THE GARY BRODY, MD, FAMILY LECTURESHIP
The Expanding Role of Education and Research in International Healthcare Christine M. Jones, MD,* C. Alex Campbell, MD,*† William P. Magee, MD,† Ruben Ayala, MD,† and Donald R. Mackay, MD*† Abstract: A recent report of the Lancet Commission on Global Surgery has continued to emphasize the importance of surgery in global health. Plastic surgeons have been involved in humanitarian care of children in developing countries for many years. The ability to repair children with cleft lip and palate in resource-poor settings has made this desirable for many plastic surgeons. A number of philanthropic plastic surgery organizations arose to deal with the problem in a more structured way. Dr. Donald Laub at Stanford established Interplast (now ReSurg) in 1969. Dr. Bill and Kathy Magee established Operation Smile in 1982, and many others have followed. The unifying theme of these organizations has been the desire to provide safe and effective surgical care to children who would otherwise be forced to live out their lives with deformity. Most care has been for children with clefts, but efforts have expanded to include hand surgery and burn reconstruction. The initial effort was provided through surgical missions. A paradigm shift has occurred as sustainability and local capacity have become paramount. Education and training of local colleagues and assistance in surgical safety infrastructure are expanding the reach of plastic surgical care around the globe. The inauguration of in-country permanent surgical centers allows high-volume outcomes research, as well as unique educational collaboration between plastic surgeons of both the developed and developing world. Key Words: global health, surgical mission, global surgery, cleft lip, cleft palate, international research (Ann Plast Surg 2016;76: S150–S154)
The State of Surgical Care in the Developing World The ideals of global health care are well-aligned with the altruism, service to others, and alleviation of suffering that draws most physicians to medicine. Great strides have been made in improving global health in the past 25 years, but advances have not uniformly affected all aspects of medical care. Perceived as too expensive and complex, surgical care has long been the “neglected stepchild of global health.”1 As a result, millions of lives are lost annually as a result of treatable surgical disease. In 2010 alone, 16.9 million people died from conditions requiring surgical care,2 more than the number who succumbed to human immunodeficiency virus/acquired immune deficiency virus, tuberculosis, and malaria combined.3,4 In 2013, the Lancet Commission on Global Health was tasked with improving global access to safe and affordable surgery and anesthesia. The commission delivered their report in April 2015, describing a great disparity in the distribution of surgeons worldwide. Over 5 billion people in developing countries lack access to basic surgical care. Some Received July 2, 2015, and accepted for publication, after revision November 17, 2015. From the *Penn State Hershey Medical Center, Hershey, PA; and †Operation Smile, Virginia Beach, VA. Conflicts of interest and sources of funding: none declared. Reprints: Donald R. Mackay, MD, Penn State Hershey Medical Center Division of Plastic Surgery 500 University Drive Mail Code H071 Hershey, PA 17033. E-mail: [email protected]. The Brody Family Lecture Presented by Donald Mackay at the 65th Annual Meeting of the California Society of Plastic Surgeons, May 2015, Monterey, CA. Dr. Mackay is Chief Medical Officer of Operation Smile. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7605–S150 DOI: 10.1097/SAP.0000000000000721
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patients are financially ruined in seeking care. Cultural reliance on local traditional healers can result in some patients seeking care only when problems are advanced, or in not seeking care at all. Surgical need is greatest in sub-Saharan Africa and South Asia (Fig. 1).3 An estimated 143 million additional surgeries are needed annually in these developing countries to successfully avert death and disability.3 Although the current state of surgical capacity is poor, the cost of improving access to surgical care is a good investment. Timely and appropriate surgical care can prevent disability and improve personal productivity. Thus, an investment in surgical capacity helps stimulate economic development.3 A tiered approach to surgical diseases has been suggested, dividing conditions into must-do, should-do, and can-do categories (Fig. 2). Access to affordable surgery is indeed a crucial part of a functioning health system.3
Providing Surgery for Patients With Cleft Lip and Palate in the Developing World Cleft lip and palate (CLP) are among the most common congenital anomalies, occurring in 1 in 500 to 1000 live births.5 Cleft lip and palate is one of the conditions that, although not life-threatening, greatly diminishes an individual's quality of life and potential productivity. Children with unrepaired CLP are stigmatized, outcast, and rarely given a chance for relationships, family, or employment. The worldwide burden of untreated CLP has a tremendous cost in terms of lost productivity.6–8 Several studies have found the surgical treatment of CLP to be very cost-effective.8–11 Cleft lip and palate care compares favorably to other conditions that have received billions of dollars in global aid. The cost per disability-adjusted life-year averted is less than that of antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency virus and less than that of the bacille Calmette-Guérin vaccine for prevention of tuberculosis (Fig. 3).12 Because of the easily treatable, relatively low risk of CLP surgery, plastic surgeons have been uniquely positioned to help this vulnerable population. Humanitarian organizations have been founded by plastic surgeons (Table 1), among them ReSurg (previously Interplast), Operation Smile, and Smile Train. Most of these organizations began with “mission-centered” care staffed by international volunteers motivated to alleviate suffering in the developing world. Although an effective means of providing reconstructive surgery, mission-based care does not address the longitudinal cleft treatment that is considered standard in developed countries. Postoperative outcomes are lost to follow-up. These children often do not receive speech therapy, orthodontics, or dental care, and there is little ongoing support for families and communities. A maturational shift has occurred as these organizations focus on sustainability, providing a greater emphasis on educating local surgeons, nurses, and other providers, as well as helping develop local infrastructure and systems. As an example, Operation Smile has made major efforts to shift the care from international to locally-run missions, as well as develop local centers for cleft care. In 1999, Operation Smile organized the World Journey of Hope. Over a 9-week period, volunteers travelled to 18 countries and provided free surgery for 5300 children. Although Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Research and Education in International Healthcare
FIGURE 1. Proportion of the population without access to safe, affordable surgery and anesthesia by Institute for Health Metrics and Evaluation region. Reproduced from Meara and colleagues,3 by permission from Elsevier.
successful by its sheer volume, it also marked the beginnings of incountry missions. A contract was set up with each country to manage sustainable, small-scale charity missions by local surgeons (Fig. 4). In 2007, Operation Smile ran 40 simultaneous missions in 25 countries on the World Journey of Smiles, treating more than 4400
children in 10 days. To organize a mission of such magnitude, over 3400 medical volunteers in partner countries were trained in teambased cleft care. Attention was focused on creating sustainable publicprivate funding partnerships that could establish and maintain local cleft centers (Fig. 4).
FIGURE 2. Common surgical procedures stratified in a must do, should do, and can do framework for first-level care. Reproduced from Meara and colleagues,3 by permission from Elsevier. © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 3. Cost-effectiveness of surgery in low-income and middle-income countries compared with other public health interventions. Data points are medians, error bars show range. Surgical interventions are denoted by the diamonds and solid lines, public health interventions by the circles and dashed lines. DALY, disability-adjusted life-year. Reproduced from Chao and colleagues,12 by permission from Elsevier.
This local center-based care model has been replicated in several countries. One of the most notable is the Guwahati Comprehensive Cleft Care Center (GC4) in the northeast Indian state of Assam. GC4 was established in 2011 in collaboration between Operation Smile, the government of Assam, and private enterprise (Tata Trust). This centerbased care has been found to be more cost-effective than mission-based care and also works to stimulate the local microeconomy.13 More resources are invested locally, thus creating sustainable infrastructure and employment (Fig. 5).
TRANSITION FROM PROVISION OF CARE TO SUSTAINABILITY: THE IMPORTANCE OF EDUCATION AND RESEARCH Sustainable Care Through Surgeon Education A carefully selected team of international surgeons and other health care workers with specialized expertise initiated GC4. Additional Indian surgeons were added, with further expansion by early recruitment of additional team members in all disciplines.14 Staff members were chosen based on their long-term commitment to providing cleft care locally. International experts then mentored those chosen. The medical team ultimately comprised over 90% local, full-time staff. A fellowship model was then developed in which plastic surgeons from around the world could come to GC4 for training in the high-volume, high-quality environment of full-time cleft care.15 Over 100 Guwahati visiting fellows have not only trained at GC4 but many have also gone on to lead cleft teams in their home countries.
Research in a High-Volume Cleft Center In its first 2 ½ years of patient care, GC4 provided 7000 free cleft repairs.15 Four years in, that number is now over 11 000. As this model carefully ties high clinical volume with academic interests, research done through Operation Smile local centers has resulted in over 25 publications,16–26 with almost 20 coming from GC4 alone.10,13–15,27–41 Operation Smile India spent 2 preliminary years studying the government, culture, and infrastructure of Assam to develop the successful model for sustainable care that is GC4.14,15,27 Unique methods were developed to recruit patients through nonmedical screening personnel in the community, because 87% of the population of Assam lives in rural and isolated areas.14,28 This center-based care also allowed for appropriate postoperative follow-up. Standardized, simple, and culturally based postoperative instructions were developed to improve the understanding of postoperative care and reduce the rate of complications.29 Novel methods were developed to help reduce cost of follow-up care to the families. For those able to return to GC4, free local housing was provided, patients received multidisciplinary care, and travel costs were S152
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reimbursed. Multidisciplinary teams also travel to outreach camps for patients living over 200 km from the center, to facilitate follow-up in remote communities. These methods have allowed the team to monitor over 70% of their patients despite the environmental challenges.14,30 The high clinical volume at GC4 allows for outcome evaluation of much higher statistical power than that typically appreciated even in American academic centers. An institutional ethics committee was created. The Operation Smile Global Standards of Care emphasize the provision of high-quality care over maximizing volume.14 Within this model, and despite older patients with more challenging clefts, a low rate of fistula has been noted after cleft palate repair.31 Wound dehiscence after cleft lip repair was found to be higher than expected at 3.3%.32 However, after multivariate analysis, it was determined that surgeons visiting from developed countries had higher rates of dehiscence than permanent staff.32 More research is warranted to investigate clinical outcomes and determine best practices. By marrying the research interests of international academic plastic surgeons with the zeal and high volume of centers in the developing world, questions can be answered with higher statistical power and accuracy.
Resident Education by Immersion in Global Health Surgery Plastic surgeons in the United States often encounter patients who are culturally and ethnically diverse and must adjust their care accordingly. The Operation Smile Regan and Stryker Fellowships allow senior residents in plastic surgery, anesthesia, or pediatrics to participate in its programs in developing countries. The fellowship is prefaced by an educational weekend in Norfolk, VA, in which residents are instructed on multidisciplinary cleft care and provision of care in mission countries. Residents are then sent worldwide with assigned mentors for structured participation in all aspects of team care. Four
TABLE 1. National, Non-Governmental Organizations Seeking to Treat CLP in Developing Countries Organization
Founding Year
ReSurg (Interplast) Operation Smile Austin Smiles Rotoplast International Small World Foundation Smile Train Nicaplast
1969 1982 1987 1992 1995 1998 2003
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FIGURE 4. Historical surgical statistics of the type of care provided by Operation Smile. Care has transitioned from international missions to sustainable care centers, with the 1999 World Journey of Hope and 2007 World Journey of Smile marking important turning points. (WP Magee and R Ayala, personal communication)
months after their missions, residents gather for a debriefing meeting in which they share their experiences. This model of real-world cultural education has been shown to help residents grow in each of the 6 core competencies outlined by the American Council for Graduate Medical Education. In its inaugural year, participants in the Regan Fellowship program uniformly said the experience had an overall positive impact on their lives.42 Detailed surveys demonstrated the residents developed a greater appreciation for global health and enhanced cultural competency.42,43 Residents cite this experience as incredibly empowering and often the highlight of their training.33,44 Almost 85% of Regan fellows report their missions heightened their personal sense of social responsibility, and nearly 95% say it increased the likelihood they would volunteer with underserved populations in the future.42,43 In 2013, the Plastic Surgery Residency Review Committee provided guidelines for arranging approved international rotations. Residency Review Committee–approved rotations to GC4 have been available to interested residents since that time.45 Lurie Children's
FIGURE 5. Comparison of categorical expenditures between the missions and the center in Guwahati, India. Reproduced from Nagengast ES, Caterson EJ, Magee WP, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg. 2014;25:1622–1625. Copyright (2014), with permission from Wolters Kluwer Health.13 © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Hospital at Northwestern University and Penn State Hershey gave key GC4 surgeons clinical appointments that allow residents and fellows to rotate there without having to use extended vacation time. Residents from both universities have participated in month-long American Council for Graduate Medical Education–accredited experiences as part of their plastic surgical education.46 The capacity to care and interest in serving the marginalized are traits central to what drives most physicians' interest in medicine. By nurturing young surgeons in global missions, the enthusiasm for improving global health can be passed to future generations. REFERENCES 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533–538. 2. Shrime MG, Bickler WS, Alkire BC, et al. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3:S8–S9. 3. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2015. 4. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–2128. 5. Cooper ME, Ratay JS, Marazita ML. Asian oral-facial cleft birth prevalence. Cleft Palate Craniofac J. 2006;43:580–589. 6. Alkire B, Hughes CD, Nash K, et al. Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg. 2011;35:1194–1201. 7. Hughes CD, Babigian A, McCormack S, et al. The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resourcepoor settings. Plast Reconstr Surg. 2012;130:87e–94e. 8. Magee WP Jr, Vander Burg R, Hatcher KW. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg. 2010;34:420–427. 9. Corlew DS. Estimation of impact of surgical disease through economic modeling of cleft lip and palate care. World J Surg. 2010;34:391–396. 10. Alkire BC, Vincent JR, Meara JG. Benefit-cost analysis for selected surgical interventions in low- and middle-income countries. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery: Disease Control Priorities. 3rd ed. Washington, DC: International Bank for Reconstruction and Development; 2015:361–380. 11. Poenaru D. Getting the job done: analysis of the impact and effectiveness of the Smile Train program in alleviating the global burden of cleft disease. World J Surg. 2013;37:1562–1570. 12. Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health. 2014;2:e334–e345. 13. Nagengast ES, Caterson EJ, Magee WP, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg. 2014;25:1622–1625.
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14. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care. J Craniofac Surg. 2014;25:1680–1684. 15. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability. J Craniofac Surg. 2014;25:1685–1689. 16. Lalonde DH, Price C, Wong AL, et al. Minimally painful local anesthetic injection for cleft lip/nasal repair in grown patients. Plast Reconstr Surg Glob Open. 2014; 2:e171. 17. Carter VM. Culture and credibility: the sense-making process of Peruvian parents following their child’s cleft diagnosis. [doctoral thesis]. Athens, GA: The University of Georgia; 2013. 18. Figueiredo JC, Ly S, Raimondi H, et al. Genetic risk factors for orofacial clefts in Central Africans and Southeast Asians. Am J Med Genet A. 2014;164:2572–2580. 19. Malherbe V, Bosenberg AT, Lizarraga Lomeli AK, et al. Regional anesthesia for cleft lip surgery in a developing world setting. South African J Surg. 2014;52: 108–110. 20. Mednick L, Snyder J, Schook C, et al. Causal attributions of cleft lip and palate across cultures. Cleft Palate Craniofac J. 2013;50:655–661. 21. Patel A, Sawh-Martinez RF, Sinha I, et al. Establishing sustainable international burn missions: lessons from India. Ann Plast Surg. 2013;71:31–33. 22. Pengelly RJ, Upstill-Goddard R, Arias L, et al. Resolving clinical diagnoses for syndromic cleft lip and/or palate phenotypes using whole-exome sequencing. Clin Genet. 88:441–449. In press. 23. Kodali RR, Saipriya T, Nageswara R, et al. Study of the epidemiological aspects of cleft lip and palate. Indian J Public Health Research & Development. 2014;5: 141–145. 24. Rivera ME, Hexem KR, Womer JW, et al. Parents’ satisfaction with repair of paediatric cleft lip/cleft palate in Honduras. Paediatr Int Child Health. 2013;33:170–175. 25. Yao C, Ly S, Raimondi HM, et al. Comparative analysis of environmental exposures and orofacial clefts in the Democratic Republic of Congo and the Philippines. Paper presented at: 142nd American Public Health Association Annual Meeting; November 15–19, 2014; New Orleans, LA. 26. Yao C, Ly S, Raimondi HM, et al. Maternal risk factors for the development of and risk of orofacial clefts in the Philippines. Paper presented at: 142nd American Public Health Association Annual Meeting; November 15–19, 2014; New Orleans, LA. 27. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment. J Craniofac Surg. 2014;25:1674–1679. 28. Patel A, Clune JE, Steinbacher DM, et al. Comprehensive cleft center: a paradigm shift in cleft care. Plast Reconstr Surg. 2013;131:312e–313e.
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29. Schönmeyr B, Restrepo C, Wendby L, et al. Lessons learned from two consecutive cleft lip and palate missions and the impact of patient education. J Craniofac Surg. 2014;25:1610–1613. 30. Jansen LA, Carillo L, Wendby L, et al. Improving patient follow-up in developing regions. J Craniofac Surg. 2014;25:1640–1644. 31. Deshpande GS, Campbell A, Jagtap R, et al. Early complications after cleft palate repair: a multivariate statistical analysis of patients. J Craniofac Surg. 2014;25: 1614–1618. 32. Schönmeyr B, Wendby L, Campbell A. Early surgical complications after primary cleft lip repair: a report of 3108 consecutive cases. Cleft Palate Craniofac J. 2015; 52:706–710. In press. 33. Purnell CA. Operation Smile and the Guwahati Comprehensive Cleft Care Center: multidisciplinary global activism in plastic surgery. Plast Surg Nurs. 2014;34: 181–182. 34. Deshpande GS, Campbell A. Management of lateral lip element in rotation advancement technique for cleft lip repair: tips and tricks. J Cleft Lip Palate Craniofac Anomal. 2014;1:104–108. 35. Deshpande G, Campbell A, Jagtap R, et al. Midline cleft of upper lip: review and surgical repair. J Plast Reconstr Aesthet Surg. 2014;67:1002–1003. 36. Deshpande G, Schönmeyr B. Using electronic tablet as a teaching tool for marking cleft lip repairs. J Plast Reconstr Aesthet Surg. 2015;68:122–123. 37. Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. J Indian Soc Periodontol. 2014;18:770–773. 38. Hjalmarsson J, Kjernald K. Indian nurses’ experiences of supporting parents of children with cleft lip and palate: a minor field study. [Bachelor's thesis]. Borås, Sweden: University of Borås; 2014. 39. Lee CCY, Jagtap RR, Deshpande DS. Longitudinal treatment of cleft lip and palate in developing countries: dentistry as part of a multidisciplinary endeavor. J Craniofac Surg. 2014;25:1626–1631. 40. Nagengast ES, Ramos MS, Sarma H, et al. Surgical education through video broadcasting. J Craniofac Surg. 2014;25:1619–1621. 41. Ramos MS, Hackenberg B, Caterson EJ, et al. A cost-effective projection model for basic and continuous surgical care in India. J Am Coll Surg. 2014;219:e43. 42. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. Plast Reconstr Surg. 2010;126:295–302. 43. Campbell A, Sullivan M, Sherman R, et al. The medical mission and modern cultural competency training. J Am Coll Surg. 2011;212:124–129. 44. Steinberg JP. Reflections from Guwahati. Maxillofacial News Spring. 2013;3. 45. Mackay DR. Obtaining accreditation council for graduate medical education approval for international rotations during plastic surgery residency training. J Craniofac Surg. 2015;26:1086–1087. 46. Larkin G. Global health care: India’s GC4 surgical opportunity—helping the needy while learning. Plast Surg News Jan/Feb. 2015:30.
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The Expanding Role of Education and Research in International Healthcare Christine M. Jones, MD,* C. Alex Campbell, MD,*† William P. Magee, MD,† Ruben Ayala, MD,† and Donald R. Mackay, MD*† Abstract: A recent report of the Lancet Commission on Global Surgery has continued to emphasize the importance of surgery in global health. Plastic surgeons have been involved in humanitarian care of children in developing countries for many years. The ability to repair children with cleft lip and palate in resource-poor settings has made this desirable for many plastic surgeons. A number of philanthropic plastic surgery organizations arose to deal with the problem in a more structured way. Dr. Donald Laub at Stanford established Interplast (now ReSurg) in 1969. Dr. Bill and Kathy Magee established Operation Smile in 1982, and many others have followed. The unifying theme of these organizations has been the desire to provide safe and effective surgical care to children who would otherwise be forced to live out their lives with deformity. Most care has been for children with clefts, but efforts have expanded to include hand surgery and burn reconstruction. The initial effort was provided through surgical missions. A paradigm shift has occurred as sustainability and local capacity have become paramount. Education and training of local colleagues and assistance in surgical safety infrastructure are expanding the reach of plastic surgical care around the globe. The inauguration of in-country permanent surgical centers allows high-volume outcomes research, as well as unique educational collaboration between plastic surgeons of both the developed and developing world. Key Words: global health, surgical mission, global surgery, cleft lip, cleft palate, international research (Ann Plast Surg 2016;76: S150–S154)
The State of Surgical Care in the Developing World The ideals of global health care are well-aligned with the altruism, service to others, and alleviation of suffering that draws most physicians to medicine. Great strides have been made in improving global health in the past 25 years, but advances have not uniformly affected all aspects of medical care. Perceived as too expensive and complex, surgical care has long been the “neglected stepchild of global health.”1 As a result, millions of lives are lost annually as a result of treatable surgical disease. In 2010 alone, 16.9 million people died from conditions requiring surgical care,2 more than the number who succumbed to human immunodeficiency virus/acquired immune deficiency virus, tuberculosis, and malaria combined.3,4 In 2013, the Lancet Commission on Global Health was tasked with improving global access to safe and affordable surgery and anesthesia. The commission delivered their report in April 2015, describing a great disparity in the distribution of surgeons worldwide. Over 5 billion people in developing countries lack access to basic surgical care. Some Received July 2, 2015, and accepted for publication, after revision November 17, 2015. From the *Penn State Hershey Medical Center, Hershey, PA; and †Operation Smile, Virginia Beach, VA. Conflicts of interest and sources of funding: none declared. Reprints: Donald R. Mackay, MD, Penn State Hershey Medical Center Division of Plastic Surgery 500 University Drive Mail Code H071 Hershey, PA 17033. E-mail: [email protected]. The Brody Family Lecture Presented by Donald Mackay at the 65th Annual Meeting of the California Society of Plastic Surgeons, May 2015, Monterey, CA. Dr. Mackay is Chief Medical Officer of Operation Smile. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7605–S150 DOI: 10.1097/SAP.0000000000000721
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patients are financially ruined in seeking care. Cultural reliance on local traditional healers can result in some patients seeking care only when problems are advanced, or in not seeking care at all. Surgical need is greatest in sub-Saharan Africa and South Asia (Fig. 1).3 An estimated 143 million additional surgeries are needed annually in these developing countries to successfully avert death and disability.3 Although the current state of surgical capacity is poor, the cost of improving access to surgical care is a good investment. Timely and appropriate surgical care can prevent disability and improve personal productivity. Thus, an investment in surgical capacity helps stimulate economic development.3 A tiered approach to surgical diseases has been suggested, dividing conditions into must-do, should-do, and can-do categories (Fig. 2). Access to affordable surgery is indeed a crucial part of a functioning health system.3
Providing Surgery for Patients With Cleft Lip and Palate in the Developing World Cleft lip and palate (CLP) are among the most common congenital anomalies, occurring in 1 in 500 to 1000 live births.5 Cleft lip and palate is one of the conditions that, although not life-threatening, greatly diminishes an individual's quality of life and potential productivity. Children with unrepaired CLP are stigmatized, outcast, and rarely given a chance for relationships, family, or employment. The worldwide burden of untreated CLP has a tremendous cost in terms of lost productivity.6–8 Several studies have found the surgical treatment of CLP to be very cost-effective.8–11 Cleft lip and palate care compares favorably to other conditions that have received billions of dollars in global aid. The cost per disability-adjusted life-year averted is less than that of antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency virus and less than that of the bacille Calmette-Guérin vaccine for prevention of tuberculosis (Fig. 3).12 Because of the easily treatable, relatively low risk of CLP surgery, plastic surgeons have been uniquely positioned to help this vulnerable population. Humanitarian organizations have been founded by plastic surgeons (Table 1), among them ReSurg (previously Interplast), Operation Smile, and Smile Train. Most of these organizations began with “mission-centered” care staffed by international volunteers motivated to alleviate suffering in the developing world. Although an effective means of providing reconstructive surgery, mission-based care does not address the longitudinal cleft treatment that is considered standard in developed countries. Postoperative outcomes are lost to follow-up. These children often do not receive speech therapy, orthodontics, or dental care, and there is little ongoing support for families and communities. A maturational shift has occurred as these organizations focus on sustainability, providing a greater emphasis on educating local surgeons, nurses, and other providers, as well as helping develop local infrastructure and systems. As an example, Operation Smile has made major efforts to shift the care from international to locally-run missions, as well as develop local centers for cleft care. In 1999, Operation Smile organized the World Journey of Hope. Over a 9-week period, volunteers travelled to 18 countries and provided free surgery for 5300 children. Although Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Research and Education in International Healthcare
FIGURE 1. Proportion of the population without access to safe, affordable surgery and anesthesia by Institute for Health Metrics and Evaluation region. Reproduced from Meara and colleagues,3 by permission from Elsevier.
successful by its sheer volume, it also marked the beginnings of incountry missions. A contract was set up with each country to manage sustainable, small-scale charity missions by local surgeons (Fig. 4). In 2007, Operation Smile ran 40 simultaneous missions in 25 countries on the World Journey of Smiles, treating more than 4400
children in 10 days. To organize a mission of such magnitude, over 3400 medical volunteers in partner countries were trained in teambased cleft care. Attention was focused on creating sustainable publicprivate funding partnerships that could establish and maintain local cleft centers (Fig. 4).
FIGURE 2. Common surgical procedures stratified in a must do, should do, and can do framework for first-level care. Reproduced from Meara and colleagues,3 by permission from Elsevier. © 2016 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
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FIGURE 3. Cost-effectiveness of surgery in low-income and middle-income countries compared with other public health interventions. Data points are medians, error bars show range. Surgical interventions are denoted by the diamonds and solid lines, public health interventions by the circles and dashed lines. DALY, disability-adjusted life-year. Reproduced from Chao and colleagues,12 by permission from Elsevier.
This local center-based care model has been replicated in several countries. One of the most notable is the Guwahati Comprehensive Cleft Care Center (GC4) in the northeast Indian state of Assam. GC4 was established in 2011 in collaboration between Operation Smile, the government of Assam, and private enterprise (Tata Trust). This centerbased care has been found to be more cost-effective than mission-based care and also works to stimulate the local microeconomy.13 More resources are invested locally, thus creating sustainable infrastructure and employment (Fig. 5).
TRANSITION FROM PROVISION OF CARE TO SUSTAINABILITY: THE IMPORTANCE OF EDUCATION AND RESEARCH Sustainable Care Through Surgeon Education A carefully selected team of international surgeons and other health care workers with specialized expertise initiated GC4. Additional Indian surgeons were added, with further expansion by early recruitment of additional team members in all disciplines.14 Staff members were chosen based on their long-term commitment to providing cleft care locally. International experts then mentored those chosen. The medical team ultimately comprised over 90% local, full-time staff. A fellowship model was then developed in which plastic surgeons from around the world could come to GC4 for training in the high-volume, high-quality environment of full-time cleft care.15 Over 100 Guwahati visiting fellows have not only trained at GC4 but many have also gone on to lead cleft teams in their home countries.
Research in a High-Volume Cleft Center In its first 2 ½ years of patient care, GC4 provided 7000 free cleft repairs.15 Four years in, that number is now over 11 000. As this model carefully ties high clinical volume with academic interests, research done through Operation Smile local centers has resulted in over 25 publications,16–26 with almost 20 coming from GC4 alone.10,13–15,27–41 Operation Smile India spent 2 preliminary years studying the government, culture, and infrastructure of Assam to develop the successful model for sustainable care that is GC4.14,15,27 Unique methods were developed to recruit patients through nonmedical screening personnel in the community, because 87% of the population of Assam lives in rural and isolated areas.14,28 This center-based care also allowed for appropriate postoperative follow-up. Standardized, simple, and culturally based postoperative instructions were developed to improve the understanding of postoperative care and reduce the rate of complications.29 Novel methods were developed to help reduce cost of follow-up care to the families. For those able to return to GC4, free local housing was provided, patients received multidisciplinary care, and travel costs were S152
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reimbursed. Multidisciplinary teams also travel to outreach camps for patients living over 200 km from the center, to facilitate follow-up in remote communities. These methods have allowed the team to monitor over 70% of their patients despite the environmental challenges.14,30 The high clinical volume at GC4 allows for outcome evaluation of much higher statistical power than that typically appreciated even in American academic centers. An institutional ethics committee was created. The Operation Smile Global Standards of Care emphasize the provision of high-quality care over maximizing volume.14 Within this model, and despite older patients with more challenging clefts, a low rate of fistula has been noted after cleft palate repair.31 Wound dehiscence after cleft lip repair was found to be higher than expected at 3.3%.32 However, after multivariate analysis, it was determined that surgeons visiting from developed countries had higher rates of dehiscence than permanent staff.32 More research is warranted to investigate clinical outcomes and determine best practices. By marrying the research interests of international academic plastic surgeons with the zeal and high volume of centers in the developing world, questions can be answered with higher statistical power and accuracy.
Resident Education by Immersion in Global Health Surgery Plastic surgeons in the United States often encounter patients who are culturally and ethnically diverse and must adjust their care accordingly. The Operation Smile Regan and Stryker Fellowships allow senior residents in plastic surgery, anesthesia, or pediatrics to participate in its programs in developing countries. The fellowship is prefaced by an educational weekend in Norfolk, VA, in which residents are instructed on multidisciplinary cleft care and provision of care in mission countries. Residents are then sent worldwide with assigned mentors for structured participation in all aspects of team care. Four
TABLE 1. National, Non-Governmental Organizations Seeking to Treat CLP in Developing Countries Organization
Founding Year
ReSurg (Interplast) Operation Smile Austin Smiles Rotoplast International Small World Foundation Smile Train Nicaplast
1969 1982 1987 1992 1995 1998 2003
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Annals of Plastic Surgery • Volume 76, Supplement 3, May 2016
Research and Education in International Healthcare
FIGURE 4. Historical surgical statistics of the type of care provided by Operation Smile. Care has transitioned from international missions to sustainable care centers, with the 1999 World Journey of Hope and 2007 World Journey of Smile marking important turning points. (WP Magee and R Ayala, personal communication)
months after their missions, residents gather for a debriefing meeting in which they share their experiences. This model of real-world cultural education has been shown to help residents grow in each of the 6 core competencies outlined by the American Council for Graduate Medical Education. In its inaugural year, participants in the Regan Fellowship program uniformly said the experience had an overall positive impact on their lives.42 Detailed surveys demonstrated the residents developed a greater appreciation for global health and enhanced cultural competency.42,43 Residents cite this experience as incredibly empowering and often the highlight of their training.33,44 Almost 85% of Regan fellows report their missions heightened their personal sense of social responsibility, and nearly 95% say it increased the likelihood they would volunteer with underserved populations in the future.42,43 In 2013, the Plastic Surgery Residency Review Committee provided guidelines for arranging approved international rotations. Residency Review Committee–approved rotations to GC4 have been available to interested residents since that time.45 Lurie Children's
FIGURE 5. Comparison of categorical expenditures between the missions and the center in Guwahati, India. Reproduced from Nagengast ES, Caterson EJ, Magee WP, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg. 2014;25:1622–1625. Copyright (2014), with permission from Wolters Kluwer Health.13 © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Hospital at Northwestern University and Penn State Hershey gave key GC4 surgeons clinical appointments that allow residents and fellows to rotate there without having to use extended vacation time. Residents from both universities have participated in month-long American Council for Graduate Medical Education–accredited experiences as part of their plastic surgical education.46 The capacity to care and interest in serving the marginalized are traits central to what drives most physicians' interest in medicine. By nurturing young surgeons in global missions, the enthusiasm for improving global health can be passed to future generations. REFERENCES 1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32:533–538. 2. Shrime MG, Bickler WS, Alkire BC, et al. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015;3:S8–S9. 3. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2015. 4. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–2128. 5. Cooper ME, Ratay JS, Marazita ML. Asian oral-facial cleft birth prevalence. Cleft Palate Craniofac J. 2006;43:580–589. 6. Alkire B, Hughes CD, Nash K, et al. Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg. 2011;35:1194–1201. 7. Hughes CD, Babigian A, McCormack S, et al. The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resourcepoor settings. Plast Reconstr Surg. 2012;130:87e–94e. 8. Magee WP Jr, Vander Burg R, Hatcher KW. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg. 2010;34:420–427. 9. Corlew DS. Estimation of impact of surgical disease through economic modeling of cleft lip and palate care. World J Surg. 2010;34:391–396. 10. Alkire BC, Vincent JR, Meara JG. Benefit-cost analysis for selected surgical interventions in low- and middle-income countries. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery: Disease Control Priorities. 3rd ed. Washington, DC: International Bank for Reconstruction and Development; 2015:361–380. 11. Poenaru D. Getting the job done: analysis of the impact and effectiveness of the Smile Train program in alleviating the global burden of cleft disease. World J Surg. 2013;37:1562–1570. 12. Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health. 2014;2:e334–e345. 13. Nagengast ES, Caterson EJ, Magee WP, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg. 2014;25:1622–1625.
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14. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care. J Craniofac Surg. 2014;25:1680–1684. 15. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability. J Craniofac Surg. 2014;25:1685–1689. 16. Lalonde DH, Price C, Wong AL, et al. Minimally painful local anesthetic injection for cleft lip/nasal repair in grown patients. Plast Reconstr Surg Glob Open. 2014; 2:e171. 17. Carter VM. Culture and credibility: the sense-making process of Peruvian parents following their child’s cleft diagnosis. [doctoral thesis]. Athens, GA: The University of Georgia; 2013. 18. Figueiredo JC, Ly S, Raimondi H, et al. Genetic risk factors for orofacial clefts in Central Africans and Southeast Asians. Am J Med Genet A. 2014;164:2572–2580. 19. Malherbe V, Bosenberg AT, Lizarraga Lomeli AK, et al. Regional anesthesia for cleft lip surgery in a developing world setting. South African J Surg. 2014;52: 108–110. 20. Mednick L, Snyder J, Schook C, et al. Causal attributions of cleft lip and palate across cultures. Cleft Palate Craniofac J. 2013;50:655–661. 21. Patel A, Sawh-Martinez RF, Sinha I, et al. Establishing sustainable international burn missions: lessons from India. Ann Plast Surg. 2013;71:31–33. 22. Pengelly RJ, Upstill-Goddard R, Arias L, et al. Resolving clinical diagnoses for syndromic cleft lip and/or palate phenotypes using whole-exome sequencing. Clin Genet. 88:441–449. In press. 23. Kodali RR, Saipriya T, Nageswara R, et al. Study of the epidemiological aspects of cleft lip and palate. Indian J Public Health Research & Development. 2014;5: 141–145. 24. Rivera ME, Hexem KR, Womer JW, et al. Parents’ satisfaction with repair of paediatric cleft lip/cleft palate in Honduras. Paediatr Int Child Health. 2013;33:170–175. 25. Yao C, Ly S, Raimondi HM, et al. Comparative analysis of environmental exposures and orofacial clefts in the Democratic Republic of Congo and the Philippines. Paper presented at: 142nd American Public Health Association Annual Meeting; November 15–19, 2014; New Orleans, LA. 26. Yao C, Ly S, Raimondi HM, et al. Maternal risk factors for the development of and risk of orofacial clefts in the Philippines. Paper presented at: 142nd American Public Health Association Annual Meeting; November 15–19, 2014; New Orleans, LA. 27. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment. J Craniofac Surg. 2014;25:1674–1679. 28. Patel A, Clune JE, Steinbacher DM, et al. Comprehensive cleft center: a paradigm shift in cleft care. Plast Reconstr Surg. 2013;131:312e–313e.
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29. Schönmeyr B, Restrepo C, Wendby L, et al. Lessons learned from two consecutive cleft lip and palate missions and the impact of patient education. J Craniofac Surg. 2014;25:1610–1613. 30. Jansen LA, Carillo L, Wendby L, et al. Improving patient follow-up in developing regions. J Craniofac Surg. 2014;25:1640–1644. 31. Deshpande GS, Campbell A, Jagtap R, et al. Early complications after cleft palate repair: a multivariate statistical analysis of patients. J Craniofac Surg. 2014;25: 1614–1618. 32. Schönmeyr B, Wendby L, Campbell A. Early surgical complications after primary cleft lip repair: a report of 3108 consecutive cases. Cleft Palate Craniofac J. 2015; 52:706–710. In press. 33. Purnell CA. Operation Smile and the Guwahati Comprehensive Cleft Care Center: multidisciplinary global activism in plastic surgery. Plast Surg Nurs. 2014;34: 181–182. 34. Deshpande GS, Campbell A. Management of lateral lip element in rotation advancement technique for cleft lip repair: tips and tricks. J Cleft Lip Palate Craniofac Anomal. 2014;1:104–108. 35. Deshpande G, Campbell A, Jagtap R, et al. Midline cleft of upper lip: review and surgical repair. J Plast Reconstr Aesthet Surg. 2014;67:1002–1003. 36. Deshpande G, Schönmeyr B. Using electronic tablet as a teaching tool for marking cleft lip repairs. J Plast Reconstr Aesthet Surg. 2015;68:122–123. 37. Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. J Indian Soc Periodontol. 2014;18:770–773. 38. Hjalmarsson J, Kjernald K. Indian nurses’ experiences of supporting parents of children with cleft lip and palate: a minor field study. [Bachelor's thesis]. Borås, Sweden: University of Borås; 2014. 39. Lee CCY, Jagtap RR, Deshpande DS. Longitudinal treatment of cleft lip and palate in developing countries: dentistry as part of a multidisciplinary endeavor. J Craniofac Surg. 2014;25:1626–1631. 40. Nagengast ES, Ramos MS, Sarma H, et al. Surgical education through video broadcasting. J Craniofac Surg. 2014;25:1619–1621. 41. Ramos MS, Hackenberg B, Caterson EJ, et al. A cost-effective projection model for basic and continuous surgical care in India. J Am Coll Surg. 2014;219:e43. 42. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. Plast Reconstr Surg. 2010;126:295–302. 43. Campbell A, Sullivan M, Sherman R, et al. The medical mission and modern cultural competency training. J Am Coll Surg. 2011;212:124–129. 44. Steinberg JP. Reflections from Guwahati. Maxillofacial News Spring. 2013;3. 45. Mackay DR. Obtaining accreditation council for graduate medical education approval for international rotations during plastic surgery residency training. J Craniofac Surg. 2015;26:1086–1087. 46. Larkin G. Global health care: India’s GC4 surgical opportunity—helping the needy while learning. Plast Surg News Jan/Feb. 2015:30.
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