The future of cleft care

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Visit to Craniofacial Centre Nepal November 2018

The purpose of this visit was to assess progress made at the CFC since first visiting in December 2017. The Craniofacial Centre Nepal was established in August 2017. It was the vision of Sunil Sah, Consultant Maxillofacial Surgeon at Pinderfields Hospital in Wakefield, originally from Janakpur 22 years ago and who trained in the UK. Seeing the devastation after the earthquake in 2015, he decided to return to Kathmandu with a group of UK maxillofacial surgeons to help manage the craniomaxillofacial trauma. However, as time went on, he realised there was a great need to help in and around Janakpur, identified as one of the two poorest parts of the country.

Janakpur is the capital of Province 2, in the plains of Nepal, roughly south east of Kathmandu, bordering the Indian states of Bihar and West Bengal with the local Madeshi people straddling the border. It is the birthplace of Sita, one of the central figures of the Hindu epic, the Ramayana.  In her honour, there is a massive and hugely impressive temple, one of many in Janakpur, decorated with many paintings in the local Maithili tradition

The Craniofacial Centre was built in the summer of 2017 by Sunil Sah and a group of local doctors and dentists, who like so many from Janakpur, had left to build their lives elsewhere in Nepal due to the very poor economic conditions in the region. It was built on land and attached to the Janakpur Trauma and Orthopaedic Hospital, a small well-developed hospital owned by Sunil’s brother-in-law, Prof Ram Kewal Sah, established some 20 years previously.

Since I first visited the centre in December 2017 we have managed to secure generous funding, enough to support the staff of two surgeons, two dentists, three nurses and admin staff, as well as consumables. The centre had been well equipped in out-patients thanks to the previous generosity of Sunil Sah and friends but had a rather basic operating theatre and associated facilities. The anaesthetic machine was ancient, there were two operating tables, one a wooden bench, the other a rusty unhealthy looking lump of metal, and no proper monitoring or lighting

We identified a great need for a complete upgrade of theatre facilities if the centre was to succeed. It was also apparent that the surgeons and anaesthetist needed further specialist training. On our return, I arranged for both to go to the GSR Hospital for Craniofacial Surgery in Hyderabad to get high quality high volume training at an internationally recognised centre for two months. Having identified what was required to upgrade the operating theatre, we received a further significant donation to bring the facility up to the highest possible standards. This enabled some basic but essential surgery to be performed in safe surroundings. A programme of ‘camps’ was established, visiting on a weekly basis more distant and often very rural communities, with staff from the centre being able to examine and sometimes treat many people, check for oral cancer, identify problems that needed referral to the centre and carry out some educational projects

I travelled out from Kathmandu, accompanied by a group of Spanish doctors, one a former trainee, and a Kiwi, but not before we had met with the Federal Secretary of Health, the regional DFID UK Aid Health Advisor and the former Home Minister and Founder Chairman of Janakpur University. All important and, as we came to realise, successful in support of our aims. On our arrival, we were greeted in with great warmth and usual style by the staff at the centre.

 

 

 

 

 

 

 

Initial wandering around the centre confirmed an amazing upgrade of the operating theatre, with a new state of the art anaesthetic machine, two new operating tables, one electric and one hydraulic, piped gases, several monitors and excellent suction, brilliant lighting, and significant advances made on improving the recovery room, staff changing facilities and scrub and sluice areas.

 

We saw several patients who had patiently awaited our arrival – several clefts varying in age from 3 months to untreated or poorly treated adults, an 8 year old girl with mild Treacher-Collins syndrome with bilateral microtia  in need of hearing aids (no chance of cochlear implants), severe burns scarring, patients with early signs of oral malignancies and untreated facial fractures.

In the evening, prior to a traditional dinner, we met with the Chief Minister  and Health Minister for Janakpur Province. It was obvious that there had been some discussion between them and the Federal ministers and we felt that being ‘on the agenda’ was a significant step in establishing support for the centre. A meeting was also held with the Vice-Chancellor of Janakpur and it was agreed that a new Faculty of Medicine would be started in the not too distant future. A previously built but never used hospital would also be resurrected and become the associated teaching hospital. The Craniofacial and Orthopaedic centres would be incorporated into both, negating the need for us to find land and buildings elsewhere, as previously planned.

Over the following two days, a conference was held, attended by about 70 delegates, with the headline ‘Safe High Quality Accessible Sustainable Surgery’ There were several excellent talks from the visiting surgeons and round table discussions afterwards.

Concurrently, we were able to operate on some of the patients already seen. However, although one of the young local surgeons had been to Hyderabad, it was clear that both he and the anaesthetist needed further intensive training if they were to become independent and safe operators

Just before we left Janakpur, we met the former and first President of Nepal

 

 

 

 

 

 

 

After five days in Janakpur, we returned to Kathmandu for the last three days, all filled with meetings. We were invited to meet our Ambassador, Richard Morris, and updated him on progress since our last meeting.

We also met the Deputy PM, Health Minister and the Commerce Minister

Whilst it seems we spent more time at various meetings, I felt we had made great strides in putting the centre on a firm footing.

We have developed a ‘rota’ of visiting surgeons, mainly from the UK, but also from Spain, New Zealand, and India. This will ensure the local personnel will get regular training and also make the centre appealing to others interested in its work, including UK medical students wishing to spend their electives in a developing service and trainees across several specialities. The camps are now on a firm footing, covering the entire province. On each, a surgeon, a dentist, a nurse and our liaison officer /social worker spend a day, or if they are at a greater distance form Janakpur, two days, working. We have developed a simple database which collects demographic data, records activities carried out and identifies people who need more specialised treatment at the centre. We ideally need a mobile dental clinic to simplify the travels and travails

I need to say a special thank you to Professor Ram Sah for making the establishment of the centre possible by sharing his facilities and land, for his guidance, and as a consummate medical politician who seems to know everybody who matters, for introducing us to the provincial and national policy makers, so important if we are to ensure the long term viability of the centre. Thanks also to his brother-in-law, Sunil Sah, not only for his vision but for his determination to help people in a very poor part of the world find facilities to care for them.

Les Snape(above) and, below, Spanish surgeons Prof Fernando Garcia Marin, Prof Benito Ramos, Dr Olga Correa Chacon and Dr Alicia Cortel