Monday, March 23, 2009

A Bloody Harvest

How much is your kidney worth?
In Turkey the prized organ fetches about €2,300, while an Indian or Iraqi kidney enriches its former owner by a mere €800. And the World Health Organisation estimates the going price on the black market to be about €4,000. When you consider that wealthy clients will later pay more than €100,000 for the kidney, this massive profit margin would appear to guarantee a lucrative future for the international trade in human organs, if it continues to be left unchecked.
Laudable developments in biotechnology and organ transplantation are becoming tarnished by shades of questionable conduct ranging from buying and selling organs to trafficking in humans for their valuable body-parts and outright bodysnatching. Our organs, cells, tissues, and bones are now the raw material for new commercial products, and the simple laws of supply and demand has given rise to a thriving black market.
While primarily the circulation of organs flows from South to North, East to West, from third to first world, and from poor to affluent, increasingly ordinary folks are finding themselves caught up in the macabre body shopping business. And the Irish are no exception.
Late last year Irish journalist and author Mary Kenny learned that the man behind an illicit trade in body parts in the US, which included the remains of her sister Ursula and British broadcaster Alistair Cooke, was sentenced to 18 to 54 years in prison.
Disgraced Dental surgeon Michael Mastromarino’s multimillion-dollar enterprise, Bio-Medical Tissue Services, harvested tissue and bone - many that regulations deemed too old or diseased to use – without permission from more than 1,000 cadavers between 2001 and 2005, using funeral homes in Brooklyn, Manhattan, Newark, Rochester and Philadelphia.
Although revelations about this gruesome, greedy scheme has prompted more than 900 lawsuits in the US, Mary Kenny says she doesn’t resent that her sister’s body was dissected, only that it was done without express permission. “I don't think that Ursula would have minded. If she had been asked, I think she'd have given permission for her remains to be used in medical transplants,” she says.
“But there is one disturbing question for me: are the remaining ashes that I have in an urn on the mantelpiece those of my sister at all?”
The true scale of the grisly market in body parts has only surfaced in recent years with the WHO, Human Rights Watch, Interpol and many transplant surgeons speaking out publicly against the growing problems of organ sales, transplant tourism and trafficking in organ donors in the context of the global shortage of organs.
And with those precious few organs going to patients most likely to survive and thrive following transplantation, it’s not surprising that some hopelessly ill people don’t play by the rules.
The WHO estimates that the average wait time for a kidney in Europe is expected to increase to 10 years by 2010. Most dialysis patients won’t last half that time, and the desperate are faced with a Hobson’s choice; find a replacement organ or die.
At least 10 percent of all transplants in 2007 involved patients from developed countries travelling to poor countries to buy organs, a WHO spokesperson explains. They depend on local agents who "source" kidneys and arrange the transplant. An estimated 15,000 kidneys (the bulk of the black market in human organs) are being trafficked in this way each year.
Scope magazine has learned that at least one Irish person travelled recently to Pakistan for a kidney transplant. The organ was sourced in Pakistan and the transplantation carried out by a local surgeon. It is documented that foreigners receive two-thirds of the 2000 kidney transplants performed annually in Pakistan.
Given his global connections as former Director of the International Federation of Kidney Foundations, Mr Mark Murphy, CEO of the Irish Kidney Association is in an excellent position to know if other Irish patients are travelling outside Europe for transplant surgery.
“I don’t know of any others, just this one person, and up to now we wouldn’t have considered this a potential problem in Ireland. Irish patients have had a reasonable chance of getting kidney transplants. We have almost 50 percent more organ donations than in the UK,” he says, quickly adding that there is a complacency developing in Ireland arising from this favourable comparison with our closest neighbour. Britain has one of the worst organ donor rates in Europe, he stresses.
“We’d have about 1,700 people getting dialysis treatment at the moment, of which about 500 are on the kidney transplant list and 800 ultimately would at some stage be ready for transplantation. But there were only 146 kidney transplants in 2008 and a similar number the previous year and the year before that.
“The real horror is when you look at the heart and lung transplant programmes in Ireland. There are serious issues there. We did four heart and four lung transplants in this country last year and none of those lungs were for Cystic Fibrosis patients,” he points out.
“Norway is a similar country with 4.7 million people but a more proactive organ procurement and transplant programme compared to us. They did 29 lung transplants, out of a similar amount of donors last year.
“There’s no doubt people are focusing on the Mater Hospital (Heart and Lung Transplant Programme) at the moment, particularly the Cystic Fibrosis Association wondering where are the lungs that were promised for transplantation? We have one of the highest rates of CF in the world. While good treatment is better for young Cystic Fibrosis sufferers, it will get them into their 40s, they may need lung transplantation in the last three years of their expected life at the time, giving them possibly a two-year window before they are beyond transplantation, and that’s a desperately hard situation to be in, particularly when they’re still so young.”
Mark maintains that Ireland is performing well with regard to liver transplants at St Vincent’s University Hospital – 59 in 2007. However, a scathing article in the journal ‘Liver Transplantation’ in 2004 exposed a significant inequity in liver transplant allocation in Ireland with patients holding private health insurance three times more likely to receive a transplant than those without insurance.
“I don’t believe there is a problem with Irish people going abroad for organ transplantation, they would show up, it’s too small a country to be honest, they’d present to the medical profession because they’d be looking for immunosuppression drugs. We might have the odd one who is, I don’t know, I only know of the one, but I don’t think it’s an Irish problem, yet,” he emphasises. “It will become an Irish problem if our organ donor levels or our transplantation programmes cannot keep up with demand, it will drive us in that direction because patients who need a new lung or heart don’t have the ‘luxury’ of dialysis to keep them alive. If I were put on a heart transplant list here I’d be sorting out my affairs and not expecting it.”
Mark was invited along with Mr David Hickey, one of Ireland’s top transplant surgeons and Director of Transplantation at Beaumont Hospital, to participate in the International Summit on Transplant Tourism and Organ Trafficking convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, in May last year. There they joined more than 150 healthcare professionals, scientists, ethicists and legal scholars from 78 countries in drafting the groundbreaking Declaration of Istanbul on Organ Trafficking and Transplant Tourism, which was published in November 2008.
This document proclaims that the poor who sell their organs are being exploited, whether by richer people within their own countries or by transplant tourists from abroad. Moreover, transplant tourists risk physical harm by unregulated and illegal transplantation.
Participants in the Istanbul Summit agreed that transplant commercialism and tourism and organ trafficking should be prohibited. And they also urged their fellow transplant professionals, individually and through their organisations, to put an end to these unethical activities and foster safe, accountable practices that meet the needs of transplant recipients while protecting donors.
The broad representation at the Istanbul Summit indicates the importance of international collaboration and global consensus to improve donation and transplantation practices. A vital network of ‘informants’ also sprang from the Protocol groups with the objective of communicating any illegal or suspicious practices among the medical profession and others.
“At the moment I am watching the tracking of a particular doctor in Turkey who appears to be organising organ donors for people who want them. He would be removing the organ from the donor and making the money. It’s the hospital he works at as well but he’s the ring leader,” says Mark, who is an active member of this informal grapevine. “If I saw something untoward in this country I’d be letting them know and they’d be letting Interpol know.”
When contacted by Scope, Interpol declined to release its Report into Human Organ Trafficking (2006), however an officer confirmed that reliable intelligence of these international black market operations is thin on the ground.
“Interpol has very little concrete information about organ theft or trafficking and we would appeal to the authorities in each country, and the medical profession, to keep us informed of any suspicious activities in this area,” she appealed.
She confirmed that doctors and other medical staff are often part of the criminal networks involved in this crime, and she highlighted a high-profile case of a doctor apprehended at a jungle resort in southern Nepal in February 2008 for “illegal transplanting of kidneys, cheating and criminal conspiracy” – according to the arrest notice issued by Interpol.
The fugitive doctor, Amit Kumar was the alleged mastermind of a shadowy organ transplant operation in India that illegally removed hundreds of kidneys - sometimes from unwilling donors.
"It is believed that during the past eight years around 500 people were forcibly operated on and their kidneys transplanted to foreign patients in a secret operating theatre," the global police body said.
The arrest was an important coup for those trying to combat this criminal trade but, as the WHO points out, while there is “assumed complicity in illegal organ trafficking of a minority of trained physicians and surgeons”, they have been identified in only a small number of cases “as there is extreme difficulty in documenting illegal trafficking events reliably and either substantiating or refuting rumour”.
This difficulty is compounded by the fact that many countries and professional associations may simply reject organ trafficking as immoral and illegal without taking further active steps.
Print and electronic news services are peppered with scant accounts of formal investigations into organ trading in several countries, few resulting in legal proceedings and even less securing convictions. Ireland is noticeably absent from these efforts and for good reason – no legal provision exists in this country prohibiting the sale or the purchase of an organ here or abroad. Our Government admitted as much to the Secretary General of the Council of Europe in a 2004 survey of 44 countries, prompted by concerns over organ trafficking. Ireland was among only four countries not to have legislated against this practice.
At a push, Irish legal eagles could dust off the 1832 Human Anatomy Act, which was introduced to stop people robbing bodies from graveyards for medical school dissection tables.
Albeit belated, the Department of Health’s recent public consultation into consent for the donation of organs after death for transplantation has been welcomed by various interest groups, the medical profession and the public at large.
This consultation process, which closed to submissions at the end of February this year, will feed into the preparation of the Human Tissue Bill to regulate the removal, retention, storage, use and disposal of human tissue from cadavers, including the issue of consent for donation of organs after death for transplantation. The Department is examining the case for the ‘opt-in’, ‘opt-out’ and ‘mandated choice’ systems of consent for organ donors.
Ms Ruth-Gaby Vermot-Mangold, President of the Human Trafficking Commission of the Council of Europe, recently appealed to Governments in the “rich countries” of Western Europe to vigorously promote the donation of organs in their own countries and thus begin to erode the black market demand.
In Ireland this donor drive could include the training of donor co-coordinators in hospital intensive care unit – a recommendation anticipated in an eagerly awaited National ICU audit by the HSE to identify the reasons for Ireland’s low organ retrieval rate.
Another popular option is an education and public awareness campaign blitz to boost, in particular, live donor transplants, although Ireland has yet to regulate the transplantation of organs removed from living donors. There is also a conspicuous absence of an independent Transplantation Authority in this country, and this must also be addressed.
Organ trafficking and transplant tourism is a serious 21st century problem for health service providers and governments. There is no doubt that a worldwide shortage of organs is being exploited by unscrupulous operators, and is putting donors and recipients at risk. Commercialised organ transplantation ensures the middlemen become rich, the sick get bad treatment and the poor suffer the consequences.
“Organ theft and trafficking it is not a myth or urban legend: It happens at an alarming rate in some countries. If we want to ensure that it doesn’t become a problem in this country we need to get active now, get out donor rates up and our transplantation programmes busy,” says Mark.

Skeleton Key

Bone detective Prof Sue Black is raising the standards in forensic anthropology. From the killing fields in Kosovo and beyond, she has witnessed firsthand the extremes of human suffering and human depravity, yet remains inspired by the enduring strength of the human spirit. She tells Scope that her goal is simple: to give the deceased back their identity.

“What are you doing Friday?” was the seemingly innocuous enquiry.
Up to this point, when Scottish forensic anthropologist Sue Black picked up her phone, it had been an uneventful Wednesday at Glasgow University where she was working as a consultant, but the call from friend and forensic pathologist Prof Peter Vanezis precipitated one of the most important and challenging assignments of her career to date.
“The Foreign Office has got tickets for you. You’re needed in Kosovo,” said Vanezis.
By that weekend, Sue was leading the British forensic team in Kosovo for the International War Crimes Tribunal in The Hague, just four days after the Serbs had moved out in 1999.
The team's first site was a community in Velika Krusha, where 44 men had been herded into an outhouse, shot and the building torched. One man escaped – a vital witness for the war crime indictment.
“Peter Vanezis, who was the pathologist in Glasgow, went out initially as part of the British team to Kosovo. They got to the first scene – the outhouse - about six months after the terrible event. What they found were many bodies huddled in a corner, all very badly decomposed, all partly burnt, buried under asbestos tiles because the roof had collapsed on them, and the dogs had gone in as it was a food source for them, so the bodies were mixed.
“And Peter, God bless him, walked in and said ‘I can’t do this, but I know who can’, and that’s when I got his call to come to Kosovo,” Sue recounts as she sits in her office at the University of Dundee, where she is Professor of Anatomy and Forensic Anthropology.
Her team were in Kosovo in 1999 and 2000, and again in 2002, excavating the mass graves of Kosovan Albanians, butchered by Serbian police and paramilitaries. For her untiring efforts in helping to identify approximately 1,000 bodies in Kosovo, Sue was awarded an OBE for her services to forensic anthropology.
“Normally when we’re involved in a forensic case we have no involvement with family because we work very much in clinical isolation, but Kosovo was different. We were unearthing the remains with family members along side you, it’s really quite traumatic. These people have lived through horrors that we will never know - hopefully.
“We had a particularly tough situation where a family had left their village and had gone to live in the hills to try and get away from the Serb soldiers. They had been coming down into the town to get food, travelling on a tractor and trailer. Dad was driving the tractor and on the trailer there was his sister, his mother, his wife and their eight children when a rocket-propelled grenade took the entirety of the trailer out and killed everybody on it. He was shot in the leg but managed to escape.
“He lost everyone; his children - a six-month baby, a two-year-old, a four-year-old, a five-year-old, a six-year-old, a twelve-year-old and two 14-year-old twin boys - as well as his wife, mother and sister. And under cover of darkness he returned to the scene and managed to bring together as many body part as he could, God Bless him, and buried them because if he didn’t the animals would use them as a food source.
“So then our team come along, many months later, and for indictment purposes we need to dig up the remains. I think if it had been me I would have told us where to go, but this farmer was absolutely relieved, he was so grateful, because his big fear was that God didn’t know where to find them. He needed desperately to put each and every one in a named grave, and this had caused him so much trauma.
“We dug up what he had buried, there was barely enough to fill two body bags, and took it back to the mortuary. I had written books on Developmental Juvenile Osteology, my area of expertise is identification of juvenile remains, so I felt I was in the right place at the right time to solve that problem. From the fragments present I could guarantee when he came back two days later that I could hand him back, named and guaranteed, a part of each member of his family.
“When we handed him back these body bags he was just so enormously grateful. To my mind it was almost in some way the culmination of where I wanted to be. If I ever needed a justification for forensic anthropology, this was it. I had taken those years and learned my job on the ground, I’d written the textbooks, and now I was in a position where I was probably one of the best people to help him, to give a man back the entirety of his family so that he could move on. But how you live with that enormous loss I simply don’t know.”
Her words are spoken with gentle empathy and her compassion for both victims and their families is palpable as she describes some of the dreadful tragedies her work has led her to, but one would be mistaken to imagine that this sentiment follows her into the field. At work, Sue is the zenith of professional detachment.
“You can’t afford to break down, you’ve got to be there to support your team, because they are looking to you to be able to get through these horrors. We try to deal with it as absolutely clinically as we possibly can, and it’s not easy, especially when it’s children - I have three of my own - but you just don’t go there in your head; if you went there in your head you’d be a basket case.
“And I’ve had a long, long time to get use to it, is the honest truth. I started in a butcher shop (part-time work from age 11) and I went through a dissecting room in University and then in the field. You get a mature head on your shoulders that tells you ‘I didn’t do this, I didn’t cause this, I’m not responsible for it, but I can help put the bastards away that did it’.”
The world of bones, skulls, cadavers and human remains is second nature to Sue Black. One of only eight registered forensic anthropologists in the UK, Sue is frequently called upon to identify bodies when all other means of identification have been exhausted.
Besides her well-documented humanitarian trip to Kosovo, she has assisted police with murder enquiries in the UK and abroad, worked in Grenada assisting the FBI, risked her life to recover skeletons in Sierra Leone, has twice been dispatched to Iraq on Ministry of Defence missions, and spent a month helping to identify hundreds of human remains in the aftermath of the Indian Ocean tsunami disaster.
In spite of the gruesome nature of her job, her immutable humour throughout the interview is infections and frequently self-deprecating. Sue jokes that her father, during his recent 80th birthday celebrations, asked her what she was going to do when she left school?
“I’ve never really left school, I’m still here!” she laughs. “And to be honest with you I’ve never really chosen to do this. I’m so inherently lazy, I’ve just fallen into it, although there is no other job I’d rather have.”
She says it all started with a “dustman strike” one summer when she was eight years old. She and her father encountered a rat among the accumulating trash at the back of the hotel her parents ran near Loch Carron on the west coast of Scotland.
“He asked me to hand him a brush, and I watched my father beat this rat to death. Now he says this never happened but I know it did. I remember it so well; I remember its long tail, I remember it growling at him. And from that point onwards I have an absolutely morbid and pathological fear of rodents, whether it’s mice, hamsters, gerbils or rats, I’m just a gibbering wreck.”
While studying at Aberdeen University, Sue excelled in her anatomy classes but embarking on her fourth year research project, she hit a wall, or more accurately, a rodent.
“All the research projects were like ‘lead level in rat brain’, or ‘carcinoma in hamster pituitary’, and I just knew I couldn’t do that. There was no way that I could kill a rodent and no way I could lift a dead one out of a bucket, just no way on earth. So I went to the only member of staff in the Department who could offer me something different, she suggested that I could do a research project on looking at bone identification. Fantastic, I thought, I don’t care what it is as long as it doesn’t have a long tail and pointy ears. So that was how I chose to do my research project, and now look at me!”
After her degree, as a scholarship student, Sue continued her research interests in human bone identification to obtain a PhD from Aberdeen University in 1987.
Soon after, she took up a lecturing post in anatomy at St Thomas's Hospital Medical School in London, where she helped establish an intercollated year for medical students to study forensic anthropology – the first university course devoted to forensic anthropology in the UK.
Her ingression into the field of forensic investigation began with a telephone call to the anatomy department. Dr Ian West, the Forensic Pathologist at the time, explained to Sue, who had taken his call, that the police had brought in some bones from a rubbish tip. They were looking for a missing person, was there anyone up in anatomy that can tell the difference between animal and human bones?
“So I went down and it was pretty obvious it was a sheep. It was a sort of classical situation: The police Sergeant was a miserable chap, he looked me up and down and you could see him thinking ‘what the hell does this young slip of a girl know’. So I put the bones into a plastic bag and left them on the radiator, and then after a few minutes I opened the bag and stuck it under his nose and asked him what he smelled. ‘Smells like roast lamb,’ he said. ‘Exactly,’ I said, ‘it’s a sheep’.
“From then on, every bit of bone he came in with, he’d ask to have that girl down from anatomy, and I found myself doing more and more work like this around London, and then the Foreign Office finds out about you and before long I end up doing work oversees as well.”
She recalls several high profile assignments that have required her novel expertise over the past two decades, such as a serial murder case in Italy during which she used facial superimposition between photographs and skulls to help identify the seven bodies of prostitutes unearthed around the farmhouse of a man, who had taken a variety of unsavoury photographs of his victims before killing them.
In another instance, while on a mission to investigate a potential war crime case in the depths of Sierra Leon, Sue was constantly surrounded by armed guards whose sole aim was to prevent the rebels from capturing her as a hostage.
While she rattles off a number of other precarious episodes, Sue adds mysteriously: “These are some I can talk about but, because of the Foreign Office or the Ministry of Defence, you’ll have to assume there are others I literally can’t speak to you about.”
Over the past ten to fifteen years, forensic anthropologists are more frequently being asked to assist the international community in the investigation of war crimes, abuses of human rights and humanitarian repatriation.
As expert witnesses, Sue maintains that their testimony in court carries considerable weight and therefore their training must be intensive and lengthy.
Heading up the Department of Anatomy and Forensic Anthropology at the University of Dundee, she runs a full career progression programme in forensic anthropology, which takes the student through eight years of study. The undergraduate spends four years being trained as an anatomists – “because you can’t understand the anthropology without knowing the anatomy” - then four years post-graduate training during which time they will be taken on active case work with Sue and other forensic experts deployed by the UK’s Centre for International Forensic Assistance.
She is particularly proud of her Department’s recent achievement in securing the tender to train the UK National Disaster Victim Identification (UK DVI) team.
“Every single officer that deploys on behalf of the UK to a mass fatality event either at home or overseas is trained in Dundee,” she remarks. “We’ve just finished the final groupings of DVI training, which has been a huge commitment for the last 18 months. Five hundred students, with officers from every single police department around the UK.”
She adds that it has been “tremendously rewarding” for her, personally, to bring anatomy, forensic anthropology and the DVI together in one place: “This is the first ever-graduate certificate in DVI anywhere in the world. It’s all about raising the standards so that we can help identify victims of mass fatalities anywhere in the world; to give a name to a body, to give them back their identity, that’s how we can help the deceased, and that this information might in some way help their loved ones to move on. That’s what it’s all about.”

Tess Gerritsen

Dubbed the "medical suspense queen" by Publisher Weekly, the New York Times bestselling physician-author Dr Tess Gerritsen’s books have been translated into 31 languages and more than 15 million copies have been sold around the world. She talks to Scope about how her stellar and lucrative career as a novelist has been shaped by her years as a doctor.

It was the ex-cop’s grisly account of the abduction and harvesting of organs from Russian orphans that held the dinner guest in fearful enthral.

Operating a security service protecting American businessmen in Russia, the retired policeman heard that orphans were vanishing off the streets of Moscow. Sources in the city’s police force confided that the Russian mafia was snatching children and selling them abroad for their organs.

This chance dinner conversation with US physician and author Dr Tess Gerritsen provided her with the gruesome hook from which she later hung the plot for her first medical thriller “Harvest”, but not before she raise the alarm with a reporter she knew at Newsweek.

An investigation into these horrific claims ensued but no hard evidence was found.

“If it's happening in Russia, it would involve the Russian mafia, and that would be both difficult and dangerous to track down,” Tess disclosed.

Unable to shake the gruesome story from her thoughts, she created a narrative about a young female surgical resident who derails her promising career and risks her life in pursuit of Russian Mafiosi behind an extremely profitable black market in human organs harvested from orphans who believe they are bound for adoption in the US.

Tess recalled: “I wanted to bring into it all the medical and autopsy details that I'd learned from my years as a physician. The sights, the smells of the autopsy and operating rooms - everything.”

The resulting novel, ‘Harvest’, was released in hardcover in 1996 to critical acclaim, marking her debut on the New York Times bestseller list.

And she has made that list every time since - another ten books.

Her sizeable international fan base, many of who include doctors, would be familiar with her graphic autopsy scenes and forensic details, but they may be shocked to learn that her very first published novels were actually romantic suspense.

The romantic thriller ‘Call After Midnight’ was her first book, published in 1987 while she was a resident in internal medicine, and was followed by eight more romantic suspense novels.

Since writing Harvest, the San Diego, California-born doctor has penned four more medical thrillers (Life Support (1997), Bloodstream (1998), Gravity (1999), and The Bone Garden (2007)) and six forensic thrillers featuring the unlikely pairing of volatile Detective Jane Rizzoli and the emotionally remote Boston Medical Examiner Maura Isles: The Surgeon (2001), The Apprentice (2002), The Sinner (2003), Body Double (2004), Vanish (2005) and The Mephisto Club (2006).

It may be her work as a doctor that allows her to render situations in authentic and excruciatingly gruesome detail, but she is in no doubt that her first love was always writing.

“I have been a writer since childhood. In fact, I wrote my very first book at age seven, and bound it together myself with needle and thread.

“So it was the writer who became a doctor, and for the most practical of reasons - because my Asian American father warned me that there was no living to be made at art, and I'd better find a more practical profession.

“Luckily, I was already interested in science, so medicine became my chosen profession. For a while, at least.”

With a Degree in anthropology from Stanford University under her belt, Tess went on to medical school at the University of California, San Francisco, where she was awarded her MD.

Her physician husband Jacob - a Hawaiian native - wanted to return to his boyhood home, so he and Tess applied as residents to the University of Hawaii program. The move took them from sunny California to a hectic new life as specialists in internal medicine in Honolulu.

Tess continued writing all through medical school and residency, recording the stressful, dramatic, often painful things she experienced, however it wasn’t until her years of post-graduate training that she began to write in earnest again, and then only because she went on maternity leave for a few months.

Her publishing success in the late 80’s gave her the opportunity to gradually cut back on her internist's practice and eventually concentrate full time on writing and raising her two sons, Adam and Joshua.

In 1990, she and her husband moved the family from Honolulu to Camden, Maine, a picturesque seaside town of 5,000.

“The real reason I finally had to leave medicine was because of its intense demands. As the mother of two young sons, I found I couldn't combine motherhood and doctoring without one or the other suffering.

“And with a husband who was also a doctor, there were times when we might both be called in during the night - and what do you do with your sleeping children?

“I was a specialist in internal medicine. I was accepted into a pathology residency, but chose, ultimately, to stick with living patients. Perhaps if I'd gone into pathology instead - with a far more civilised work schedule - I might still be working as a doctor!

“We finally decided that I would stay home while the children were small. And that's when I returned to my first love of storytelling.”

She recalled several perplexing experiences during her years as a doctor that still linger:

“It's always the tragedies and the eerie incidents that stay with one. I'm a confirmed sceptic when it comes to the paranormal, but there were things that happened that still give me a chill.

“For instance, there was a nurse who could "smell" when a patient was dying - days before it happened. There was the haunted hospital room where patients always complained about seeing a ghost.

“Or the time a patient unexpectedly went into cardiac arrest and died - and his daughter, who'd been out at a shopping mall, suddenly came rushing into the hospital because she'd "had a feeling" that her father needed her. No one had called her; she'd simply sensed that he was dying. Those sorts of things make one wonder, don't they?”

One gets the impression that Tess is drawn in by chilling oddities and dark possibilities. Like the harrowing conspiracy-inspired plot in ‘Harvest’, many of her stories were seeded by creepy ideas that just wouldn't leave her alone.

Vanish, for instance, was inspired by a true news story about a woman who was found dead in her bathtub in a Boston suburb. She was zippered into a body bag and transported to the morgue - where she woke up a few hours later.

“That gave me such a chill that I knew I had to write a book about just that scenario - a corpse who wakes up in the morgue.

“Body Double was another story that started with a chill. It happened while I was watching an autopsy, and suddenly had the horrifying thought: what if I could watch myself get autopsied? Wouldn't that be a frightening experience? Since I don't write ghost stories, I had to find another way to make it happen in the book.

“I use true news stories for a lot of my inspiration,” she revealed “Gravity was inspired by an accident that took place aboard Mir Space Station. It got me wondering: what if there was a medical emergency in space, a disease condition so horribly contagious that the astronauts are quarantined in orbit and left to die?

“It's quite far afield from that original accident aboard Mir, but it drew its inspiration from a news story.

“I also incorporate true forensic cases into the stories. In The Apprentice, the killer kills couples, first forcing the husband to watch while he assaults the wife. One little detail in the story (the placing of chinaware on the husband's lap) is taken from what a real criminal has done.

“I've also used interesting facets of medicine. The Sinner, for instance, dealt with the subject of leprosy. Life Support was about the spread of mad cow disease in Boston.”

Tess’s latest novel, The Bone Garden, acquaints the reader with a dark and tragic chapter in the history of medicine. Set in the early 1800’s, one of the main characters, a penniless medical student named Norris Marshall, has found ghoulish employment after dark. He is a “resurrectionist”, one of the local grave robbers who supply medical schools with cadavers.

While The Bone Garden is a crime thriller with requisite serial killer in situ, it also deals with “childbed fever”, which was then rampant in maternity wards, and explores a frightening time when doctors killed as many patients as they cured. And when brilliant doctors like Oliver Wendell Holmes were just beginning to understand contagion.

Tess explained that she wanted to give her readers an inspiring look at the first glimmerings of microbial theory. And a glimpse at one of the gifted men who changed the face of modern medicine.

“Science has long been an interest of mine, and I consider myself something of a ‘popular interpreter’ of science when I write my books. I try to make it understandable and interesting.”

So then how important was her training and experience as a doctor to her work now as a full-time author?

“While medicine did give me some subject material for my stories, and it did give me a chance to incorporate fascinating facts, it didn't really teach me anything about storytelling,” she said.

“In some ways, I think a science background is a detriment for a storyteller because science forces one to be objective and logical. And storytelling is anything but logical.”

Tess is approached “very often” by other doctors with plot suggestions for her next bestseller, although she confessed that most of the time “their ideas don't strike me as very interesting”.

“Oftentimes they involve evil drug companies or malpractice suits - subjects that may be interesting to doctors, but are often not so interesting to the average reader,” she added.

Nevertheless, the level of interest from doctors who aspire to write fiction reached such a degree that she and fellow physician/author Michael Palmer now teach a course once a year that is specifically geared for doctors who want to be novelists.

The medical thriller is a hardy genre, so it is very natural for doctors and surgeons to want to circumvent the frustration of their professional lives by the writing of such novels.

After all, they know the territory, they have the facts, and many believe that if they were smart enough to get into medicine, it follows that they can do just about anything. Right?

“Doctors are unique students - they're diligent, intelligent, and they're quick to grasp new principles. But they're also somewhat handicapped by years of scientific training that's taught them to write emotionless, logical prose, and that can deaden their writing. Michael and I try to get them out of their doctor mode and into their artistic mode.”

Her advice for the medic and struggling scribe is to “read read read”.

“Identify which genre you enjoy most, because that's probably the genre you should be writing. The number one problem I see with many aspiring doctor/novelists is that they haven't read enough, and so haven't absorbed the techniques of writing gripping scenes. Or they try to over-explain by telling instead of showing,” she said.

Reflecting on her flourishing second career as an award winning, best selling author, Tess acknowledged: “If I'd been a doctor, I wouldn't have travelled nearly as much, or had the opportunity to learn about so many diverse subjects.

“Writing has opened so many worlds to me. And it's provided me with a far better income than I ever could have had as a doctor.”

The Flying Irish

A sailor in a round-the-world race is in severe distress with a broken femur, but he is 800 miles off the Australian coast in one of the most dangerous expanses of the Indian Ocean and a storm front is closing in.
What do you do?
The response of the Australian Navy and medical officials was to send in the best person for an emergency medical rescue of this nature – Irish man Dr David McIlroy of the Royal Flying Doctor Service (RFDS).
The French yachtsman Yann Elies, who had been taking part in the perilous single-handed Vendee Globe race, called for help on his satellite phone after he fractured the femur in his left leg and several ribs when his 60ft boat Generali was swamped by a huge wave on Thursday 18 December.
Hours later an international rescue mission was launched, led by one doctor, Antrim-born Dr McIlroy, who was deployed by the RFDS to accompany Naval officers on the HMAS Arunta. The Anzac class frigate left early on Friday morning on a two-day journey to reach the stricken sailor.
Elies was without pain relief for 48 hours until David McIlroy and a Naval medic boarded his yacht on Saturday 21 December in what he described as “probably the most exciting but also most physically demanding” medical evacuation of his career to date.
Hours after the successful rescue effort, RFDS Medical Director Dr Stephen Langford told Scope Magazine that David “had a very physically challenging rescue in 4 to 5 metre swell”.
“In those sorts of conditions, really cramped, the boat banging around and he was trying to put in an anaesthetic block, to block the nerves in the yachtsman's leg to take away some of the pain, and then put some IV fluids in and some other pain relief,” Dr Langford said.
David then had to splint the Yann’s leg, shift him onto a rescue stretcher, and manage the difficult task of transferring that stretcher across from the yacht to the inflatable boat with lines on each end. The HMAS Arunta docked in Fremantle south of Perth on Monday 22 December and David accompanied Yann on his transfer to the Royal Perth Hospital.
This astonishing mission of mercy grabbed headlines around the world and David was praised for his skill and professionalism in stabilising and safely transferring the injured sailor in dangerous sea condition. Certainly, he can add this latest rescue to a growing catalogue of adventures in his work as a flying doctor.
Currently the only Irish doctor employed by the RFDS, David loves his job. It’s evident in his enthusiastic recounting of challenges and daily trivia on the job as a doctor for the first, largest and most comprehensive aeromedical organisation in the world.
“It has got to be the best job you can do in medicine. I love it,” David declares in his unmistakable Northern Irish accent. “This job would probably appeal to people who enjoy emergency work, it’s just that you do it on your own, but like emergency medicine it also has a high burnout rate. I think the biggest polarizing factor when you ask emergency doctors if they’d like to work the with RFDS is that some would love the challenge and others are absolutely horrified that you’d leave yourself without a support network around you.
“That is probably the biggest hurdle to get over as on transfers or retrievals it is just yourself and a nurse, no trauma teams or fancy investigations. You learn to rely on signs and symptoms and history taking. And that’s how it is. You can only send in one doctor to any case, so if there’s someone better than you, they should be the ones going. You must get the most complete set of skills, and no one knows everything so you can only take what you’ve got to the scene and pray it’s enough.”
Doctors and nurses in the RFDS look after 200,000 isolated patients over 12 million square kilometres of the Australian outback. David’s first encounter with a ‘flying doctor’ was in 2006 while working in Emergency Medicine at the Royal Darwin Hospital. “The doctor involved brought in a intubated, ventilated patient with drains and lines everywhere and it was one of those moments where you think I'd love to do that, or be good enough to do that.”
In January 2007 the young doctor from Larne in Co Antrim realised his ambition and signed up with the RFDS.
“I think this job is probably the best mix of cases and challenges you can get in medicine. I am training as an Emergency Specialist so the very acute exciting stuff is more natural to me, but we also do clinic work, which is more GP orientated.
“One of the earlier cases that sticks in my mind was a young lady who got caught in some farm machinery and lost an arm and badly damaged a leg. She was only 19 years old. I was struck not by the extent of her injuries, which were pretty horrific, but by how stoical she was, unbelievably matter of fact. This is common in outback folk as they seem to put up with more than most of us,” David remarks.
“By the time they met our plane they had had already travelled more than 200 kilometres over rough roads. This is just how tough she was: with her right arm off and her right leg mangled, probably worst than her arm, I asked her: ‘you look like you’re in a fair bit of pain, what would you say your pain was out of ten’ and she said ‘it was 7 but it’s gone up to about an 8’. And I had to think ‘I wonder what ten is on your scale?’ I would give that a minimum of ten.
“It was a two-hour flight to the hospital. She remained really, really calm during the whole thing, absolutely genuine and matter of fact.
In 2007 the RFDS performed an average of 96 daily aeromedical emergency evacuations, totalling more than 35,000 that year. The Service also consults with rural and remote doctors and flies a regular clinic circuit to areas without doctors. These free clinics are the equivalent of visiting a local GP and are as much about health education and prevention as they are about addressing immediate health issues.
Remote control medicine became a reality for the flying doctors when medical chests were introduced to outback stations in 1942. Over 3500 RFDS medical chests are located at remote locations across Australia, such as isolated pastoral properties, Indigenous communities, out-stations, remote mining sites and lighthouses.
Each chest is identical and contains numbered drugs, bandages and other first aid materials, allowing the doctor to instruct the caller to use medication or treatment by referring to numbered items on the lid list of the chest.
Many tall stories grew up around the service and one about the medical chests is typical. A station manager was told to give his wife a number nine tablet. Later he told the doctor, "We'd run out of number nines, but I gave her one five and one four and she came good right away!"
And of course David has his own story to recall, one that brought the medical MacGyver in him to the surface
“We do a lot of advice calls and these medical chests can provide an invaluable lifeline for people who are hundreds or thousands of miles away from medical assistance. When I was in Meekatharra, there was a young kid had a very severe croup and I could hear him on the phone with his mother, really horrible sounding breathing with inspiratory stridor and wheeze and she described a kid that was basically getting towards its last legs.
“It was going to be 90 minutes before I was going to be able to get to them but I was fairly sure the kid would have died within the next hour if he didn’t have treatment. His mum told me that there was an old nebulizer from the grandmother when she’d lived on the farm so I asked them to get that and see if it still worked. There’s adrenalin in the chest’s anaphylaxis kit, so I got them to take all the adrenalin out, break the ampoules, put it in the nebulizer, and mix it with a bit of water or saline and nebulize the kid some adrenalin.
“There’s some dexamethasone in the chest and also everything you need to give an injection. I talked mum through how to drop the injection and how to give it, so mum gave a big dose of the steroid into her kid’s leg, and when I landed about 90 minutes later at the station, the kids was almost better from the treatment that mum had given.
“I blew up a glove and drew a face on it and the kids played with it all the way back. I had nothing to do, it was one of the easiest flights I have ever had and it was only because mum treated the child before we got there.
“This is the sort of job where you have to think outside the box. You look at the list of what they’ve got in the medical chest and around them and who can help you to do what has to be done before you get there.”
David has no plans to return to Ireland as of yet, although by mid 2009 he will have to leave the RFDS for a period to finish his training in Emergency Medicine and sit his consultant exams. But after that, he is adamant that his path will return him to the RFDS “long term, because I love it”
Although an allure of an adventurous and stimulating lifestyle can make it easier to recruit new doctors to the RFDS, due to the remote and lonely living conditions, and sometimes dangerous situations associated with night flying, these recruits often do not stay on past twelve months. David may prove an exception, as another Irish man, the famous Royal Flying Doctor pioneer Dr Tim O'Leary did for 27 years.
The late Dr O'Leary was a legend in his own lifetime, famous for his compassion, sense of humour, and medical skill. A born raconteur, he published two books of memoirs describing some of his adventures in the provision of health services to the Australian Outback: North and Aloft, and Western Wings of Care.
His son, Bill O'Leary, has written a screenplay “The Flying Doctor” based on the amazing story of his father's adventures, and is offering first option on the script to Mel Gibson’s ICON Productions.
Opening scenes are Tim’s steeplechase accident as a teenager in Ireland that nearly cost him his leg, to working alongside Mother Theresa in India prior to taking post as Ship's Surgeon bound for Australia in 1951. He landed penniless in Sydney, and 'picking' the Flying Doctor Job out of a cup.
The script covers three decades of adventure including surviving the fatal RFDS plane crash in 1953 that killed his first wife Renee, only six weeks after their wedding, and his best friend Captain Martin Garrett.
Over the next 30 years Tim was an outback legend - surviving fatal plane crashes, being attacked by spear-throwing aboriginals, swimming through flooded crock-infested rivers and flying thousands of miles to save the lives of isolated Australians.
“The story is so amazing it needs to be told and we are certain the world will love it,” says Bill, who resides in Thailand with his family. “A charismatic hero's journey sweeping two generations and three continents filled with highflying adventure, tragic plane crashes, riveting life-saving stories and an unexpected 'twist' buried so deep even the most astute sleuths will be blown away. The final scenes reveal that Doctor Tim was......Nah, sorry - you'll have to read it yourself or see the movie.”

The Kindest Cut

There are more than 6900 ways to say thank you, but for a growing number of charitable Irish doctors a smile is thanks enough.
This group of surgeons, anaesthetists and paediatricians from all over Ireland readily give of their time and skills free of charge, travelling to the developing world to carry out complex surgery on children and adults whose deformities prevent them from smiling.
Their humanitarian missions, organised by medical charities such as Operation Smile Ireland and Irish Friends of Albania, also provide a vital opportunity to train local surgeons to correct cleft lips and palates, and other reconstructive surgery procedures, and educate on the safe administration of anaesthetics.
These noble objectives have taken dozens of Irish doctors, nurses and dentists on humanitarian trips throughout the developing world, including India, Jordan, Belarus, Albania, Kenya, Ethiopia, Morocco, Russia, China and Cambodia.
In late 2006, plastic surgeon Mr Michael Earley made national headlines by repairing a Moroccan toddler’s bilateral cleft lip and rare ocular facial cleft at the Children’s University Hospital, Temple Street as part of Operation Smile’s annual World Care programme.
However, what received little column inches was that he had been working diligently behind the scenes since 2003 building up Operation Smile Ireland with several friends and colleagues.
Michael was initially approached in 2003 to help develop an Irish resource chapter of the International organisation by Teri Kane and her father Tom, a New York-born businessman and former Marine fighter pilot in Vietnam, who now owns and runs Adare Manor Hotel in Limerick. Tom is a close friend of the founders of Operation Smile, Irish-American surgeon Bill Magee and his wife Kathy.
Then an encounter with Adi Roche of the Chernobyl Children’s Project gave the fledgling Operation Smile Ireland its inaugural mission to Belarus in April 2004. Just over 50 patients were treated Belarus at the Minsk Children’s Hospital over a period of a week.
He explains that this number was actually quiet low compared to a typical Operation Smile mission, but at that time, given the logistics and the equipment made available to them, it was the best that could be achieved.
“Usually we would treat around 150 people or more, mostly children. If its a big team of volunteers there would be about six surgeons, and we try to ensure that at least half of those surgeons are local because the whole object of this operation is as a teaching and information exchange,” Michael stresses. “Really what you’re chasing after is the sustainability of the idea rather than going out to these countries and being guilty of what use to be known as ‘surgical parachute mission’s – fly in, do the surgery and be the big white hope, which is not the way it should be done. What we’re trying to achieve is to create something that the local surgeons can continue on with.”
By the end of 2005, fifteen Irish medical professionals had volunteered on six international missions with Operation Smile Ireland to Belarus, China, India, Jordan, Kenya, and Morocco. And the volunteer bug has bitten quiet a few more doctors since then.
His friend and colleague Dr Liam Claffey, a consultant anaesthetist from Temple Street, accompanied Michael and four other Irish volunteers on Operation Smile Ireland’s recent outing of mercy to Cambodia in October this year.
“There are so many different stories on these trips that stay with you long after you’ve returned home. What struck Liam and myself when we were in Cambodia was the very real sense that the surgeons and other doctors, paramedics and nurses, everyone, really appreciated us all being there, and the huge thirst for knowledge and wanting to learn from you. It was really great.
“When we were in China the one incident that struck us all was a grandmother, a mother and a child, all with clefts, none of them ever repaired, and we repaired the three generations. That was a very remarkable story. They were all very emotional, and so were we. It makes it very worthwhile.”
Mr David Orr, Operation Smile Ireland’s Medical Director and one of its founding members, points out that cleft lip palate occurs in approximately one in 500 births in the developing world.
If left untreated these congenital defects cause major difficulties for those affected such as severe facial deformity, psychosocial problems and difficulties with speech and feeding.
A Consultant Plastic Surgeon at Our Lady’s Hospital for Sick Children, Crumlin, David Orr is not a stranger to medicine in the developing world, having cut his teeth working as a medical volunteer in Africa when only a medical student.
“This is something I’ve always been interested in, but when you’re a specialist surgeon, part of the difficulty is to find a vehicle to get you to the developing countries in the first place and get you operating,” he remarks.
From his first trip with Operation Smile to Eldoret in Kenya in 2003, David has returned to Africa to operate and pass on his skills to local surgeons on many occasions. This experience was duly recognised in December 2006 when he was appointed team leader for Operation Smile’s mission in Addis Ababa, Ethiopia.
“We’d literally take over part of a hospital for the best part of two weeks and operate on maybe 150 to 200 cases. We could do more of these cleft lip and palate surgeries in a week in these countries than we’d do in Ireland in a whole year.
“Traditionally the model that Operation Smile has had is a two-way engagement, any country we go to is a partner country, and the idea is that we have resource countries and we have partner countries that are recipient of aid.
“During the missions you’re teaching the local surgeons how to do the procedures, after which they become accredited as operation smile volunteers and they continue the cleft lip and palate programme in their own country, largely as volunteer because you could imagine that something like cleft lip and palate comes so low down the list of priorities for public health authorities in the developing world,” he says.
Obviously clean water and vaccination programmes would be hugely beneficial in these countries, but such efforts typically take several years to complete, while Operation Smile can provide immediate medical treatment that will last the child's lifetime.
None of the doctors who participate in these missions are naive enough to think they’re going in to save the world, but to enable a child to grow up like his peers is to give him a fighting chance.
With an eye to the future, David is also spearheaded an ambitious venture through Operation Smile Ireland to set up a more permanent base in Ethiopia by way of a new Plastic Surgery Centre in Jima Hospital in the south west of the country.
Much preparatory work has been completed: a site has been secured, preliminary agreements signed and only a project manager remains to be appointed before the unit can begin to take shape.
A key attraction of this work with Operation Smile for David is that he finally gets to put away his gloves and get on with what he is passionate about, surgery.
“If you’re a surgeon working in the Irish health service, most of the time you’re fighting with people to be allowed to treat your patients. I’m forever fighting with people to get some space in theatre or to get my patient into hospital. So a huge amount of what you do here is making yourself very unpopular because you want to treat people. But when you go to a developing country people come up to you and maybe ask do you mind staying on for a couple more hours to do another few cases and you’re like ‘Oh, do I really mind staying here and doing my favourite operation again?’” he laughs. “No, not at all!”
The desire of doctors on these missions to work, and to work hard, is reiterated by Mr Jack McCann, a Consultant Plastic Surgeon in University College Hospital in Galway who set up the medical charity Irish Friends of Albania.
“There’s an enormous willingness of people to help us on our trips to Albania,” he says of his medial and surgical colleagues in Ireland. “The harder they work the better they like it. The more you give them to do, the more they want to do out there. They like when they go out there to be busy, they would work around the clock if you’d let them.”
Jack’s links with Albania began in 2002 when he and several Irish volunteers visited Mother Theresa Hospital in Tirana, Albania. This visit resulted in the transfer of Alba, a four-year-old Albanian girl suffering from severe burns, to UCH Galway.
She was treated for four months in Galway and made a fine recovery. The following year when Jack returned to Tirana to check on Alba’s progress he was asked to help three other children with hand deformities and hand burns.
“We knew that these children also needed follow-up so myself and my wife Moya went over to see if we could set up come sort of treatment centre over there, if we could operate over there rather than the patients having to come over here.
“We made contact with Prof Gjergji Belba, who heads up the only plastic surgery unit in the country in the Mother Theresa Hospital, and we agreed to set up a partnership. We brought out a truck load of equipment each time we travelled to Tirana - anaesthetic equipment, theatre lights, theatre tables and so on – and we equipped three theatres out there over the following year or two.
“Then we began to send full surgical teams to work together with the local hospital staff for on-the-job training. Over 60 Irish surgeons, anaesthetists, doctors, nurses, bio-engineers and CSSD specialists have volunteered for these teams,” Jack says proudly.
“Since we started up, we’ve completed seven visits to Albania. We’ve operated on 300 adults and children, we’ve seen almost 600 patients, and brought about 15 or 16 to Ireland for surgery over the years,” he adds.
Fundraising is a huge aspect of their work, year round, culminating in their annual Irish Friends of Albania Ball every October. The Herculean efforts of their committed team of administrators and friends help accrue up to €200,000 annually to fund the association’s charitable endeavours.
“Each visit to Albania costs about €50,000 because we usually bring out a team of up to 20 people, but we’re planning to make the teams smaller in the future.
“We recently purchased a microscope for the unit and are now sending them on courses to learn to do microsurgery and flap surgery. We’ve also set up a telemedicine link between Ireland and Albania.”
Jack explains that while his team have mostly worked in plastic surgery up to now, there is a shift of late into other areas of surgery, and as a result more surgeons coming on board, including Mr Paddy McCann (maxillofacial surgeon), Mr Denis Quill (general surgeon), Mr Ciaran Brady (paediatric urologist), Mr Ken Kaar, Mr Bill Curtin, Mr Aiden Devitt and Mr Finbarr Condon (orthopaedic surgeons). Some of the plastic surgeons that have travelled to Albania include Mr Padraig Regan, Mr Jack Kelly and Ms Patricia Eady.
“Whoever has offered to come out, we’ve brought them out. In my experience, there is a huge willingness among Irish doctors and nurses to volunteer to help others who may not otherwise get the help they need. It’s a wonderful quality. The enthusiasm these volunteers bring to our group is amazing; it keeps us moving forward. They are the good Samaritans.”

The unsung heroes:

A poster child with cleft lip and sad, shy eyes, beseeching the onlooker to contribute to Operation Smile is an effective visual tool; it raising the money that provides the vehicle to get surgeons out to developing countries to help these children. There’s no denying that their efforts have a hugely positive impact, but that surgery doesn’t actually save lives.
The anaesthetist, on the other hand, brings a vital knowledge to the theatre table that can make the different between life and death.
The harsh reality is that most surgical operations are still being done in developing countries without the services of an anaesthetist due to manpower shortage in this field.
“Anaesthesia in the developing world has actually become more dangerous. A lot of anaesthetics are given by technicians that aren’t even qualified doctors,” says David Orr, Consultant Plastic Surgeon at Our Lady’s Hospital for Sick Children, Crumlin, and Medical Director of Operation Smile Ireland.
“When we go to a developing country, every time one of our kids is put to sleep by one of our paediatric anaesthetists, such as Bill Casey, Martina Healy, Dave Manion, and Liam Claffey who are at the absolute top end of anaesthetics in the world, they are teaching the local anaesthetists how to give a safe, reliable anaesthetic.
“So when we leave, whatever about having trained a few surgeons how to repair cleft lips, the really important thing is that all of those anaesthetists who have worked with our anaesthetists would have had their standards brought up enormously.
“And the next time they have to put a kid asleep for an infected tonsil or an appendectomy or whatever, those kids get much safer anaesthetics. That I think is the hidden benefit of these trips.”

Smile Train – trouble on the line?

The Smile Train has taken a different tack from Operation Smile in exporting surgical care to developing countries. Instead of sending teams of doctors on overseas visits, The Smile Train manages cleft lip and palate by upgrading local infrastructure.
Since March 2000, the mile Train has treated 230,000 children with cleft lip and palate.
Recently the charity introduced The Smile Train Medical Exchange Program, which represented a change of policy by having surgeons visiting the developing world from the developed world.
However, a new book has thrown a shadow of suspicion over this practice. The authors of ‘Management of Cleft Lip and Palate in the Developing World’ claimed that this approach was facilitating trips by surgeons who may not have any experience of cleft surgery in their home practice. Also the application for the new program includes only the “most cursory questioning” on competence to perform cleft lip/palate repair.
“While The Smile Train has always had high standards, there is concern that their commitment to the highest quality care will be derailed in favour of sending more surgeons “into the field”, irrespective of expertise in cleft lip/palate repair,” warn the authors.

The extent of the problem:

Every year nearly a quarter of a million new babies with cleft lip and/or palate are born in the poorest parts of the world. The vast majority of these children will receive very limited or no treatment at all.
This occurs on a cumulative annual basis, resulting in a reservoir of many millions of under-treated and untreated individuals.
In India and china alone this may result in 22.5 million cleft lip and palate subjects for each country over a period of 50 years, assuming this is the minimum average life expectancy.