Temple eye banking: cornea donation practice at Pashupati crematorium in Nepal

ABSTRACT

In high-income countries where eye care is advanced, cornea harvesting is hidden from public view. Here entire eyeball enucleations performed on corpses are done in hospital morgues without mourners’ presence. For the last two decades, the traditional public crematorium area next to the Pashupatinath temple at the holy river Bagmati east of Kathmandu, has become a major Nepal Eye Bank site for motivated cornea donations. To be cremated in the premises of the Pashupatinath temple is considered highly auspicious. After families have given their consent, the cremation rituals are briefly interrupted by the Nepal Eye Bank staff, and cornea button excisions are performed in public space. Thus, mourners regularly view and assist during the removal of cornea button tissues from the deceased before the bodies are burned on the open funeral pyres or in the electric crematorium. How is it that Nepali mourners at Pashupati crematorium accept and comply with cornea donation practice? I argue that cornea donation at Pashupati is a collective achievement accomplished by complex socio-material arrangements that bring together various professionals, procedural manuals, legal framework, equipment, medical intervention, the deceased body, and mourners during the cremation practice.

KEYWORDS:

• Eye donation
• cornea
• cremation
• multiple ontologies
• Nepal

Introduction

Diseases affecting the cornea are one of the major causes of blindness in low-income countries like Nepal (Bajracharya et al., 2020). Corneal blindness is caused by a wide variety of infectious, congenital, traumatic, nutritional, and inflammatory eye diseases, which cause corneal scarring. The cornea is the transparent tissue covering the front of the eye. It serves as a window to allow light entering the eye. If the cornea is injured, it becomes cloudy, and vision is dramatically reduced. Treatment for this condition is corneal transplantation using donated corneas from a deceased body, harvested within eight to twelve hours after death (Bajracharya et al., 2020, p. 95). Most people can donate their corneas irrespective of age as there are few restrictions to cornea donation. The major restrictions are positive serology of some specific infectious diseases, such as HIV, hepatitis B and C, rabies, and syphilis. Thus, corneal transplantation is the most common form of necro donation transplantation performed globally (Lawlor & Kerridge, 2014). However, Lawlor and Kerridge underscore that the number of potential corneal donors is much greater than the number of potential solid-organ donors, as corneas may be procured up to twelve hours after cardiac death and therefore a declaration of brain death is not a precondition for donation (Lawlor & Kerridge, 2011). Röck et al. (2016) report that corneal transplantation is the most frequently performed transplant procedure in the world. Nevertheless, despite the large availability of potential corneal donors globally, in most countries there is a mismatch between the need for and the availability of donated corneas. Out of all organs, corneas have the highest rate of refusal of donation (Röck et al., 2016, p. 702). In a study based on interviews with 21 individuals in Australia, Lawlor and Kerridge explored the reasons why these individuals decided whether to donate, or not to donate, corneas. They found that the eyes are a central feature of social interaction and that continued social relationships with the deceased played a decisive factor for refusal of donation consent (Lawlor & Kerridge, 2014, p. 57).

Nepal is a low-income country with a diverse health system and with a limited capacity to deliver comprehensive high-quality healthcare to the entire population (Dixit, 2014; Harper, 2014; Ministry of Health, Nepal, 2016a). However, it is remarkable that the level of cataract eye care and corneal eye care in Nepal is on the quality level of high-income countries (Nikpoor et al., 2018; Pokhrel, 2018; Williams, 2019). Since 1999 Nepal has been self-sufficient in the supply of corneas (Bajracharya et al., 2020; Twyana, 2002). The Pashupati crematorium has become one of the major Nepal Eye Bank sites for cornea harvesting. In this article, my investigation deploys an anthropological approach to mortuary ritual practice to answer the question; - how is cornea donation done through the situated cremation practices at Pashupati crematorium?

Method and theoretical approach

This article explores how cornea donation has been practiced in Nepal over the last decades. I specifically explore how the practice of cornea donation is embedded in the cremation practice at Pashupati crematorium. I focus on the multiple ontologies of the cornea donor, the deceased, and the corpse during the cremation practice (Hadders, 2017). In my exploration, I draw on published literature, official websites, published video documentation, procedural manuals, internet media coverage, public official documents, interviews, personal communications, and observations gained during my fieldwork in Nepal. During two visits, in February and November of 2017, and one visit in November of 2019 I conducted a total period of four weeks of ethnographic fieldwork at Pashupati crematorium. I spent time following the practice of Pashupati Area Development Trust crematorium staff, Nepal Eye Bank technicians and counsellors to get acquainted with them and their work. I observed cornea donation and cremation practice at the traditional crematorium, and at the electric crematorium. With the help of a Nepali research assistant, I carried out 10 interviews in Nepali with crematorium staff, Nepal Eye Bank technicians and counsellorsOver the last century, anthropologists have underscored that the orchestration of mortuary rituals accompanying death of any member of a certain group or society is closely tied to that person’s changing social position in that group or society (Hertz, 1960; Bloch & Parry, 1982; Metcalf & Huntington, 1991; Robben, 2004). These anthropological studies of mortuary rituals have paid close attention to the connection between the treatment of the body, the mourners, and the fate of the soul¹ as an illustration of the relationships between the living mourners and the deceased during the gradual transformation of the social person.² This anthropological approach is an apt departure for an analysis of cornea donation and cremation practices (Davies, 1997; Lock, 2002; Rachel Douglas-Jones, 2017).

Cremation practice in Nepal

Traditionally cremations in Nepal are performed with open pyres. These cremations are fluid public events organised and managed by relatives, local communities, and ritual specialists. The main purpose of the cremation practice is to purify and free the soul from the body of the deceased to secure a rebirth in another realm, render the soul a safe journey to heaven, and to turn the soul into a benign ancestor instead of a haunting ghost. Transmigration and reincarnation play a central part in the cosmology of the boarder religious traditions in South Asia. This practice is tied to cyclical rebirth, known as samsara, and the moral codes for righteous living, known as dharma. Further, tied to these concepts is the law of karma, the inevitable fact that every action has an effect, resulting in merit or sin, determining future rebirths. The final goal is salvation and release from the cycle of rebirths. These cosmological notions are seminal in Hinduism and Buddhism and have far-reaching consequences for mortuary practice (Davies, 1997, pp. 82–83; Filippi, 1996; Flood, 1996; Michaels, 2016; Parry, 1994).

Death causes considerable contagion and is fraught with potential danger for mourners, as well as for the community at large. Therefore, mourners must observe several regulations and ritual rules to avoid polluting themselves and others. Performance of various mortuary rituals by mortuary priests and ritual specialists is crucial for mourners to regain ritual purity, for atonement of bad karma and for their social re-integration in caste-oriented community. Through their work and association with death these priests and ritual specialists are traditionally low-caste and considered polluted and ritually defiled. The Pashupati temple priests have a high ritual status, are mostly secluded in the holy Pashupati temple, and have nothing to do with the cremation practice at the Pashupati area (Hadders, 2001; Hertz, 1960; Michaels, 2016; Parry, 1994; Van Gennep, 1960).

Cremation practice at Pashupati temple area

Since the 7^th century or earlier, Pashupati (literally lord of the animals) has been a tutelary deity of Nepalese Licchavi, Malla and Shaha kings, and there has been a temple for Pashupatinath at Pashupati area since that time (Michaels, 2011, p. 125). The divinity Pashupati, a form of Shiva, is regarded as a protective deity of Nepal and his main temple is one of the largest and most popular shrines Nepal, a sacred national monument for most Nepalese people (Michaels, 2008, 2011). The current Pashupatinath temple, located on the western banks of the Bagmati River, was built in the 17^th century and is one of the holy places (dhams) which a Hindu pilgrim in South Asia aspires to visit during a lifetime. There is historic evidence that the Pashupatinath temple, and the surrounding area with hundreds of temples, has been a prominent pilgrimage since the 16–17th centuries, and that the area next to and south of the temple has been considered favourable for cremation. To be cremated in the premises of the Pashupatinath temple at the bank of Bagmati is considered highly auspicious, like other Hindu pilgrimage sites, such as Banaras in India, and safeguard a favourable reincarnation (Michaels, 2008, p. 215; Parry, 1994).

Pashupati Area Development Trust (PADT) has provided various services and managed cremation practice at Pashupati area since the PADT was established in 1986 (His Majesty’s Government Nepal, 1987). Ghat Sewa Kendra office is the managing body of PADT, responsible for the management of traditional open pyre crematorium at Pashupati area, which is open 24 h a day. Either mourners arrive at Pashupati crematorium with the deceased from their home or they bring the deceased directly from the hospital, which is becoming increasingly common (Dangol, 2010, p. 56). When a death takes place in the hospital setting, a physician routinely certifies it clinically. When death occur at home, the death certificate is either issued by the Village development comity (VDC) or by a municipality office (Mahrajan et al., 2015). It is an obligatory to present a death certificate to the PADT Ghat Sewa Kendra office, prior to cremation at Pashupati. About 20 cremation attendants are employed by the PADT and organised by the Ghat Sewa Kendra to conduct the open pyre cremations. It is estimated that approximately 40% of the deceased in Kathmandu valley are cremated at Pashupati, with an average of 30 to 40 open pyre cremations per day. In Nepal, 81% of those cremated are Hindus, while 11% are Buddhist. Cremation is the main form of disposal practiced for Hindus and Buddhists (Hadders, 2017; Heiden, 2002).

On the 24^th of January 2016, Pashupati Area Development Trust (PADT) inaugurated the first functioning modern electric crematorium in Nepal at Pashupati. Figure 1 shows the traditional Pashupati crematorium area with the Pashupatinath temple in the background to the right side. Figures 2 and 3 show the PADT electric crematorium and furnace. The electric crematorium is used by a broad cross section of social, ethnic, and religious groups in Nepal, including Nepali Christians (Sharma, 2013). The main incentive for PADT to establish an electric crematorium was to diminish river pollution, carbon dioxide emission and to curb deforestation. Nepal Eye Bank has harvested cornea tissues at the PADT electric crematorium from the beginning. Since the establishment of the electric crematorium in January 2016, about 25% of the cremations at Pashupati area have taken place in the electric crematorium, offering a cheap option for all (Dube & Rawat, 2013; Hadders, 2017).

Figure 1. The traditional Pashupati crematorium area with the Pashupatinath temple in the background to the right side. Photo by author, 2017.

Figure 2. PADT electric crematorium. Photo by author, 2019.

Figure 3. PADT electric crematorium furnace. Photo by author, 2017.

There is a well-furnished separate room for improved aseptic cornea excision managed by NEB staff, located inside the PADT electric crematorium building, next to the electric crematorium registration desk. Adjacent to this facility is a small NEB staff office where consent forms are presented to mourners and signed. This NEB facility has been operating successfully since the launching of the PADT electric crematorium in January 2016. The door to this facility is intentionally kept open and mourner witnessed cornea excision is common occurrence in this room (see Figure 4.). In 2017, a total of 345 corneas were donated at the Pashupati crematorium (85% from electric crematorium and 15% from traditional cremation). This amounts to 40% of the total number of corneas collected by the NEB in 2017.³

Figure 4. Witnessed cornea excision at the PADT electric crematorium. Photo by author, 2017.

Eye care in Nepal

In 1985, the Nepal Ministry of Health and WHO survey of blindness (Brilliant et al., 1985) revealed a prevalence of blindness of 0.84%, and that the blindness in the country – of which 72% was due to cataract and 10% was due to corneal disease – was avoidable. Nevertheless, blindness in Nepal at this time remained largely unaddressed, due to lack of personnel, poor quality surgery, and rudimentary resources (Brilliant et al., 1985; Dixit, 2014). However, in 2015, some 350,000 high-quality cataract surgeries were performed in Nepal. Among others, the major contributors to this achievement were Tilganga institute of Ophthalmology (TIO) and Nepal Netra Jyoti Sangh (Nikpoor et al., 2018; Pokhrel, 2018). Due to the wide-scale advancements within eye care, the prevalence of blindness in Nepal dropped from 0.84% in 1985 to 0.35% in 2012, which amounts to a remarkable 58% decrease during this 30-year period. Currently, there are 35 secondary or tertiary eye hospitals, 96 community eye care centres and 254 ophthalmologists in Nepal (Nepal Netra Jyoti Sangh, 2020). TIO is well known globally for high-volume, high-quality cataract surgeries and corona transplantations; free of cost for poor patients, or for a nominal fee (TIO, 2020; Williams, 2019). The financial model practiced at TIO is based on the ‘Robin Hood’ principle of cost recovery where 33% of patients pay nothing, 33% pay a nominal fee, and the 33% high range affluent category of patients pay handsomely (Williams, 2019, p. 337). The ‘Robin Hood’ financial principle, which was first applied at LV Prasad Eye Institute in India, has been known as ‘compassionate capitalism’. TIO manage a high patient flow and give service to approximately 500 patients per day (Nikpoor et al., 2018, p. 30; Williams, 2019, p. 334). Some of the innovations that have made TIO success and the ‘compassionate capitalism’ model possible are cheap high-quality suture less fast recovery cataract microsurgery technique, intraocular lens manufacturing facility in Nepal and eye camps in outreaches supported by committed NGOs. Figure 4 shows a cornea excision at the PADT electric crematorium.

Establishment of Nepal eye bank

The Nepal eye bank was inaugurated on the 16^th of September 1994 by the current crown prince Dipendra Bir Bikram Shah Dev. Nepal Eye Bank (NEB) is a non-profit organisation, within Tilganga Institute of Ophthalmology (TIO), and operates on the principle of equitable distribution of corneal tissue to hospitals all over Nepal. NEB, the only eye bank in Nepal, was established with national and international funding, support from International Federation of Eye and Tissue Bank, and the Indiana Lions Eye Bank, Indianapolis. The main objective of the NEB is to procure, process and preserve corneas to combat corneal blindness. A lease contract between Pashupathi Area Development Trust (Pashupati crematorium) and TIO of 2544 square metres of land, a few hundred metres south of the crematorium, was signed on 21 September 1992 for the construction of the TIO eye hospital building.⁴ On the 7 June 1994 Tilganga Institute of Ophthalmology, the operating body of the Nepal Eye Program in Kathmandu, was officially opened. Initially, it contained the surgical clinic, education and training centre, intraocular lens factory, research unit, and the Nepal Eye Bank (Nikpoor et al., 2018, p. 29).

Initiating cornea donation in Nepal

The first cornea harvests performed by NEB were whole eye enucleations. This cornea retrieval procedure has been the preferred ‘gold standard’ in international eye banking and was common practice by colleagues from American TIO partner institutions at the time (Filev et al., 2018). Enucleation entails harvest of the entire eye globe. During enucleation each eyeball is eased out, the head is propped up to restrict blood flow, and the four extra-ocular rectus muscles are severed before the final cutting of the optic nerve (Filev et al., 2018; Simpson, 2017, p. 151). Harvesting corneas by enucleation in situ is quick, relatively simple and enables the most efficient preparation of the cornea tissues ex situ, in ultimate aseptic clinical conditions in a full-fledged laboratory at a later stage.

However, due to fear of negative public perceptions of the invasive disfiguring whole eyeball extraction practice, NEB soon changed their standard harvesting procedure to the more demanding direct corneal-sclera excision in situ. With the in-situ cornea tissue excision technique, one excises the corneoscleral disc only, the slim front layer of the eyeball, on site at the hospital bed or at the crematorium. In comparison with, in situ whole-eye enucleation, direct corneal-sclera excision in situ is a, technically, considerably more demanding and time-consuming procedure, due to various precautions taken to minimise microbiological contamination and physical damage of the cornea (approximately 30 min). This careful removal of the cornea, leaving most of the remaining eyeball intact in the body, is visibly and cosmetically more acceptable to the witnessing mourners (Bajracharya et al., 2020; Filev et al., 2018; Twyana, 2002).

In the beginning, the small NEB procurement team operated through some of Kathmandu’s main hospitals and relied mostly on voluntary donation. Sometimes relatives would contact the team, and cornea excision was performed in the residence of the deceased. The number of corneas being donated increased at a slow rate. In 1996 NEB collected 38 corneas, and in 1997 a total of 92 corneas were donated. Due to the meagre amount of donated corneal tissues between 1994 and 1997, NEB imported 451 corneas with the coordinating assistance from International Federation of Eye and Tissue Banks. Although, some of the corneas imported from abroad were of not optimal quality. Nevertheless, these corneas were a valuable support during the initial phase of NEB establishment. When the immediate need in the Kathmandu area was fulfilled, NEB quickly transferred the corneas to other districts in Nepal to avoid waste of the valuable corneas. More recently, NEB occasionally export corneas for international use (Bajracharya et al., 2020).

Due to the favourable relationship between TIO and PADT, established through the crucial eye hospital land deal in 1992, and to the fact that Pashupati crematorium is situated some 100-m north of the eye hospital, TIO executive director Sanduk Ruit and NEB colleagues decided to change their strategy. They realised that if they could harvest corneas from only a fraction of the many thousands of deceased cremated annually at Pasupathi, it would be a great boost to their project (Heiden, 2002; Ruit et al., 2002). When NEB started to harvest corneas at Pashupati crematorium in the late 1990s, the eye bank ‘technicians’, who perform the cornea excision, often used to approach mourners at the traditional cremation site alone. During the last decade they have usually worked in tandem with a NEB ‘eye donation counsellor’ who approach the mourners to gain their consent.

Organisation of cornea donation at Pashupati crematorium

Together with their partners and supporters NEB launched a concerted effort consisting of several actions started in 1997. First, NEB received the needed support and permission from the PADT and the Ghat Sewa Kendra office, the managing body of cremations at Pashupati. The Lions Club of Pashupatinath ⁵started an information centre, in a small room made available by the PADT, at the cremation area patrolled by Lions Club volunteers who regularly consoled mourning families and encourage them to donate. A large signpost was erected by NEB asking mourners to give the ‘great gift of sight’, (maha dan) stating that it generates good karma to donate your corneas (Fred Hollows Foundation, 2020; Ruit et al., 2002). Sanduk Ruit and NEB colleagues realised the importance of gaining full support from, crematorium staff, local religious leaders, and priests. In the beginning, these groups were sceptical towards donation due to lack of trust, religious beliefs, and misconceptions about the corneal excision procedure.

Awareness campaigns, news casted support, and NEB eye donation pledges and donations from various famous people helped to create awareness and acceptance among the public (Ruit et al., 2002; Twyana, 2002). All these measures had a positive effect on the amount of donations. In 1998, a total of 240 corneal tissues were collected and the NEB only imported four tissues that year. As a result, the total number of obtained corneas increased manifold to 547 tissues in 1999. Because of this increase the NEB has stopped importing corneas and has not imported corneas since. Most corneas were harvested at Pashupati crematorium by one of the committed NEB ‘technicians’ on call who shared the 24-hour shifts (Relin, 2013; Twyana, 2002). NEB routinely received informed written consent from relatives prior to cornea collection from the very beginning.

After lengthy discussions in 2012, a new combined strategy for cornea collection was launched as NEB followed the successful model applied by many eye banks in India and added a so-called Hospital Corneal Retrieval Program to their prevalent Pashupati cornea donation program (Gulati, 2014; Gupta et al., 2018). The underlaying logic of this strategy was the considerable increase in hospital deaths in urban and semi-urban areas. NEB employed five so-called Eye Donation Counsellors (EDCs), to be posted at Pashupati crematorium, as well as at three large hospitals in Kathmandu. After the launching of the Hospital Cornea Retrieval Program with the EDCs the number of donations increased considerably to 637 corneas in 2013 and have maintained a level between 600 and 700 corneas per year until 2016 (Bajracharya et al., 2020; Twyana, 2002). In 2014, NEB utilisation rate peeked to 80% and they managed to send 176 corneas to other institutions in Nepal, as well as exporting 34. After NEB boosted the cornea donation program further in 2017, donations peeked to 1178 corneas in 2018, with a utilisation rate over 90% (TIO, 2020). At present NEB has seven permanent EDCs in full-time service.

Motivated eye donation and counselling

The two modes of cornea donation in practice at NEB are voluntary and motivated donation. Voluntary donation is initiated by family members or the community of the deceased on their own accord. In most cases, the deceased has pledged eye donation with NEB, while alive. In addition, some dedicated ethnic communities and social organisations in Kathmandu valley support NEB and contact them regularly after the death of one of their community members. Nevertheless, the major and by far the most effective mode of donation for NEB, motivated donation, is initiated entirely by NEB staff. During motivated donation one of the full-time EDCs approach a family member of the deceased at Pashupati crematorium or at a hospital and give so-called ‘grief counsel’ to get consent for eye donation. In a recent NEB publication, by Bajracharya et al., of a comparative study between voluntary and motivated corneal donation, 87.7% of the 639 included donors were motivated (Bajracharya et al., 2020). In this context, so-called ‘grief counselling’ is described as communication with the family to make them aware of the program and motivate them for eye donation, and eventually gain their written consent.

According to the Nepal eye bank EDCs I interviewed, mourners can be categorised in high-, middle-, and low-level groups, based on their education and prior knowledge about eye donation. The wealthy high-level group is well informed about eye donation and their right to decline consent. They often decline consent and sometimes base their refusal on high caste perceptions about ritual purity, demanding that the donated corneas should not be given to low-caste people. Such reservations are partly based on conceptions about prana ‘life essence’, and personal karma. The middle-level group have some prior knowledge of eye donation, few objections and commonly agree to donation. The low-level group have very little prior knowledge about eye donation and often decline consent. In some cases, they base their decline on religious grounds, eschatological conceptions, and the need for the eyes in after life. Nevertheless, according to the EDCs interviews, all three level groups donate if they spend ample time on ‘counselling’, convincing mourners about the various benefits of eye donation. Approaching mourners at the time of funerals can be very challenging. The EDCs reported that it is not uncommon that relatives deny consent despite lengthy ‘counselling’. Some the grief-stricken mourners become frustrated and react with anger and abuse. Other potential reasons for refusal of cornea donation are; disagreement among family members, a wish to keep the body intact, forensic barriers, difficulties drawing blood for disease screening, positive identification of disease present in blood sample, other medical contraindications, trauma to eyes, and deceased without family.

Mourner witnessed corneal donation practice at Pashupati crematorium

Whether at the crematorium or at a hospital, the first step when approaching a potential donor family is to identify the main decision-maker in the family. Initially, the counsellor introduces themselves and their affiliation to NEB, express sympathy and console the mourners.⁶ The eye donation counsellors (EDCs) take their time to gain trust and to inform the family about the process of eye donation with the explicit goal of gaining their consent. Among other things, they inform about; donor anonymity, little time needed for the excision, no delay in the funeral ceremony, the need for a blood test, the process of excision, the absence of disfigurement of the deceased, and reassurance that the corneas shall not be sold. Further, the EDCs inform families about the magnitude of cornea disease and the difference they can make by donating the eye tissues of the deceased, giving sight to two people, instead of wasting the corneas on the cremation pyre. Finally, they explain to the family that religion is not a barrier to donation, on the contrary a blessing, in this and the next life. The EDCs actively promote eye donation as a socially and morally favourable act, which generate good karma.

When the EDC has gained written consent from the relatives, the NEB ‘technician’ interrupts the funeral for a short while and perform the cornea excision in the open public space, on the ground next to a cremation platform, or sometimes on the funeral pyre itself, prior to ignition by the main mourner. Prior to the excision the ‘technician’ draw 5 ml of blood from the deceased body for serology. Test result from the laboratory will usually be ready within a day or two. In the case of a positive finding of disease in the blood sample, the donation process is stopped. The ‘technician’ does the excision effectively as the mourning party watch in silence. The eyes and skin of the deceased are carefully cleaned with disinfectant, gently opened wide with a small retractor and the corneas along with a thin layer of the sclera is skilfully cut loose one by one. Family members often assist the procedure, holding the vial with the preservation fluid and open the vial cap as the eye bank manger finally place the neatly harvested cornea carefully in the preservation liquid without contaminating the tissues. Removing the vial cap just before the cornea button is placed in the storage medium minimises contamination and safeguards the successful transplant of the cornea tissue. The placing of the clean tiny corneoscleral disc in the vail of preservation fluid marks a decisive moment of the entire procedure. It is an enactment of a reincarnation process, materially as well as spiritually (Mol, 2002; Rachel Douglas-Jones, 2017, p. 10). The mesmerising visual viewer impact of the comparatively less invasive and elegant corneoscleral disc retrieval is less offensive to the viewer than the strong visceral visual impact of the invasive entire eyeball enucleation. Although none of my informants made any explicit comments about the significance of this elegant act, it is a prominent enactment of the donation, the ‘gift of sight’ or ‘gift of the eye’ (akha dan), and a ritual transfer of residual life force from the deceased to the blind receiver (see Figure 5 below).

Figure 5. Enactment of cornea reincarnation, the ‘gift of sight’/‘gift of the eye’ during witnessed cornea excision at PADT electric crematorium. Photo by author, 2017.

Once the cornea button has been placed in the vail with the pink ® Cornisol medium solution, the tissue is bestowed with liminal life in cold storage for up to 14 days at +2–8 Celsius degree temperature at NEB laboratory, prior to the final reincarnation of sight during the transplantation (Aurolab, 2021). The storage medium contains dual antibiotics which reduces risk of infection and enhances chances of a successful tissue reincarnation. At the NEB laboratory, the cornea is carefully evaluated for transplantation usability through the counting of cornea endothelium cell density by NEB staff. In this context, the cornea serves as a relic, and the bestowing of the faculty of eyesight is an immortalisation of the donor (Rachel Douglas-Jones, 2017).

As I have underscored above, for the purpose of mourner discretion during witnessed harvesting, the standard excision procedure performed by NEB technicians has been direct corneal-sclera excision in situ. In the NEB information brochure titled ‘Go for Sight’,⁷ under the heading ‘Does removal of eye disfigure the face of the donor’ it is clearly stated that ‘The Eye Bank Technologists or Doctors will treat the dead body with respect and only the cornea is removed from the eyes (NOT THE WHOLE EYE BALL) [capital letters in original] … ’ (Nepal Eye Bank, 2019). Further, for optimal aseptic purpose and for discretion, the NEB ‘technicians’ usually cover the face of the deceased with an operation cloth, with small slots for the eyes only, during the physical skilful technical surgical performance of cornea removal. After the removal of the corneas the NEB ‘technicians’ place small plastic caps on the eyeballs to minimise disfigurement, before they close the eyelids. These plastic caps have a ruffled surface, which stops the eyelids from sliding back. Therefore, there is no need for stiches to keep the eyelids in place. As I have illustrated above, the brief interruption of funerals by NEB staff does not result in any obstacles for the propriety of mourners’ ritual performance of the traditional cremation practice at Pashupati. However, there is one minor exception; the ritual use of red powder (abhir) often spread on the face of the deceased for an auspicious blessing of the departing soul, before the cremation. Excessive use of this powder can damage the corneas and is discouraged. In their information brochure, NEB explicitly ask mourners to restrict the use of powder, close the eyes of the deceased and protect them from the red powder (Nepal Eye Bank, 2019). When the cornea harvesting is completed, the cremation practice commences again, and the momentary silence is broken by the collective wailing by the women mourners. The cremation pyre is ignited by a close family member, initiating the transformation of the corpse, via the vital fire element, with a modern lighter or traditional firebrand. The funeral pyre is traditionally lit with fire from the domestic hearth by the chief mourner and legal heir, the eldest surviving son, or the nearest available male relative. In the modern urban setting, a female relative sometimes performs this role. Prior to igniting the funeral fire, the chief mourner will circle the corpse on the pyre thrice with a burning tinder. The chief mourner then ignites the pyre at the mouth of the corpse, an important ritual, facilitation of the passing of the soul (Heiden, 2002).⁸ This ritual ignition of the corpse (dagbati) is done by all communities at the electric crematorium, except Christians, before insertion of the deceased body in the furnace. Figure 5 shows the enactment of cornea reincarnation, the ‘gift of sight’/‘gift of the eye’ during witnessed cornea excision at PADT electric crematorium.

Finally, for several years, the Nepal Eye Bank EDCs regularly present the relatives with a certificate of appreciation, signed by executive director of TIO, Sanduk Ruit and NEB manager Shankha Narayan Twyana.

Through this letter we honour … [name] for giving sight to people with blindness by donating cornea after death on … [date] It is a meaningful and humanitarian work. We pray his/her soul may rest in peace.

In addition, an annual mass condolence memorial service is conducted at the eye hospital premises celebrating the deceased afterlife and pay homage to all the eye donors during the year. TIO, NEB staff and donor families pay their respect to the deceased relatives. The benefactors (cornea transplanted patients) join to express gratitude and share their personal experience of their ‘journey from darkness to light’ (TIO, 2020). Some people bring photos of their deceased relative and place it at the memorial site. Candles are lit, incense and flowers are offered to the souls at a temporary alter at a memorial plaque with all the names of the deceased who have donated their corneas during the year. Participants take photos and videos with their mobile phones of this ceremony and share these digital memorial images on digital platforms (enabling digital after-life of souls and persons). This annual event is a powerful public awareness tool for cornea donation and eye banking.

In 1998 ample funds were collected from the Lions Club of Pashupatinath, Fred Hollows Foundation, Jan Kok Foundation, and the PADT to construct a small cornea excision room next to one of the traditional cremation platforms at Pashupati. In this small room, made available by the PADT, the eye bank ‘technicians’ could extract corneas in an aseptic environment (Ruit et al., 2002; Twyana, 2002). This facility was often used for aseptic cornea excision, if the mourners did not specifically ask for an excision to be performed near the cremation pyre, in the open space. A smaller number of relatives often witnessed the procedure and assisted inside the cornea excision room. On one evening, the lights went out during the excision procedure due to a power cut and the NEB ‘technician’ at work asked mourners present to illuminate the deceased face with their mobile phones. This was easily done, as they were already filming the procedure with their phones.⁹ In fact, it is not uncommon that mourners generally document cremation practice with the help of their mobile phones and often record cornea excisions as well. Such digital visual medium recordings enable the continued residual life of the deceased and is a way to share the cremation event with a larger social group. In some instances, mourners share these video memorial recordings on digital media platforms, such as YouTube and Facebook to encourage cornea donation through this digital memorialisation of the deceased.¹⁰

Discussion

As I have pointed out in my introduction, despite an established tradition of necro organ donation, eye banks in many countries still struggle with low cornea donation consent rates (Lawlor & Kerridge, 2014; Röck et al., 2016, p. 702). Nepal is a country with little experience and awareness of necro organ donation, where most of the population still have a traditional mindset based on collective social and religious values (Paneru et al., 2019). However, Nepal Eye Bank (NEB) have established a high level of public trust. The repeated awareness campaigns, annual memorialisation event for donors, their general openness, transparency, and the fact that cornea donations are performed in the open public space, often witnessed by relatives and mourners, have helped to maintain public trust. Without this openness, it is rather unlikely that NEB could have succeeded with their entrepreneurial cornea donation program. NEB has practiced full openness and written informed consent from family members since the beginning. In this regard and generally, NEB comply with SightLife, their international partner, quality and ethical procedural standards and have received SightLife quality certificate in 2015 (Bajracharya et al., 2020, p. 96). The current Human Organ Transplant Act, which generally safeguards organ donation practice in Nepal was updated with some amendments in 2016 (Ministry of Health, Nepal, 2016b). NEB’s open approach differs greatly from the manner cornea extraction was performed in Egypt in the 1960s. This professional practice resulted in largescale public mistrust of cornea donation and medical professionals (Hamdy, 2016). Hamdy reports about this scandal, where Egyptian elitist profit-oriented ophthalmologists decided that it was impractical to inform family members. Hamdy relates that ‘the practicalities of establishing consent were rendered simply impractical and unnecessary within a strongly paternalistic medical context that systematically ignored poor patients’ wishes and beliefs about their own bodies and medical treatment’ (Hamdy, 2016, p. 226). Thus, the Egyptian ophthalmologists routinely performed largescale corneal transplants with corneas secretly harvested by enucleation in public hospital morgues without informed consent and mourners’ awareness (Hamdy, 2016, p. 226–227).

Currently NEB cooperates with recently established regional Nepali cornea collection centres in Biratnagar, Lahan, Hetauda, Bharatpur, Pokhara, Lumbini and Kailali. NEB collect more than a thousand corneas per year and have a utilisation rate of over 90% (Nepal Eye Bank, 2019). According to news reported by The Himalayan (2019), over 75,000 persons have signed the NEB pledge form agreeing to donate their cornea posthumously, while more than 15,000 persons have regained sight after corneal transplantation since the start.¹¹ Those who pledge are kept in the Tilganga institute of Ophthalmology (TIO) records and receive a donation card with photo identification and a small ‘eye donor’ badge (Nepal Eye Bank, 2019). In the Sri Lankan context, the primary ontological framework within which the act of cornea donation, make sense is referred to as the ‘rhetorics of corporal charity’ by Simpson (2017). Simpson underscore that; ‘The conflation of the gift as religious duty and as an act of corporeal charity proves remarkably successful when it comes to activating the intention to donate, if not the actual post-mortem practice’. (Simpson, 2017, p. 155). Like the development of cornea donation practiced by Sri Lanka Eye Donation Society, where donation draw on Theravada Buddhist ideas of the ‘charitable gift’ – ‘dan’, cornea donation in Nepal has become widely accepted and assimilated in local Hindu and Buddhist ontological terms advocated by the NEB as a gift act ‘dan’, or ‘maha-dan’, ‘the great gift’ which bestow the donor with merit, good karma, in this world and in the next. Cornea donation is also advocated by Tilganga NEB to embrace systems of inequality outside the crematorium, a chance for the mourners and their community to commit a final act of philanthropy for the benefit of some fellow human beings and let the soul of the deceased reincarnate in the receiving recipients.¹² The concepts of karma, rebirth and reincarnation within Hindu and Buddhist culture easily conflate with ideas of re-incarnation and immortalisation through organ transplant. Objections to cornea donation based on eschatological ideas are declining. In his master thesis, where he explores the ‘socio-cultural’ aspects of cornea donation in Kathmandu valley, eye bank manager Shankha Narayan Twyana reports that only 5.2% of the respondents who disagreed to cornea donation based their denial on the belief that there is a need for intact eyes in afterlife (Twyana, 2002, p. 100). In a recent study about awareness of eye donation in the community in western Nepal, Punam and Pratiksha (2017) report that 42.5% of the participants had a high level of awareness regarding the benefits of eye donation and that only 9.4% believed that one may be born blind in the next life if one donates corneas. An obvious limitation of my study is the lack of relatives’ experiences of the cornea cremation process through interviews with the mourners. In a future study of cornea donation at Pashupati crematorium, interviews and interaction with the mourners through fieldwork should be a priority.

Concluding remarks

Various cosmological, eschatological, and bio-medical factors shape the form and content of cornea donation practice and procurement at Pashupati crematorium. I argue that cremation and cornea donation practice at Pashupati is a multiple affair, embedded in material, social, legal, aesthetical, and bio-medical practice – at collective as well as individual levels. Further, cornea donation is a collective achievement accomplished by complex socio-material arrangements that bring together various professionals, procedural manuals, legal framework, equipment, medical intervention, the deceased body, and mourners during the cremation practice (Mol, 2002). In this context, the public does not necessarily perceive the cornea donation as an aggressive and dehumanising practice imposed on the mourners by the EDCs during donation. NEB staff has become one of several accommodated professional groups and mortuary ritual specialists that appear and assist the mourners during cremation practice at Pashupati (Hadders, 2017; Parry, 1994). The most common purpose for the observance of cremation practice amongst Hindus and Buddhists are to free the soul of the deceased from the corpse, remove impurities to ensure auspicious rebirth, heed religious and social duties, such as, that of the son towards his father, and the duties towards the ancestors. Nugteren emphasises that ‘Failure to perform these [rituals] may negatively affect not only one’s own status, but also that of the dead relative’ (Nugteren, 2016, p. 121). Mourners’ insistence to perpetuate traditional cremation practice and to accommodate various demands by mortuary ritual specialists is linked to strong social ties and binding social obligations to perform traditional cremation practices. Finally, the mourners believe that welfare and the prosperity of the family partly depend upon the blessing of the ancestors (Michaels, 2016). My study of the development of cornea donation practice at Pashupati illustrates the importance of continued public awareness programs, openness, and transparency to gain public trust. The success of the Nepal Eye Bank cornea donation program is a remarkable example for other Eye Banks to follow.

Acknowledgement

My thanks goes to the editors and reviewers of Mortality, Susan Matland and Ellen Kristvik who have read and commented drafts of this article. The Institute for Comparative Research in Human Culture and Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Technology and Science provided funding for this study. I am particularly indebted to my research assistant Rojisha Poudel, and all the participants in this study who generously shared their time.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Hans Hadders

Hans Hadders, PhD in social anthropology, RN, is an associate professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology Trondheim, Norway. Hadders main research focus is on mortuary rituals and standardisation of death in South Asia and within the Norwegian health care.

Notes

1. The soul is an imprecise term, inadequate to cover the many nuances concerning mind, vital essence, animation, or life principles dealt with in connection with the topic discussed here. However, for the sake of convenience I still use this term as a denomination for a larger eschatological field.

2. For a detailed discussion of ‘the category of the person’, see Carrithers et al. (1985).

3. Personal communication with NEB manager Shankha Narayan Twyana, June 2019.

4. Personal communication with Govinda Tandon, former member secretary of PADT, March 2020.

5. The Lions Club of Pashupatinath has actively supported the NEB cornea donation program since the beginning. See this video about their activities; https://www.youtube.com/watch?v=0vd_BbDt7fs.

6. The EDCs carry visible valid NEB identity cards.

7. The Nepali version of this info folder is titled ‘gift of the eye’, ‘the great gift’ (Nepal Eye Bank, 2019).

8. See ‘Before I burn’, a documentary by Joel Addams, filmed in 2011; http://floatingsoulfilms.com/beforeiburn.

9. See photographer Yani Clark’s video, 2015; https://www.youtube.com/watch?v=PjuyhHb-kNw&t=7s.

10. See for instance video from PADT electric crematorium NEB cornea excision room, 2017; My Venerable Heavenly Father Purna Maharjan, I wish you peace of mind and I am very happy to be able to make a great donation like eye donation at the time of death!; https://www.youtube.com/watch?v=Eg0fqrWTwgw.

11. https://thehimalayantimes.com/kathmandu/75000-persons-pledge-to-donate-cornea/.

12. See the recent Tilganga NEB information video advocating cornea donation from 2019. ‘Donate your eyes! Let your soul outlive you’; https://www.youtube.com/watch?v=ux6tbXnB0k8.