everyone would gather around Dr. Samuel as he figured out the patient's diagnosis and explained the mechanism and treatment for their condition.  It reminded me of "rounding" on rotations, when all of us students would join the residents and attending to see patients and glean pearls of knowledge from the attending.

"rounding" at the end of the day (photo cred: Luke Sherman)

kids who lived at the clinic

Luke and I ended up leaving the eye camp a day early so I could make my flight back to Zambia, but by the end of the camp Dr. Samuel had completed 260 cataract surgeries.  Many of the patients had been blind, with cataracts in both eyes and we had had the opportunity to see them leaving the clinic grounds, confidently going back into the world with a new lease on life.

Dawn Breaks

The distinctive inflections of the imam's call to worship form a duet with the rooster's crows, alerting the town that dawn is near
Half empty beer bottles and chairs stacked high in the hotel lobby- vestiges of last night's patrons
Shadowy figures pass through the dimly lit courtyard outside
It's time for the eye camp to begin

Blindness in Bedele

"They would rather eat chat than their own breakfast!"
- Sister Evelyn, referring to the predilection of the inhabitants of Jimma for chat, a plant with a stimulant effect popular in Ethiopia and its neighboring countries

The city of Bedele from my hotel window

A few hours after landing in Jimma Airport, my traveling companion Luke and I found ourselves packed inside a tightly-filled minibus as techno blasted from the car's speakers.  The minibus driver pushed on the gas pedal as he drove us over bumpy, tortuous roads passing by red hills and pastoral farmland, all while chewing on chat.

Addis Ababa (Ethiopia's capital) on the top right, Jimma (where we flew into) on the bottom left, and Bedele on the far left

I had taken a red eye flight from Zambia to Ethiopia two days prior, in order to join a one week eye camp in Bedele led by Dr. Samuel, whom I had worked with in the summer of 2013.  Luke was a recent college grad currently based out of Ethiopia's capital, and had traveled to the previous four eye camps to take pictures and record videos for people back in the US.

The greater Jimma area, part of Oromia province in western Ethiopia, was the birthplace of two very important Ethiopian drinks (as the wall next to the baggage claim at Jimma Airport reminded us)- coffee, said to have originated in Kaffa, and Bedele beer, said to have originated from the brewery in Bedele.

Bedele also happened to be home to a brewery which Jimma seemed to be very proud of

Our journey from Jimma to Bedele took us roughly 3 hours.  Outside the minibus windows, the high-rises, museums, and Starbucks-type coffee shops I had explored with my girlfriend Amanda the previous day in the capital Addis Ababa were replaced by lush green vegetation, corrugated metal mosques, and local citizens chewing chat.  We were unmistakeably back in western Ethiopia, in a similar region to the one I had spent a few months in during the summer of 2013.

We were re-entering Oromia amidst rumors of violence and protests against the government, and it was only once we had spent some time again with our Oromo friends that we truly learned the extent of the situation on the ground.

When we arrived at the hotel where we would be staying with Dr. Samuel, Sister Evelyn, and the rest of the eye team, we learned that there was no water in the hotel.  Apparently, while improving one of the main roads in Bedele, construction workers had hit a water line, leaving half the town without water (apparently the brewery was safe, as it had its own water supply!).  Electricity was never a given either, as rolling blackouts were common.  Suffice it to say, I loved it.

After a brief reunion with Sister Evelyn and Dr. Samuel, I rested in my room until dinner, when I got to reunite with virtually all of the members of the eye camp in Gambella from three years ago.  It was one of the high points of my trip to be able to see everyone again, although one of the ophthalmic nurses, Mitiku, was so happy he hugged me for a full minute, to the point where my non-touchy feely self was desperately trying to wriggle away.

UN trucks outside the hotel

As we turned in for the night in preparation for the first day of the eye camp the following day, I couldn't help but feel a mixture of anticipation, hope, and thankfulness thinking about the people we would be serving.  I thought as well about the opportunity to return to the eye camp, where I had had the chance to witness the power of medicine to meet a tremendous need in the world three years prior.