Opponents of medical missions justify their stance by frequently citing the cost savings derived from allowing local surgeons to perform the operations. In Cambodia, it costs local surgeons U.S. $80 per cleft lip reconstruction, whereas an international medical mission may face expenses of U.S. $1000 for the same procedure.1 This reduces the argument to an economic one, where evaluations of cleft organizations are based heavily on 990 tax forms, focusing specifically on treatment costs and number of children treated. Using Operation Smile as a model, we demonstrate that such a myopic view fails to consider the feasibility of local surgeons performing cleft repair, the quality of the surgery maintained, and the intangible, unquantifiable stream of benefits of mission trips, all of which remain critical in evaluating cleft organizations.
The reality, however, is that all forms of support of children with clefts are important. In most developing countries, local surgeons receive little or no reimbursement for their efforts to routinely repair these cleft deformities, and the dearth of specialists such as pediatric anesthesiologists and intensivists prevents the assembly of multidisciplinary teams necessary for mitigating the risks in cleft repair.2,3 Therefore, many patients in these nations do not receive treatment from local providers and continue to experience clinical complications and the social stigma associated with these untreated facial deformities. Operation Smile's medical missions fill this void by providing surgical care for local populations while facilitating the training of local and international plastic surgeons and specialists through programs such as its annual Physicians' Training Program.4
As nonprofit rating services tend to rely heavily on the treatment expense per child for evaluating cleft charities, the pressure for these organizations to demonstrate a low treatment expense or a high annual number of children treated on their 990 forms continues to mount. Simple comparisons of 990 forms do not account for the organization that partially funds a mission (perhaps only the plane ticket for a surgeon on the trip) and still counts all the children treated on that surgeon's mission in its yearly total, inevitably lowering its treatment expense per child. Furthermore, the 990 form provides no information regarding how an organization handles postoperative complications, assuming a system has been implemented to notify the organization about these complications, nor do the forms include information regarding the credentials of those treating the children.
- Operation Smile's funds cover all aspects of the mission, from hotel rooms to speech therapists for children undergoing palate repair.
- Operation Smile's comprehensive care centers monitor and treat postoperative complications year round.
- Operation Smile's internal review ensures that all mission members meet standard accreditations.
Appraising intangible benefits that Operation Smile produces by advancing the understanding and management of congenital facial deformities through university partnerships or by inspiring individuals to pursue careers in international health care by permitting medical students and residents on missions is inherently difficult to quantify and list on a 990 form.
We recommend that those critics harping on the costs of mission trips consider the ethical dilemma of saving dollars at the expense of quality of care that occurs when paying local surgeons (who may lack the appropriate training) or other specialists necessary for optimal cleft repair. Analyzing other rubrics, including qualitative metrics not on a 990 form, will be a starting point for fathoming the value that cleft organizations such as Operation Smile engender for society and for evaluating cleft organizations more accurately.5
Anup Patel, B.S.
John A. Persing, M.D.
Section of Plastic and Reconstructive Surgery
Yale University School of Medicine
New Haven, Conn.
Neither of the authors has any commercial associations or financial disclosures that would create a conflict of interest with information presented in this article.
1. Dupuis CC. Humanitarian missions in the third world: A polite dissent. Plast Reconstr Surg
2. Mulliken JB. The changing faces of children with cleft lip and palate. N Engl J Med
3. Bermudez RLE. Operation Smile: Plastic surgery with few resources. Lancet
4. Poe D. Operation Smile International: Missions of mercy. Plast Surg Nurs
5. Collins J. Good to Great and the Social Sectors: Why Business Thinking Is Not the Answer
. Boulder, Colo: Jim Collins; 2005.
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