Cleft Lip & Palate: From Origin to Treatment, 1st Edition

33. International surgical missions

S. T. Lee

For the foreseeable future, there will always be a need for international surgical missions to deal with the backlog and the increasing number of patients with oral clefts in the world. These volunteer field missions should, however, be only a part of an overall global strategy. Rather, the emphasis should be on genetic and environmental research, to understand the causative factors of oral clefts, which might lead to the development of preventive strategies to reduce incidence.

Based on the current world population and birth statistics (United States Bureau of the Census, http://www.census.gov/ipc/www/idbnew.html), 132 million babies were born in 2001, out of a global population of 6.2 billion individuals. If the prevalence at birth of cleft lip with or without cleft palate (CL/P) is taken to be 1/500 live births, 264,000 babies were born with oral clefts in 2001. This enormous number illustrates the magnitude of the problem, which needs to be addressed on a global scale. It is likely that the population with oral clefts will increase globally, unless there are dramatic genetic breakthroughs or new preventive strategies that can reduce this ever-increasing number.

Concurrently, there is also the problem of limited global health resources, especially when dealing with a non-life-threatening condition such as cleft lip and palate (CLP). The overwhelming numbers of newborns with oral clefts are found in countries with high birth rates (e.g., China, India, Indonesia, Africa, South America, Southeast Asia) (Lee, 1999b), where there are invariably limited resources for dealing with the problem. This unequal distribution of expertise and resources is a global dilemma. Resource-rich countries have fewer patients, while countries with minimal resources are inundated with more cleft patients than they can handle. Therein lies the challenge of matching the resources/expertise with the CLP population in the world.

Philosophy of Volunteer Missions

Traditionally, volunteer surgical missions have been sponsored by religious groups, service clubs, nongovernment organizations, philanthropic institutions, and altruistic individuals. They are usually motivated by a sense of charity, compassion, and public-spiritedness toward those who belong to the more vulnerable and disadvantaged groups in society.

International cleft missions should mobilize these positive forces and encourage volunteer work as an expression of a concerned and caring society. Voluntary work, as most volunteers on cleft missions have found, is not necessarily a one-way street: the volunteer gives time and expertise and gains much in return from the experience. Interaction with different cultures and different socioeconomic groups can be a very enriching experience, broadening one's outlook of the world community, creating of new bonds, and heightening the sense of personal fulfillment at being able to do something positive, meaningful, and totally voluntary in nature.

Goals of International Missions

There is a common thread which runs through all of the goals and objectives of international surgical missions. As far as cleft missions are concerned, the “purist” approach is to deal only with oral cleft patients, to the exclusion of any other medical condition.

As far as this author is aware, only a few teams, such as Michael Mars' from the Great Ormond Street Children's Hospital (Mars et al., 1990) and Amado RuizRazura's of Operation San Jose (Ruiz-Razura et al., 2000), conduct their missions in such an exclusive manner. Almost all other missions deal with a high percentage of CLP cases (usually over 80%) and, to a lesser extent, burns, contractures, chronically unhealed wounds from snakebites and other causes, tropical ulcers, and cancrum oris.

Volunteer organizations usually have five main goals, which are humanitarian in nature (for more details, International Medical Corps, 1997; Interplast Australia, 1999; Interplast, Inc., 1998; Operation Smile, 1997):

1.   Provision of direct care to cleft patients and those requiring reconstructive and other ancillary services

2.   Provision of educational training to the local population of doctors, nurses, and paramedical personnel

3.   Provision for more complex cases, who cannot be treated locally, to be brought back to the donor country for treatment

4.   Promotion of self-reliance and establishment of local teams capable of continuing the work of volunteer teams

5.   Collection of epidemiological and other research data which could give a better insight into the causative factors and result in preventive strategies

Preparation for a Surgical Mission

The preparation of a surgical mission is as important as the actual execution of the mission itself. The preparatory work may take from 6 months to a year for all of the necessary correspondence and clearance with the relevant medical bodies, ministries, etc. to be completed. Assessment of the needs and the local facilities means that a site usually must be visited by the team leader and key personnel prior to the mission itself.

Embassies in the countries to be visited are usually a repository of relevant information about local health hazards, immunization required for the team, local information on food, accommodation, entry regulations, areas to avoid because of security problems, social taboos, etc. In addition, the ambassador and embassy staff are usually very solicitous and proud of the visiting team and can provide useful contacts with local ministry officials to facilitate the team's movement and activities. Contact with the embassy is to notify the team's visit rather than the actual organization of the mission itself.

Close contact with the main liaison of the host country will need to be maintained. With the availability of the Internet today, communication has become less of a problem. The team composition, the inventory of equipment and supplies, the basic screening of patients before arrival of the team, and the operating schedule for the duration of the mission need to be jointly worked out between the team leader and the liaison beforehand.

As far as the preparation of the team members is concerned, they need to be briefed on the nature of the mission, their individual responsibilities even though they may be volunteers, the local customs and culture, and their role as medical “ambassadors.” They need to take the necessary immunization and prophylactic procedures against, e.g., malaria (where chloroquine resistance is a problem, check with World Health Organization and local health authorities on appropriate prophylaxis). Each member of the team should be personally insured against injury as well as covered medicolegally. Either the organization or the institution will need to provide this coverage, and its importance cannot be overemphasized.

Recipe for Success: the Dos and Don'Ts

Guidelines have been drawn up by various volunteer organizations (Lee, 1999a; Reconstructive Surgeons Volunteer Program, 1999; American Cleft Palate Association, 1994) to help those who wish to volunteer their services in developing countries. These guidelines are necessary, to provide a minimum standard of care for cleft patients and to prevent the “downside” of volunteer missions. Much has been written about the unfavorable outcomes of medical missions (Lehman and D'Antonio, 1992), and this disquiet prompted the Reconstructive Surgeons Volunteer Program to organize a symposium entitled “Volunteering Overseas: Avoiding the Downside” in Boston, Massachusetts, in 1998. From these discussions, the following 10 guidelines for the conduct of volunteer surgical missions have been accepted.

Guidelines for Volunteer Medical Missions

1.   Go where there is a need and go where you are wanted.

2.   The goals should be service, training, education, and, where possible, research.

3.   All volunteer missions should liaise closely with the host organization and seek clearance from local government authorities and national organizations.

4.   Proper planning and attention to details of the missions will ensure success, e.g., proper timing, customs and immigration, flight arrangements, and patient screening.

5.   Local host participation is important to the success of the mission, e.g., local transport, storage of equipment and supplies, food, and accommodation for team members.

6.   Personal health and liability are the individual responsibilities of team members themselves, to avoid sickness during or after the mission. Proper vaccination and prophylactic measures should be undertaken.

7.   Sources of funding may be personal donations, industry, philanthropic organizations, private sector, nongovernment organizations, and governments. Recipient countries may contribute toward local transport, food, and accommodation.

8.   Team members should be experienced specialists in their own fields, to ensure quality of care. Only senior residents or trainees should be allowed to operate under the supervision of senior team members.

9.   Postoperative care and follow-up must be of the highest quality, to avoid complications, especially after the team's departure.

10.       Volunteer teams should always avoid self-promoting publicity, especially in the host country. Sensitivities may be aroused by undue and unwanted publicity among the local medical fraternity; but publicity at home, especially after completion of a successful mission, is welcome and good for raising awareness and funds.

In general, volunteers should maintain the highest standards of care. They should work in conjunction with local doctors and transfer skills and knowledge to them so that they can be self-reliant in delivering services after the departure of the team. Technical aid programs to bring doctors, nurses, and paramedical personnel for further training in the donor institutions should be made available. Medical volunteers are ambassadors of care as well as goodwill and should be sensitive to local customs and culture. They should be adaptable to local conditions of medical practice and living. Team members should be chosen for their adaptability as much as their surgical skills.

How Host Countries can Ensure the Success of a Mission

The perception by the local professional community of the goals of a volunteer mission is important in determining the level of cooperation. If volunteers are perceived as providing a “superior” service and this is the belief among the local patients, then professionals may feel threatened or there be a “loss of face.” It is important to realize that the local professionals may not be able to accept that their skill levels are not equal to the visitors' and that any discussion of sophisticated technology will further enhance feelings of inferiority and animosity. To avoid such negative feelings, active steps should be taken by the volunteer team to dispel such perceptions. The best way to accomplish this is to have the local professionals work alongside the visiting team members from the start.

Host countries can participate actively to ensure the success of missions in several ways.

1.   Needs, whether they involve service, training, or equipment and supplies, should be identified as accurately as possible.

2.   The patient population needs to be screened so that only those suitable for surgery are presented to the team. Usually, the short duration of the mission precludes dealing with every patient, and there needs to be some prioritization. Investigation and surgery for some complex craniofacial anomalies will need to be done in the donor institution/country.

3.   Facilitation of entry and customs requirements as well as local transport and accommodation will allow the volunteer team to settle in and get to work as quickly as possible.

4.   Host country and institutions can demonstrate responsibility in the usage of funds and supplies/equipment so that donors can be assured that the donations have reached the people most in need of help.

5.   Follow-up of patients after the departure of the volunteer team will need to be carried out by local professionals. Documentation and records are important for subsequent recall of patients who may require staged repair or secondary procedures.

6.   To develop the concept of multidisciplinary team care for cleft patients, host countries and institutions should identify suitable individuals for training in orthodontics, speech therapy, pediatric anesthesia, and specialized cleft nursing. They are encouraged to function as a unit and to work with the volunteer team on subsequent visits. If opportunities are available, they should be sent for training in the donor countries/institutions so that eventually a selfreliant and independent CLP team can be created for long-term care of the local cleft population.

Future of Surgical Missions

As Gorney (1987) said: “there is no more undervalued a weapon of foreign policy as reconstructive surgery.” When volunteers bring hope to those born with clefts and deformed faces who would otherwise have to face a life as a castaway and shunned by society, they are regarded as angels of hope and humanitarian ambassadors for their countries.

No amount of foreign aid will touch as many lives as those operated on by the volunteer teams or generate the aura of goodwill and understanding between peoples and nations.

However, volunteer missions must be audited for their performance. They must not leave behind a trail of mishaps and complications to sully the reputation of volunteer missions. Untrained personnel and those who do not have the credentials to carry out the surgical procedures in their own countries should not do so in the guise of a “foreign expert” in developing country. Volunteer missions, after all, are not safaris for hit-and-miss surgeons. They are for the most experienced in the specialty so that spot decisions can be made in the field. There are no intensive care units when something goes amiss, and only experience clinical judgment of the best course action will sometimes save the day.

Those who are starting off as volunteers are advised to adhere closely to the guidelines set out by international bodies such as The Reconstructive Surgeons Volunteer Program, The American Cleft Palate Association, and The International Plastic Reconstructive Aesthetic Society. They should consult veterans of volunteer missions, who will usually have many interesting anecdotes to tell and down-to-earth advice give. Volunteer missions will continue to be needed until cleft teams are established in all developing countries and the population of individuals with oral clefts stops growing. This will not happen in the foreseeable future, and until it does, volunteerism will provide the avenue for following our humanitarian drive and achieving our hippocratic ideals.

References

American Cleft Palate Association (1994). Cleft and Craniofacial Surgery Services in Developing Nations: Guidelines for Volunteers, edited by K Stueber and L Wilson.

Gorney, M (1987). Principles of successful medical expeditions to developing nations. In: A Different Kind of Diplomacy, edited by JC Fisher and D Armstrong. San Diego: Plastic Surgery Education Foundation, pp. 10–14.

International Medical Corps (1997). Annual Report 1997. Los Angeles: International Medical Corps.

Interplast Australia (1999). Annual Report 1999. Melbourne: Interplast Australia.

Interplast Inc (1987). The Story of Interplast—Shared Miracles. Palo Alto: Interplast.

Lee, ST (1999a). International Plastic Reconstructive and Aesthetic Society, Committee on Projects in Developing Countries. Guidelines for volunteer missions overseas. IPRAS Newsletter.

Lee, ST (1999b). New treatment and research strategies for the improvement of care cleft lip and palate patients in the new millenium. Ann Acad Med Singapore 28: 760–767.

Lehman, JA, D'Antonio, LL (1992). Volunteer medical missions. Cleft Palate Craniofac J Vol 29, pp. 1–2.

Mars, M, James, DR, Lamabadusuriya, SP (1990). The Sri Lankan Cleft Lip and Palate Project. Cleft J 27: 3–6.

Operation Smile (1997). Annual Report 1997. Norfolk, VA: Operation Smile.

Reconstructive Surgeons Volunteer Program (1998). RSVP Guidelines for Good Guests. Arlington Heights, IL: Reconstructive Surgeons Volunteer Program.

Ruiz-Razura, A, Cronin, ED, Navavro, CE (2000). Creating long- term benefits in cleft lip and palate volunteer missions. Plast Reconst Surg 105: 195–201.

United States Bureau of the Census. International Data Base. 2001. http://www.census.gov/ipc/www/idbnew.html.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!