The three-wheeler navigated its way through dirt roads and sewage-filled gullies. The driver just barely avoided pedestrians, cows, and bicycles. His being able to maneuver so adeptly was nothing short of astonishing. I sat forward gripping the railing on the vehicle and as we bounced along the unpaved road, I couldn’t help but think that 24 years earlier I had been coasting down the I-5 South on my way to Lindbergh Field in San Diego. And yet, here I was, on my way to India again.
I first discovered the laid back coastal utopia known as San Diego in 1990. Saddam Hussein had invaded Kuwait in August of 1990 and as U.S. troops were deployed, I opted to come to Fort Ord in Monterrey California to train in the event that further deployments were needed. It was my final year as a medical student at Case Western Reserve University in Cleveland,Ohio. I felt an obligation to my adopted country, going from a reservist to active duty. It was sometime in October when I arrived at the army base and over the next two months, I spent my days working in the Emergency Room on base and my nights catching up on reading. At the end of my two months, the head of the E.R. rewarded my hard work by giving me five days off, recommending that I explore California. I rode my motorcycle down the 101 and eventually ended up in San Diego. It was clear to me then that I would be back, somehow, some way. In 1996, I returned to San Diego as a resident in plastic surgery at UCSD. After a craniofacial fellowship, I set up my practice here in 1999. Soon after, I moved my entire immediate family to Southern California.
Despite working in excess of 100 hours a week and taking trauma calls at several different hospitals, I was always thankful for being fortunate enough to have a few hours a week to take in this city. I would often walk the gardens and take in the ocean, reflecting on my past in Cleveland and sometimes even further back to my beginnings in India. There were several occasions when guilt encompassed me. Yes, I worked extremely hard for nearly half my life here, but there were thousands of individuals in my birthplace who worked endlessly and would never have the same opportunities. My father recognized this lack of mobility and courageously migrated to the U.S. in 1970. My mother, brother, sister and I arrived two years later. Like so many children of Indian descent, our sole purpose became to excel academically and position ourselves for professional success. Perfect scores on exams were expected, not celebrated. Career goals were dictated with little room for autonomy – the choice between becoming a physician or an engineer would be ours. Unfortunately this rigorous preparation didn’t allow for adequate socialization and integration into American culture. My generation of Indian-Americans became a perplexed hybrid, not fully identifying with being Indian or American. These very same sentiments are shared by thousands of Indians who have been raised here but long for an Indian self-identity. And in this same vein, it has allowed for the collaboration of like-minded individuals to form ASIPS – The American Society of Indian Plastic Surgeons.
The founding of ASIPS dates back to 2009. I received a phone call from a Dr. Kusuma, who informed me that he had been given my contact information from two sources, a Dr. Landon Pryor and a Munish Batra. Seeing as how I shared a name with this latter individual, I asked perplexed to whom he was referring. He went on to explain that an individual in Cleveland named Munish Batra and a former plastic surgeon resident at UCSD Landon Pryor, had both recommended he contact me before going to India to embark on a charitable surgical mission. He was informed that I had been traveling to Indian early every year since the Tsunami of 2004 and had worked with various NGOs (Non-Governmental Organizations) to provide reconstructive surgery to individuals who could normally not receive care. Dr. Kusuma wished to reach out to see if I would consider joining their surgical mission to Jalandhar. We would consist of a group of five plastic surgeons and I was to be an asset to their maiden mission, as I had previous experience in providing surgical services in India. I felt honored and enthusiastic to be part of a team of Indian surgeons. Like me, they felt compelled to return to their homeland and assist those who did not have the opportunities in life that we were given.
Now, after nearly 24 hours of travel, being cramped against an airplane window, watching every featured episode on the plane, while trying desperately to sleep, but being unable to do so, I finally arrived in New Delhi. I spent another six hours on a train from Delhi to Jalandhar and a one-hour adrenaline-filled ride in a three-wheeler to my destination at Shingara Hospital. As the three-wheeled taxi turned into the paved driveway of the hospital, it was very apparent that our mission would be overwhelmingly busy. The taxi slowly weaved its way down the driveway as patients and their family members mobbed the car to make their case for surgery. I grabbed my backpack and was led through the waiting room which was cramped with impoverished patients, many of whom couldn’t shield their deformities.
Despite having made several charitable surgical missions to India, I was intimidated by the sheer number of people seeking care. The sense of hope and enthusiasm took a back seat as I was completely humbled by the number of patients seeking help. I wondered if the other surgeons felt the same sense of despondency. The hospital staff attempted to clear a pathway through the sea of patients. My goal was to get into the operating theater.
Over the years, I have learned to travel the path from the hospital entrance to the operating room without resting my gaze on any particular patient. The mere recognition of any one patient’s existence always brings with it the expectation that the U.S.-trained surgeon will be able to cure their deformity, and in the event that this cannot be done, the reactions are often devastating to watch.
Yet, every mission is marked by one or two individuals whose gaze cannot be shaken off or forgotten. On this trip, it was the parents of a seven-year-old whose face was nothing more than a skeleton, missing lips, chin, and the bottom half of his nose. The dire sight is still seared in my mind. The child did not take notice of me, instead playing with his younger sibling. His father’s gaze, however, pleaded the case for his son- imploring me to make his son whole again. In that instant, I knew there was nothing I could do in this setting to help that child. He needed a face transplant. The walk along the 40-foot corridor from the hospital entrance to the operating room felt endless, as a baby with a cleft lip was shoved in front of my face and an adolescent girl with deformed hands begged for assistance, placing the stumps of her forearms together.
I was still focused on the boy with the missing face when the double doors to the operating room opened. The pungent smell of formaldehyde overcame me. I changed into my scrubs and was greeted by the other surgeons of ASIPS. We would now start the triage process of prioritizing patient care. Dr. Kusuma and I were directed to a small exam room equipped with a desk and a picture of Guru Nanak, the founder of Sikhism, on the wall. The chaotic masses of people waiting to be seen were jostled into a make-shift line. One by one, a prospective patient and their family members were sent into the exam room. A 17-year-old girl with a scarf concealing her face was accompanied by her father. He tearfully pleaded her case while she held her head down, gazing at the floor, refusing to make eye contact with me. The father explained in Hindi that she would not be able to get married if her face remained deformed. She unveiled the scarf to reveal the badly scarred remnant of the right half of her face. A jilted male suitor had thrown acid on her when she refused his advances. The scars from the blind right eye, down the cheek onto the neck, shoulder and right breast resembled molten wax. I was overcome with sorrow knowing that, despite extensive skin grafting, she would never look like her former self.
After nearly two hours of prioritizing care, the child with the exposed facial skeleton walked in holding his father’s hand. His mother trailed a step behind. He sat on the bench looking straight ahead while his father explained his injury. As a four-month-old, he was left in his crib while his mother went to gather some vegetables. She returned to the thatched home to find a stray dog eating her son’s face. Over the years, as he grew older, the neighborhood kids befriended him and while he was treated lovingly by everyone in the village, the parents knew that one day he would have to fend for himself. He was oblivious to his deformity at this stage in his life.
The story left both Dr. Kusuma and I speechless! All that remained of his facial structures were his upper eyelids and portions of his lower eyelids that were scarred and pulled down revealing the whites of his eyes. He had no lips, an exposed jaw, and the internal structures of his nose were uncovered and dried by the endless exposure to the polluted air. He couldn’t close his eyes, which constantly teared to lubricate his exposed cornea, streaming down his face.
I tried unsuccessfully to hold back my own tears, as I saw the physiological response of his eyes to stay moistened. Dr. Kusuma approached the case more pragmatically, discussing with me in English that the child was a candidate for a face transplant. We both knew that this child would never get the care he needed, but I certainly didn’t want to convey that reality to his parents.
As Dr. Kusuma discussed the specialized care the boy would require, the parents quickly realized our inability to help their son. The father silently wept, while the mother distracted her son with a story. He would live on the fringes, his childhood friends would be his only solace when his parents would no longer be alive. I too silently grieved with his father. I wondered if Dr. Kusuma felt the same sympathy under his stoic demeanor.
It took nearly four hours to get through the assemblage of deformed bodies and hopeful stares. Dr. Kusuma and I pushed open the doors to the operating theater – the smell of formaldehyde now burned my nasal passages. It was used to sterilize and clean everything; instruments, tables, and the equipment. The smell brought back memories of the cadaver lab in medical school.
It would take three separate operating rooms, running 14-16 hours a day, to get through the nearly 100 patients we planned on treating. We had anesthesia support from local hospitals that opted to volunteer their time. Our host surgeon was adept at spinal anesthesia and provided his expertise for the individuals requiring lower extremity surgery. Yet, a number of patients would be managed under local anesthetic due to a shortage of anesthesiology support. These cases would normally be handled under general anesthesia in the U.S. The adolescent girl who had covered her face with a scarf in the panel was one such patient. Under local anesthesia, I released burn contractures on her elbow and axilla (the region under the arm), and harvested skin from her abdominal wall to resurface her arms. The burning from the local anesthetic caused her to cry silently in pain and tears glided down her cheeks. I did my best to minimize her pain, and caressed her shoulder as I injected the burning solution into her axilla. Afterwards, I voiced my discomfort with our mission, stating to Dr. Singh that I wasn’t sure how I entirely felt about these trips, because I felt I wasn’t able to give the patients the best care I could. He remarked, “I know how you feel, but you have to remember they would get no care otherwise.” His logical conclusion did nothing to take away my unease.
The last day of the surgical retreat arrived and only minor cases were scheduled. We were ahead of schedule but exhausted from work days having started at 7 a.m. and ending as late as 9 p.m. The enthusiasm upon our arrival six days earlier had given way to fatigue. We had run out of most of our supplies and were numbed to the smell of formaldehyde.
Dr. Bhupesh Vasisht and I were sipping tea in the surgeon’s lounge, when a local dignitary approached with his adolescent daughter, asking that she have a Rhinoplasty. I pretended not to acknowledge his request while Bhupesh did a cursory exam on the girl. He turned to me to ask my opinion on the matter—what I felt would be the best course of action for her nose. “Nothing,” I replied. “I didn’t come on this trip to do cosmetic surgery!” Bhupesh asked the girl to go to the waiting room and diplomatically explained why he felt it was important for us to do the Rhinoplasty. “If we are going to come back here one day and have the opportunity to do another hundred patients, then we need to occasionally take care of the cosmetic needs of the wife or daughter of one the dignitaries.” As much as I resented it, he was right, and I conceded to help him with the Rhinoplasty.
I exited the surgeon’s lounge to go scrub up for the case. As I approached the sink, the doors to the operating theater opened and frail man with sunken eyes and an emaciated body asked me for a minute of my time. His fragile appearance elicited sympathy and I approached him. “Dakh Saab, hummara kuch kurlo, sub hummara mazakh kartay hain, hum ko buhlathay hain deld moochay”—Doctor, everyone makes fun of me and calls me “one and a half mustache.” He was a rickshaw driver who had an oil lamp explode on his face, leaving part of his upper lip burned. His otherwise manly mustache was interrupted by a half-inch segment of scarred skin. He went on to explain how other rickshaw drivers laughed at him and had nicknamed him “deld moochay” – one and a half mustache. He sought help from several doctors, but none took him seriously, nor were they willing to operate on him because he had AIDS. This brief interaction in the hallway was a plea to help him regain his dignity. The mustache, a sign of power, virility, and nobility in Indian tradition, became a source of self-effacement for him.
Mahatma Gandhi, perhaps the most dignified Indian the world had known, wore a mustache. For Deld Moochay, it held great significance and he was certain his existence would improve if that patch of burned skin could be removed and his mustache was whole again. His despairing plea made it clear to me that I needed to operate on this patient. I told him to wait and walked back into the operating theater and shared the story with Bhupesh. He asked, “Are you sure you want to operate on a guy with AIDS?”, “Yeah, I think it will do him a lot of good,” I replied.
Deld Moochay left his worn sandals at the door and walked barefoot with his torn shirt and cotton pants into the operating room. He lay motionless as I injected the burning, numbing solution into his upper lip- as if to validate that he would endure any amount of pain to have the corrective surgery. Twenty minutes later, the thickened scar was gone and his mustache connected across his upper lip. When he finally sat upright on the table, one of the orderlies handed him a silver tray so that he could see the outcome. I took off my gloves and went back to the sink to wash my hands. When I walked away down the hall, I saw him still looking at his reflection in the tray.
I smiled knowing that in that half-hour I had given him his self-esteem back; and whether it is repairing a cleft lip, a deformed nose, or erasing the physical scars from a traumatic life experience, we all have the right to A Dignified Life!
MUNISH BATRA, MD, FACS has built a highly-prestigious cosmetic surgery practice in San Diego, California. Recognized by his patients and peers for his humble demeanor, honesty and excellent technical skills, he has gained a national reputation for his work in aesthetic facial surgery, cosmetic breast surgery and body sculpting. He has been honored as a Black Diamond Account for Allergan, based on his volume of breast augmentations. Dr. Batra is also known internationally for his charitable work and giving back to those less fortunate.