China Report – Nov. 2009
Dr. Salyer’s Report – Shanghai, China
Funded by the Ray Tye Medical Aid Foundation
Accompanied by Akira Yamada, visiting professor of the WCF, I spent one week [November 22nd-November 29th] in Shanghai, on behalf of the WCF. The objective of our visit was to further assess the development and expansion of craniofacial and cleft surgery for the indigent patients in China, and specifically Shanghai. 
For the first time, China’s 1.3 billion people currently surpass the U.S. in the demand for automobiles and other luxury items. However, the Chinese government does not assume the responsibility for the health of their people. The estimated incidence of 1 in 1,500 children is born with a craniofacial deformity. There are 20 million Chinese newborns every year; 100,000 of which have congenital craniofacial deformities. Very little is offered to these patients. If a family wants their child to be treated, they frequently have to raise money to support this care. There is minimal indigent care in China.
There are only three craniofacial surgery centers in China at this time. They are located in Shanghai, Beijing, Xi’an. Most craniofacial deformity patients have to travel many miles from home to get the care they need. Due to the high expense of surgery, most children do not receive treatment. As a result, there are a large number of untreated adult craniofacial deformity cases.
Our week was very informative in assessing the possibilities for the development of craniofacial surgery in Shanghai. I had been led to believe that we could develop a second craniofacial unit in Renji University Hospital. Upon our arrival, the level of commitment and ability were lacking. We saw major facial clefts in the clinic on Monday, November 23rd, with the idea of operating on them the next day. It was only at this time that we were informed that the anesthesiologist would not do the cases because he lacked the skill set and confidence to sedate such young children. Another opportunity was presented to operate on an older male patient the following day. On Tuesday, November 24th, Dr. Yamada performed one total external ear reconstruction using rib cartilage. The operation went beautifully.
The major craniofacial center in China is the People’s 9th Hospital. This, of course, is the government-run hospital. The patients presenting themselves for care are required to pay for their surgery. At this time, no indigent patients are cared for by the hospital.
On Tuesday, November 24th, I met with Liu Jinfen, President of the Shanghai Children’s Medical Center, Dr. Nan Bao, Director
of Pediatric Surgery/Neurosurgeon, and Jenny Xu, Program Officer for Project Hope. Ten years ago, through Project Hope, the funds were made available for the Children’s hospital. This is primarily a pediatric cardiac surgery center. They currently perform over 3,000 congenital heart operations per year. This hospital is the largest in the world, and is a direct result of American funding and education. The physicians were trained through the internationally-recognized cardiac center in Houston, and now provide state-of-the-art care in cardiac surgery.
The WCF, in cooperation with other foundations, needs to provide teaching, infrastructure, and develop a craniofacial program in China. Craniofacial surgery was initiated by Prof. Tisheng Chang (pictured second from the right, above) at The People’s 9th Hospital in 1977. Little progress has been made since then. On Thursday, November 26th, Dr. Yamada and I performed one primary cleft lip nose demonstration. The second case was a complex hemi-nasal absence with a cleft lip.
(Patient 1, pre-op) (Patient 2, pre-op) (Patient 2, post-op)
This was a specially requested case by Dr. Wang and his staff. I was able to show my techniques and taught them new methods. This was very beneficial and we were able to help two needy children.
On Friday, November 27th, Dr. Yamada and I performed an intracranial forehead remodeling and LeFort III with internal distraction. To my knowledge, this was the first time internal distraction had been used in China. To this point, only external distraction had been used. In my opinion, the level of anesthesia was inadequate.
The assistants from the nursing staff need education and teaching. The neurosurgeon was very timid, hesitant, and not able to give the kind of help that is necessary to provide good neurosurgery. In the name of safety, I altered my entire operation and did not do nearly as an effective correction. A considerable amount of work, teaching, and performance of many cases will be necessary over time. I believe that if we do this, we will ultimately be able to literally help tens of thousands of children. The pediatric cardiac surgery center should serve as a model for the development of a pediatric craniofacial center. Due to the lack of pediatric intensive care, properly trained pediatric intensivist, and pediatric anesthesiologists, the People’s 9th Hospital is unable to perform infant surgery at this time. There are four pediatric neurosurgeons at the children’s hospital. The potential for teaching craniofacial surgery in infants is present.
The president of each hospital we visited will meet to discuss a proposal to develop an international craniofacial unit. In addition, they are open to developing an education program to teach updated craniofacial and cleft surgery. I deeply believe that the optimal way to help thousands of children, long-term, is through the development of this program.
On Wednesday, we traveled to Hangzhou. We met at the Operation Smile hospital, which we helped open. We met Dr. Han Kai and his staff for a discussion of the progress of their Cleft Center. It is his intention and need to develop a larger hospital. He intends to raise 50 million dollars on behalf of Operation Smile to develop a larger hospital and a better facility. He made me an official consultant and requested that I teach and operate in the future. This provides another resource for us to teach, and at the same time, provide care for a significant number of patients. This is contingent upon the amount of time we can devote to this project.
China remains a developing country, although it is politically and economically poised to provide a major impact in the economic balance of the world. In the arena of healthcare, they are better positioned to develop their healthcare system than India. However, government policy makes this complicated and difficult. I am hopeful, that with the right support, we can help hundreds of thousands of China’s facially crippled children and adults who remain social outcasts at this time.
Recommendations:
1) Organize a workshop/mini-symposium to launch the teaching of craniofacial surgery.
2) A WCF team of multi-disciplinary experts travel to Shanghai, toward the end of May, to provide education in the workshop and live surgery, with demonstration of infant craniofacial surgery, as well as surgery on older children with craniofacial deformities.
3) A proposal developed by professor Mu with the input of other teachers and professors, including myself, for the development of a teaching program in China in cooperation with the WCF.
4) Initiate a campaign through the WCF to raise money to partially support this program. Additional funds would be provided by developing donors in China and Hong Kong, as well as soliciting the People’s 9th Hospital, Children’s Medical Center. In addition, request support from other foundations in the U.S.
Follow Up:
As previously mentioned, we intended to operate on two children on Monday, November 23rd. We were not able to execute the operation due to lack of experience by the anesthesiologist. We were able to consult with these patients (pictured below) and we plan to operate on our next visit to China in May of 2010.
