- The Observer,
- Sunday July 13 2003
Tadese Berhe lives near the dry, dusty Ethiopian border with Eritrea, growing wheat and a local crop called tef. Tadese has the waif-like body of a child and the face of a man older than his 49 years, but he hasn't been able to see either properly for more than three years, ever since something began to go horribly wrong with his eye. He went to his local doctor at first, who referred him to a hospital in Addis Ababa, 500 miles away. By now his eye was hideously distended, bloodshot and blind, and they said they could do nothing, it was too difficult. Yet still it kept swelling. Tadese had only one chance left, the city doctors said. It was possible that one day Orbis would come, and would maybe make his eye see again. The told him to go home and wait.
A year later, he made the long bus journey to the city again, in his worn beige suit and baggy brown overcoat. Menelik II hospital would look vaguely agricultural to you or me, but to Tadese it is the finest in Ethiopia. Outside what looked like a stable block, 100 patients waited on rows of low wooden benches. Some wore traditional shawls, others tracksuits, and several had no shoes, but all had something wrong with their eyes. Toddlers stared out of milky blue cataract clouds; on an elderly woman's eyelid a tumour grew, like a chunk of pink coral. Flies looped lazily in the morning sunlight, coming to settle in the streaming red eyes of blank young men. Foreigners in smart navy blazers with clipboards buzzed among them, calling out names, ticking off lists, leading them inside one by one to consulting rooms. The modest rooms are a scrum of local medics and microscope stands, at the centre of each stood a white doctor, loud and confident, dispensing streams of opinions in the intricate language of international ophthalmology, which would be incomprehensible to most of us, and even more so to Tadese, who speaks no English. A foreign film crew ducked in and out, capturing the doctors' brisk decisions of who would have their sight restored, and who would not.
Throughout his examination, Tadese sat motionless, submitting so pliantly as to give the impression of not being there at all. An Italian ophthalmologist, an intense young man with faintly impatient energy, massaged the bulging eye; local doctors crowded round to peer at X-rays. Dr Francesco Bernardini quizzed them over Tadese's head.
'You have a surgical saw? Yes? OK, we can do him. Three hours, Monday.'
The farmer was led back outside, having no idea what had been decided. He didn't ask anything, though, he just sat down again and waited. Only at the end of a long, hot day did he receive the news that tomorrow Orbis would operate on his eye.
The following morning a Land Rover drove him out to the airport. Tadese had never been on board an airplane before. He had never even seen one, nor did he know how unusual it was to find an operating theatre where economy class should be. The farmer wondered whether it would take off into the sky with him on board. In the loo he changed out of his brown suit and overcoat into a surgical gown. Before the Finnish anaesthetist put him to sleep, an Australian nurse asked an Ethiopian translator to find out if the farmer had any questions.
Tadese hadn't asked anyone what was wrong with his eye. Two of his friends had been killed in the last war with Eritrea, and he thought that this was what had caused the problem. He had wept and wept. In the end, he told me, he cried too many tears, and that was why his eye began to swell.
He didn't know he had a massive tumour behind his eye and had no clue that the Italian doctor was about to saw open his head and try to pull it out, but he had no questions to ask. He merely smiled and closed his eyes.
Orbis is an ex-Continental Airlines DC-10, which has been turned into the world's only flying eye hospital. Every other month, it lands in the capital city of a developing country. The plane remains parked on the airport tarmac for three weeks, and each week three different eye surgeons arrive from all over the world, volunteering their services free of charge. Local ophthalmologists invite their most difficult cases to the city hospital for the first day of the week, where the three specialists examine them all, and then select patients for surgery.
Surgery takes place throughout the week on board the plane. The economy section has been converted into an operating theatre, a sub-sterile area and a recovery room. Where business class seats once were, there is a conference room, divided by a glass screen from the theatre, equipped with laser-surgery technology. Next door is an audio-visual television suite. Fifteen on-board cameras are controlled from here, filming operations in theatre and transmitting them live on a giant screen at the front of first class.
First class is the only part of the DC-10 to resemble a normal airplane, but is the most important. It functions as a classroom, where around 50 local doctors sit and watch each operation as it happens; a live audio link to the theatre allows the doctor performing surgery to talk them through each procedure, and answer any questions from the class. A full-time team of about 20 ophthalmologists, nurses and bio-medical engineers, from 10 different countries, are there to assist the volunteer surgeons and to train local medical staff. Some of the lessons are painfully primitive - as basic as the importance of sterilising instruments, or how to change a fuse.
Cataract patients are treated using a modern technique called phaco-emulsification - a procedure which involves puncturing the eyeball and sucking out the damaged lens. On the screen it looks deceptively simple - like hoovering dust off skirting boards. In the operating theatre, though, to the naked eye, it looks more like science fiction than housework. Once the cataract is removed, a folded lens is inserted through the tiny incision. It pops open and within a day the patient can see.
Scarring of the cornea is another major cause of Third World blindness and the volunteer surgeons bring donated corneas with them in their hand luggage for transplant operations. First of all, the surgeon clips the patient's eye wide open, sounding like a TV chef as he talks his audience through each step. Then he lowers a kind of miniature cookie cutter on to the centre of the eyeball and cuts out the damaged cornea, exposing what looks like black jelly underneath. With another instrument, this one more like a hole punch, he cuts the donor cornea to size, lays it over the black jelly and then sews it on to the eye. Like a cataract operation, the graft is performed under local anaesthetic and takes less than an hour, but it restores the patient's sight for life.
Since its first flight to Panama in 1982, it has flown around the globe 12 times, visiting 80 countries, helping restore sight to millions of people. It is the kind of good news story that can tempt you to feel cheerful about what western science can give to the world. Except, Orbis is the only project of its kind, on a planet with 45m blind people. It survives entirely on charitable donations. The president of Orbis spells it out in simple terms. 'It's not Aids. It's not cancer. The point about blindness is, we know how to cure it. It should be easy.'
The week begins at the Menelik II hospital with a screening day. This often makes for heartbreaking, chaotic scenes. If word has spread that Orbis has come, hundreds and hundreds may turn up, pleading for treatment. But only the most useful training cases are selected and the rest are all sent home. Screening days - or 'screaming days,' the nurses grimace - have turned ugly, with angry patients unable to accept doctors' decisions. But that might be less upsetting to witness than the scene here in Addis, where uncomplaining Ethiopians submit humbly to the bitter caprice of clinical selection. Most have the impassive calm of volunteers in a medical trial as though nothing were at stake, and at the end, when the chosen names are announced, there is not even any way of guessing to whom they belong. There are no whoops of joy and no one looks disappointed.
Even when the chosen patients board Orbis for their operation, they appear curiously unmoved. Captain Gil Chase from Idaho has been a volunteer pilot for Orbis many times, but is still as excited as ever. 'Ain't this just something? God I love it.' He loves showing visitors on board and delights in their dropped-jaw amazement. Orbis is a major event in Ethiopia, and even the president makes a visit. He arrives with a vast entourage, right at the most grisly moment of Tadese Behre's operation - as Dr Bernardini is pulling a giant tumour out of his head - and looks duly impressed.
Yet all week, the patients come on board and express not the faintest surprise that this is where their sight will be restored. Merely being on an airplane is so far beyond their frame of reference that nothing they find could surprise them. Their faith in the miracle powers of the west is absolute; anything is possible.
The operating theatre at the hospital, on the other hand, takes some of the Orbis team aback. The surgeons perform some of their procedures at the hospital, to demonstrate to local medics that they can be done without the hi-tech flash of the plane. One of them, Dr Kevin Lavery, tries to be diplomatic about the conditions. 'You know, it's amazing how they work with what they've got. You have to go in humbly.' Dr Bernardini is a little more forthright. 'This place is hell on earth. I came here by myself last year to teach. It is like a century behind. Chaos. I start to use the drill and all the lights go off. And then sometimes the anaesthetist will just go off and pray. They have instruments and they just don't get them to work. Last year I used their saw, it was the first time they'd seen it working! They say, "Oh, now we know it works."'
Dr Bernardini operates on the woman with the pink tumour on her eyelid. The theatre is a scruffy room with peeling walls, chipped and rusting furniture and a cracked mattress on a table, covered in what looks like an old curtain. Used cotton buds and empty wrappers are scattered about and forceps sit in an old can on the floor. Nurses wander in and out wearing stained, shabby scrubs, sometimes chatting on mobile phones, while a fly buzzes over the patient's face. Dr Bernardini adjusts her head a little, and finds a wad of blood-soaked swab under her neck, left behind from the previous operation.
A Filipino nurse from the DC-10 is assisting, but has been distracted by what he has just discovered in the sub-sterile room. The autoclave machines which sterilise instruments do not work - nothing is sterile, but nobody seems to have detected this. Instruments are rinsed, put inside these useless machines for an hour, then removed and used again.
The operation is taking place under local anaesthetic, but the patient is terrified and keeps raising her right hand for someone to hold. The anaesthetist forces it back on to the bed. Up it comes again, and this time he makes as if to hit her; the nurses scold her, and try to tie it down with the sheets. 'She's only nervous,' Dr Bernardini tries. 'Who speaks her language? Nobody? Shit.' The anaesthetist has no intravenous narcotics, so injects a blend of diazepam and ketamine to sedate her; it's a crude substitute, and minutes later she stops breathing altogether, and has to be revived with an oxygen mask.
'Well, it's a challenge!' grins another Orbis nurse, Tania Cigognini, taking a breather outside in the sunshine. 'Bit rough, eh? It's a different system here, isn't it? I guess patient care isn't part of their training. Even the washing machine's broken, so they're having to do all the laundry by hand. It's hard to be professional when you have so little. They just yell at each other all the time. Some of it's just pure ignorance, I guess. I mean, they were chucking their needles in the waste bin, along with everything else. What about HIV, for Christ sakes? But then, they don't know if they'll even be paid for the overtime they do while we're here, so what can you say? You learn to take it all in your stride, and just hope they're learning something . The really amazing thing is the stoicism of the patients.'
Habib Mohammed is 15, a slender, serious boy with a shy smile and a Backstreet Boys T-shirt. He has been blind in one eye for nine years. As nurses prepare him for a corneal transplant operation with Dr Lavery, his older brother, Yusuf, hovers anxiously, but cannot stop smiling. 'How can I express what this means? He is so excited to get his chance. His life will be miserable if he can't do what he wants to do. It will be smashed down. My brother, he is top of the class, he wants to be a doctor. But he cannot see.'
Is Yusuf angry that his brother had to wait nine years for an operation I could have tomorrow? He says he doesn't understand the question.
'Are you jealous?'
'No, I'm not jealous. Why would I be jealous?'
'Well,' I try, 'because it isn't fair.'
He looks at me pityingly. 'I know. But what can you do? Making angry is not necessary to us. There's nothing we can do. That's why we don't feel nothing.'
Orbis doesn't fly to somewhere like Ethiopia to hold patients' hands. It doesn't even really come to save the sight of those it treats; they are only the raw materials of teaching to enable others to be treated long after the plane leaves. The charity also has a small permanent office in Ethiopia, and its director gives a tour of some of the work being done half a day's drive from the capital, deep into the rural savannah. Here, with no access to running water, an infection not seen in the UK since the 30s is rife. Its called trachoma, it makes the eyelashes grow inwards, causing a quarter of all blindness in the region. One dose of a drug called Zithromax may be enough to prevent the disease, and a massive distribution is under way. Queues tail back across arid fields, waiting their turn for this sophisticated drug which could transform the region - yet not even the water with which to take it can be provided, and everyone must bring a sip of their own.
Back at Menelik II hospital, on the final day, some of the patients' bandages are removed. It is the miracle moment and even hardened Orbis doctors are moved to tears. A beautiful 18-year-old girl is looking stunned, almost in a state of grace, as she sees for the first time in five years with an eye that had been blinded by a cataract.
'I will graduate!' she gasps. 'Oh, I'm OK, I'm very much OK. I can't explain how OK I am. Before the Orbis comes here, I don't have a chance. And now I will graduate.' In another ward, Habib Mohammed is grinning at his brother, blinking at his newfound sight. 'The doctor, he is a good guy.'
And there in the far corner is Tadese Berhe, lying in bed in his old beige overcoat. He beckons with a brilliant smile, waving both hands, then gestures for me to hold up my fingers. Covering his good eye, he holds up the same number. I fold two fingers away - and so does he, laughing triumphantly. Between each new variation comes another burst of jubilant glee.
Tadese speaks a northern dialect, but through a complicated three-way translation involving other patients, I understand this much: 'When the bandage came off, I could see perfectly. I don't know what the doctor did, I don't know anything. That is OK. I went to sleep and now I can see. I feel very happy. My wife will be very happy. Now I will go home and everyone will be very happy.'
I am in danger of growing light-headed with so much happiness. The 18-year-old girl's mother sees me overcome, and she smiles. 'Before, my daughter doesn't have any chance. She has no chance to go upward. But now she is treated.'
She gazes at her daughter, both faces iridescent with joy. For a moment this filthy wretched hospital seems the happiest place on earth and for all that I have seen here, I grow forgetful, and exclaim, 'It was just such a simple thing!' But the woman shakes her head.
'Not for us. For our life, it is not simple at all.'
· For further information or to a make a donation, call Orbis on 020 7278 5528 (office hours only) or go to www.ukorbis.org. You can also write to Orbis at 17 Islington High Street, London N1 9LQ.
