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Vital Signs with Dr. Sanjay Gupta
Surgeons Operate on Children in Nepal with Cleft Lips and Palates; Nepal Center for Burn Injuries Profiled. Aired 2:30-3p ET
Aired January 27, 2018 - 14:30 ET
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
SANJAY GUPTA, CNN CHIEF MEDICAL CORRESPONDENT: Twenty-six-year-old Lalita Kuwar (ph) is hours from home. She walked here with her three- year-old son Sundesh (ph) on one arm and a bag of their belongings on the other. In Birkdian (ph) Nepal, she waits. For Sundesh (ph) this might be his only chance to receive an operation that will shape the rest of his life. Help is on the way, but it is not easy to reach them. We are along for the ride, for "Vital Signs" from Nepal.
Nepal is a stunning country. Home to the Himalayan mountains, bordered by India to the south and Tibet to the north. But that same beautiful landscape presents a challenge, effectively cutting off those who live in rural areas. Nepal has a total population of more than 29 million people, but consider this -- just over a million live in the capital city of Kathmandu, and only 19 percent of the total population lives in an urban area. The rest are in rural communities.
DR. SHANKAR RAI, PLASTIC SURGEON: I come from a very remote area, so I have that understanding of how difficult it is to access the medical care in Nepal.
GUPTA: The Dr. Shankar Rai is a plastic surgeon in Nepal. During his surgical training he observed an operation to fix a cleft lip on a small child.
RAI: I watched the whole surgery which took about half-an-hour, 45 minutes, and then at the end of the surgery, I could not believe my eyes. The transformation of the face from the cleft to the normal looking child, and then immediately I thought I will do this. I would like to become a plastic surgeon.
GUPTA: He is now the leading plastic surgeon in Nepal.
RAI: So they come from a very remote area.
GUPTA: But it wasn't enough to run a clinic in the capital city. He wanted to reach as many people in need as possible, in rural areas like where he grew up. That's where the idea of surgical scouts came about.
RAI: We have sent teams to far away places like Junla (ph), Hunla, (ph), Katplajun, (ph), to those remote areas. We have identified five centers scattered all over the country where we go every month and provide this surgical service, but we have people, we have team members stationed here who take care of the patients preoperatively and postoperatively, and at the same time they also provide speech therapy to our cleft patient and then splinting for the patients who have been operated on.
Many of the patients are very poor, so right from the beginning of my medical school, I had that feeling that we should be able to go out and provide the needed service to our poor people.
GUPTA: Dr. Rai's program provides medical care free of charge thanks to funding from ReSurge International, a California based nonprofit. He has also teamed up with Dr. Shaye, a facial plastic and reconstructive surgeon. Dr. Shaye works at Harvard and its affiliate hospital in Boston, Massachusetts, but he has always had a special connection to Nepal.
DR. DAVID SHAYE, SURGEON: What brings me to Nepal is the fact that I grew up here in my early childhood and my parents worked for an international aid organization called "Save the Children." And those early experiences growing up here shaped me for the long term, brought me into medicine and eventually wanted me to reconnect here through a collaborate effort to bring surgery back to Nepal.
GUPTA: One of Dr. Rai's surgical scout teams is on a journey to reach Lalita (ph) and her son. It began the day before with the three-hour drive from the city of Pokhara. After an overnight stay, the team drove again along steep cliffs and mud roads, bumping along for nearly 10 hours until the vehicle could go no further. There in the Birkdian (ph), Lalita and Sundesh (ph) were waiting. Then it was time to make the same journey all over again in the other direction. It is a long and difficult trip, but without it, it's unlikely that Sundesh (ph) would ever receive the treatment he needs.
SHAYE: If it wasn't for some surgical outreach program, some program that goes farther out and sends either scouts or people who are identifying these people to bring them, at least bring the care closer to people even in these remote areas, many of them would not have any care at all. Many people grow up and they never go a few days' walk from their own village, so to say that they are going to come to even Kathmandu where all this care is available is just not feasible.
GUPTA: In Pokhara, (ph) a six-hour drive from Kathmandu Dr. Rai is waiting at a surgical camp with Dr. Shaye. Together they screen patients and answer questions from parents who are worried about surgery for their children. In addition to the children with cleft lips and palates, there are burn victims of all ages. Today's patient pool also includes Lalita's son Sundesh (ph).
RAI: Once they arrive at the site, we screen them for their healthiness. They have to be healthy enough to undergo surgery under anesthesia. And the pediatricians, the child specialists will have a look at them. The anesthetist will put these children to sleep. They also look at the patient, the children, and they are to OK, and they should be comfortable putting the patient to the sleep. And then we will decide to operate on them.
GUPTA: Sundesh (ph) is approved for surgery and scheduled for the next day. The outlook for life here for this little boy who has traveled so far with his mom is about to change.
GUPTA: At a surgical camp in Pokhara Nepal, Dr. Shankar Rai and David Shaye are preparing for a full day of operations.
RAI: We have five centers, and Pokhara is one of them. These are hospitals, regular hospitals where surgeries are performed safely. There is an ancillary facility. They have an ISU. They have a nice ward. Nurses clean and anesthetists all train. So Pokhara is one of them. So in these centers we already have a prefixed date when our team reaches there. We have several team members who are stationed there. They advertise are to screen the cases there before we get there, before the surgeon gets there basically.
SHAYE: Today, we are operating on patients who are coming from very remote areas in Nepal, and they have been identified by surgical scouts, these are lay people who have been trained in very basic medical evaluation and surgical evaluation, to go and round up patients and identify them, and send the appropriate patients to a remote camp which is here in one of the cities. And so not all of the way to the capital city, but somewhere closer to where they live. And then we as the surgeons are running a program where we go closer to where they are and perform the surgery.
GUPTA: Among the patients, three-year-old Sundesh (ph). His mother Lalita journeyed more than 12 hours to get him here. She says she is grateful for Dr. Rai's team as she could not have done it alone. Her husband is working overseas in Saudi Arabia.
LALITA: In my village elders used to say people with cleft lips are blessed with good luck and that it can't be fixed. It was the first case in my village. People used to make all sorts of assumptions of how it happened. I was afraid that people would bully my son because of his condition.
RAI: In Nepal we did a small study which showed that about one out of 500 live births would be a cleft child, one out of 500 cleft deformities. Cleft deformities are simple to correct, but at the same time it has a big, very deep social impact in the family as well as in the tribe when they grow up. They are outcasted from the society. We have many incidents where the children were left alone by the families because of the deformity. We have had many other stories like the father committed suicide when they came to know that the child had bilateral cleft lip, and things like that. So it is a horrible kind of feeling in the family, especially in the parents, because they start to feeling guilty, even though it has nothing to do with them probably. But it has a long impact in the family.
So, but at the same time, it's a simple defect to be corrected. With a little bit of training any plastic surgeon or surgeon can operate on these patients and correct the deformity.
GUPTA: So how does a cleft palate and lip happen? The lip forms between the fourth and the seventh weeks of pregnancy. During development, tissue joins together to make the face, including the lips and mouth. When it does not fully join, an opening in the upper lip will form known as a cleft lip. A cleft palate is a gap in the roof of the mouth. Besides the visible deformity, children with cleft lips and palates often speech impediments and trouble eating, plus issues with their teeth and their ears. The cause is unknown, but surgery can fix it, which is what Doctors Rai and Shaye are doing today for Sundesh (ph).
SHAYE: Almost all of the parts are already there, they are just mal- aligned or formed or gone in different directions. So the idea is if you can see that ahead of time, and the majority of the operation is marking the points ahead of time, it's like creating a big puzzle and then taking it all apart and putting it all back together in layers, with the inner layer of the lip, the muscle of the lip, and then the skin, all very carefully to reestablish the normal anatomy.
The cleft lip is one form of surgery which can change someone's life. Although it's not life-saving, it's life-changing. So someone who has a cleft lip and grows up their entire life with a physical deformity or a speech deformity, these people either can't find work or can't get married. It's completely affects their life. So if you can reconstruct that completely, it changes their life and they become fully integrated back into society. And this is just one example in surgeries, but you could have any number of surgeries, for instance a broken jaw, a large benign tumor of the face, all of these things if they can be corrected with a single or two surgeries, someone can become a fully functional member of society again.
GUPTA: The operation goes smoothly. Afterwards, Lalita is pleased if a bit unsure. She has only ever known her son with a cleft lip. She tells us that she wonders if her other sons, Sundesh (ph)'s older brother, will even recognize him, but she knows today marks a new beginning for Sundesh (ph).
RAI: When I started operating on the cleft patients, there were many adult patients, many, many old patients who had cleft lip and cleft palate which are not operated at all. So we have operated on all of them, and now almost all of the cleft patients are children which means we have made a big change.
In Nepal our culture is a little different. As a doctor, when I fix it, it is my responsibility. I'm not doing a favor to the family. I'm a doctor and so it is my regular work. So there is nothing for me to be thanked for. So that is how we take. But you can see the gratefulness in the face, and many of them cry for happiness.
GUPTA: After the operations are complete in Pokhara, it is time to travel once more. We continue on to Kathmandu, next.
GUPTA: Kathmandu, the capital of Nepal, sits nearly 4,600 feet above sea level. It is a kaleidoscope of colors from the Hindu temples to the bustling street markets. It is home to more than a million people and to Nepal's largest burn center. When he is not operating at one of the five surgical camps across the country, Dr. Shankar Rai runs the Nepal Cleft and Burn Center. RAI: Burn injuries are very common in Nepal mainly because of the
fact that most of our people use open fire for cooking, and then the fireplace is usually at the ground level and people sit around the fireplace so that they can keep themselves warm. And at the same time the children can crawl onto the fireplace. The statistics quoted by the government of Nepal, the minister of health, says that about 56,000 people sustain burn injuries every year in Nepal and they go to the government hospitals. And then of course in the remote villages many people when they get sick or injured don't go to the government hospitals. They just treat themselves with the local faith healers and shamans.
GUPTA: Today, Doctors Rai and David Shaye are giving a lecture to medical students.
RAI: Dr. Shaye spends almost three or four, sometimes even six months every year in some of the African countries, low income countries just like Nepal, and he trains a lot of people there.
SHAYE: So thank you, first of all. Thank you very much, Dr. Rai, for the invitation to be here. Thirty percent of the global burden of disease is surgical.
GUPTA: Then it is time to give Dr. Shaye a tour of the hospital.
RAI: On this day we have in the hospital, we have over 200 patients coming every day in the outpatient clinic.
GUPTA: Dr. Shaye is based in Boston, Massachusetts. Though Nepal is still classified as a developing country, he is impressed with what he has seen.
RAI: We have ventilators and monitors which are all separated with the energy from the solar. The extra energy that we manufacture there in the day time goes to the central grid, and so we are able to operate here without any problem.
GUPTA: Dr. Rai has found a way to make the best out of a challenging geographical area.
SHAYE: The medical infrastructure here is fantastic in that they have so much, they have decentralized their surgical process so much that they have procedures where they may do follow-up by phone. They may send a small plane out to a small remote camp in other places. The surgeons are being brought closer to the patients which makes the care possible for patients. Whereas if we have, if we replicate, say, the model in the U.S. or Europe where there are just large centers and then patients can are refer and can travel because it is not as much of an issue, this does not translate over here where it is so difficult and so strenuous to travel.
RAI: And so the heights, and you know, the high points will be a lot.
SHAYE: Why what Dr. Rai is doing is so amazing is because he has developed comprehensive cleft care for the entire country in a country that's really very challenging settings like Nepal where the geography is a major hurdle to overcome.
RAI: It will be an easy operation.
I think that we have carried out more than 25,000 free surgeries for the poor patients. Of course, the number of actual number of surgeries is even more patients who pay, I am not counting them, but patients who have been treated free of cost must be around 25,000 altogether, and not just cleft or the post ones, but also some other patients who have other surgical, plastic surgical problems.
The fact that we have been able to take care of the poor patients and the fact that the service has been continued for a long time because I have not only walked like this for the last 17 or 18 years now, this is fantastic for any plastic surgeon. It is amazing to be able to operate on poor patients who don't have to pay anything.
GUPTA: After the tour, Dr. Rai prepares for another operation. He has dedicated his life to helping those in Nepal who likely otherwise would never receive treatment. In a country with a heavy stigma towards birth defects and deformities, he and his team are giving them chance at a normal life.
SHAYE: The world needs more people like Dr. Rai who will bring surgery to people who would otherwise have no other access to surgery. The vast majority can't access any surgical care whatsoever. So it is our job to really think as surgeons, how can we bring this type of care all over the world to the whole population of the world?
It has challenges, but when I work in my hospital in Boston, every single thing that we do right now, and every single piece of equipment was once thought to be impossible. Now we have to, this may be thought to be impossible to bring the care to the most re mote districts of Nepal, but it's not. Just like everything else was impossible, it is now possible, and this, too, will be possible to bring care to the most remote areas of Nepal.