Mountain girl: a young Afghan outside her family’s home in the interlocking network of caves and grottos in the sandstone hills that line the city of Bamiyan, home to the famous statues of Buddha destroyed by the Taliban in 2001. Photo by: Travis Durfee

Sight for Sore Eyes

By Travis Durfee

Travis Durfee spent the past month taking bucket baths, sleeping on mats and eating lamb kabob as he traveled throughout the Central Asian nation of Afghanistan. The following is but one of many stories he brought back with him.

The brilliance of the morning’s crisp sunshine lingers in the canopies of the budding poplar and locust trees that line the streets of Kunduz, a small city in northeastern Afghanistan roughly the size of Albany. Pink, yellow and red rose bushes are starting to bud in carefully irrigated dirt plots, the work of determined gardeners willing to give it another go despite the drought that has crippled agriculture throughout much of the country for the past six years. Swallows, warblers and magpies dive and flicker and flit about, chirping a soundtrack to the beautiful spring morning. Despite their number, you have to strain to hear their symphony. It’s difficult to make out the birds’ tunes above the clamor of men.

A sea of bodies six deep, probably 30 in all, undulates around the window of the 1970s-era Russian bus, maneuvering for the attention of the man inside. The pushing, pulling, reaching and shouting are intense. Head wraps are dislodged, fingers are twisted and beards are pulled. Spit flies and shoving matches ensue as the men reach for the freshly scribbled-upon pieces of paper. Another two-dozen men wait patiently just beyond the scrum. Some, arms folded, will wait till the crowd disperses. Others on the periphery plot their entrances and wait for an opening, an exiting body, an opportunity to drop a shoulder and barrel into the crowd. There is no stated limit on the number of people who will be seen, but there is a rush. The crush lasts for over an hour. And then the women get their chance.

These Afghans aren’t reaching for the autograph of a famous Bollywood star on a bus-stop tour to promote the release of an upcoming film. Nor is this a line for free food from the World Food Program. The man in the bus is an ophthalmic technician—an eye-doctor’s assistant—and the little pieces of paper the Afghans fight for are appointment cards. Today is the first day of a two-week eye camp run by the National Organization for Ophthalmic Rehabilitation, or NOOR for short.

One at a time, please: a crush of patients seeking eye care in Kunduz, Afghanistan. Photo by: Travis Durfee

Roughly 70 percent of Afghanistan’s population, which the best guesses put at 25 million, live in remote regions of the country’s rugged landscape. Few medical facilities exist in these rural areas, and the idea of a doctor in rural Afghanistan specializing in eye care makes about as much sense as a Rolls Royce repairman setting up shop in Schoharie County. Despite the shortage of facilities and adequately trained ophthalmologists and opticians, the need for eye care is pervasive. Infections like trachoma and conjunctivitis, and visual impairments like low vision and cataracts—matters that could be easily corrected if diagnosed and treated in the United States—often lead to blindness in Afghanistan, placing further strain on already stressed families. The World Health Organization estimates that 2 percent of Afghanistan’s population is blind, one of the highest rates in the world. It is thought, however, that 80 percent of that blindness is preventable or correctable through cataract surgeries or other treatments. But since most of the country’s population are too poor to travel, Afghanistan’s blind often stay needlessly sightless for years.

One of the many programs run by NOOR (which means “light” in Persian) brings eye care to Afghans in these remote areas through eye camps. Small buses or Range Rovers loaded up with medical equipment trek out to areas of need for two or three weeks at a time to provide a range of basic eye-care services like testing vision, providing drops and ointments, and filling eyeglass prescriptions. NOOR-trained doctors also perform basic surgical procedures, like cataract removal and lens replacement.

As with much of the country, there are no trained eye doctors in Kunduz province, a 500,000-person rural area bordering Tajikistan. For the next two weeks, Afghans who’ve traveled to the only hospital in the province’s capital will be examined by trained ophthalmologists and technicians. For many it will be the first time in their lives.

As the eye camp’s first morning stretches on, a teenager wiggles away from the chaos in front of the bus with an appointment card. Later that afternoon he will lead his sightless, elderly grandfather to a simple surgery to remove the cloudy, opaque cataracts that left him blind two years ago. Three women, who traveled two hours from a neighboring village, leave with the satisfaction of new eyeglasses to cure the near-sightedness that finds them squinting from beneath their burqas. A 55-year-old government employee will have his vision tested for the first time and receive a replacement for the pair of reading eyeglasses he picked up in the bazaar a few years ago: a beat-up pair of tortoise-shell frames with only one arm remaining and a rubber band-and-string headband to hold them in place.

Mohammed Guma, a 45-year-old rice farmer from a neighboring village, also fought his way through the crowd this morning, but so far has received little more than a promise. Guma’s 7-year-old daughter, Qandygul, has been blind since she was 7 months old. When they visit with a doctor later in the day, Guma is told that his daughter’s blindness is the result of something called congenital cataracts. As is often the case in Afghanistan, Guma married within his family. He fathered eight children with his second cousin, and Qandygul’s blindness is a result of their shallow gene pool.

But this Guma does not understand. He contends it was chickenpox, after a case of which his daughter slowly began losing her sight. Guma realized his daughter was going blind when as a toddler she began walking around with her arms outstretched, often tripping and falling. He hopes the doctors will be able to fix this, but he will have to wait. Guma is one of some 400 patients registered during the early hours of the eye camp’s first day.

Ins’Allah: Mohammed Guma, whose daughter Qandygul visited the eye camp seeking surgery to correct the cataracts that have blinded her since infancy. Photo by: Connie Frisbee Houde

NOOR, a program of the Kabul-based International Assistance Mission, has operated almost continually in Afghanistan since 1966. And although it receives no government funding, NOOR provides the majority of eye-care services in Afghanistan.

Tom Little, 56, originally from Kinderhook, is NOOR’s program director. Little and his wife, Libby, maintain a home in Delmar for their annual visits to the States, but the couple has lived in Afghanistan for the past 26 years, where they have raised three daughters. A well-built man of average height, Little has a full head of graying, sandy hair, wears NOOR-manufactured glasses, and bears a slight resemblance to David Letterman.

Fluent in Dari, one of two Persian-based languages spoken in Afghanistan, Little, or Mr. Tom as he is called by the Afghans who work under him, spends his days visiting NOOR facilities in Kabul and throughout the rest of the country making sure that they are running up to speed.

Little oversees NOOR’s three 40- to 45-bed eye hospitals, one in each of the country’s three major cities of Kabul, Heart and Mazar-I-Sharif, as well as a number of smaller 8- to 10-bed facilities in the smaller cities of Khost, Nilli and Talaqon. The program also provides support and pays the doctors and technicians at the Ministry of Health’s main hospital in Kabul, an 80-bed facility. NOOR operates roughly a dozen eye camps throughout the country each year, as well as a number of day clinics just outside of the cities containing major hospitals. All told, NOOR facilities saw 234,570 outpatients in 2003, and operated on more than 14,000 patients.

All of these hospitals are staffed and run by Afghans trained and paid by NOOR, which employs more than 200 Afghans nationwide. The doctors earn an average of $300 per month, an excellent salary in a country where many families eke out an existence on less than $30 per month. All of the doctors and technicians were educated at the ophthalmic training program NOOR runs at Kabul University, which graduates a handful of ophthalmologists and technicians annually.

NOOR also runs a fully functional, and quite busy, eyeglasses-manufacturing shop in Kabul. Working with imported glass from Pakistan and India, donated frames from across the globe, and antiquated machines donated by a man in Pennsylvania, NOOR produces and sells approximately 25,000 pairs of low-cost eyeglasses per year. NOOR also employs a dozen women throughout the country who produced more than 350,000 bottles of medical eye drops in 2003.

Even the Taliban recognized NOOR’s singular role in providing eye-care services in Afghanistan. Despite the repressive regime’s viciously enforced rule that women were not allowed to work outside the home, NOOR convinced the Taliban to allow its all-female-staffed eye-drop manufacturing operation to remain open in Kabul. Little fed the Taliban the white lie that these women were the only people in the entire program who knew how to produce the drops, and the half-dozen women employed there were permitted to work throughout the regime’s rule.

Little likes the program to run autonomously, with himself and the few other expatriate managers providing as little oversight as possible. “That way if we’re ever kicked out of the country again the hospitals don’t have to shut down and people can still get glasses,” Little says. And besides, Little wasn’t supposed to be doing this anyway; one of his reasons for coming to Afghanistan in the first place was to avoid practicing eye care.

Little spent his summers and vacations throughout his undergraduate and graduate studies working in his father’s successful ophthalmology practice in Hudson. After Little received his graduate degree in theology, his father was pressuring him to apply to med school so he could one day take over the family business. Not ready to make a decision, Little decided to get as far away as possible.

He and his wife connected with a missionary group providing social services to hard-up hippies who’d traveled from all over the West to Afghanistan on quests for . . . well, you name it. Whether it was part of the journey or not, many of them found drugs, addiction and jail terms in less-than-civil judicial systems. Little and his wife moved to Afghanistan with their 5-year-old daughter in 1979 and settled in the northeastern city of Heart. Within weeks, though, Little had connected with NOOR people and was working as an optician. Despite how matters unfolded, Little says his father never razzed him nor leveled the big I-told-you-so.

A marshalled peace: a German soldier from the International Security Assistance Force, the 34-nation, 6,500-troop military peacekeeping force, in Kabul patrolling the deteriorating Shrine of Nadir Shah, the father of the Afghanistan’s current king, Zahir Shah. Photo by: Travis Durfee

“I think he understood and respected the work I was doing,” Little says. “I think he would’ve liked to do it himself,” he later added, mentioning that his father once provided similar services to families in remote areas of the Canadian province of Saskatchewan before opening his own practice.

The Littles’ lives in Afghanistan have mirrored the war and civil strife that has plagued the Central Asian nation for the past 25 years. With prodding after dinners and over tea, Little and his wife recall story after story—some candidly, others somberly—of what they’ve been subject to throughout a quarter-century in Afghanistan.

There are far-off glances and long silences between the gruesome details the couple remembers from the 1979 Russian massacre and subsequent Afghan uprising that claimed hundreds of lives and ultimately led to the Russian invasion. The uprising took place mere months after they’d arrived in the country. It was so brutal that the U.S. Embassy told their relatives back home that the family was assumed dead. The Littles recall exchanging morning forecasts predicting the number of shells that would drop during the years of civil war that destroyed Kabul, the nation’s capital. “Well, it feels like a 10-shell day today,” Little says, remembering how he and his wife used to joke. As if their lives weren’t in danger at the time, the Littles offer hilarious renditions of being kidnapped by the Taliban on multiple family picnics; the Littles’ eldest daughter has since sworn off these family outings.

It’s mid-morning on the eye camp’s third day, and Guma, his wife and daughter idly pass the time under a budding locust tree in the courtyard of Kunduz’s Spinzar hospital. They have yet to visit the surgeon. A technician examined Qandygul on the first day and she was scheduled for surgery yesterday, but the hospital lost power for most of the afternoon and the operation was put off. A power cord run from a generator was fed to the operating room through a freshly broken window—in the middle of a dust storm, no less—to allow the surgeon to finish the day’s operations. Considering the circumstances, the doctor thought Qandygul’s surgery should wait. Maybe today will bring better news.

The Gumas have not seen home nor tended their fields since setting out by bus four days ago. The four-hour ride into Kunduz from the neighboring village of Imamsib cost the three Gumas 100 Afghani (the equivalent of $2). Guma bristles at the price; that could’ve bought a cut of meat, some rice and beans, and a stack of naan—enough to feed the family for a few days. But the trip will be well worth the cost if his youngest daughter regains her sight.

A chubby-cheeked young girl, with ruddy, slightly pocked skin, Qandygul hovers at her mother’s side in the hospital garden. Wearing a heavy, kelly-green dress bearing a red floral pattern, Qandygul playfully tugs on her mother’s burqa as the two whisper and giggle to each other. If she could look into a mirror, Qandygul would see wide eyes in a rich, chocolate brown, the whites bright and clear. Sitting in the courtyard, Qandygul’s head darts about quite often, tracking down each passing sound. She smiles a lot.

Can you see: Massoud Ahmedi, 20, an ophthalmic technician with NOOR, explaining an eye chart requiring patients to say which direction the prongs on the letter “E” are pointing. The length of many Arabic letters are such that they cannot be used for eye exams. Photo by: Connie Frisbee Houde

Qandygul’s lenses, the part of the eye that allows humans to focus on objects, have atrophied and clouded over. Not only do her lenses not focus, but they do not allow light to pass through them. Ordinarily, the opaque masses that have become Qandygul’s lenses would be removed and replaced with plastic ones. This is a relatively simple operation. And when it occurs, Qandygul’s cataract surgery will in all likelihood be one of 12 or 15 the doctor will perform that day. But there are still questions as to whether the operation will restore the little girl’s sight.

Qandygul has been sightless since she was an infant and her doctor is uncertain whether or not the neural pathways that should have developed during her early childhood will know how to process the light that will soon pass through her optic nerves. The doctor says there is a possibility that the operation will only lead to a different blindness—an all-white, incomprehensible blur, as opposed to the current black cloud. It will be a matter of months after the operation before the doctors will know if Qandygul has retained any semblance of normal vision.

But that will now be several months plus one day. The surgery will not happen this afternoon, either, the Gumas are informed after lunch. The anesthesiologist and the head of the hospital entered into a shouting match and the former has left the hospital for the day. Local anesthetic is recommended for a child receiving a cataract surgery, so Qandygul’s quest for sight must wait.

NOOR’s history in Afghanistan has been no walk in the park. Hospitals have been looted, homes have been vandalized, coworkers have been murdered. But despite these hardships the group always found a way to move ahead.

Ironically, Little says, it wasn’t until a relative calm befell the country following the U.S.-led forces’ overthrow of the Taliban in November 2001 that NOOR’s future became truly uncertain. When the Transitional Islamic Government of Afghanistan named what it saw as the basic aspects of the nation’s health-care system that most needed funding in 2003, the Ministry of Health’s focused on a basic package of health services: more and better maternal and prenatal care, increased childhood immunization programs, public nutrition, disease control, mental health and disability services and steady pharmaceutical supply. Eye care was left out.

That was all it took for a long-tapped donor community to begin withdrawing support, and despite surviving years of carnage and war, NOOR was faced with the possibility of closing its doors for lack of funding. The group’s money had already been appropriated for the year, but whether NOOR would be able to operate in 2004 remained uncertain.

By the year’s end, NOOR was bailed out by a generous contribution from the Germany-based Christoffel Blind Mission, but Little knew his organization needed to find a new way to keep its programs afloat. What he devised was a new way to present fund-raising for NOOR projects—pitch the program’s various projects to smaller donors as investments. The return on which, Little says, is knowing that a $2 donation can provide a pair of eyeglasses for a poor patient, $10 can surgically repair eyes damaged by a landmine, a $50 donation would purchase an intraocular lens surgery for one patient, a $1,000 donation provides an Afghan ophthalmologist with a good salary for one year, and $2,000 pays for an eye camp.

“Somehow people are more willing to donate if they feel like they know exactly what their money is going to,” Little says. “It is easier to think about people writing a check to pay for a handful of cataract surgeries as opposed to just donating money to an organization and not knowing what they’re going to do with it.”

Little returned to the States last summer to present his investment idea to a number of potential donors across the country, but he found one investor before he left Afghanistan. Connie Frisbee Houde, 57, of 20 Grand St. in Albany, traveled to Afghanistan for 10 days last February and was moved after witnessing the nation’s many needs. Looking for a way to help, Houde found a suitable charity after a dinner with Little in Kabul.

“I was so taken by the way Tom described the NOOR project, how it worked and the whole thing about $50 buying a cataract surgery,” Houde remembers. “He said he was trying to interest donors back home and right then the wheel started clicking for me—maybe I could put together a little money for the eye camp.”

Houde, a freelance photographer who works for the New York State Museum, spent the next year showing her photos and speaking to different groups about her experiences in Afghanistan, all the while collecting funds for an eye camp. Prior to returning to Afghanistan last month, Houde hosted an Afghan-style dinner at Albany’s Westminster Presbyterian Church on State Street to raise even more money for the NOOR project. Houde says that over 150 people attended. All told, Houde says she raised almost $7,000 for NOOR, or approximately 3.5 eye camps.

“After seeing how the operation works, I feel good about knowing that that money is going to good use,” says Houde, back home from her trip to Afghanistan. “I’m frustrated when I donate money to organizations and so much of it goes into administration and salaries. What struck me about this program is, yes, the money you donate is going to people’s salaries but it is going to salaries of Afghans who otherwise wouldn’t have a salary, not just another bureaucrat sitting in an office somewhere.”

You ain’t from around here are ya, boy: Tom Little, NOOR’s program director, grew up in Kinderhook and maintains a home in Delmar. Photo by: Connie Frisbee Houde

“Someone might ask me why didn’t I raise money for some project here in the States,” Houde continues, “but you know, we have so much here. To raise $7,000 for Afghanistan, which does so much, is really just a drop in the bucket. There is so much that needs to be done there.”

The Guma family has been sit-ting on the floor outside of the operating room since early this morning when the surgeon’s assistant comes to inform them that Qandygul will have her surgery a little before noon on the eye camp’s fourth day.

Though it was to her mother’s side that Qandygul has clung over the past four days, it is in her father’s arms that she is delivered to the operating room and placed on the cold, metal operating table draped with a thin cotton sheet. Her body barely spans half of the table. It is 11:05 AM and Qandygul begins to cry as the doctors insert an IV into her arm. Minutes later the anesthesiologist delivers a shot of Ketamine and within seconds Qandygul’s eyes glaze over. Her lids shut a few seconds after that.

At 11:17 AM the gloveless doctor swabs Qandygul’s face and eyes with an iodine-drenched cotton swab and drops it into a red plastic bowl on the floor below the operating table. The bowl contains syringes, used blades, discarded human lenses and other surgical waste from the half-dozen cataract surgeries the doctor performed earlier this morning.

With his forefingers pressed against Qandygul’s wrist, the anesthesiologist pulls double duty as a heart-rate monitor since none exist. The little girl’s dress has been lifted to expose the rising and falling of her belly; it is the only means the doctors have to tell whether their patient is still breathing.

The operating room’s light bulb has been flickering for a few minutes when the doctor places a speculum in Qandygul’s right eye and covers the rest of her face with a thick blue cloth. With the sliver of razor that he broke off from a larger blade, the doctor makes his first incision into Qandygul’s cornea at 11:20 AM.

The doctor slides a thin, crooked metal device the width of a sewing needle into the slit in Qandygul’s cornea to detach the lens from the rest of the eye. This procedure creates debris in the eye that needs to be flushed prior to proceeding, and the doctor assembles a surgical device to wash away the detritus. It’s 11:22 AM.

As the doctor brings the hydrating device over to Qandygul’s head it’s apparent there is a problem. It usually shoots a thin, steady stream of water, but now produces only a steady drip, drip, drip. The doctor fiddles with the device but can’t seem to correct the problem. The blue cloth covering Qandygul’s face begins to show a puddle and the doctor lets out a sigh. Qandygul’s stomach rises and falls and still drip, drip, drip. Frustrated, the doctor disassembles the electronic device and rigs a manual facsimile with the plunger from a nearby syringe. The other doctors in the room crowd around the table. It’s 11:26 AM. The rigged device does the trick and the doctor proceeds. He removes the first of the two deteriorated lenses at 11:30 AM.

A battery-operated radio is blaring and the doctor is stitching Qandygul’s cornea when the operating room loses all power at 11:35 AM. The doctor’s hands freeze and the anesthesiologist leaves his post as a heart-rate monitor and assumes the job of operating-room spotlight, for which he uses a nearby flashlight. Qandygul’s stomach continues rising and falling. Someone starts a diesel-powered generator outside. Power is restored to the magnifying lamp at 11:37 AM and the operation continues to the din of a two-stroke.

By 11:57 AM, the doctor has removed both lenses and is preparing Qandygul’s eyes for recovery. Two gauze pads are placed over each of her sockets and secured with tape. Before removing the blue cloth from Qandygul’s face, the doctor wipes the blood from his fingers with a cotton ball soaked in alcohol. The little girls rests on the table, awaiting a move to her family and one of the hospital’s many crowded recovery rooms.

Qandygul is one of more than 3,000 patients treated at the two-week eye camp in Kunduz. Her doctor performed more than 100 cataract operations. From the dirt-floored examination rooms at Kunduz’s Spinzar Hospital, NOOR provided hundreds of eyeglasses and filled countless prescriptions for simple medicine like eye drops and ointments.

In six weeks Qandygul will return to this hospital to have her eyes examined and fitted for new lenses. The replacement surgery will follow a few weeks later. Shortly after that surgery doctors will be able to tell if Qandygul’s brain will be able to register the light that is now flooding her eyes.

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