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.