Hope In Sight Book Chapter

After joining Dr. Aisha Simjee on a medical mission to Buca Bay, Fiji, she asked me to write the chapter about the trip for her book, Hope In Sight. In her inspirational work, she recounts in each chapter her journey to a new country restore vision for the local people. I was honored to be asked to write this chapter, which will appear in a second edition of the book. Please enjoy the text below.

“The world is ruled by those who show up.” – Robert Johnson and Richard Weingardt, 1992.

The eyes are islands within the body – though they are systemically connected in crucial ways, unique microenvironments self-regulate and the presence or absence of tiny variables can throw the delicate system off balance and crucially affect vision. Similarly, while Fiji is in some ways part of the modern world, it does not have the facilities or talent to adequately care for its people, leading to many end-stage conditions which would have been treated much earlier in the United States. By examining the eyes of those patients who could make the journey to meet us, our work helped to right that imbalance. In isolated environments like these, the adage above is even more applicable.

I was asked to join the trip to Fiji by Tom Tooma, a renowned laser eye-surgeon from Orange County, CA, and I sensed that the need would be great in the island nation. After the Fiji Islands were granted their independence from Great Britain, the economy gradually improved, but faced major setbacks from internal political tensions which caused three coups in 1987, 2000, and 2006. The lower GDP of the country has contributed to an emigration of talented individuals; there are simply not enough doctors or medical facilities. Further, whereas graduates of Fiji Medical School used to be required to work in health clinics around the country, this requirement was abolished when the school transferred ownership in 1995. There are only five Fijian ophthalmologists listed on the Fijian Medical and Dental Secretariat website, of whom all are located on Viti Levu – four are in Suva and one is in Lautoka, near Nadi. This is especially difficult for a population which is susceptible to pterygia; in 2009, roughly 40% of Fijian exports were based on farming, fishing, or lumber, all of which involve long days in the sun. Further, I feared that the near-westernized levels of caloric consumption would have brought an onslaught of diabetic retinopathy, especially as diabetes is the highest cause of morbidity in that country.

We worked at Mission Natuvu Creek, a facility on Vanua Levu owned by the Tooma family, Tom and Marta, and I was lucky enough to travel with a fantastic team. I was fortunate to be joined by Dr. Zaiba Malik from Cincinnati, OH, an experienced ophthalmologist who was eager to churn through patients in the OR while I could offer procedural opinions. I was also joined by Dr. Nathan Abraham, an ophthalmology resident at Howard University, Jeanne Jackson, a skilled and contagiously friendly RN who worked with me in Ecuador and other countries, and Ben Margines, a medical student who had been shadowing me for several months at the St. Joseph Hospital mobile eye clinic in downtown Santa Ana, CA. Rachael Rokoiri, a local scrub and circulating nurse was invaluable to finding the necessary materials around the facility. In addition, our work was greatly supported by a team of students from Pepperdine University. While many were invaluable in screening patients for glaucoma and taking refractive and keratotomy readings, I am grateful for Tyler Beutel, who skillfully brought order to the deluge of patients who inundated the clinic the first few days. I also admire Cooker Storm, a professor from Pepperdine who deftly organized and oversaw the work of the 22 students.

While Natuvu Creek had the best facilities that I had seen in my travels, it still proved a challenge. The mission sits in Buca (pronounced “Bootha”) Bay, on the far eastern side of Vanua Levu, the second largest and second most populated island with 130,000 residents. It is a two hour bus ride from Savusavu, and four hours from Labasa, two of the main cities on the island. It would have been difficult enough to find supplies in those cities, let alone find them in Buca Bay – the closest general store was a 20 minute drive. Still, the Tooma family had done an excellent job of designing and constructing the mission. The property is focused around a central clinic with a wing each for ophthalmology and dentistry. Our team had two exam rooms, a pre-op, and operating room. Still, only the OR had functioning air conditioning and neither the positive air pressure nor the hand-written sign mandating a closed door could keep the flies out. I nearly jumped to hold back a scrub nurse from swatting a pest preening on the patient’s exposed toes. Dr. Malik’s careful focus through the ophthalmic microscope allowed the students and nurses to swat and shoo without her or the patient’s knowledge. So long as the instrument tray and the immediate operating area were not impacted, the work continued.

I was disappointed but not surprised to find many of the machines yellowing and in disrepair. At our disposal were a phacoemulsifier, an IOL Master, an autorefractor, a YAG laser, and two slit lamps. Without a functioning phacoemulsifier, we fell back on Manual Small Incision Cataract Surgery (MSICS), which takes significantly longer and limited the number of patients we could see. Further, the box of supplies which I hand carried 5,000 miles was useless to us. The patient’s four-hour journey was still worthwhile though, as we were able to create a chart and diagnosis, but they would have to remake the journey at a later date to have their eyesight restored.

The outcome was similar for the IOL Master. On one of the quiet mornings, I found that Ben brought the machine in a wheelchair to the one place with both wireless internet and cell signal. He called Carl Zeiss Meditech tech support, but the call was routed around to too many departments before being connected to support center, by which time it had closed for the day. Another morning, before the clinic had even opened, I passed a utility closet where I saw Ben, screwdriver in hand, scratching his head over the malfunctioning YAG laser. An hour later, he found me and triumphantly held up a piece of paper to the fluorescent light. When I saw light peeking through the microscopic hole, I called back two patients who needed surgery. Within that utility closet, we performed two posterior capsulotomies and a Laser Peripherial Iridotomy (LPI), greatly helping three patients. One older gentleman began smiling as soon as he saw the light in the hallway.

The finicky autorefractor gave results most of the time, but seemed to refuse some eyes. Besides holding open any ptosed eyelids, the students taking the readings had no other strategy than to keep trying. Patients were instructed to stare endlessly at an image of a hot air balloon soaring high above a country road perfectly bisecting an auburn agricultural area. I can only imagine that each element of that photo evoked confusion. These people come from a land of dense vegetation, mountainous peaks, and no wasteful spending, and the visual portal to America underscores how disconnected Fiji is from the rest of the world. Still, the people pride themselves on being disconnected, and they were sufficiently happy to receive medical attention that they persevered.

Despite the limitations, our work in the clinic and operating room was a success. Once Tyler and the other students organized the flow of patients, Dr. Abraham and I were able to examine patients after they had been screened. Candidates for cataract surgery were queued and scheduled, and often times the patient would find a place to stay the night at the mission or the nearby surrounding houses. With one functioning slit lamp, patients quickly flowed in and out of the exam rooms, and with some luck and skill, only one chart was misplaced and needed to be recreated. The operating room was well stocked, and while I am very glad that I brought my surgical instruments, I was happy to see cabinets full of cannulas, injectable material, antibiotics, steroids, and lens implants. The organization of the material was more reminiscent of what might happen in a home compared to a hospital – a box of a hundred multifocal lenses was marked as expired in a utility closet but not discarded. With the help of the scrub nurse Rachael’s skill, we were able to find everything we needed to operate. I left the Alcon lenses I hand carried packed away – they will not expire for several years.

In addition to the patients which I had expected – rural, poor Fijians and the Indian population which had emigrated here over the past few generations – there were a few surprises. The news that a team of American ophthalmologists was going to be at the clinic spread far and wide. “Coconut cable!” one woman replied in jest when I asked how she knew about the clinic – it was her name for “word-of-mouth.” Patients came not only from Vanua Levu, but also Taveuni (an island one hour away by ferry) and Viti Levu (the main island, several hours away by ferry). Although many patients appeared to have no access whatsoever to medical care, some were relatively wealthy. In fact, one patient even was on staff at the Fijian Ministry of Health. This fact highlights both the dearth of facilities and the level of experience that American physicians have. The clinic was inundated during the first few clinic days. Word of mouth also magnified the fact that Dr. Malik and I speak Hindi and Urdu – after the first day, patients returned home to Labasa, a predominantly Indian city, and told their friends and family. Dr. Tooma mentioned that this was the largest proportion of Hindi-speaking patients that the clinic had ever seen, and Dr. Malik never had imagined that her Hindi and Urdu would have helped so much. To me, it only reinforced that patient communication is 50% of caring for the patient. The doctor patient relationship is invaluable.

When we arrived, the two corneas which Steve Moreau, our CEO at St. Joseph Hospital, carried with him, had only 24 hours of shelf life remaining. Fortunately, we found a candidate immediately; I evaluated a 34 year old woman with advanced keratoconus in the left eye, and she agreed to stay the night and be the first case in the morning. After several hours and twenty-two discontinuous 10-0 nylon sutures, she recovered and returned the next day with better vision and a gift for Steve. The candidate for the second cornea came two days later, and I did not feel comfortable transplanting the tissue. Had the patient, a 25 year old woman also with keratoconus arrived sooner, we may have been able to help her.

Dr. Malik accomplished 7 MSICS procedures, including some difficult cases with very advanced, thick cataracts. She and I both worked on 9 pterygium cases, including more than one which had caused extensive vascularization of the cornea. After the procedure, Dr. Malik favored cauterizing and stitching the conjunctiva over performing auto-grafts. In the clinic, I was able to see over a hundred patients. While many came for a checkup and reading glasses, I saw some significant infections. A young male wearing sunglasses because of acute photophobia revealed his eyes, and I immediately saw a severe infection. Fortunately, the clinic had plenty of antibiotics. The Pepperdine students also identified one patient with high IOP, who I found on examination to have potential for angle closure glaucoma. I used the YAG laser to perform an LPI on this patient. On one day, one of the students became a patient. Jake, a 20 year old male student had misused his contact lenses and had 20% erosion at the midperiphery at 7 o’clock. I patched his eye and gave antibiotic ointment.

Some patients were unfortunately beyond our ability to help. One day, a young Indian couple brought their baby with bilateral congenital cataracts who was completely blind. He was a sweet child with characteristic wandering eyes which only reacted to bright light. I looked at the hopeful mother and asked if this was her first child. She began sobbing. In fact, this was her sixth child – the other five ended in miscarriages, and even the boy who lived was born two months prematurely. I suspected that his premature birth caused his blindness, and recommended that she be examined by Dr. Alan Ackerman, a fantastic OB/GYN from St. Joseph Hospital, who joined us on the mission. Privately, he mentioned that she may have developed a late second trimester fibroid uterus. Though I encouraged her, the woman cried in front of her husband and confided that it was because Dr. Ackerman is male. I invited her to Orange County, where there will be more resources to examine her and her child, but I know that it is highly unlikely that she will make the journey.

Also, I again saw the need in developing countries for cosmetic contact lenses, of which we had none. This need hit me most poignantly in Afghanistan, where I saw a girl who was repeatedly turned down for marriage because of an opaque cornea. In Fiji, I saw two young men who had suffered trauma to the head. One of them was a handsome 19 year old electrical engineering student at Fiji National University who had a completely disorganized anterior segment with 90% corneal opacity. Only 10% superiorly was transparent, and there were significant anterior synechias. He was intelligent, kind, and was not asking for much. Another patient was a pretty 20 year old female. She accepted her condition and also only sought to look normal. I fully understand her need, and I asked Dr. Tooma to bring cosmetic contact lenses with him when he next comes to Fiji.

Besides our work, I enjoyed some new experiences in Fiji. In a moment of down time on the final day, I rode on a zip line – this was very enjoyable, but I will not be repeating the experience. I was also convinced to ride in a kayak and go on a short, scrambling hike to some caves where cannibals supposedly used to eat their prey – the bones were an excellent and macabre anatomy lesson.

Fiji is isolated from the rest of the world, and the residents pride themselves on that point. The benefit was clearly palpable in some respects – magnificent sunsets unspoiled by pollution and clean beaches dotted with palm trees which are laden with their own fruit. Still, without adequate medical facilities, the population will continue to suffer from ophthalmologic conditions which are quickly solved in the US. Our work was a much needed dose of help, and I’m glad that we were helpful to most of the patients who showed up. Still, we only accomplished so much; more work will be needed to restore eyesight for the rural Fijian population.