Daily Journal of Unite For Sight Volunteer Experience in Bihar, India

By Austin Chiang, Duke University Student, Unite For Sight Volunteer in Bihar, India

Day 3: Starting the Volunteering Experience

We woke up early in the morning to have tea with Dr. Renu out on the veranda. Every morning, we would have hot Darjeeling tea with milk and chomp on Indian cookies. About an hour or two later, we would have breakfast, which consisted of toast, an omelette, fruit, lassi (yogurt mixed with sugar and water), and other Indian dishes. Throughout the week, we would have mangoes - some of the sweetest mangoes I've ever had.

Soon after, we left for the ABEI. Patients would first file into the room Alex and I were in, where we would screen them before they went on to see either Dr. Pooja or Dr. Sacha. We would have the patient undergo an autorefractometer reading, and then we would ask them what complaints they had. We also measured their blood pressure manually and had them read off an eye chart with an eye covered each time. We would also test their color vision and their reading vision. The clinic operated on a PA system where patients' names would be called by either Dr. Pooja or Dr. Sacha. A young fifteen year old boy named Ravi Kumar would run the errands between the rooms.

On the first day of volunteering, I learned of a condition called Nystagmus. Nystagmus is the involuntary jerking of eyes back and forth. It is very rapid and Dr. Pooja informed that though there are many causes for it, one reason is either the inability to focus an image. The eye compensates for it by constantly searching for a clear image in every which direction. In Dr. Pooja's office, we also learned the basics of looking through a slit lamp and how to use an indirect ophthalmoscope. At the ABEI, I was also told that they were in need of equipment and medications. The ABEI would be grateful for donations of an old fundus camera, B-scan, IOLs, medications, or pen tonometers. The ABEI is still very conservative with their expenditures, and they use pins rather than staples to keep the patients' medical records together for their reusability. Often, there would be blackouts due to distribution of electricity around the city. There simply wasn't enough electricity to go around the entire Patna. The blackouts would even occur during surgery, but thanks to generators and voltage stabilizers, these blackouts shouldn't pose any serious problems.

I noticed that many of the patients that walked in looked much younger for their age than they were. Many of the Indian men were very small, and it seemed to be a result of malnutrition. This is just speculation, however, and it was also brought to our attention that many Indians do not have the custom of eating lunch. Usually, they only eat fruit.

In the first day, I already observed a child who had lost sight an one eye due to an accident. The optic nerve had been irreversibly damaged, according to Dr. Pooja, and she prescribed steroids, which would reduce inflammation of the optic nerve, as consolation to the child. The efficacy of the steroids, however, was bound to be low.

Another young girl had the aforementioned Nystagmus, and this was caused by an underdeveloped retina, according to Dr. Pooja. The eye was constantly trying to search for a focused image. Unfortunately, due to her underdeveloped retina, the girl would never have clear vision, and has been unable to attend school for this reason. It deeply saddened me to know that she would probably be illiterate for the rest of her life. Her fate was seemingly set in stone, and it was at such a moment that you realize how important an education is. Her illiteracy would not only hinder her from any lofty career goals, but also from social acceptance in the future. I could only hope that the girl would have a good marriage and a dignified way to feed herself after she becomes an adult.

After the morning clinic, we went home for a quick lunch (around 3 or 4 PM) and we learned a few basic terms in Hindi so that we could better communicate with the patients. Each day, the Sinhas go to a different charity clinic, and Monday's were reserved for the Red Cross Charitable Hospital near Gandhi Maidan. The Red Cross clinic was in shambles and the building was also very dirty. Patients were waiting outside a big room that had nothing more than a desk, a basic eye chart, some broken equipment under some dusty cloth. It was a pity to see that a charity clinic belonging to such a large organization as the Red Cross was in such a condition. We plowed through fifty or so patients like a factory assembly line, having each one of them read off an eye chart. A blackout occurred for five to ten minutes and we all waited in the sweltering heat (there was no air conditioning in the building to start with). After the patients underwent our preliminary screening, they went over to either Dr. Pooja or Dr. Sacha for their advice. The charity clinics were open to anyone, and many patients would arrive early in the morning even if they knew we'd be there in the afternoon. Many patients would travel from other parts of the Bihar state to come to these charity clinics, and often it would cost them an arm and a leg to travel this far on public transportation. Dr. Pooja and Dr. Sacha would then decide whether they'd like to follow up on a certain patient, and subsequently extend an invitation for them to visit the ABEI at a later date. To visit the ABEI would mean greater traveling farther for these patients, which meant yet another financial burden for these patients. Luckily, treatment and visits are complimentary, and cataract surgeries would also be complimentary thanks to Unite for Sight's donations.

Another highlight of that day was meeting a man who shared a name with Saddam Hussein, but of a different spelling. We also observed an old man who complained of some foreign body sensation on his eye. We realized that he had trichiasis, a condition where one's eyelashes grow inward.

Dr. Sacha later taught me of the different cataracts surgeries: small incision, intracapsular, extracapsular, and phacoemulsification (I would observe these surgeries later in the week). He also described the use of foldable and non-foldable IOLs in these surgeries. After charity clinic we returned the ABEI for the night shift, where approximately 15 more patients were seen by Dr. Sacha. By the time we got home for dinner, it was around 10 or 11 PM. Later that night, we decided to sort all of the reading glasses according to power and package them so that we could take them to charity clinics later in the week and distribute them to patients immediately after Dr. Sacha gives his prescription. For about an hour, Dr. Sacha, Dr. Pooja, Alex, and I sat on the floor of the living room where we emptied all the boxes of glasses onto the floor. We were told that the next day at Danapur, we would probably be seeing the poorest patients we would see the entire week.

Day 4: More of Patna

We awoke to what I thought was the clinking of Dr. Renu's spoon to her teacup outside, but what was actually the wind chimes in the living, that would continue to ring throughout our entire stay.

We began the day by making a visit to the blind school Dr. Ajit Sinha had founded. Today, the school provides free housing and education for twenty to thirty girls up until they complete their secondary education. Dr. Ajit explained that he expects all the girls to continue onward to college. Driving through the gates along a narrow road surrounded by tall grass and swampy ponds, we make it to the blind school, a one story building where classes were held and the girls lived. The girls were in the middle of singing their morning prayer when we arrived, and we were given a quick tour of the school and its humble interior. A small staff keeps the school running. The girls were asked to demonstrate their extraordinary reading skills, and interestingly their "writing" skills, where they use a special punching tool to punch out Braille characters. After punching out a sentence, one of the girls read what she wrote to us, "Welcome from America. We are very glad to meet you." Alex and I left a short message in their guestbook, and we also saw that previous Unite for Sight members left messages as well. Next to the small building, a new three-story school was being constructed, which would allow them to admit girls that they had to previously reject due to overcapacity. Dr. Ajit estimated the completion of the construction to be in six months. Interestingly, he said the construction cost was 1 million rupees ($20,000). For the price of a car, you could easily build a school. That really made me think twice about the choices I make in my own spending.

At the OPD, we continued to practice the indirect ophthalmoscope in Dr. Pooja's office. Dr. Pooja told us that one patient we practiced on was delighted after we practiced because he thought that he had just received a consultation from American doctors. I also was able to observe (through protective goggles) laser treatment for a patient who was suffering from hemorrhaging due to diabetic retinopathy. Another boy had a congenital cataract and Dr. Pooja had to emphasize the importance of getting it treated. Many parents do not comprehend the importance of an operation on their children's cataracts before the situation worsens.

Later on, Dr. Pooja brought us into the operating room for the first time to give a steroid injection to a man who had ingested "Thai alcohol." Because the quality of the alcohol was much like rubbing alcohol, it caused inflammation of his optic nerve and Dr. Pooja was attempting to reduce the inflammation.

In the afternoon, we gathered our bags of glasses and embarked on a 45 minute trip to Danapur Cantt, an area of even greater poverty. We drove under the scorching sun past some military confinements and horn-honking was, for once, prohibited. We arrived two and a half hours later than we had anticipated because we left much later than we should have, and patients were waiting for us under a large white banner that read "Free Eye Camp for Cataract courtesy Unite for Sight, USA & A.B. Eye Institute, Patna." What a welcome. We "set up shop" in the small foyer of the building (which usually is a school) and we put our glasses in little piles. Dr. Sacha and Dr. Ajit sat in the other very small room where they took patients. We distributed prescription reading glasses to those who needed them, but we tried to give all children sunglasses if they didn't have a pair at home. The children often thanked us by saying "Dhanyavaad," thank you in Hindi, and one kid ran back after doing so to say "Good Evening, Sir!" We shot photos at the same time of the elderly and the young alike donning their new sunglasses. One boy had a spiffy pair of Spiderman shades while another girl had star-shaped sunglasses. Dr. Pooja, who sat with us in the foyer, told us that some of these kids would be happy for the next two days while they show off their new glasses.

Dr. Ajit called us in a few times to see a few special cases, one of which was a man with "aphakia" or the lack of a lens. This was a result of a primitive cataract surgery where the entire lens was removed and the patient was given glasses to compensate for his focusing ability. Like the previous day, even if the patients were invited to Patna for a free and more extensive checkup, it would be difficult because patients themselves would need to come up with the funds to pay for transportation to Patna. On a side note, one visitor was an albino Indian, who surprisingly looked just like any other blond man in the U.S. Perhaps it's due to the Indians' prominent facial features that a simple change of skin tone and hair color could make them look not as if they were albino, but as though they were of a complete different race. Interesting.

Because it was July 4th, the Sinhas decided to take us to the only five-star hotel in town, the Maurya Hotel of Patna for dinner. I guess having done their fellowships at Stanford University, Dr. Pooja and Dr. Sacha both sensed the importance of Independence Day and wanted to celebrate with us. The plan was to have dinner (a late one of course at 10:45 PM) and go home to watch the World Cup game between Germany and Italy (that didn't happen because we were dead tired). We had our chicken sizzler plates, and ended the meal with a very strong tasting Betel leaf (which left our tongues very red!).

Day 5:

After our normal morning routine, we decided to head over to a schoolhouse around the corner before going to the OPD. The schoolhouse provided free education for 100 children. We had all the kids come in two at a time to our makeshift clinic, where we hung an eye chart across the room from a mirror. The kids covered an eye each time and read down the eye chart. For those who did not possess 20/20 vision according to our screening had their names taken down by Dr. Ajit. These names were handed over to the teacher, who would be responsible for contacting the kids' parents. These kids, like patients from other charity clinics, are entitled to free checkup at the ABEI.

In the operating room we observed a cataract surgery of the small incision type. No sutures were necessary after the procedure, and very little bleeding occurred.

In the afternoon, we headed over to the Punjabi Biradari Charitable Eye Clinic, which was located in a small room to the side of a narrow alley. There, we set up shop once again with our piles of glasses and this time we also brought along medicine samples for those that needed it. We separated the medicines into piles of antibiotics, artificial tears, steroids, etc. and according to Dr. Sacha's diagnosis, we would hand whichever one was relevant over to the patient. At this charity clinic, there were girls to whom we offered sunglasses, but they refused to take them fearing embarrassment. For some patients we didn't have any glasses that matched their prescription, and often we'd try to find glasses with only the frames (and not the lens). We learned that even providing frames for these people would allow them to save a good amount of money. This way, they could bring the frames to their local optometrist and have them make the lens. Another memorable experience at this charity clinic was when a man touched my feet as a sign of respect. I had only seen this gesture done to the elders and to those who are highly respected. Many a time, I had seen Dr. Ajit and Dr. Renu greeted in such a manner, but never would I have thought anyone would do it to me. I felt very honored, even if all I did was hand him a pair of sunglasses.

To end the day, we headed over to a bridal family party of some soon-to-be-newlywed relatives of the Sinhas and enjoyed some delightful Indian food while we were there.

My experience thus far had been amazing, and it really serves well that the Sinhas are leading by example, especially in so destitute a community. In a full-page newspaper advertisement in memory of a late executive of the Reliance conglomerate, they quoted a verse from the Bhagavad Gita (Ch. 3 - Text 21), and I managed to copy it down.

Whatever action a great man performs, common men follow. And whatever standards he sets by exemplary acts, all the world pursues.

Day 6: The bloodiest day

We began the day by going straight to the operating room. It was a procedure we had long awaited. We were told early in the week that a boy had suffered severe trauma to the eye when fellow student accidentally stabbed him in the eye. The boy had asked for a pencil and when turning around to receive it, the unthinkable occurred. Because the boy left the eye untreated for a few months, the eye had become infected and rather than being filled with vitreous, the eye had become filled with pus. The operation the boy needed to undergo is called an evisceration.

Dr. Ajit Sinha proceeded to cut around the iris. After the opening was made, blood gushed out of the eye ball and Dr. Ajit used a spoon-like utensil to scoop out the contents of the eye. He sealed the wound using thick thread, and eventually we would expect the sclera to collapse. An artificial eye would then be put in four weeks after the operation.

In the afternoon, Dr. Sacha took us to the All India Radio Station. Walking past a guard house (and a pile of burning trash outside the fences of the station), we entire a building that lacks air-conditioning, but is poorly guarded. Here, Dr. Sacha would be interviewed and recorded about common questions people have about whether green vegetables help with vision, whether pills can help improve vision, etc. He would also answer questions many people have such as, "Are glasses bad for children?" He clarified that sitting close to the TV isn't a sign that a child is naughty but rather a sign that he is having trouble seeing. Dr. Sacha believes that it is not the TV that causes nearsightedness, but rather the eye's own propensity to change its shape. Dr. Sacha tells us that Patna is still without FM radio, and that they are currently developing digital recording. Most radio stations are government owned, and only recently are private radio stations emerging. But Patna is still behind in that aspect as well, and we see that as soon as we are told to sit in a dusty library of old tapes. We meet a lady, who we later find out will interview Dr. Sacha, and she introduces us to her son and also offers lassi for us to drink while we wait. Finally, we are led to the recording studio, where Alex and I are told to sit in the control room. We see Dr. Sacha being interviewed through a window and we can hear the recording as it happens in the control room. The engineers are all female, and they tell us that photography is prohibited. After the ten minute interview, Dr. Sacha and the hostess come into the control room to listen to the playback and make sure everything was recorded. Dr. Sacha told us that in past interviews, blackouts have occurred and often they would have to re-record everything. He also told us that he forgot to turn off his cell phone during the interview, so he was thinking about that the entire time.

On our way back to the ABEI, Dr. Sacha decides to take us to a special place where we can get a view of the entire Patna city. The Golghar Granery was erected by Queen Victoria in the 1700's as a way to store food when India was then undergoing a famine. Climbing up about 200 steps, we made it to the top of the dome, and there, we had a breathtaking view of not only Patna, but also of the North, where there was a large expanse of empty plains and of course, the Ganges river. The weather was sunny, but if the weather was ideal without any haze, Dr. Sacha told us that we could see the Himalayas in the distance (all the way from Patna!).

In the afternoon, we went to the charity clinic at Netra Chikistalaya in Patna City. Other than Danapur, this was the poorest region we visited during our stay. We took a half an hour car ride to the outskirts of Patna, and not only were the roads crowded and filthy, the air was full of dust and car exhaust that it was difficult to breathe. I could barely see through the windows as well. Every activity possible was happening at the sides of the street: bathing, defecating, playing, eating, etc.

When we arrived at the clinic flies were swarming in the air, goats were roaming around the streets and we were greeted by the sight of a street vendor who was selling sweets in a glass cart, only they were covered with flies and bees were floating around in the sugary water. A pharmacy was located next to the clinic, and calling the place a clinic would be an overstatement. It was more like a cave to the side of the road, an alley where there was barely enough room for the patients waiting. We squeezed past the patients to a two small rooms where Dr. Sacha would be conducting his checkups, and we were fortunate to have a table to put our glasses on display.

At the charity clinic we saw a young woman holding a baby who had black eye shadow-like material smeared around the baby's eyes. Dr. Pooja explained that many Indians believe that this black substance actually helps the baby's eyes, when in fact, it is actually harmful to the eyes. Another man that came by needed reading glasses. None of the glasses we had in our small stack on the table fit him well (we left most of the glasses in the bags, only taking a small portion out on the table). At the sight of us flipping through the bags to find a more suitable pair for him, he started being very picky. Noticing that we had more glasses than were on the table he said, "Take them all out and let me choose from them." Dr. Sacha and Dr. Pooja were very upset at this sight and told the man to either take the pair we offered or to leave them for someone else. We were offended by the fact that we were trying to do some good by providing a pair of free glasses when he took it as though he could shop around our collection. The man decided to leave the glasses and his prescription and storm out of the clinic.

On my way out I wanted to take a picture of the street vendor and his insect-infested treats. I hesitated, thinking that it might be offensive to take a picture of this fiasco inside his box, but Dr. Pooja reassured me that the vendor would actually feel honored because he thinks he's selling the best food in the entire world. So, I snapped a picture, and to a horde of people staring at us (as usual) we hopped on a car and left. Next thing I know, there is a horse-drawn carriage and Dr. Pooja tells me to get off the car and take a picture with them. I climb up next to men who are sitting in the buggy, and Dr. Pooja snaps two pictures of me. The men and those surrounding the horse didn't look too amused that I interfered with their routines, but perhaps they didn't know how else to react to a foreigner climbing in next to them.

At night, we headed over to the pre-wedding party part two, called a Haldi. Here, relatives of the groom are invited to smear turmeric all over the face of the groom, and also have some smeared in return. There was a long line of people waiting to smear the yellow curry powder on the man, who was sitting before an altar.

Day 7: The final day

My journey had come to an end, but it was definitely a bang and not a whimper. After breakfast, I went in to the operating room to observe a string of procedures. First, I had the chance to observe an ECCE (extracapsular cataract extraction). This type of procedure is perhaps the easiest to perform, because a big incision is made and the entire cataract is removed in one piece. This is a more primitive form of surgery, but alas, it serves its purpose after Dr. Sacha slid an IOL in the place of the cataract. This procedure did require sutures, and actually, most patients from charity clinics who are in need of cataract surgery are given this surgery complimentarily (thanks to Unite for Sight).

Another patient underwent phacoemulsification (phaco for short). This procedure is done by inserting a "jackhammer" like instrument that also doubles as a water jet and a suction device. The "jackhammer" essentially breaks the cataract into pieces, and the suction gets rid of the resulting debris. The water jet also helps to wash out debris by forcing it out of the eye. Very little bleeding is involved and no sutures are required after inserting the IOL.

The last patient we observed had previously undergone cataract surgery, but because some debris was still left behind after surgery, fibers had grown over the backside of the IOL and needed to be cleared. Dr. Sacha simply went in and used a water jet to wash out whatever he could without risking injury to the feeble interior of the old patient's eye.

Having brought my camera to the ABEI that day, we made sure to shoot group photos of the entire staff there, and of course, I took pictures of some of the workers doing Jackie Chan poses. They were excited because many of us need to understand that these people often do not own cameras or perhaps rarely get their photo taken. I have since passed the photos onto the staff via the internet.

Later in the day, we went over to the Drishti Clinic to observe Dr. Pooja and Dr. Sacha use the YAG laser and the B-scan. This equipment was not available at the ABEI, and this was simply because the ABEI could not afford such equipment at the moment. The head of the Drishti clinic was kind enough to allow the Sinhas to use their facilities at a small price. The Sinhas told us that most doctors in the area are very competitive and thus compromise their service for their own glory. Because each doctor seems to want to have an autonomous practice, independent of everyone else, they simply can't procure the funding for better equipment.

The YAG laser was used to clear some fibers that had grown over an old lady's IOL, and Dr. Sacha used the laser to clear a hole in the middle of the lens so that the patient could at least have better central vision. The B-scan was used to show whether any unwanted material was present in the anterior chamber. Normal B-scans would show no elevation in the central portion of the reading, but Dr. Pooja demonstrated on a patient who had something in his vitreous how elevation appears on the B-scan. Earlier in the week, Dr. Pooja also performed an angiography on another patient, where dye was injected into the patient's arm, and photos of the optic nerve and the surrounding blood vessels could be taken on a retinal camera as the dye passed into the retinal circulation.

Our afternoon charity clinic was a brief one, considering the Sinhas only recently joined that charitable hospital. At HMRI in Rajabazar where the charity clinic was held, about five patients came in to have their vision checked and to get a brief checkup from Dr. Sacha. On man came in complaining that he had waited too long, only to be confronted with the fact that everyone else had also been waiting and that he had come to a charity clinic and not somewhere where he paid to have an appointment. Another young man that walked had obvious problems with one eye. It was entirely swollen and you could not see the iris at all, it looked as though the entire eyeball was a swollen white sack. The man said six years ago he was injured by a stick that impaled his eye. Up until three years ago, he said, the eye was fine. But since then, the eye, according to Dr. Sacha, has not been infected, but the cornea is extensively scarred.

After a quick charity clinic session that day, Dr. Pooja and Dr. Sacha decided to take us out for a little shopping, just so we could take home a little bit of India. We went out to purchase some kurta pajamas, a type of clothing Indian men wear. We also bought some fancier kurta pajamas along with a scarf, which Alex would wear later that evening to the wedding ceremony I would miss. I was bound for Delhi later that night, and so we decided to head back to the house so I could pack up before I went on my way. Before I left however, Dr. Sacha handed me a copy of the DVD he had shown us on the very first night describing what the Unite For Sight experience would be like. I would come back to the US and show this DVD to more interested Unite For Sight members. As a surprise, the Sinhas prepared a carved wooden statue with my name and a small certification that I had completed the program as a good bye gift. After taking last minute pictures, Alex stayed behind with Dr. Sacha and Dr. Pooja, and they would go straight to the wedding. Dr. Ajit and Dr. Renu were in the same car as me, and they would accompany me to the airport before joining the festivities. I felt bad that the two doctors were missing out because they needed to send me off. They said it would be their pleasure to spend these last few minutes with me, and it was very kind of them to say that. As I got off the car, Dr. Ajit wanted to send me off at the door of the airport. Dr. Renu remained in the car, and as I said my goodbyes, she told me to lean in toward the window where she sat. She touched my forehead "as a blessing" she said.