User:GravityFong/Reader's Digest/Jan 2007/Miracles by the Thousands

Ram Shrestha is a heavily built man with a weather-beaten face and a scraggly moustache. But as he lies under green sterile drapes on an operating table in Kathmandu's Tilganga Eye Center, all I can see of him is his right eye. Painted with a brownish yellow disinfectant and illuminated by a small spotlight, it stares sightlessly at the ceiling.

For several years, Shrestha has been afflicted by cataracts, a disease that clouds the eye's lens, progressively dimming vision. Eight months ago the 54-year-old Nepali farmer went completely blind and could no longer work his land.

Peering through an operating microscope, surgical instruments in his gloved hands, Dr Sanduk Ruit makes a small incision in the side of Shrestha's eye. Going in deeper, he reaches the diseased lens and gently teases it out. As the milky blob slithers down Shrestha's cheek, Ruit then inserts a similarly sized clear plastic-like lens in its place. Five minutes is all it has taken.

Shrestha's eye is bandaged and he sits to one side while Ruit starts operating on another cataract patient. Ruit then repeats the procedure on Shrestha's left eye.

Tomorrow morning Shrestha will return to have his bandages removed, and discover if Ruit has successfully performed another small miracle.

In the last 23 years, Dr Sanduk Ruit has personally conducted nearly 70,000 cataract surgeries, often saving more than 100 people a day from blindness. And by developing simpler and cheaper techniques, he has brought the procedure within reach of thousands who could not otherwise have access to it.

For these extraordinary achievements, Reader's Digest is proud to name Sanduk Ruit its Asian of the Year for 2007.

The next morning at the Tilganga Eye Center, the bandaged farmer is led in by his wife Lakshmi. Ruit removes the bandages. Shrestha's eyes remain tightly shut for a couple of seconds. Then, as they slowly open and cautiously move around, his face remains impassive.

"How many fingers?" Ruit asks, opening his fist. "Five," Shrestha replies.

“Touch her nose,” Ruit says, pointing to Lakshmi, who's been watching anxiously. Breaking into a grin, Shrestha steps forward and places a finger right on target.

“What colour is his beard?” Ruit asks, looking at me.

“White,” Shrestha says. “It's black.” “No, it's white,” Shrestha says firmly – and correctly. As Ruit moves on to his next patient, Lakshmi quietly whispers, “He is like God.”

The modest and softly spoken doctor would vigorously disagree. Born in 1954 in the foothills of Kanchenjunga, the world's third highest mountain, Ruit was sent to boarding school in India at age six by his small-trader father because there was no local school.

When Ruit was 16, his younger sister died of drug-resistant tuberculosis. It was then that he resolved to become a doctor. Ruit's special gift for surgery – “He has God-given hands,” says his colleague Dr Govinda Paudyal – soon became evident.

After assisting at cataract eye camps – where surgery was performed free for poor patients – he was so impressed by the impact the fast surgery had on their lives that he decided to become an ophthalmologist. He got his postgraduate degree in 1984, at age 29, from New Delhi's All India Institute of Medical Sciences.

A talented doctor, Ruit rose steadily up the ranks of Nepal's medical establishment. But he soon decided that the country's blindness prevention programme could do better. At the time, in Nepal – and the rest of the developing world – cataract surgery for the poor consisted of removing the diseased natural lens and giving patients spectacles with lenses as thick as a Coke bottle. This helped them see things directly in front of them after a fashion – they could, for example, distinguish a goat from a cow. But their peripheral vision was rudimentary.

A much better procedure, an intraocular lens implant – in which the eye's lens was replaced by a highly specialised clear plastic substitute – was being performed in Nepal, but only for the better off because the lens alone costs well over a hundred dollars, a small fortune for a subsistence farmer.

Given their limited funds, local public health officials and World Health Organization experts felt the procedure was not cost-effective enough and that the ultra-sterile conditions needed were impossible to achieve in rural eye camps.

Ruit disagreed. To cut costs, he developed easier and faster surgical techniques and worked out simple ways – such as making patients wash their own faces thoroughly before surgery – to ensure highly sterile conditions.

With microscopes much less sophisticated than those normally used for eye surgery, he began successfully implanting plastic lenses donated by Western friends. It worked: post-surgical infections were extremely rare.

One serious obstacle, the high price of lenses from Western manufacturers, remained. Ruit conceived a plan to make the lenses in Nepal.

But could he convince his fellow ophthalmologists in Nepal and the West that his plan would work? Only a handful of Western eye specialists, who'd taken the trouble to go to Nepal and watch Ruit at work, backed him. In Nepal many ophthalmologists were hostile, including his superiors. Letters criticising him were even sent to Nepal's prime minister.

Rex Shore, a close friend, recalls one telephone call from Ruit. “He was almost crying,” Shore says. “He said, ‘I don't know if I can keep going.' “

But the doctor's mild manner conceals an iron will. A few years earlier, Ruit, a Buddhist from Nepal's Lama community, faced parental opposition when he married Nanda, a young ophthalmic nurse who was a Nepali Hindu. But Ruit prevailed. His parents finally came around four years later, relenting when his son was a year old. Today, they live happily with him, Nanda and their three children.

Now, with so much opposition to his radical eye treatment plans, Ruit's iron will was to be tested again. To pursue his dream he would have to abandon his prestigious hospital job and strike out on his own.

One of his few supporters was New Zealand-born Australian Fred Hollows, who earlier had helped Ruit sharpen his surgical skills. Hollows pledged to raise the money to set up a lens factory in Kathmandu.

In 1992 Ruit took the plunge and established the Nepal Eye Program. His plan was to build an eye facility in Kathmandu that would serve as a base for launching rural eye camps and a training and research facility for ophthalmologists.

The Tilganga Eye Center and The Fred Hollows Intraocular Lens Laboratory, built with donations from the Australian government, a Kathmandu temple trust, a Buddhist charity and local businesspeople, opened in 1994.

After 18 months of trial and error, the laboratory started producing lenses in January 1996. Today, the lenses are used in 70 countries. Price: around $5.

With his enormous success, other eye organisations started emulating Ruit. Some 98 per cent of surgery in cataract camps in Nepal are now lens implants, and the number of Nepalis blinded by cataract is falling significantly.

“Can't you give us a concession?” Sanjay Kumar Shah asks Tilganga ophthalmic assistant Satish Shrestha. Sanjay's elderly father, Jagadish, needs cataract surgery, and Sanjay has been asked to pay 6000 Nepalese rupees, the full fee.

“Come on, you can afford it,” Shrestha replies, and after a little grumbling, Sanjay, a house painting contractor, agrees.

Cataract surgery at eye camps is free, but at Tilganga those who can afford it – in full or in part – must pay. Thanks to this policy, the centre makes enough to meet all its running costs, including salaries. Outside aid is needed only for cataract eye camps and for new equipment.

About a third of Tilganga's patients are too poor to pay. But Ruit has laid down that all patients must be treated alike. Geoffrey Tabin, an American ophthalmology professor whose Himalayan Cataract Project provides much of Ruit's outside funding, says, “He takes as much care and love on the surgery of the poorest of the poor as with the highest VIP.” Ruit insists that even the poorest may choose their surgeon. Recently a patient came in asking to be operated on by the “doctor who was in the newspaper.” “We presumed,” says Ruit's deputy Dr Reeta Gurung, “that he meant Dr Ruit and put him on his list.”

Such indifference to class is rare in feudal Nepal, but Ruit has little patience with convention. Some years ago, when he was inducted into King Birendra's panel of ophthalmologists, he went – as had all his predecessors – to the palace, taking along the bulky equipment he needed. But he wasn't happy – the room provided for the checkup was poorly lit – and he felt proper standards were being ignored for the king's supposed benefit. So he asked the king to come to Tilganga. His temerity raised some eyebrows, but Birendra agreed.

Two years ago any lingering doubt among sceptics was laid to rest by a clinical study in Nepal, in which 108 blind cataract patients were randomly divided into two groups – one assigned to Ruit and the other to Dr David F. Chang, clinical professor at the University of California, San Francisco, and one of America's fastest and best cataract surgeons.

Chang performed the operations with state-of-the-art ultrasound equipment that cost $100,000. Ruit used tools less than one-sixth as expensive and was able to operate in half the time. Yet 98 per cent of both groups regained excellent vision.

Seeing Ruit's programme firsthand, Chang says, “is an awe-inspiring experience.”

Now medical professionals from Asia, Africa, Europe and the United States come to the Tilganga Eye Center to learn new techniques.

Ruit himself travels to demonstrate his methods. He likes to go to countries with the greatest need, and in 2005 took a team to North Korea where they performed more than 700 surgeries. The country has a large number of patients with advanced cataracts. They want to revisit this year but, Ruit says, “getting funding for North Korea is very difficult.”

At the Lhasa Institute of Eye Care, in Tibet, five local doctors crowd around Ruit, watching him operate on an elderly woman's cataract. Some of Ruit's favourite Hindi film and Nepalese songs play softly in the background.

Ruit pauses and looks up. “By creating a wound shaped like a funnel, the cataract can be easily removed.” An interpreter translates, and five masked-and-gowned heads nod vigorously.

As Ruit spreads new techniques to these doctors and many hundreds of others, hope is growing that one of the great public health challenges of the 21st century can eventually be overcome. Some 20 million people – mostly poor – are blind because of cataracts, and without drastic intervention this number will climb to a massive 40 million by 2020.

Since the Tilganga centre is now well established, with professionals capable of taking over if Ruit leaves, I ask him why he doesn't go abroad and make some real money. He's fit, thanks to an hour of vigorous badminton most mornings, but he's nearly 53 and his children are still young.

Ruit shakes his head and smiles. “Nowhere else can I make such a difference in people's lives as I can here,” he says. “I am very fortunate, really.”

Reader's Digest will present Dr Sanduk Ruit's award as Asian of the Year in a ceremony to be held in mid-January. Visit rdasia.com to find out more about the ceremony. Our website also have links to Dr Ruit's projects and his eye centre in Nepal.