Surgical Correction of Cleft Lip and Palate
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Interplast, a nonprofit organization providing free reconstructive plastic surgery to children around the world, agrees with Dr. Mulliken in his Perspective article (Aug. 19 issue)1 that children in developing countries who undergo surgery for cleft lip and palate should receive the highest-quality medical attention and proper continuity of care. However, his portrayal of our work is outdated. The changes he suggests have already been successfully implemented. Developing medical independence so that the poor have access to the reconstructive care they require year-round — and for generations to come — is our goal. Educating, empowering, and building local surgical capacity with overseas medical partners is Interplast's focus. Last year, visiting educators conducted workshops at 14 sites.
Interplast international medical partners perform the volume of operations necessary to maintain both competency in the repair of cleft lip and palate and optimal year-round care. The center in Nepal treated 3000 patients in its first three years and provides follow-up care, as well as auxiliary services; its director, Dr. Shankar Man Rai, was recently honored as outstanding international physician by the American Medical Association. Although Interplast also provides direct services with trips by volunteer surgical teams, these groups of competent surgeons return year after year to the same sites, providing follow-up care and medical training.
William J. Schneider, M.D.
D. Scott Corlew, M.D.
Interplast
Mountain View, CA 94041
bill@interplast.org
References
Mulliken J. The changing faces of children with cleft lip and palate. N Engl J Med 2004;351:745-747.
To the Editor: I would take issue with Dr. Mulliken's assessment of volunteer groups that travel to developing countries to repair cleft lips and palates in children. Discouraging donations to these programs does a disservice to the children who would otherwise lack access to surgical care.
I traveled with Interplast, providing pediatric support to the surgical team. The surgery was skillfully accomplished. Local health care providers were involved in delivering care and learning alongside the Interplast team. Follow-up is not perfect in areas where dental, ear-nose-and-throat, and speech care is not available, but the surgery makes the patient cosmetically and socially acceptable. The need outstrips resources in developing countries. Teams set an example for volunteerism and are ambassadors of goodwill. They provide valuable service, and the personal experience adds to their compassion and understanding as physicians. The families are intensely grateful for the help. American families should not discount experience gained internationally in choosing a cleft-lip-and-palate surgeon. Donors can be confident that their funds support essential care and vastly improve the future for needy children.
Eugenia Marcus, M.D.
Pediatric Health Care at Newton Wellesley
Newton, MA 02462-1602
emarcus@pediatrichealthcare.com
Dr. Mulliken replies: Dr. Marcus suggests that parents should not disregard operative experience gained in other countries when choosing a surgeon to repair their child's cleft lip or palate. I cautioned parents to select a surgeon who is active in an established cleft team, rather than one who operates on clefts, primarily and periodically, overseas.
I agree with Dr. Marcus that volunteer care for children with cleft lip and palate in other countries rekindles the wonderful feeling of being a physician. To treat a person without regard for a fee is the purest form of medical practice. Without question, children benefit from these humanitarian missions, but their number is finite. Furthermore, once the team departs, the local health care system usually fails to provide the necessary follow-up services for speech, dental care, and otology — and nothing changes. In contrast, large U.S.-based nonprofit organizations, such as Interplast and the Smile Train, are helping to establish independent cleft centers in developing countries,1 as noted by Drs. Schneider and Corlew. However, there are many other, smaller groups that continue to operate under the old paradigm of "itinerant surgery."
Dr. Marcus believes my Perspective article discourages donations to volunteer groups. Rather, I underscored that donors, both individual and corporate, should be aware of the differing philosophies and goals among the various organizations so that they can decide how best to dispense their largesse. For 30 years, Christian Dupuis, a Belgian plastic surgeon, has spent 1 to 2 months a year in Southeast Asia, working with local surgeons. He notes that although the operations performed by foreign teams are free for the family, the donors' monies probably are not well spent.2 He calculates that the cost per operation, in Western dollars, is enormous, and he proposes that the funds be used to cover the expense of procedures performed by well-trained local surgeons. Thus, for the same amount of money, the number of operations would increase 10-fold, and the increase in the number of children helped would be exponential. Remember the old Chinese proverb: "Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime." But the teacher should be skilled at fishing.
John B. Mulliken, M.D.
Children's Hospital Boston
Boston, MA 02115
References
Zbar RIS, Rai SM, Dingman DL. Establishing cleft malformation surgery in developing nations: a model for the new millennium. Plast Reconstr Surg 2000;106:886-889.
Dupuis CC. Humanitarian missions in the Third World: a polite dissent. Plast Reconstr Surg 2004;113:433-435.
Interplast international medical partners perform the volume of operations necessary to maintain both competency in the repair of cleft lip and palate and optimal year-round care. The center in Nepal treated 3000 patients in its first three years and provides follow-up care, as well as auxiliary services; its director, Dr. Shankar Man Rai, was recently honored as outstanding international physician by the American Medical Association. Although Interplast also provides direct services with trips by volunteer surgical teams, these groups of competent surgeons return year after year to the same sites, providing follow-up care and medical training.
William J. Schneider, M.D.
D. Scott Corlew, M.D.
Interplast
Mountain View, CA 94041
bill@interplast.org
References
Mulliken J. The changing faces of children with cleft lip and palate. N Engl J Med 2004;351:745-747.
To the Editor: I would take issue with Dr. Mulliken's assessment of volunteer groups that travel to developing countries to repair cleft lips and palates in children. Discouraging donations to these programs does a disservice to the children who would otherwise lack access to surgical care.
I traveled with Interplast, providing pediatric support to the surgical team. The surgery was skillfully accomplished. Local health care providers were involved in delivering care and learning alongside the Interplast team. Follow-up is not perfect in areas where dental, ear-nose-and-throat, and speech care is not available, but the surgery makes the patient cosmetically and socially acceptable. The need outstrips resources in developing countries. Teams set an example for volunteerism and are ambassadors of goodwill. They provide valuable service, and the personal experience adds to their compassion and understanding as physicians. The families are intensely grateful for the help. American families should not discount experience gained internationally in choosing a cleft-lip-and-palate surgeon. Donors can be confident that their funds support essential care and vastly improve the future for needy children.
Eugenia Marcus, M.D.
Pediatric Health Care at Newton Wellesley
Newton, MA 02462-1602
emarcus@pediatrichealthcare.com
Dr. Mulliken replies: Dr. Marcus suggests that parents should not disregard operative experience gained in other countries when choosing a surgeon to repair their child's cleft lip or palate. I cautioned parents to select a surgeon who is active in an established cleft team, rather than one who operates on clefts, primarily and periodically, overseas.
I agree with Dr. Marcus that volunteer care for children with cleft lip and palate in other countries rekindles the wonderful feeling of being a physician. To treat a person without regard for a fee is the purest form of medical practice. Without question, children benefit from these humanitarian missions, but their number is finite. Furthermore, once the team departs, the local health care system usually fails to provide the necessary follow-up services for speech, dental care, and otology — and nothing changes. In contrast, large U.S.-based nonprofit organizations, such as Interplast and the Smile Train, are helping to establish independent cleft centers in developing countries,1 as noted by Drs. Schneider and Corlew. However, there are many other, smaller groups that continue to operate under the old paradigm of "itinerant surgery."
Dr. Marcus believes my Perspective article discourages donations to volunteer groups. Rather, I underscored that donors, both individual and corporate, should be aware of the differing philosophies and goals among the various organizations so that they can decide how best to dispense their largesse. For 30 years, Christian Dupuis, a Belgian plastic surgeon, has spent 1 to 2 months a year in Southeast Asia, working with local surgeons. He notes that although the operations performed by foreign teams are free for the family, the donors' monies probably are not well spent.2 He calculates that the cost per operation, in Western dollars, is enormous, and he proposes that the funds be used to cover the expense of procedures performed by well-trained local surgeons. Thus, for the same amount of money, the number of operations would increase 10-fold, and the increase in the number of children helped would be exponential. Remember the old Chinese proverb: "Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime." But the teacher should be skilled at fishing.
John B. Mulliken, M.D.
Children's Hospital Boston
Boston, MA 02115
References
Zbar RIS, Rai SM, Dingman DL. Establishing cleft malformation surgery in developing nations: a model for the new millennium. Plast Reconstr Surg 2000;106:886-889.
Dupuis CC. Humanitarian missions in the Third World: a polite dissent. Plast Reconstr Surg 2004;113:433-435.