Developing World Site Evaluation

Potential for Indian Burn Outreach Program

  Patient in Burn Unit 
  Originally uploaded by interplast.

The hospital also has a small burn unit. While there, I demonstrated Interplast Grand Rounds to Dr. Puneet, and he is very interested in becoming a member. He is also very interested in our burn outreach program for the future. Some of his post-op cleft patients were in the hospital and on the wards when I visited. We also examined the patients he had arranged for us to see together to discuss potential care plans for them. Some of these patents will be brought for our team visit.

India: Almost Overwhelming

  Indian Kids 
  Originally uploaded by interplast.

One's first experience of India is almost overwhelming...India stimulates all senses...visual, smell, sound, touch, and ultimately, taste. There are great areas of poverty in India, which has the second largest population in the world (and will become first in the not-to-distant future).  India has the largest actual number of poor people in any country...40% of the population. Driving through India, as I did much of, one can witness this first hand.  Fortunately, even poverty cannot wipe a smile off of someone's face, as these girls by the side of the road demonstrated.

Well Suited For An Interplast Surgical Team

  Bill and Dr. Puneet Pasricha 
  Originally uploaded by interplast.

My visit to Jalandhar in the state of Punjab was a bit marred by an illness on my part. I visited the Pasricha Hospital, a private hospital there owned by Dr. Puneet Pasricha. He is a plastic and reconstructive surgeon. He already is a Smile Train partner, doing clefts on poor patients. The hospital is very clean, small, and well suited for an Interplast surgical team visit.

Dr. Yogi's Hand With Henna

  Dr. Yogi's Hand With Henna 
  Originally uploaded by interplast.

Dr. Yogi got his hand painted by a child while in Haridwar.

Aarti at Haridwar

  Aarti at Haridwar 
  Originally uploaded by interplast.

We went to Haridwar, a very sacred city for Hindus. It is often called the Varanasi of the North, as it is located on the Ganges River near where it emerges from the Himalayas. Many people go there to bathe in the river. We went to attend the evening Aarti, when people float lighted flower baskets down the river as prayer offerings.

Snakes in a Basket

  Snakes in a Basket 
  Originally uploaded by interplast.

Note the tattoo on the hand of the handler.

Snakes on an Interplast Blog

  Cobra in Snake Charmer's Village 
  Originally uploaded by interplast.

Dr. Yogi has taken care of a number of patients from the snake charmers' village. He offered to take me there to see the place. He describes the snake charmers as the Gypsies of India. They live in very poor conditions and do things like pan-handling. They are all very poor. He has taken care of them free of charge as he feels they really need the help. We even saw a child while visiting who had a hemangioma (perianal) and Dr. Yogi told them to bring in the child and he would remove it. Needless to say, I was also shown the snakes, which they believe are sacred.

Sivanna Charitable Hospital

  Sivanna Charitable Hospital 
  Originally uploaded by interplast.

On the way to Haridwar we stopped at the Sivanna Charitable Hospital which is run by an ashram and treats the very poor. It is very small and is very crowded with patients. We stopped there so that we could speak with the doctors who will be able to recruit many burn contracture patients for our team. Haridwar is a very interesting place with many people bathing in the river. There is much going on all the time with many vendors selling flowers, food, bangles, etc.

This is a podcast interview I did with communications and technology coordinator Seth Mazow about my site evaluation trip to India.  Check it out.

Traditional Rajasthani Performance

  Traditional Rajasthani Performance 
  Originally uploaded by interplast.

I was greeted the first night with a show put on by a group of performers from Rajasthan doing traditional dances (with pots on heads) and other amazing and traditional Indian things such as eating fire and dancing on broken glass (barefooted). It was quiite a performance, followed by the mayor presenting me with the key to the city. The accompanying Indian music was really terrific.

Women Washing

  Women washing 
  Originally uploaded by interplast.

This was a common scene near rivers.

Traditional Meal with Dr. Yogi

  Traditional meal with Dr. Yogi 
  Originally uploaded by interplast.

I was invited to dinner at the home of Dr. Yogi for a traditional indian meal. The food was delicious, not too spicy, and quite varied. I met the wives of Drs. Kush and Aeron and had a delightful evening visit. Dr. Yogi has three sons and one daughter. Dr. Yogi's son Lauv, was our main contact with between him and us as he lives in the Bay Area. Dr. Kush has two children, a boy and a girl. The photos show Drs. Yogi and Kush at the dinner table at Dr. Yogi's house.

Test Driving Interplast Grand Rounds

  Test Driving Interplast Grand Rounds 
  Originally uploaded by interplast.

Me demonstrating Interplast Grand Rounds to Dr. Yogi at Kush's house...Dr. Yogi is very interested in becoming a member.  We have doctors in dozens of countries around the world, but no Indians yet.  Looks like that's about to change!

Cleft Lip Patient

  Cleft Lip Patient 
  Originally uploaded by interplast.

A cleft patent seen with Dr. Yogi. This young man will be waiting for the Interplast team.

Evaluating the Operating Room

  Drs. Kush Aeron, Yogi Aeron and BIll Schneider 
  Originally uploaded by interplast.

We toured the entire hospital to examine all the facilities. This is essential prior to committing to send an Interplast team anywhere in the world. We must be certain that the facilites are adequate to ensure the possibilty of quality and safe work. This photos also shows Dr. Kush Aeron, Dr. Yogi's son, who is an ER phyisician, but also works with his father. He wil be the primary contact for us at this site. Here we are seen evaluating the OR.

On The Road For Interplast: India Site Evaluation Trip

  Plastic Surgeons Dr. Bill Schneider and Dr. Yogi Aeron 
  Originally uploaded by interplast.

Hi.  I'm back again, this time in India to evaluate two sites in Dehra Dun and Jalandhar to see if Interplast could work here.  I had a tough time loading up all this info in India, so I had to wait until I got home to pass it on to Seth.   But I will post it (or, more accurately, have Seth post it) in order anyway.

I first went to Dehra Dun to visit the Disha Hospital there where Interplast plans to work It is a small private hospital, which meets all of our requirements. Our host there will be Dr. Yogi Aeron, a plastic surgeon. He has practiced there many years and is a very experienced surgeon. He often, with his own time and money, takes care of poor patients. The photo shows Dr. Yogi and myself examining a young girl whose face was burned.

Interplast Plans to Expand in Five Countries

Sara Anderson - director, communications and public education: In the upcoming 2007 fiscal year, Interplast has the opportunity to expand and serve needs in Ethiopia, China, Ghana, India and Mali. Expanding in these regions of the world will allow Interplast to reach thousands more children in need of our services and provide valuable education and outreach programs for local physicians and surgeons.

China:

Before and After
Originally uploaded by interplast.

The World Health Organization estimates there are approximately 35,000 babies born every year in China with cleft lip and/or palate. China has an ample supply of skilled doctors and nurses, but impoverished families, especially those from rural regions, simply cannot afford the medical help their children require. In China, Interplast plans: to eliminate all existing cleft lips and palates in the BeiBei area of Chongqing in the next five years; expand its medical education and empowerment programs in Chongqing and in Yunnan province’s capital, Kunming; and provide life-changing surgeries in Kunming.

Africa:

Mother and Child With Cleft
Originally uploaded by interplast.

Since 1999, Interplast has worked in perhaps the most challenged continent in the world: Africa. For more than six years, the international humanitarian organization has supported the Interplast Surgical Outreach Center in Lusaka, Zambia, providing rare access to reconstructive plastic surgery; its director is the only plastic surgeon in the country. In FY2007, Interplast has the opportunity to: establish a surgical outreach center in Ghana; send a volunteer surgical team to Bamako, Mali; and provide visiting educator workshops in Ethiopia and Ghana.

India:

Kids Smile, Kerala India
Originally uploaded by Jennifer Esperanza.

Interplast also is planning on working in India, one of the world’s most populous and poverty-stricken region; 40 percent of the world’s poor live in India. Dr. Bill Schneider, Interplast’s chief medical officer, will head to India on May 23 to evaluate six sites that are under serious consideration for establishing direct service (free plastic surgeries), education and year-round surgical outreach programs. Schneider will visit: Jalandhar, Punjab; Debra Dun, Uttranchal; Chennai, Tamil Nadu; Bangalore, Karnataka; Trivandrum, Kerula; and Parbatia and Tinsukia, Assum.

To follow along on his site visits, please visit this blog at the end of May.

Test Driving Interplast Grand Rounds

Test Driving Interplast Grand Rounds
Originally uploaded by interplast.

The Korle Bu Teaching Hospital in Accra, Ghana is the largest hospital in all of Ghana. Plastic surgery has its own unit in a separate building, with 70 beds. They also have their own surgical theatre.

They treat, as in Kumasi, many truamatic injuries, multiple types of skin ulcers, including Buruli's, which is endemic to here and Kumasi. The chair is Dr. Albert Paintsil, shown here "test driving" Interplast Grand Rounds, which he is very enthusiastic about. He also is interested in our Visiting Educator program, and has picked out some topics. His two associates, Dr. Laing and Dr. Mork are also plastic surgeons here. Their cleft work is supported by Transforming Faces Worldwide, with whom we also have a relationship.

Interplast, International Aid and J&J

Staff (L to R) Interplast, International Aid and J&J
Originally uploaded by interplast.

I visited Korle Bu Surgical Skills Teaching Center located at the Korle Bu Teaching Hopital. It is a separate structure completely refurbished and equipped by Johnson & Johnson and International Aid (a US based charity). They both continue to support the center and its program. The center is used to teach surgical courses for physicians all over Africa. There are plans in the works to expand the teaching program over the next two years. I met with two representatives of International Aid and with a representative of Johnson & Johnson. We had a long and very fruitful discusson of how Interplast might be able to participate in future teaching projects. International Aid is very enthusiastic about our input. The center has four surgical tables where practice surgery is performed using animal subjects.

Astonishing Cleft Story

Pius and I Looking at a Patient
Originally uploaded by interplast.

We also saw two patients, more had been told to come, but didn't...maybe they were afraid, shy or embarrassed. We saw one girl with a cleft and another with a Tessier cleft of the face. Pius also would like her posted on Interplast Grand Rounds. All in all a very intriguing story, with much yet to be learned. His preliminary study suggested there is a great deal of intermarriage in this complex of villages. If all this cleft story were indeed true, it would be truly astonishing...and as a realist with a scientific bent, surprising.

But regardless of the story, we know there are some clefts, and Pius plans to work to get them repaired.

Remote and Poor Village

Local Ghanaian Girl
Originally uploaded by interplast.

The village is very remote and poor. The dwellings are mostly mud hut type structures with thatched roofs. Chickens and goats wandering freely, small children everywhere. Some children are in rags.

Hundreds of Clefts

Village Head And His Associates
Originally uploaded by interplast.

Pius discussed with the head man
and his associates (the head man, shirtless on the left, his assistant in the middle, and the village announcer on the right with the grey beard) the cleft situation. The announcer travels to all the villages in this grouping and he tells us there are "hundreds of clefts." But there is a great stigma to their being seen. Again, I remain skeptical, but very interested. Emma, his AA as discussed in the last series, is a very intelligent young woman, and a sociology major. She is working on devising a plan to do the study this year.

Meeting The Locals

Ghanaian Girl In Need Of Interplast's Help
Originally uploaded by interplast.

We went off the main road on a track into the bush (we of course were
in a four-wheel drive vehicle). Pius had, though intermediaries, arranged to have the head man meet us in the main square of one of the villages, with
some villagers who had clefts. We were not sure is this would actually happen.

We came to the village at the appointed time. Several villagers were indeed
there waiting. Three wooden benches were arranged in a U shape. A traditional greeting was done...Pius would say in EWE (the local language) a phrase and the villagers would respond in unison. Four different phrases were said with responses. We then walked around the bench and each of us shook each of their hands. Then we were seated and they all walked around and shook our hands.

Villages Full of Clefts?

Local Kids
Originally uploaded by interplast.

If Sogokope is off the beaten track, and Denu is way off the beaten track, our final stop for the weekend barely has a track. Pius has been intrigued by anecdotal stories of villages in an area called Wudoaba, also near the Togo border, but north. The stories suggest there are a great number of clefts in the area, more than expected by the population. He has done a preliminary study, but really wants to do an extended survey/study. I may try to find a way to help him do this. Stories abound in this village area that there are many who speak poorly. Also, once a week a market is held at night. No one has ever encountered this in Africa, the suggested reason being that the people who come don't want to be seen because of their clefts. There is much superstition in this complex of villages. Although I am personally skeptical, the circumstantial evidence is of interest.

Lots Of Interest In Interplast Grand Rounds

Ghanaian Baby With Cleft And Her Mother
Originally uploaded by interplast.

One of the young patients can be seen with her mother. The other is an 18-year old girl who had Noma as an infant. This a typical outcome. She needs extensive reconstructive surgery, and it is a very complicated problem.
Pius has asked me to post this case on Interplast Grand Rounds when I return. There has been great interest everywhere I have traveled in
IGR...we will be adding a number of new participants.

This area of Ghana was a prominent slave market area. We also visited a Danish slave fort in Denu, right on the beach. The slaves from here were sent to St. Thomas, St. John, and St. Croix, the Virgin Islands then controlled by Denmark. The fort is replete with dungeons, chains on the walls, etc. A bleak and stark reminder of a sad past time.

Perfect Candidate For The Interplast Outreach Program

Informing Patients Of Plans For Their Reconstructive Surgery
Originally uploaded by interplast.

We went to a place called Denu which is located directly on the coast of Ghana, about one kilometer from the Togo border. We saw a number of patients at a church. The church is really a thatched roof pavilion about 50 yards from the beach. We saw the
patients in a back corner. Over the course of the weekend we identified about 20 patients for surgery. Dr. Pius plans to come to the regional hospital at Sogakope to do the surgery. This site is a perfect candidate for the Interplast outreach program. Dr. Pius is sophisticated and skilled enough that he would be an excellent candidate for the Interplast surgical outreach program.

Emma Gudhe, Dr. Pius' administrative asstistant can be seen talking with the
patients and informing them of the plan for their reconstructive surgery. Dr. Pius hopes to bring a team down in a few months and do all of them.

No Plastic Surgery Services Available...Yet

35-Year Old Ghanaian With Cleft Lip
Originally uploaded by interplast.

Dr. Pius then took me to visit Sogakope, a region near the border of Togo where there is a regional hospital. We spent two days there. The original plan was for me to fly back to Accra where they would pick me up to go on to Sogakope as they said the roads were very bad. But I told them that I would rather drive with them than go back on that same airline. So we drove 8 hours to get to Sogakope.

Dr. Pius is trying to establish an outreach program there as there are no plastic surgery services available in the area. The local doctors had arranged for us to see several patients when we arrived late in the day.

One was a six-day old infant with a cleft lip and no palate. Dr. Pius plans to repair it later. Also there was a 35-year old man with an untreated cleft lip.

Malaria Is A Common Concern

Women with Baby
Originally uploaded by interplast.

The hospital is very large. Dr. Agenenorku says it was built for 500 patients, but may now have up to 1,000 patients. There were indeed places where mattresses had been placed on the floor between beds to hold more patients. This child was in one of the wards we passed through. The most common admission on pediatrics is for malaria.

Wonderful Opportunity For A New Visiting Educator Site

Drs. Akpaloo, Ageneroku and Ada
Originally uploaded by interplast.

I visited the Komfu Anokye (pronounced KOM-fu a-NO-che) Teaching
Hospital, or as they say here, KATH. There are three fully trained plastic surgeons. The senior surgeon is Dr. Pius Agbenorku. I was taken on teaching rounds with the residents and the students which included the burn unit and several wards. They treat a great deal of traumatic injuries largely secondary to motor vehicle accidents. They also run the burn unit and do hand surgery. They are very interested in our visiting educator program and in fact are very eager for us to begin.

Pictured here are the three plastic surgeons, from the left are Dr. Joseph Akpaloo, Dr. Pius Agbenorku, and Dr. Emmanuel Ada holding the x-ray. The patient has a complicated foot wound with osteomyelitis and we discussed possible therapeutic options.

Arrival in Ghana

I am now in Ghana, the last stop on my three nation site evaluation trip for Interplast.  It has been a very valuable trip so far, and I hope to make as many useful contacts in Ghana as I did in Mali and Ethiopia. 

I first visited Kumasi, Ghana, which is located in the center of the country.  I almost didn't get to go.  I arrived at the airport 2 hours ahead of the scheduled departure to find that they had had no aviation fuel for two days, so all flights were cancelled.  Because there was a great commotion (since many people had tried to leave the day before and come back the next day), I decided to lay back and wait to find out what was going on.

After two hours they added the flight back, taking one plane to several cities instead of two planes to different destinations. About half the travelers had left in disgust after the first announcement, so there was now room on one plane...and apparently (since I got there) enough fuel for one.

Significant Need For Healthcare Services In Ethiopia

Woman at Ethiopian Market
Originally uploaded by interplast.

Ethiopia is a very poor country. I talked with two Food and Agriculture Organization (FAO) workers from the UK who are studying hunger in Ethiopia. They say Ethiopia has one of the highest "wasting" rates in Africa (10%), which they say is very high. Wasting is the technical term for low body weight relative to height....perhaps obviously a precursor to starvation. These photos were taken at a market in the north of Ethiopia. There is a significant need for healthcare services in Ethiopia.

Ethiopia's Coptic Christians

Coptic Christians
Originally uploaded by interplast.

The primary religion in Ethiopia is Coptic Chritianity, or as they say,
Orthodox Christianity. I attended an outdoor Sunday service. Involved in the service is a great deal of chanting and prayers with responses. The religion is very important to the people, even or perhaps especially in the very poor areas. Many people attending the service were reading their Bibles. In the South of the country there is a Muslim region near Somalia. The primary language in Ethiopia is Amharic which is closely related to Aramaic.

Leprosy Patient's Hands

Leprosy Patient
Originally uploaded by interplast.

This is one of the leprosy patients at the hospital. Leprosy affects the peripheral nerves, ulnar or median, or both resulting in loss of sensation and some motor activity. This patient shows one of the classic deformities associated with the disease. Leprosy is treatable at an early stage, but there is a huge stigma still attached to the disease in Ethiopia, so most patients hide that they have it until it is too late to treat. There are two hand surgeons at ALERT and Dr. Yegerem and Dr. Tewodros also do some hand surgery. There may be some interest in Interplast doing a hand visiting educator trip in the future.

Site Visit at Leprosy Hospital In Addis Ababa

Drs. Yegerem, Tewodros, Schneider and Ruth
Originally uploaded by interplast.

I am in Addis Ababa, Ethiopia , and I spent today at the All Africa Leprosy Education Rehabilitation and Training (ALERT) Hospital. They have 120 beds, but only half of them are devoted to leprosy patients. They do clefts at this hospital as well. I am shown here meeting with who I believe are the only two surgeons doing cleft work in the whole country of Ethiopia (population: 73 million people).

On the left is Dr. Yegerem who recently returned from cleft training in Germany. On my right (his left) is Dr. Tewodros, who was my initial contact for this site. He is an Ethiopian-American who has moved back to Addis Ababa. To my left is Dr. Ruth, who is the administrator of the hospital. I was very impressed with the skill and character of these three doctors. I am not sure if an Interplast surgical team trip will happen, although it is possible. My inspection suggests the hospital is quite acceptable for Interplast’s purposes. There is also the possibility of visiting educator programs in the future. Likewise, we might even get to the point of an surgical outreach center, as both surgeons are quite capable.

A Definite Need for Interplast in Mali

Mother and Child With Cleft
Originally uploaded by interplast.

I went to visit an orphanage/shelter run by Maly, my Bamako contact. While I was there she showed me a woman with a baby who has a cleft. The mother had no means to get it fixed, and was also staying at the shelter because she has no resources.

If our team can come to Bamako next year like I am hoping, we will be able to fix the child's cleft for free. I actually saw two others in a similar situation and I am sure there are many more, so it seems like there is a definite need for Interplast here in Mali.

AIDS Orphans

AIDS Orphans
Originally uploaded by interplast.

While visiting the Gibreal Toure Hospital, where I anticipate we will work, I toured the pediatric ward. There was a large group of children waiting to be seen, standing in the hallway. The two girls in the photo are just two of that group. As it turns out, I was told that they are all AIDS orphans.

Abrahim And His Father

Abrahim And His Father
Originally uploaded by interplast.

I told Abrahim’s father that Interplast would come to Mali in the future and help his son. Abrahim’s father has on the traditional long robe (called forokia in Bambara, the local language) worn by many men here.

Abrahim's Cleft Palate

Abrahim's Cleft Palate
Originally uploaded by interplast.

Abrahim has a cleft of the secondary palate (soft palate). His speech is vey difficult to understand, as one would expect. There is no one in Mali who does cleft palate repair. He was brought to me when I visited a the Luxembourg hospital, built for Mali by the government of Luxembourg. It's a small and nice hospital, but it’ not suitable for us.

Imam and Cleft Baby

Imam and Cleft Baby
Originally uploaded by interplast.

They first asked me to see about ten patients with cleft problems, primarily so that I could tell them we would be here to help them in future. One of the patients is shown here with his parents (his father is an imam). I did an extended written questionnaire and evaluation of the hospital in addition to the tour. I think this is a very suitable team site for our next fiscal year.

Evaluating Sites in Mali

Evaluating Sites in Mali
Originally uploaded by interplast.

I am Dr. Bill Schneider, Interplast’s chief medical officer. Part of my job is to evaluate sites for future Interplast surgical team trips, visiting educator trip and surgical outreach center directors. I am currently in Bamako, Mali, the first stop of a three week fact-finding trip to Africa that will also include Ghana and Ethiopia. Currently Interplast has a surgical outreach center in Lusaka, Zambia, and I am excited about the prospect of expanding our development work elsewhere in Africa.

Today was spent visiting several hospitals here in Bamako, Mali to determine if this would be a good place to bring an Interplast surgical volunteer team. There are no plastic surgeons in Mali, a country of over 12 million people. It appears that there are only two surgeons who do cleft lip repairs, and no one who does palate repairs. The Gibreal Toure Hospital has the largest pediatric department in Mali and is the primary pediatric referral center. They are interested in lectures and teaching in all of our specialties.