Eye

Interview with Dr Judith Simon, July 2012

In 1988, with a fresh diploma I started to work as an ophthalmologist under impossible conditions. I was allowed to do only secretarial and technician’s work. I thought that I would try my luck in a foreign country. I went to the United States, first only for a few months. Later, I settled there with my husband, who is an anesthesiologist, and did research for two years. Only after this could we get our green-card and work as doctors. Luckily, we both got jobs, and for seventeen years we have been living in New Jersey.

    I always wanted to work in a developing country; I was already preparing to go to Africa during my university years, but back then I could only skip a year for a very serious reason. Meanwhile, our two sons were born, 15 and 12 years old. While they were young, it was unthinkable that outside of daily work there would be time to do other things. However, by 2003 they were old enough, so when I got a letter from a gynecologist inviting me to a one-week trip to Mexico, I seized the opportunity. I did not know this doctor personally, but later I found out that she sent a letter to all the three hundred ophthalmologists in New Jersey, and I was the only one who answered. I called her, and she told me where we would go. I would have to organize the trip myself. The destination was a small village in the state of Chiapas in Mexico named Ocotepec, where its residents live in extreme poverty. They do not starve to death, but they are severely malnourished, and almost everyone is infected with tuberculosis. Half of the population does not speak Spanish, but only their native language, Zoque, therefore they cannot assimilate or get jobs. Their laziness is not genetic, but rather cultural: it simply is not a custom to work. Most men just sit at home and do nothing. They have a very low standard of living. If they get sick, they either get better on their own, or they die. There was no road from the capital of the state pf Chiapas, Tuxtla Gutierrez, which is seventy five miles from Ocotepec, until now. It used to take six to seven hours to get there. By now they have built a paved road.

    The way the gynecologist and her husband who was a dentist got to Ocotepec was to first send their sixteen year old son to the Salesian Sisters’ orphanage. The sisters were part of a Catholic order doing progressive social work. Their son worked at the orphanage for two months, with the aim of learning Spanish, and changing his moral values. Unfortunately, in America, most children are terribly spoiled. Frequently, the only thing that matters is the size of one’s house and one’s car, and how much money one has. His parents would have liked him to see other things in life. He was able to adjust. He made Mexican friends, and perfected his Spanish. The parents, although they were not at all religious, were so grateful to the nuns that they asked them what they could do in return. The director of the orphanage asked them to give healthcare to the poor locals. The orphanage is in the capital of Chiapas, Mexico’s southernmost and most poverty-stricken state. In the end, the doctors did not go to the capital because there are doctors there; instead they went to Ocotepec, where there is also a convent. However, it is completely isolated from the outside world. The couple first examined the area. The dentist pulled teeth; the gynecologist examined women and handed out antibiotics and other medicine. For the past seven years, they go back every 6 months with an increasingly large group and lots of medication. When I was first with them, I could not do much because the circumstances were horrible. For the eyes of people living in the developing world, the best way to help is by performing cataract surgery. The number one cause of worldwide blindness is cataract. People suffering from glaucoma cannot be treated in developing countries because of the lack of equipment. However, a cataract can be removed in a thirty-minute long surgery. The shame of the world is that despite this, twenty million people are blind because of cataract worldwide, and the number is growing from year to year. In India it costs five dollars for an eye operation, but many people cannot even pay for that, and people starve to death because they are blind. Unless one is lucky, and someone takes care of them, in a developing country blindness frequently leads to death. I know a doctor who became an ophthalmologist because he thought that out of all medical specialties, an ophthalmologist can help the most. Internists, for example, cannot help much: to treat chronic illnesses, they would always have to be present. In the best case, they distribute antibiotics and pain relievers, and the patients feel better for a few days or weeks. But the problems are still not solved. The villagers usually do not understand how to take medication. The concept of a “healing tablet” is totally foreign to them. We heard on one of our trips that children were playing “marbles” with pills and eating the toothpaste. Dentists can only pull teeth, which helps a lot because many patients suffer from years of toothache. They have no time to do fillings. The people can go to the capital to get treated for only a few dollars, but they cannot even pay for travel. In Mexico, nobody is treated for free. The achievement  of ophthalmologists are truly significant: whoever was blind before surgery was able to see afterward. 

    I went back to Ocotepec multiple times. However, preparation for travel is serious work. First of all, I had to obtain equipment: a slit-lamp, an operating microscope and an autoclave. I received thirty to forty year-old equipment that still worked from my former employer. We brought eye drops, eyeglasses and surgical supplies which got donated by various US companies. The second time, I went with a Canadian and a Mexican ophthalmologist. This helped a lot because back then I did not speak much Spanish, and they were both fluent. Also, I could share the decision-making and the responsibility with them. It is not hard to find partners to go on medical missions because in the US there are many decent, helpful people who are willing to sacrifice a week of vacation and pay for their travel. But it is very difficult to find someone who can help in planning, organizing, obtaining supplies and fundraising. This means many-many work hours, lots of phone- calls, emails, etc. I also made contact with the locals in Mexico so they can prepare for our arrival. In Ocotepec we got a terribly filthy workspace. The nuns were advertising in the churches several weeks prior to our arrival, so lots of people would come. We examined hundreds of patients daily, and distributed the eyeglasses, mostly reading glasses. Although most of the locals cannot read, the glasses are useful for cooking and sewing. There were a few nurses and laymen whom we trained how to distribute the glasses. Our main activity was performing cataract surgery. This consists of removing the cataract and implanting an artificial lens. The next day we examined the patients. We arranged with a local ophthalmologist from the capital of the state that he would check on the patients in two weeks and one month. Unfortunately at first we were only able to perform surgery on three patients because the microscope was not working well –  it probably got damaged on its trip. 

    We went back to Mexico every six months, a total of five times. The third time we went, the ophthalmology team consisted of nine people. We separated from the rest of mission with all the other doctors because we would have been in each other’s way. Many people did not come after one trip because they cannot tackle the task. There was one person who began to cry because he could not emotionally deal with not being able to help a patient suffering from glaucoma. Another person did not dare to perform surgery under substandard circumstances where the paint was peeling, the environment was filthy, and the equipment was faulty. My girlfriend, whom I share an office with, consistently comes with me, even though she had a hard time adjusting in the beginning. She was a princess who came in high-heeled shoes and fancy clothes for the first trip, and everyone made fun of her. In spite of this, she did not give up even though the circumstances – the bad odor, dust, mud, the lack of warm water – must have appeared more terrible to her than to me, who grew up in Eastern Europe. Before the surgery we tidy up the operating room: we wash the floor, and we clean the walls three times with bleach. We bring an autoclave, and therefore the instruments are sterile. In Mexico, we have already performed surgery on sixty to seventy patients, and only the very first patient got an infection when the microscope malfunctioned. Not all surgeries turned out perfectly, but since we follow the same techniques as in the United States and Hungary, other people did not get infections. We had to be very careful not to make mistakes, because if word spread of bad outcomes, no one would come next time we are there. This would render the whole trip pointless. I have heard of incidents where US doctors went to Mexico to practice their surgical skills, and made several people blind, then abandoned them. This is extremely immoral, and unfortunately there are plenty of negative examples. The Mexican government does not interfere with these issues. Many people, who participate in missions have good intentions, but they do not plan well and do not understand the local circumstances. Frequently, they do more harm than good. Some only go to brag about it upon returning. Not long ago, the gynecologist distributed birth control to women in the village to prevent hemorrhaging, and the Salesian Sisters discovered it. It created a huge uproar. In their rage, they were first going to oust the team of doctors, but then they tried to reach a compromise. Since then, the team of doctors has finally been asked to leave by the Catholic Church. In spite of this they will continue to go there, but they will work and live in their own building which the US mission has built since, also in Ocotepec. The sisters would very much like for us, the ophthalmologists to return. However, I think it is not worth it because there are too few patients who are surgical candidates. Presently I am organizing a trip to Nicaragua in March for one week. There is a US-based organization called El Ayudante, “The Helpers,” whose only function is to organize missions. We will be able to operate on much more patients over there, or so we hope.

The healthcare system of a Mexican village consists of four layers: the “social security” doctor who is sent from Mexico City, whom the Americans did not even know about. I only met her by accident. She receives a wage of 100$ a month, a sum which even there is not much. For this amount of money she works only a few hours weekly. As she does not speak the local language, the patients do not trust her, they hardly ever go and see her. During our stay, a 42 year old man with eight children suffered a stroke. The doctor refused to see him; she said she was busy. A nurse from our team went out to examine him, and decided he should go to the hospital. The ambulance car was there, but could not take the patient without the doctor’s order. So the patient stayed in Ocotepec-he either recovered on his own or died since.

The second level is the Salesian Sister’s small pantry where they store medicines collected from various places, much of which they do not know the use for. A nun without any medical degree hands them out more or less randomly. We inspected the medicines, labeled them and did all we could to explain to the nuns how to use them. We discarded a few due to their side affects which could be dangerous in these conditions. The third level is the “witch doctors” who have common sense. They have knowledge of healing herbs, can stitch smaller wounds, and can treat basic injuries. The fourth level is the Americans who visit every six months. I did all I could to organize the first three levels to work together. I had to be quite aggressive to convince the politically rivaled sisters and the local doctor to at least communicate with each other. Upon returning I saw that the cooperation we all agreed on before totally failed. I also could not convince the Americans to stay for longer periods and to establish a better and continuous healthcare system. In theory they agree, but in practice they do not do much for the cause. 

    There are many challenges the American missionaries face in Ocotepec. For instance, a wonderful couple who is experienced in 3^rd World missions tried to help by installing a water filtration system for the villagers. This is more important than anything else because the water is extremely polluted; it causes severe diarrhea and intestinal infections among the locals. They built a system out of sand and bricks that filters the water. They returned there in August, and noticed that the water filtration system that they had installed last year and worked perfectly, broke down because the villagers were too lazy to clean it. (It would require 2-3 hours of work every six months.) He became so disappointed that they decided not to go back there again. Instead, they are coming with us to Nicaragua. The non-medical volunteers who came with the doctors also dealt with other matters, such as teaching the locals to built chimneys in their homes. For centuries, the villagers cook inside their house with wood and they have not even cut a hole on the roof to let the smoke out. They sit in the smoke all day, which causes chronic bronchitis, difficulty breathing, eye-irritation and makes them more prone to contact tuberculosis. (Which nearly everybody has.)With great difficulty, the Americans raised money from donors, had the chimneys built out of tin, brought it to a selected house and installed it. The residents of the house did not lift a finger to help them. On top of that, the chimney was a failure because it was not made according to the specifications, and even more smoke was trapped in the house than before. The rumors about the Americans spread in the village, and no one else wanted a chimney. Later they successfully installed a working chimney, but by then no one was interested in it. An engineer wanted to revolutionize cooking. As a tradition, the villagers cook inside their houses over a log fire. This causes deforestation, air pollution and a severe health-hazard due to smoke poisoning, as mentioned before. This engineer wanted to introduce a very simple method called sun-cooking. Since the weather is mostly sunny, it is enough to blacken a cooking pot with ash, build a half cylinder out of cardboard and cover it with aluminum foil. This reflects the heat of the sun onto the pot, and if one places it in the center, one can cook food in a few hours. If this became more popular, there would be no need to cut and carry home wood, people would not sit in smoke all day, and their respiratory and eye diseases would improve. This did not succeed either because no one listened to the engineer. The gynecologist had an idea to breed rabbits. This would supplant the diet of the villagers consisting of mainly corn and beans with animal protein. She built a few cages, and bought two rabbits in Tuxtla. Despite her being a gynecologist, she did not notice that both of the rabbits were males and they were pet rabbits, not to be bread for food. This sounds funny, but everything depends on small details like this. Hard and continuous work frequently leads to only minimal or no results. I decided not to go back to Ocotepec because it is not worth it. We operated on whoever was a candidate for cataract surgery the past five times we were there, and everyone has three pairs of glasses. Maybe I will try to find another Mexican settlement with the help of the Salesian Sisters or I will continue my work through another organization.

    Starting last year, I have been to Ghana twice. I did not organize the first trip, but rather joined an ophthalmologist who retired at an early age. He has been going on eye-mission trips for 7 years. He is a deeply religious Presbyterian. He and his wife are wonderful people. Earlier, they went 6-7 times a year on missions; now they only go 4-5 times because the price of airfare has increased. They fund their trips with the help of the Presbyterian Church. Since they already have all the necessary equipment, they only need to pay for the trip itself. Physicians traveling along with them, just as I, pay for the air fare, the expenses, the lodging, and meals. It has been calculated that an eye surgery costs about 50$. This is not much money in the US, and many people donate that much to make a blind person see. In exchange, they receive a photo of the healed person whom they helped to be able to see. In Ghana we operated on seventy six people in two weeks. For this to work, everything had to be very well organized. For example, in Mexico we were only able to operate on ten to twelve people in four days. Along these trips, many problems can arise, and one has to be well prepared in advance. This couple has had much experience, and they are excellent organizers. The husband and I took turns in examining and operating on patients. The wife worked as a scrub nurse. We had helpers who gave out glasses and eye drops. We worked about ten to twelve hours daily.

    Besides the operation and the glasses, the best help is health education, because these people do not understand even the most basic rules of hygiene. In Mexico, for instance, we had to explain things which are obvious in our culture. If someone has a red eye, headache and difficulty breathing, it is because there is smoke in the house, and building a chimney would be the solution. What is obvious to us, they cannot grasp. Severe genetic disorders – mental retardation, blindness, etc – are passed on from generation to generation, but they believe that it is a punishment from God. We examined and advised a family of genetically blind people – we tried to explain to them that if a child is born to them, he or she will also be blind because all of the relatives are blind. I was not sure if they understood what we were explaining to them. Translators helped us to communicate with the locals, and at first, when I did not know any Spanish, it was quite difficult to talk with them. We spoke to the translators in English, they translated it to Spanish, and the locals translated it to their local language, Zoque, and vice versa. In Ghana, the official language is English because it was a British colony. Our patients mostly spoke their native language – 5-6 different languages, depending on the area where they came from. More than one translator was required because of this. We set up a list of the most frequent problems from one through fifteen. During the examination, we determined what condition the patient had. By then, the interpreter knew which prewritten text he had to translate, in which he explained to the patient what his condition was, how to treat it and what he should do. In many situations, only advice was necessary. For us it is natural that above age forty, reading glasses are necessary. The indigenous people become scared of seeing blurry; they think they will soon go blind. To the doctors, this means a serious challenge. We cannot treat these people as we would in America. For example, in Mexico it occurred that a colleague gave out medicine with the following instructions: “take this every six hours, that every eight hours, the third one every four hours.” He did not realize that these people did not have watches or clocks, and they do not understand why they are receiving different types of medicine. The dentists gave out toothbrushes and toothpaste. Afterward, we found out that the children ate the toothpaste because it tasted good. One has to be smart enough to realize that under different circumstances, he or she has to adjust practices accordingly. I have learned a lot from the doctor who I went to Ghana with. The following year he asked me to arrange a trip alone to a place where he can only go every other year. If he does not go, no one gets treated. Even though there is a hospital, a cataract surgery costs one hundred dollars with everything included. Besides financial reasons, patients do not go to the hospital because they do have no trust in the local doctors. They may even have good reasons. It is interesting that in Ghana the situation is somewhat better, even though Mexico is wealthier. The second most amount of millionaires in the world live there. Shocking poverty and unbelievable luxury live alongside each other. In Ghana, nearing the shore, living conditions improve. I have not been to the poorest northern half. They do not starve to death, but they are severely malnourished. People are much more hardworking than in Mexico, but the drought is so bad that nothing can grow. They cannot irrigate even though Lake Volta is nearby. There is no irrigation ditch, and the generator would have to be fueled by gasoline, but that is one-and-one-half times its price in the United States, and therefore unaffordable. Due to severe drought caused by global warming, the cocoa plants have died. They cannot even keep livestock because during the dry season, there is no grass for them to graze on, and because there are no roads and no gasoline, they cannot import it. Since then, it has come to my attention that the frequent power outages which cause us great difficulties in Ghana were caused by too little rainfall (possibly global warming). The hydroelectric dam which provides Ghana with electricity, only works partially. By the way, the same situation is present in the United States. I just visited the Hoover Dam, and it is only working at seventy percent capacity because of drought, but here electricity sources are replaceable, while in Ghana they are not. In developing countries, the biggest problem is overpopulation. In Mexico, the situation is hopeless because the Roman Catholic Church has a huge influence. In Ghana there is birth control because it is sponsored by the government. However, only the upper class uses it. The rest try to bear as many children as possible for cultural and material reasons. Infant mortality is very high, and growing.

    In Mexico, people only harvest enough crops to feed their family: beans, corn, and bananas. It is the basis of their work morals to only produce enough food to prevent them from starving. During their free time, the men sit and stare into empty space, which is quite a frightening sight to us. They very rarely live a cultural life, and very few people have professions. The women work all day long to support the household and the children. The Salesian Sisters’ efforts try in vain to help. For instance, they have set up a sewing workshop with machines, taught the youth how to operate them, and people who worked there got paid. Since they built paved roads, the merchants have come. There would be goods to spend money on. But these trained workers were not motivated; they were like children: if they were not supervised, they did not do anything even though they were paid for their work. The nuns and the volunteers who work there fully agree that improvement is hopeless. The education system is very poor. In many places, children are taught through a television broadcast because teachers are not available. The problem is that after two days, all of the television sets are stolen. If a teacher is somehow, with great difficulty, called in from the capital, he or she arrives late Tuesday afternoon and leaves on Thursday. They teach in Spanish, but the majority of children who attend school for six to eight years still do not know Spanish. It is only imaginable how much they understand from the teaching. There are always a few talented and sensible children who are encouraged to continue their education in the capital, and then return to help their family. But even though these children stand out from their companions, and even though the nuns somehow acquire the tuition, they cannot compete with the children in the capital. After six months, they drop out of college because they are not familiar with the basics. In comparison, it would be like sending an elementary school student to a medical college.

    The second time I went to Ghana, I planned the trip myself. This three-month preparation demanded serious work. Six of us went, two of us were doctors, two were nurses, and two were laypeople. I acquired all the equipment, packed eight seventy-pound suitcases and sent them to the plane. At landing, however, a suitcase which contained the most important instruments required for surgery was lost. My responsibility was tremendous because if we do not find a solution, everyone’s airfare would have been lost. At last, with the help of friends I borrowed instruments from a local doctor. Of course, nothing went as I had planned. I had to invent a new technique to remove cataracts. Progress was slower than usual because there was only one set of instruments instead of two; after we used them, we had to sterilize them, and wait for them to be ready. Sometimes the generator would stop; there was neither electricity nor water. Sometimes I completely lost hope. Unfortunately, eye surgery requires so many instruments that without them, performing surgery is prohibited. For example, on the last day, every light bulb for the microscope light burned out. Despite this, we operated on forty one patients, two thirds of which were earlier completely blind, the rest only half blind. 

    The stress was massive, but if one takes it lightly, one is not even supposed to go to these places. Whoever gets the hang of these trips later cannot stop attending them; it is like a drug. At home, if I do not operate on a patient, I know that he will find another eye doctor around the corner, because in America there is an abundance of doctors. Here, everything is easy; everything is organized, routine work. But in a developing country, every minute brings a challenge, which brings a feeling of success. I needed all of my creative talents to solve some of the problems.

Written by: Judit Horgas