Journal from a Romanian Surgical Expedition,
May 2002:

Each time I attend a meeting of the American Academy of Ophthalmology, I stop by the booths representing the various charitable programs that bring modern surgical services to underdeveloped sites throughout the world. Year after year I deferred making any commitment for any number of reasons, some valid and others just excuses.

This year after the numbness of 9/11 lifted, I thought about the ability of so few people to do such enormous evil. It seemed a fitting counterpoint in this context to seek out ways to amplify those gifts we give each other.  It didn't take much longer to sign on to participate in a clinic sponsored by SEE International in Romania. The inviting doctor was a Dr. Mihai Cociu, who has been struggling to bring state of the art eyecare to an impoverished town south of Bucharest called Giurgiu.

I wanted to take a photographer along to document Dr. Cociu’s efforts, hoping this medium would give me a perspective I otherwise would not have, as well as provide a way to get more people involved in the project. My daughter, Emily, had the foresight to recommend her former photography teacher, Lincoln Turner, who has considerable expertise in this area. Fortunately he was available and signed on surprisingly soon upon my invitation. Things fell into place smoothly thereafter. Within a few weeks of our scheduled departure, Elizabeth Robbins and Pam Magenheimer from SEE Intl. did their magic organizing the expedition, shepherding an extensive amount of donated medical and surgical supplies to me. The best way to avoid customs’ hassles was to take the equipment with us as personal baggage.

The charity of many, the employees of the pharmacy and Surgease at Bridgeport Hospital as well as the representatives from Alcon, Allergan, Merck and other eyecare corporations went beyond my expectations. The outpouring of generosity swelled the number of cartons to twenty as the day of departure neared. This was well above the airline limit. Transporting all of this material through heightened airport security dominated my concerns. Fortunately,  good luck followed us throughout the trip. We met many helpful, now nameless, employees of the airports, British Airways and even U.S.customs officials, who upon presentation of the proper documents, seemed eager to help.

 

 

We arrived in Bucharest after some nine hours of flight time with a stopover in London. Our host ophthalmologist, Dr. Cociu and a colleague of his, Dr. Paul Grecu, were at the airport to meet us. Their anxiety was palpable, although the cause was unclear. When we finally left the airport, a relieved Dr. Cociu explained how fortunate we were to get that volume of cargo into Romania without incurring the usual roadblocks of customs. Like so much of the Romanian bureaucracy, authority can be very arbitrary, a prerogative of power, a whim of wrath or greed. Even though a particular cargo is clearly meant for the poor, there can remain no choice but to pay the toll. Maybe it was the travel fatigue, but I forgot where I was not and approached the starchy uniformed officials as public servants rather than private enterprise. Perhaps this very naivete allowed for our easy passage.  We were treated as though we were mentally handicapped and given rapid entry with the twenty cartons into this distant edge of Europe. Anyone stupid enough to show up with twenty odd cartons of goods at the Romanian customs and conduct himself with an "attitude" was probably too oblivious to understand the local political topography.

 

The ordinary look of the neighborhoods around the airport surprised me. After travelling so far and having read about eastern Europe, I expected instant culture shock. Instead, there was more of the familiar than otherwise. But as we drove farther from the airport, the car-rentals, transport and cargo companies gave way to the more pedestrian, urban landscapes of Bucharest. As the wide boulevards opened into plazas, our driver was quick to highlight events, mostly tragic, that unfolded in this or that square. While I had heard of Ceaucesceu, the scope of his megalomania unfolded vividly as we drove into the Center City. He left his mark, a scar across the face of a beautiful old city. Several soviet-style buildings stand vast and imposing over a capital that once prided itself as an outpost of Paris in the east. The stories about Ceaucesceu’s madness abound. His vast building projects, destruction of architectural gems and eventual bankruptcy are legendary. Now the carcasses of incomplete projects tower over the landscape, many with masonry and rusting equipment piled as though the workmen left for a break and never came back. Ten years have passed since his helicopter lifted him above the chaos of the masses embroiled in the bloodbath of revolutionary purge. The predictable fate awaited in nearby Tergoviste, where a summary execution ended the first couple's life, but not the problems his regime brought to Romania.

 

              

With Leo, Dr. Cociu's lifelong friend, as escort, driver, tour guide and translator, we eventually left for Giurgiu. The road there was narrow for an intercity route, but generally in good condition. As elsewhere in the capital, it was lined by the stark, empty frames of multi-storied apartment blocks standing like skeletons telling tales of broken dreams. Since Ceausescu's demise, inflation has risen to such punishing heights that the average pensioner must make do on $20./month. After we left the outskirts of Bucharest, the urban quickly turned rural. Horse drawn wagons, coached by gypsies, slowed the flow of traffic as they impassively pursued their ageless wanderings and gathering of refuse. Many wagons bore a cargo of scrap metal placed in a jigsaw pattern for maximum haulage. Some remnants were the rusted shells of cars overturned and disfigured like corpses piled atop lorries after the consumption of battle. The gypsies, irritants and outcasts throughout Europe, seemed to impart new life to civilization's debris, burdens carefully balanced atop wooden carts, an effort as worthy as an ant towing his grasshopper prey home.

As the road led through miles of well-kept farms and humble homesteads, we passed small towns. Men and women went about their Sunday routines. The orthodox churches with their towering domed steeples were clearly the town center, a safe repository where the townsfolk could lift hope aloft and tend culture beyond the transience of politics. The architecture of their eastern rite showed that inflexibility struck in the fires of misery's kiln.

                        

Here and there along the route, a relatively large home of whimsical Ottoman design rose up from the landscape. The surrounding dusty fields were tended by old women stooped and sheltered by shawl and babushka. Everywhere the grey skeletons of abandoned block apartments stood their watch. Leo explained that a few gypsies, despite their apparent poverty, manage to acquire substantial wealth through incredible guile. They build elaborate homes, leave them largely unfurnished and occupy but one room in the company of a large extended family. I sensed his ironic pride in the gypsies' and similarly the Romanians' ability to survive the odds and even live well, but on their own terms. After an hour, a small road sign announced we had come to Giurgiu. The landscape gradually showed a more residential character with dense three to six-storied apartment blocks, earth toned and mottled from neglect and the harshness of climate. Many units had terraces protected by glass or makeshift barriers of wood, fabric or whatever else was available to keep out the elements.

The streets were lined by markets, where men lingered in small groups chatting and smoking fixedly on small cigarettes. Women pursued darting children, while they gathered whatever provisions were needed. The restfulness of the Sabbath was all about. A church hosted a wedding party with each member dressed for that special day when the drab surrenders to the formal and hope becomes promise.

Eventually we came upon the tired, rectangular iron gates of the regional hospital. We drove into a complex of gray stucco buildings, a long-abandoned public project, kept alive by the familiar need for sanctuary and care. The surrounding landscape was untended. Tall grasses and overgrown shrubbery blew in the warm afternoon breeze, where lawns and gardens were once planted to add  respite where medicine failed. Here and there stood smaller buildings in various stages of decay.

Patients milled about grasping the tethers of their hospital-issued robes with one hand, while the other clutched the ubiquitous cigarette in a gesture that accepted whatever else life would bring. A beautiful woman, reflecting the sensuality that drove Roman emperors to Romania for their concubines, stood in madonna-like stance, her face blushed with youth and promise,  her body draped in an unappreciative hospital robe. She seemed aloof and impervious to the old, the slumped and the motionless sitting about her in a Dantesque ring.  A chapel presided over this collage, humbled by wear, its roof straining to support the filigreed lightness of a tethered cross.

We eventually came upon the building that the ophthalmology department shares with that of dermatology and venereal diseases, an odd company of specialties. The main entry opened abruptly into high-ceiling corridors flickering green with fluorescent light. Bare pale walls, sparsely covered by government-issued paint, struggled to maintain a welcome. At the end of most corridors, large glass partitions enclosed solaria as though natural light needed some special place for tending. In the stark atmosphere of the halls, these enclosures stood as small shrines for each ward, places of repose from the tired halls. Within, a vase with roses stood alone atop a table, tranquil and altar-like.

We were escorted by Dr. Cociu into the ophthalmology ward and introduced to his staff of nurses, who bowed deferentially, as they greeted us. We were  welcomed by their warm words and home-made treats. The operating room was at the end of the corridor with its double doors standing like guards restricting a secret fate. In an adjoining room two scrub sinks stood suspended alone and solitary against the tile wall. On the opposite wall the steel, round pneumatic doors of several defunct autoclaves were arranged in an orderly configuration from floor to ceiling. Their helm-like locks evoked a gothic, Jules Verne scene. The clatter of faulty plumbing and the drip of leaking faucets broke the stillness as rust bled onto the marble floors.

The main operating room contained three articulated operating tables. Rusted handles, bent shafts and cranks worn clean of their chrome stood frozen , motionless and expectant.  Along the wall stood two white enamel cabinets with glass doors revealing a meager content of supplies. Against the opposite wall, a cold white marble slab was set along the room’s length to serve as workbench. We entered within to this pallor of marble floors and work areas. Hulks of anesthesia equipment were positioned museum-like along the wall as though recalling a past, when medicine began to rely upon the sturdiness of consoles, dials, cylinders and tubes.

The next day we awoke to the baying of stray dogs. It seems everywhere in Romania, dogs are free to wander, as though flaunting their survival in a world of few welcomes. The vanities of breed and grooming blend into a common, urban squirrel-grey protective coloration.

Leo escorted us each morning to the clinic, where Dr Cociu had already been at work interviewing and examining patients most suitable for our intervention. When we arrived, the floors had been scrubbed to a slippery wet sheen, discharging their detergent odor throughout the corridors and warrens of rooms. Furnishings were covered with the loose fabric of sheets and blue surgical drapes to conceal the lack of upholstery and bare surface beneath.

 

 

Along the tiled walls of the corridors, patients stood silently, queued in tight groups, dimensionless like the Byzantine saints and churchmen staring out from the mosaic icons.  Heads were lowered. Eyes seemed to avert our gaze.

Dr. Cociu presented the patients to us, sketching the tragic interplay of chance and its burden of blindness. Each case bore a similarity of desperation, one last chance to let some light into a life darkened by bad luck and its evil twin, chronic scarcity. Patients came forward as quickly as their infirmities would allow. Our instruments showed us the scars, irregularities and imperfections in eyes that stared fixedly and dispassionately. Most of our patients were women, whose faces reflected a leathery firmness cut by furrows sketched by the sun and wind. They were dressed in a random blend of printed aprons, sweaters and shawls. Despite Dr Cociu's frank compassion, many responded as though they stood before a tribunal, perhaps one of Ceaucesceu's . We were reminded  how slowly repression loosens its grip.

 

Dr. Cociu and Dr. Pulice review clinical cases

When the examinations were complete, we sketched the framework of our common observations and impressions.  While an ocean may spread between us, and different tongues hamper the easy exchange of thought, our common medical heritage quickly bridged the gaps. The congeniality and warmth of the Italian team, Drs. Ivo Vulpi, Saverio Contu and the team leader, Dr.  Luigi Castellano set the tone of trust and common purpose. These men were jewels of personality, wit and clinical skill.

Dr. Vulpi was a mastermind of adaptation and was quick to share his fluent wit. He set up the microscopes, autoclaves and instrument stands, urging new and creative roles from the exhausted furnishings. Dr. Contu played Robin Hood to the nearby orphanage delivering a bounty of toys and candy he had coaxed from his Italian patients. When all was ready, we scrubbed our hands with betadine over the lonely sinks trickling sterile water. Patients were gently led to the expectant tables covered with fresh linen. Although each surgeon brought his own equipment, instruments were freely shared according to the needs of the individual patient. We alternated our role as surgeon, teacher and assistant/circulator to promote the best efficiency and use of skill. Dr Gabriela Murgoi, an experienced Romanian orbital surgeon, gave freely of her time, clinical expertise and facility with English, Italian and Romanian.

Each day we were able to treat well over sixteen patients, despite the inefficiencies of the autoclaves, one of a kind instruments, and the relative lack of support personnel. A strong fellowship emerged as we came to respect the different experiences and skills each brought. Techniques were freely exchanged in the service of need.  Time seemed to pass quickly as the brilliant daylight succumbed to the soft tones of evening. Our accommodations were clean and comfortable, certainly adequate to support the surrender of sleep. Despite the fatigue, there was always someone ready to give a bit more.

 

 

In the morning our team would gather around the breakfast table to allow Dr. Castellano’s strong espresso to perform its magic of revival. We shared vignettes from the previous day as well as prospects and plans for the time ahead. Lincoln would use this time to share his unique perspective with the group. In the company of Leo, Dr. Cociu’s friend, he had made home visits to document and portray the background of the people we were treating. Through the instant gratification of digital photography, we were given the opportunity to see the reflections of ourselves. More importantly, the photography seemed to easily divide the personal from the clinical in ways I had vaguely imagined. We marveled at the unique vision of the lens and its clear messages. In the grainy iridescence of the display screen came images of people whose lives told epics about the spirit. Courage and stamina were as commonplace as misfortune.

Within a few days, we fell into a routine, each team member doing what he did best as the opportunity presented. Whether it was preparing the instruments, instructing, operating, repairing the equipment, or seeing the patients before and after the surgery, the work was done in as efficient a manner as the limitations allowed. This collaboration continued well beyond our repacking  the equipment dividing it among its owners. Of the twenty cartons we brought from the U.S., only five remained to come back. We had done our work. Our burden was lightened.

After a few days visiting the area around Bucharest, an absorbing experience guided by Dr. Cociu and Leo, Lincoln and I prepared to go home. As our last stop before the airport, we met with an American Embassy Office for the Development of American Economic Interests as they pertain to health-related issues. Our idea was to encourage U.S. participation in the clinic site in Giurgiu, either directly through grants or indirectly through corporate sponsorship. Although they seemed convinced that Dr. Cociu’s work would be an excellent investment of their resources, funds were already fully allocated. Hence we would have to wait for a corporate angel to come along. But we were encouraged that the embassy would make an onsite visit

Close at hand was the very familiar world of stratospheric travel. Despite cramped seating, the pent up fatigue and dull engine hum brought on a half sleep setting my thoughts back over the last few weeks. I reflected on the choices abundance has given me. The small individual screen of the onboard television, affixed to the back of every seat, brings me twenty odd channels of distraction. We are visual beings, and how great the risk the image holds in becoming its own reality. Click! The desecrations of unholy priests, stewards of a dying past. Click! Ashen file-footage of refugees queued before a derelict authority. I have seen theses images before, painful intrusions into the privacy of grief. The closer I am zoomed into the belly of this misery, the greater the disconnect grows between image and reality. Click! A trio, piano, violin and cello, gently but relentlessly dipping rhythmic strokes into timeless waters. I allow the awe to settle me to sleep. As the music builds to a crescendo, a crackle of the PA system breaks in to announce our arrival in New York.. The strained pitch of the engines signals our descent., while the clouds thin to reveal the golden sparkle of skyscrapers piercing the distant horizon. Ribbons of roads snake about them. As I look over the wounded New York skyline,  the thunder of cascading steel, paper and dust that scarred the Fall, cobalt sky invades me again. Like many others I went to this holy ground looking to merge image and reality. When I got there I found only the silence.

As surgeons we are both custodian and slave to vision and imagery. Did I need the photographer’s images to connect or to separate from our patients’ pain? Much of the progress in ophthalmology has come through the enhanced view of the eye’s inner workings. The phenomenal clarity of the newer microscopes, coupled with the optical precision of lasers and fiberoptics have opened up new vistas in a space millimeters wide, just as the Hubbell Telescope has revealed phenomenal details in the vastness of space. Sometimes we surprise ourselves with new findings. More often we find confirmation of what intuition has already told.

The old question still haunts us as the images of life project on the wall of that ancient cave, and we are still unable to stare out into the light of day. How often do blind images obscure the real, ideas exact their mortal toll, blind wealth tower over silent, humble need, and blind ideals guide determined cockpits toward their prey?

Within moments we flew over the glow of ground zero. I stared into the belly of a cold blue luminescence, to seek a clarity not to be found in that void of desecration and sanctity.