Developing-world corrective surgery

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  • Cleft lip/palate and other correctable conditions can cause speech problems, eating problems, and social ostracization.
  • Developing-world corrective surgery charities send volunteer surgeons overseas and/or fund local surgeons to correct conditions.
  • We have not yet found a corrective surgery charity that we can confidently recommend. When we last investigated organizations in this area (in 2009), ReSurge International (formerly Interplast) stood out from the others.

Published: 2010

Table of Contents

How do charities help?

The charities we've seen generally send volunteer surgeons overseas, and/or train and fund local surgeons, to address a variety of conditions. Below we discuss what we know of these conditions, and how much it costs to correct them.

Cataracts

A cataract is a condition that can cause vision problems.1 Most of our information about the costs and effects of cataract surgery comes from our review of the Aravind Eye Care System.

Aravind appears to perform surgeries for about $35 each, employing local surgeons in India (and recouping its costs by charging some - though not all - of its patients). From very limited information, its surgeries appear to significantly improve vision quality. Jamison et al. (2006) seems to estimate the costliness of these surgeries as much higher, at $183 per disability-adjusted life-year (DALY) averted.2 (If a $35 surgery resulted in a single year of blindness averted, it would be equivalent to about $58-64 per DALY averted since a year of blindness is defined as 0.55-.60 DALYs.3 ; more on the DALY metric.)

Cleft lip/palate

A split in the lip or the roof of the mouth (palate) can lead to an extreme facial deformity.4 If surgery and speech therapy are not available, a child may have problems with eating, speech, hearing, and increased risk of cavities, as well as facing the social consequences of a facial deformity.5

Note that people with cleft lips or palates often need more than a single surgery. In the United States, children receiving cleft lip and palate surgeries likely receive multiple surgeries by the time they are 16.6 In addition, they typically receive orthodontic care and speech therapy over a number of years.7 It appears that very little is known about the long-term impact of a single surgery in a developing nation without a comparable support system.8

Our best information about the costs of developing-world cleft surgery comes from our 2007-2008 review of ReSurge International (formerly Interplast). We estimate that a surgical mission (i.e., flying developed-world doctors overseas to perform procedures) can perform one cleft surgery for about every $1400 spent.9 The use of local surgeons can be significantly cheaper: a total cost - including administrative expenses - of about $400 per surgery, but this approach raises some additional concerns about quality and the use of limited skilled labor (discussed below).10

A paper by ReSurge International's (formerly Interplast) Chief Medical Officer estimates that each surgery in this category is equivalent to 4.6 disability-adjusted life-years (DALYs) averted,11 which would imply that missions cost ~$300 per DALY averted and local operations cost ~$87. (More on the DALY metric)

Obstetric fistula

Obstetric fistula is a term for a "hole between the mother's vagina and bladder ... or between the vagina and rectum ... or both" resulting in "leaking of urine or faeces or both."12 It appears that technical literature on this condition is relatively thin, perhaps because the condition is extremely rare outside of the developing world.13 A report published in the Lancet on a specific type of obstetric fistula (vesicovaginal14 ) implies that reconstructive surgery is possible, but is relatively complex and has a significant failure rate,15 and may leave women incontinent even after the hole is closed.16 The details of how surgery is performed appear not to be standardized, and variations may be important to the outcome.17

We find fistula repair surgery to be a promising intervention in that it addresses a devastating problem, but we have found very little non-anecdotal information on it. We are not able to provide any reliable information on cost-effectiveness aside from an unsourced claim by the Campaign to End Fistula that "the average cost of fistula treatment —including surgery, post-operative care and rehabilitation support—is $300."18 It seems unlikely to us that fistula repair is less costly than cleft repair (which we estimate as costing significantly more than $300 per surgery, as discussed directly above), since fistula repair appears to be at least as complex.

Charities working to address obstetric fistula are engaged in a wide variety of activities including funding general hospitals and specialty fistula centers, training surgeons in fistula repair techniques, increasing public awareness of the problem, and funding research and technical publications to increase knowledge on the subject (see below).

Other conditions

ReSurge International (formerly Interplast) is an example of a charity that addresses a variety of other conditions, including hand conditions and burn scars.19 Burn scar repair appears slightly, though not much, costlier than other surgeries;20 we are not able to estimate the costs of surgeries to repair hand conditions separately. We believe that the severity of burns and hand conditions and the impact of surgery varies extremely widely,21 though ReSurge International's (formerly Interplast) representative has stated to us that they are generally significantly debilitating.22

What are the challenges of finding a great charity in this area?

Before supporting a developing world corrective surgery charity, we would need to have substantial information addressing the following concerns (details below):

  1. What is the bottleneck to more surgeries: money or skilled labor?
  2. How is quality assured?
  3. Is one surgery enough?

What is the bottleneck to more surgeries: money or skilled labor?

We believe that in many cases, funding isn't the bottleneck to more surgeries - surgeons are. In addition to our general concern about diverting skilled labor within the developing world, we have some additional specific reasons for concern in this area:

  • After a discussion of this problem with an ReSurge International (formerly Interplast) representative, we are concerned that surgical centers may often be overbooked and charitable funding of local surgeons may result in changes in which people (rather than how many people) are treated.23
  • Financial data from Smile Train, a large organization that focuses on utilizing developing-world surgeons (rather than on flying developed-world surgeons overseas), indicates that a large proportion of funds are regranted to other (mostly large) charities,24 raising the question of whether additional funds can be productively used for the core activity of supporting local surgeons.
  • We are also concerned about possible distortive effects of fees paid to surgeons. For example, ReSurge International (formerly Interplast) states that a cleft palate surgery is more time-consuming than a cleft lip surgery, while the time to perform burn surgeries varies dramatically.25 (Note that a cleft palate is believed to have a higher effect on quality of life than a cleft lip).26 Flat fee-per-surgery arrangements may therefore result in surgeons shifting toward shorter, simpler surgeries.
  • We are generally concerned that the model of paying developing-world surgeons to perform more surgeries may result in more revenue for surgeons or changes in whom they treat, but may not increase the supply of skilled labor and thus ultimately may not result in more surgeries.
  • A similar problem may apply to missions (i.e., flying developed-world surgeons overseas). Missions rely on volunteer surgeons,27 without which they would likely be far more expensive than the numbers that are generally quoted (numbers that are fairly expensive as is).28

Before recommending a charity that funds local surgeons, we would require a compelling answer to the question of how more funds will translate to more surgeries - for example, credible data on surgeons eligible for funding but not receiving it because of limited available funds.

Similarly, before recommending a charity that conducts overseas trips, we would require information about available volunteer surgeons and trips that could be carried out if more funds were available.

Many charities put some effort into training local surgeons, but from what we've seen, such effort is generally a small part of their budgets and is not accompanied by long-term follow-up on whether surgeons are correctly and consistently applying what they've learned.29

How is quality assured?

Charities that fly developed-world surgeons overseas may be putting them in highly unfamiliar environments with unusually difficult conditions. Charities that support developing-world surgeons are relying on people whose medical education may be very different from what is standard in the developed world. In either case, we find it very important that a charity share information about how the quality of surgeries is assessed and what the complication rate is.

In addition, charities that send money to developing-world surgeons should share information about how they ensure that these surgeons are not taking payment for surgeries that they've charged patients for separately, or otherwise violating guidelines. The evaluation materials we have seen raise significant concerns about how quality and compliance are ensured.30

Is one surgery enough?

As discussed above, surgeries may require significant follow-up care. From what we've seen, there is relatively little information available about the long-term life impact of surgeries when unaccompanied by follow-up care.

This is a particularly strong concern for charities that fly developed-world surgeons overseas, rather than supporting local surgical capacity.

Charities we've examined

We have examined the following surgery-focused charities. We do not feel confident enough in any to strongly recommend them to donors overall, as we have seen little information to address the concerns above. We feel that Aravind and ReSurge International (formerly Interplast) stand above the others.

Note that we have been in contact with all six cleft, burn, and eye surgery charities listed below except for CURE International.

Charities focused on cleft, burn, and eye surgery
Organization Focus Information we have to address questions above
ReSurge International (formerly Interplast) Cleft lip and palate, burns Number and types of surgeries performed; some quality control data
The Smile Train Cleft lip and palate None
CURE International Cleft lip and palate None
Aravind Eye Care Eye surgery Number and types of surgeries performed; significant quality control data
Fred Hollows Foundation Eye surgery Number and types of surgeries performed; no quality control data
ORBIS International Eye surgery Number and types of surgeries performed; no quality control data

Charities focused on obstretric fistula repair
Organization Primarily Fistula? What do they support? Expenses Our notes
Fistula Foundation (Website) Yes Grants to hospitals that provide fistula repair surgery.31 $2,474,252 (2008)32 Charity review
Worldwide Fistula Fund (Website) Yes Building specialized fistula centers in Africa $406,735 (2008)33 Charity review
Women's Dignity Project (Website) Yes Research and advocacy34 $998,928 (2007)35 Outside our scope (research and advocacy)
OperationOF (Website) Yes Treatment, psychological counseling, business training, microcredit36 Unknown37 No apparent track record
One by One (Website) Yes Advocacy and grants to support treatment38 $480,274 (2009)39 No evidence of quality control for grants
West Africa Fistula Center Foundation (Website) Yes Treatment, education aimed at prevention, and assistance with reintegration40 $335,423 (2008)41 Grants for direct services without evidence of quality control
UNFPA: End Fistula Campaign (Website) No Treatment, training doctors, and advocacy.42 More than $25 million raised since 200343 No evidence of quality control for grants
EngenderHealth (Website) No Treatment, training doctors, education aimed at prevention, and assistance with reintegration44 $57,086,271 (2008)45 Fistula is one of many activities; no evidence of quality control for grants
Bugando Medical Centre (Website) No Full-service hospital that performs obstetric fistula surgeries.46 Not available Fistula is one of many activities; no evidence of quality control.

See also this email exchange with a donor interested in supporting fistula correction.

Bottom line

We haven't yet found a charity focusing on surgery that we can confidently recommend. We believe the Aravind Eye Care System is a standout organization, but as our review of Aravind states, it does not require donations to support its operations, as it is able to cover its costs by charging for some (not all) of the surgeries it performs.

For donors interested in improving health in the developing world broadly, we recommend our top charities, which focus on non-surgical interventions. For donors committed to supporting corrective surgery, we recommend starting with ReSurge International (formerly Interplast), which we feel stands above surgery other charities for reasons outlined in our review of ReSurge International (formerly Interplast). We also recommend asking the following questions:

For charities focusing on surgical missions (i.e., flying developed-world doctors overseas to perform procedures):

  • Do you have volunteer surgeons available for unfunded trips? (i.e., are there trips that you could fund if you had more money, or is there a labor bottleneck?)
  • Many surgeries require follow-up treatment (including additional surgeries). Do you have a way of providing these to patients?
  • How do you assess whether surgeries are completed competently and appropriately? What process do you use to monitor this and can you share past results from this process?
  • What is the rate of complications during and following surgery?

For charities focusing on funding local surgeons:

  • How do you assess whether surgeons are performing additional surgeries that they would have not had the funding or motivation to perform otherwise?
  • How do you assess whether surgeons are charging their patients for the surgeries you fund?
  • How do you assess whether surgeries are completed competently and appropriately? What process do you use to monitor this and can you share past results from this process?
  • What is the rate of complications during and following surgery?

For charities focusing on training local surgeons:

  • Do you follow up with the surgeons you've trained to assess whether they are successfully applying their training?
  • What information is available on the activities - and competence - of the surgeons you've trained?
  • Where do surgeons work after completing training? Do they serve poor patients?

Sources

  • 1

    WebMD, "Cataracts - Topic Overview."

  • 2

    Jamison et al. 2006, Pg 60.

  • 3

    See Lopez et al. 2006, Pgs 119-123, Table 3A.6.

  • 4

    WebMD, "Normal and Cleft Palate."
    WebMD, "Cleft Lip."

  • 5

    WebMD, "Cleft Lip and Cleft Palate."

  • 6

    "In the US, with a cleft palate, there are at least 2-4 operations before you're 16 years old." Scott Corlew, phone conversation with GiveWell, June 2, 2009.

  • 7

    "A child born with a cleft frequently requires several different types of services, e.g., surgery, dental/orthodontic care, and speech therapy, all of which need to be provided in a coordinated manner over a period of years. This coordinated care is provided by interdisciplinary cleft palate/craniofacial teams comprised of professionals from a variety of health care disciplines who work together on the child's total rehabilitation." Cleft Palate Foundation, "About Cleft Lip and Palate."

    See also our discussion of this issue on our blog: "Cleft Lip/Palate Charities: What Does One Surgery Really Accomplish."

  • 8
    • "As is common with surgical data, most quality improvement work relates to anesthetic considerations, and the protocols in place reduce anesthetic problems to a minimum. What is more difficult to measure, however, is the actual quality of the long-term results of the operations. Even palatal fistula rate is difficult to quantify without being able to see all of the children long term. For so many of these patients, their geographic isolation makes this quite a far-reaching (and expensive) endeavor. The advisability of even pursuing projects such as these in the developing world has been questioned, and the increasing numbers and ability of surgeons in the developing world has led Interplast to change its strategic direction from that of service to that of education, and to increase its emphasis on problems such as burn scar contractures and hand problems rather than clefts." Corlew 2007, Pg 13.
    • "GIVEWELL: We're concerned about the possibility – especially with team trips – of a person's coming in for the initial surgery but never receiving follow-up care. What would this person's life be like? Would they talk normally, eat normally, interact normally?

      RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: ...That is the same question I asked in my thesis. I looked far and wide in the literature at the time and there was nothing on this question. The World Health Organization's Global Burden of Disease doesn't really give us enough information. We know from UNICEF that only 3 percent of disabled children in developing countries go to school, but every culture/community is a little different on what they consider a disability. In some places, there are children with cleft lips going to school and in others, they are systematically abandoned as babies. And what does it mean for quality of life if someone has a beautifully repaired lip but her teeth remain unfixed? There really is nothing on that.

      That being said, there is a Ph.D. student at UCSF who is hoping to do ask that exact question in Nepal over the next couple of years. She's going to focus on the sociological rather than the surgical aspect – if you go rural Nepal, and find an unrepaired adult, are they working? What's their social life like? This Ph.D. student at UCSF is going to take at least 2-3 years for her study, which will at least give a start on the question you asked." Scott Corlew, phone conversation with GiveWell, June 2, 2009.

  • 9

    Calculation in our report on ReSurge International (formerly Interplast).

  • 10

    Calculation in our report on ReSurge International (formerly Interplast).

  • 11

    "For all procedures combined, without age weighting and discounting the DALYs averted totaled 10.3 per person and 9353 aggregate. Including age weighting and discounting decreased these to 4.6." Corlew 2007, Pg 7. Note that the DALYs from Jamison et al. (2006) which we use in most other places, are not calculated exactly equivalently: they use discounting but not age-weighting (Jamison et al. 2006, Pg 29). We believe that Corlew's (2007) second figure is likely to be closer to equivalent (for a rough illustration, see Lopez et al. 2006, Pg 402). Jamison et al. (2006) itself does not provide estimates in these terms for cleft surgeries (and on Pg 1255 it states that "Data on the cost-effectiveness of surgical interventions for specific conditions in developing countries are scarce").

  • 12

    United Nations Population Fund, Campaign to End Fistula, "Frequently Asked Questions."

  • 13

    "Fistula from obstructed labour was eradicated from industrialised nations by the middle of the 20th century as effective systems of obstetric care were developed to cover the entire population of childbearing women. As a result of this success, contemporary published work on obstetric fistulas is woefully inadequate by the standards of 21st century evidence-based medicine, a situation that is not uncommon for medical problems that are largely confined to poor countries. A comprehensive review in 2005 of existing medical and surgical reports on obstetric fistulas concluded that 'the Western medical literature on obstetric fistulas is old and relatively uncritical by current scientific criteria. This literature consists mainly of anecdotes, case series (some quite large), and personal experiences reported by dedicated surgeons who have labored in remote corners of the world while facing enormous clinical challenges with scanty or absent resources at their disposal.'" Wall 2006, Pg 1201.

  • 14

    "Vesicovaginal fistula is a devastating injury in which an abnormal opening forms between a woman's bladder and vagina, resulting in urinary incontinence." Wall 2006, Pg 1201.

  • 15

    "The ultimate goal of fistula surgery is to restore normal function of the lower urinary tract and any other pelvic structures affected. This process is more challenging than simply closing the fistula, which has been done with a high degree of success in 80—95% of cases in most series. The best chance of fistula closure is generally agreed to be at the time of the first operation. In a large series of 2484 patients, Hilton and Ward reported successful fistula closure in 83% of patients at the first attempt, whereas successful closure was achieved in only 65% of patients who needed two or more operations." Wall 2006, Pg 1204.

  • 16

    "The emphasis on vesicovaginal fistulas as a cause of urinary incontinence in developing countries often leads to the assumption that closure of the fistula is all that is necessary to restore continence in affected women. Unfortunately, even in cases where the fistula has been successfully repaired, 16—32% of women remain incontinent." Wall 2006, Pg 1204.

  • 17

    "Treatment of women with persistent stress incontinence after fistula closure is frequently challenging, because of the extensive scar tissue that often forms around the affected tissues. Several authors have recommended the routine placement of urethral suspension stitches at the time of fistula closure to prevent post-repair incontinence, but these techniques have only had limited success. The best results seem to be obtained with procedures that involve some combination of urethrolysis, which frees the urethra from entrapment in scar tissue, and the addition of some type of compressive suburethral sling." Wall 2006, Pg 1205.

  • 18

    United Nations Population Fund, Campaign to End Fistula, "Frequently Asked Questions."

  • 19

    See our report on Interplast.

  • 20

    This is based on our analysis of data from Interplat. Compare the expense per surgery for cleft to the implied cost per patient for burn surgeries in our 2007-08 review of Interplast.

  • 21

    Corlew's (2007) attempt to estimate cost-effectiveness for corrective surgery states that "Because of the wide variability associated with burn releases and hand procedures, these patients were not included in the study. It was determined that attempting to assess the effects of these procedures was not possible without further detailed data collection." Corlew 2007.

  • 22

    "GIVEWELL: It seems like hand deformities could vary a lot in terms of how debilitating they are. Some might render a person's hands unusable whereas other deformities might affect only a couple of fingers.

    RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: Definitely. If you look at the original World Health Organization's Global Burden of Disease study, they didn't even try to assign disability weights to hand injuries because it's too wildly varied. We're generally going to try to treat people who have major and largely correctable disabilities or deformities. If we can give someone the ability to feed themselves or to hold a pencil, we will do whatever we can to help.

    GIVEWELL: Can you give us your educated guess on what the frequency distribution looks like, i.e., out of 100 burn scars treated – about how many are totally debilitating, vs. significantly debilitating, vs. minor/cosmetic?

    RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: Approximately 10-15 percent are totally debilitating, around 85-90 percent are significantly debilitating and about 2 percent are minor." Scott Corlew, phone conversation with GiveWell, June 2, 2009.

  • 23

    "RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: Interplast supports local surgeons with training opportunities, funding and oversight (quality assurance). These local surgeons operate on their own and always have, but they can't take care of all the poor people for free. We're able to pay enough to put the poor people at the head of the line with the people who can pay for themselves. For example, if you have the capacity to serve 30 people, but 100 are lined up, of which 60 can pay, you'd ordinarily treat only people who can pay, but Interplast pays for free surgeries and that puts the people who can't pay on the same basic footing in terms of priority.

    GIVEWELL: That seems to imply that the Outreach Centers do a constant number of surgeries, because of limited capacity, and your expectation is that the Interplast funds reallocate some of those surgeries from wealthier patients to patients who are unable to pay.

    RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: Right. In India, for example, the public-sector capacity isn't there. People who need treatment mostly seek it from the private sector. I like to think that we're able to take people who would otherwise fall through the cracks and put them on more equal footing with wealthier people. I think that's what happens and that's certainly what I want to happen.

    GIVEWELL: So do you think that by paying for free surgeries, Interplast is reducing the number of surgeries done for people who can pay?

    RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: I do not think that is true at all. People who can pay generally get taken care of. Generally, people paying for themselves will pay more than what Interplast can pay.

    GIVEWELL: Do you think Interplast's activities are increasing the surgical capacity in these countries overall? It sounds to me from what you're saying like Interplast isn't increasing capacity – it's more increasing equity of access to surgical care.

    RESURGE INTERNATIONAL (FORMERLY INTERPLAST) REPRESENTATIVE: I think both. By providing surgical care for a large segment of the population who had no other access to care, I think that we are definitely increasing capacity. We also have partner surgeons who do more operations now, caring for more people, because they have funding to care for the poor. For example, there's a surgeon who works until 2 in the morning one day a week (after his government hospital job) to care for the poor, and if not for our program I don't think he would be able to do that. Our educational programs---from our visiting educators to our medical scholars---are also helping to build capacity in the countries in which we work. Three of our SOC directors have started the first plastic surgery resident programs in their countries, so that is another way of increasing capacity." Scott Corlew, phone conversation with GiveWell, June 2, 2009.

  • 24

    See our report on Smile Train.

  • 25

    "But generally a cleft lip will take 45 minutes to an hour; a cleft palate will take about 1.5 hours. Burn cases vary dramatically and go from under an hour to more than two hours, per procedure." Scott Corlew, phone conversation with GiveWell, June 2, 2009.

  • 26

    "Because of the greater functional significance of cleft palate, with the associated greater disability weighting factor, palate repair resulted in greater gain than did lip repair." Corlew 2007, Pg 7.

  • 27

    See our report on Interplast.

  • 28

    As stated above, our best estimate of the cost of a surgery performed by a mission trip is $1400 ($300 per DALY). See our list of priority programs for context on these figures; $300 per DALY is relatively high for developing-world interventions.

  • 29

    See our reports on Interplast and Smile Train for examples.

  • 30

    See our report on Smile Train.

  • 31

    Kate Grant, phone conversation with GiveWell, July 21, 2009.

  • 32

    Fistula Foundation, "IRS Form 990 (2008)."

  • 33

    Worldwide Fistula Fund, "IRS Form 990 (2008)."

  • 34

    Women's Dignity Project, "IRS Form 990 (2007)," Part III.

  • 35

    Women's Dignity Project, "IRS Form 990 (2007)."

  • 36

    OperationOF, "Obstetric Fistula Treatment, Reintegration, and Prevention."

  • 37

    As of July 7, 2010, no available IRS Form 990.

  • 38

    "In addition to raising public awareness of fistula and encouraging widespread participation, One By One believes that our resources are best used to address the unmet needs of fistula treatment and prevention programs in the developing world. To this end, we make direct grants to support fistula treatment and prevention in Africa and beyond." One by One, "About One by One."

  • 39

    One by One, "IRS Form 990 (2009)."

  • 40

    "With your help and donations we can eliminate this forgotten epidemic: by treating the ongoing cases; pre-operative hostel for waiting patients; providing educational background as to the causes and how to prevent fistula; post operative treatment up to 14 days (average); reintegration back into society by means of vocation school or enterprise training." West Africa Fistula Foundation, "Prevention Methods."

  • 41

    West Africa Fistula Center Foundation, "IRS Form 990 (2008)."

  • 42

    UNFPA, "Fistula Can be Surgically Repaired."

  • 43

    UNFPA, "The Campaign in Brief."

  • 44

    EngenderHealth, "Fistula Care."

  • 45

    EngenderHealth, "Annual Report (2008)."

  • 46

    Website down at last check (July 7, 2010).