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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 98-102

Building an ecosystem of safe surgery and anesthesia through cleft care

Smile Train, New York City, New York, USA

Date of Submission06-May-2021
Date of Acceptance06-May-2021
Date of Web Publication7-Jun-2021

Correspondence Address:
Ms. Erin Stieber
Smile Train, 633, Third Ave, 9th Floor, New York NY 10017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_16_21

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How to cite this article:
Schaefer S, Stieber E. Building an ecosystem of safe surgery and anesthesia through cleft care. J Cleft Lip Palate Craniofac Anomal 2021;8:98-102

How to cite this URL:
Schaefer S, Stieber E. Building an ecosystem of safe surgery and anesthesia through cleft care. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2022 Dec 10];8:98-102. Available from: https://www.jclpca.org/text.asp?2021/8/2/98/317780

Cleft lip and/or palate (CLP) is among the world's most common congenital anomalies, affecting an estimated 1 in 700 live births. CLP can lead to a wide range of health problems, including feeding difficulties that contribute to malnutrition, oral health challenges, delays in speech and language development, and long-term emotional and physical health issues. Receiving timely high-quality cleft surgical and anesthesia care, in addition to a range of interdisciplinary health services, is critical to the health and development of children impacted by CLP.[1],[2]

Too often, however, whether a baby receives this essential treatment is dependent upon the city, country, or region in which they are born. The global burden of surgical disease is a significant and long-neglected area within global health that disproportionately affects low-and middle-income countries (LMICs) compared to high-income countries (HICs). The estimated 1.7 billion children who live without access to surgical care around the globe, including many with CLP, live with a greater risk of life-long disability and a higher risk of mortality.[3],[4]

Barriers to surgical care in LMICs include a lack of trained health-care providers, inadequate infrastructure, high out-of-pocket costs, and lack of political prioritization. Historically, short-term missions have sought to address the burden of surgical conditions such as CLP, but this short-term, siloed approach fails to address – and in many cases has only perpetuated – the systemic causes of global surgical inequity, which cuts across sectors, disciplines, and borders. As momentum for the prioritization of surgical care grows, it is also clear that outdated models must be replaced by approaches that strengthen the entire ecosystem of safe surgery and anesthesia care[Figure 1].[5],[6],[7]
Figure 1: An estimated 1.7 billion children across the globe do not have access to surgical care

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Smile Train, the world's largest CLP nonprofit organization, supports a sustainable solution and scalable global health model for cleft treatment. By empowering local medical professionals with education, training, and resources, they need to provide care to patients within their own communities, and Smile Train is increasing access to safe surgical and anesthesia care not only for patients with CLP but also for all surgical patients in the countries where Smile Train partners work [Figure 2].
Figure 2: Increasing access to safe surgical and anesthesia care

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  Safety and Quality Top

Empowering local medical professionals contribute to the overall safety and quality of surgical care. Smile Train's sustainable model of treating children with clefts involves working to build local capacity to provide not only surgical care but also a complete and comprehensive approach to treatment that cannot be provided by short-term surgical missions. Comprehensive cleft care, which includes services such as nutrition, speech therapy, orthodontics, and psychosocial support, ensures that patients can safely receive surgical care and benefit from optimal postoperative outcomes. Nutrition services, in particular, are critical to ensuring timely and safe surgery, as patients with CLP often struggle to feed and reach a healthy minimum weight for surgical care. It is also essential that families and patients have access to any necessary follow-up care after their surgery.

In LMICs and HICs alike, unsafe surgery leads to increased morbidity and mortality, and it is thus essential to ensure that surgical and anesthesia care is not only accessible but also high quality. Smile Train's mandatory Safety and Quality Protocol is based on the World Health Organization (WHO) and World Federation of Societies of Anesthesiologists (WFSA) standards, and partner medical centers regularly undergo audits to verify compliance to the protocol. Through adherence to these safety and quality standards, as well as improvements to resources and infrastructure, Smile Train partners have seen an increase in the overall quality and volume of surgical care throughout their treatment facilities.[8],[9]

In 2012, Smile Train partnered with Lifebox, a global nonprofit that saves lives through safer surgery and anesthesia, to distribute cost-effective pulse oximeters designed for low-resource settings to operating rooms around the world. In 2020, Smile Train and Lifebox announced the launch of the Smile Train-Lifebox Safe Surgery and Anesthesia Initiative, a long-term partnership focused on elevating the quality and safety of cleft and pediatric surgery in more than 70 countries. The initiative focuses on capacity building through education and training, the development of innovative technology, and critical research in cleft care and pediatric surgery. During the COVID-19 pandemic, the two organizations partnered to distribute 500 pulse oximeters for COVID-19 care and – along with the WFSA – developed the COVID-19 Surgical Patient Checklist to protect surgical teams from infection.[10]

In 2020, Smile Train also launched a partnership with Kids Operating Room (KidsOR), a global health charity that provides world-class surgical facilities so children can get the care they need, training new surgeons and building high-quality children's Operating Rooms for them to work in. Together, Smile Train and Kids OR have announced a joint goal of equipping 20 pediatric operating rooms throughout Africa by the end of 2021.[11]

  Education and Training Top

One of the pervasive challenges in scaling access to surgical care is a lack of adequately skilled professionals. This is why, in addition to programs that support the treatment of patients with CLP, Smile Train also focuses on education and training programs, which are especially critical in preparing surgical teams to address surgical conditions and increasing the number of surgical specialists available in a given country or region. Through scholarships, fellowships, surgical training resources, workshops, and symposiums, with a significant increase in virtual programs and opportunities during the COVID-19 pandemic, Smile Train provides training and education opportunities to cleft surgeons, anesthetists, nurses, and related medical professionals around the world, utilizing a “Train-the-Trainer” model that enables trainees to, in turn, train others[Figure 3].[12]
Figure 3: “Train-the-Trainer” model

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Smile Train also partners with academic institutions for long-term educational capacity building and specialization. Through partnerships with the College of Surgeons of East, Central and Southern Africa, and the West African College of Surgeons (WACS), Smile Train is supporting scholarships for fellows and trainees across a variety of surgical specialties. During the COVID-19 pandemic, Smile Train and WACS have also partnered on a virtual education series on cleft care, drawing in thousands of attendees and surgical experts across Africa and the globe. In Brazil, Smile Train is partnering with Rotary Club Campinas-Sul (Brazil), Rotary Club of Evanston-Lighthouse (USA), and the FUSP-Foundation of Support to the University of São Paulo (Centrinho Bauru) to support a 1-year training program in CLP surgeries for five Fellows, with scholarships that combine theoretical studies and practical applications.

Smile Train has also developed and disseminated innovative simulation tools, both hands-on and virtual, to serve as training resources on the latest techniques for cleft surgery. In partnership with BioDigital, Smile Train developed the Virtual Surgery Simulator, a web-based, interactive virtual simulator that has been shown to increase knowledge and surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons-in-training. A mobile application version, which increases its accessibility in limited-resource settings, was launched in 2021[Figure 4].[13],[14]
Figure 4: Training resources on the latest techniques for cleft surgery

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In 2020, Smile Train took on operations of Simulare, a high-fidelity 3D printed simulation training supplier, to provide hands-on training simulators for CLP surgeons. Smile Train will incorporate the simulators into its portfolio of training programs around the world, making cleft surgery both safer and less costly, as simulator training tools have been shown to improve trainee's grasp of key concepts and shorten the learning curve.[15]

  Building Country-Led Multistakeholder Partnerships Top

Ultimately, national governments must lead surgical systems strengthening within their countries to ensure long-term sustainability and effective service delivery. Thus, multistakeholder partnerships that include policymakers and governments are an essential aspect of ensuring sustainability. Smile Train's regional and global teams work with governments worldwide to raise awareness around cleft, mobilize patients, implement programs to support safe surgery and anesthesia care, and support overall surgical capacity-building. For example, in Nigeria, in coordination with the government of Nigeria and various stakeholders leading the development of a National Surgical, Obstetric, Anesthesia, and Nursing Plan, Smile Train is supporting the development and implementation of key resources and programs, including an E-Registry for individuals with clefts, as well as capacity building around research, life support, and biomedical engineering. Given the increasing globalization and prioritization of surgical care, national governments will be key in the funding, implementation, and long-term sustainability of surgical systems strengthening efforts[Figure 5].[16]
Figure 5: Building Country-Led Multi-Stakeholder Partnerships

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  Advocacy Top

To build political prioritization for cleft care and surgical care, Smile Train staff and partners work with coalitions and stakeholders to engage in both top-down and bottom-up advocacy. At the national level, Smile Train staff and partners advocate to governments to raise awareness of CLP and the necessity for timely treatment, to raise awareness around the economic benefits of investing in CLP treatment, to increase health workforce training, and to support the prioritization of surgical care, particularly among marginalized populations.[17]

Smile Train also works with partners and coalitions to advocate for the political prioritization of safe surgery and anesthesia care at the national and international level. As a founding member of the Global Alliance for Surgical, Obstetric, Trauma, and Anesthesia Care (the G4 Alliance), alongside an array of academic and governmental stakeholders, Smile Train has participated in and co-hosted annual side events at the World Health Assembly and the UN General Assembly, advocating to Member States to report and implement the recommendations in the 2015 WHA Resolution on Strengthening Emergency and Essential Surgical Care and Anesthesia in the context of Universal Health Coverage. In 2019, Smile Train, along with the Henry Family Advised Fund, the G4 Alliance, Jhpiego, and the Global First Ladies Alliance co-hosted a UN General Assembly side event on eradicating the backlog of neglected surgical conditions, including CLP, alongside the Kenyan Ministry of Health.[18]

Through a variety of coalitional partners, including the Frontline Health Workers Coalition, the Global Health Council, and the G4 Alliance, Smile Train has also advocated to the US government for the increased prioritization of the global health workforce and funding for priority global health interventions, including surgical care [Figure 6].
Figure 6: Build political prioritization for cleft care and surgical care

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Ultimately, progressing the global health agenda to achieve the Sustainable Development Goals and Universal Health Coverage will require all stakeholders in global health – and many who exist outside of traditional conceptions of “global health” – to adopt a holistic, ecosystem approach, engaging in multistakeholder partnerships that can effectively and efficiently implement solutions that go beyond stop-gaps, including the mission model of care. The deep-seated causes of inequity in global health must be addressed by long-term, strategic interventions. If we as stakeholders in cleft care, in global surgery, and in global health envisage, as the WHO Constitution does, “the highest attainable standard of health as a fundamental right of every human being,” we will work beyond silos to support a better standard of care and health for all [Figure 7].[19]
Figure 7: Working beyond silos to support a better standard of care and health for all

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  References Top

World Health Organization. Addressing the Global Challenges of Craniofacial Anomalies. Report of a WHO Meeting on International Collaborative Research on Craniofacial Anomalies. Geneva: World Health Organization; 2006.  Back to cited text no. 1
Jenny HE, Massenburg BB, Saluja S, Meara JG, Shrime MG, Alonso N. Efficacy of facilitated capacity building in providing cleft lip and palate care in low - and middle-income countries. J Craniofac Surg 2017;28:1737-41.  Back to cited text no. 2
Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth 2016;25:75-8.  Back to cited text no. 3
Butler EK, Tran TM, Nagarajan N, Canner J, Fuller AT, Kushner A, et al. Epidemiology of pediatric surgical needs in low-income countries. PLoS One 2017;12:e0170968.  Back to cited text no. 4
Available from: http://www.theg4alliance.org/learnmoreg4. [Last accessed on 2021 Apr 30].  Back to cited text no. 5
Louis M, Dickey RM, Hollier LH Jr. Smile train: Making the grade in global cleft care. Craniomaxillofac Trauma Reconstr 2018;11:1-5.  Back to cited text no. 6
deVries CR, Rosenberg JS. Global surgical ecosystems: A need for systems strengthening. Ann Glob Health 2016;82:605-13.  Back to cited text no. 7
Available from: https://www.who.int/patientsafety/safesurgery/en/. [Last accessed on 2021 Apr 30].  Back to cited text no. 8
Volk AS, Davis MJ, Desai P, Hollier LH Jr. The History and Mission of Smile Train, a Global Cleft Charity. Oral Maxillofac Surg Clin North Am 2020;32:481-8.  Back to cited text no. 9
Available from: https://www.smiletrain.org/medical-professionals/training-programs. [Last accessed on 2021 Apr 29].  Back to cited text no. 12
Volk AS, Eisemann BS, Dibbs RP, Perdanasari AT, Braun TL, Marsack KP. The utility of an open-access surgical simulator to enhance surgeon training. J Craniofac Surg 2020;31:72-6.  Back to cited text no. 13
Cheng H, Podolsky DJ, Fisher DM, Wong KW, Lorenz HP, Khosla RK, et al. Teaching palatoplasty using a high-fidelity cleft palate simulator. Plast Reconstr Surg 2018;141:91e-8e.  Back to cited text no. 15
Truché P, Shoman H, Reddy CL, Jumbam DT, Ashby J, Mazhiqi A. et al. Globalization of national surgical, obstetric and anesthesia plans: The critical link between health policy and action in global surgery. Glob Health 2020;16:1 https://pubmed.ncbi.nlm.nih.gov/31898532/ [Last accessed on 2021 Apr 30].  Back to cited text no. 16
Corlew DS, Alkire BC, Poenaru D, Meara JG, Shrime MG. Economic valuation of the impact of a large surgical charity using the value of lost welfare approach. BMJ Glob Health 2016;1:e000059.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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