Opération Sourire - Activities Report

2009

OPÉRATION SOURIRE ACTIVITIES REPORT ›› BANGLADESH ›› BENIN ›› CAMBODIA ›› MADAGASCAR ›› MALI ›› MONGOLIA ›› NIGER ›› CHAD

Madagascar © Catherine Henriette

CONTENTS

Madascascar © MdM

// 3 Introduction // 4 Opération Sourire’s mission: To rebuild faces and lives // Objectives // The Various Stages of Our Missions

// 7 Missions // Bangladesh // Benin // Cambodia // Madagascar

Madagascar © Catherine Henriette

// Mali // Mongolia // Niger // Chad

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// 13 Map of Missions // 14 Summary of the year // Opération Sourire in a few facts and figures // MdM France // MdM Germany // MdM Japan

// 18 Participants // 19 Plans for Opération Sourire 2010

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

INTRODUCTION Opération Sourire celebrated its 20th anniversary in 2009.

It continues to steadily grow, led and inspired by founding members and new participants joining on every year.

In 2009, MdM France, MdM Germany and MdM Japan treated 873 patients, which, when added to those treated over the previous years means that our teams of volunteers have given 7,000 people back their “smiles”.

New growth opportunities are opening up thanks to the trust the L’Oréal Foundation has shown in us by funding the entirety of MdM France’s activities. Embarking on new sites, improving our training activities, strengthening our partnership with local organisations… so many ideas, so many projects to develop…

François Foussadier

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Cambodia © Catherine Henriette Mongolia © Catherine Henriette

OPÉRATION SOURIRE’S MISSION: TO REBUILD FACES AND LIVES OBJECTIVES Founded in 1989, the reconstructive surgery mission, Opération Sourire, celebrated is 20th anniversary in 2009. Established for forgotten populations and in close collaboration with partners in Asia and Africa, this mission responds to the specific needs of physically repairing faces, restoring the functioning of limbs or entire bodies.

Opération Sourire has a twofold objective: to carry out surgical operations and to train national staff.

The operations bring about dramatic improvement in the patients’ lives both physically and socially. They regain a normal face and the use of their limbs. The physical restoration also enhances social integration for people who for the most part were living “in the dark”, hidden away because of their difference.

Training local staff and sharing techniques holds a privilege place among all our missions.

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The collaborative practical training is done by attending operations and then participating in them. In the interim between MdM team tours, there is regular knowledge sharing with referent surgeons on site in order to support them in their activities. As teams change, there is regular knowledge-sharing with on-site reference surgeons in order to support these in their activities.

In 2009, the Opération Sourire teams from France, Germany and Japan carried out 22 missions in 8 countries. Thanks to the dedication and effort of 105 volunteers, 873 patients were operated on. Thus, we have succeeded in reaching a total of 7,493 patients operated on since the creation of Opération Sourire. The number of operations is greater since some patients require multiple operations.

Of the missions planned this year, four had to be cancelled due to security reasons or the professional demands on surgeons.

This year, Doctors of the World participated in the 54th Congress of Plastic Reconstructive

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

Mongolia © Catherine Henriette

and Aesthetic Surgery held in Paris from 23rd to 25th November. The aim of this participation was to publicise the Opération Sourire programme and to recruit specialists in order to develop new missions. The MdM booth also served as a place for Opération Sourire surgeons to meet. Furthermore, this event allowed for exchanges with organisations or hospitals conducting similar projects.

THE VARIOUS STAGES OF OUR MISSIONS Made up of one or two surgeons, an anaesthetist and a nurse, the Opération Sourire teams carry out short-term missions of 8 to 15 days. Regular missions are organised at the same intervention site over several consecutive years.

“This is the fifth time I’ve worked with the MdM team and with the anaesthetist Anne-Marie. I observe and I try to remember as much as possible. I learned how to use new equipment: how a syringe pump works for pain relief, how to adjust the monitor ... I also learned the dosages of new drugs, how to calculate doses ...

And our surgeons have made progress, they no longer handle all the mission’s

Local partners prepare patient recruitment upstream in collaboration with the team lead surgeons and by carrying out an initial triage based on the medical conditions treated by the Opération Sourire specialists. ( Continued on page 6 )

major operations, the schedule is less busy and with medication and equipment twice a year, working conditions are easier.

We’re always very happy to work with the French team; we would like them to be here as often as possible.”

Otran, Nurse anaesthetist, Ulaanbaatar

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Medicines and medical equipment.

The Opération Sourire teams operate by adapting to local conditions and therefore by using the technical equipment of the host hospitals’ surgical units. Some devices essential for the proper performance of the operations (e.g. diathermy, surgical light etc.) are given to these hospitals. A stock of surgical kits and other devices are available at the MdM headquarters and sent out to the missions. Medical products and medicines necessary for the operations and post-operative care are purchased by the MdM logistics department and then transported by freight or sent along with the teams. Some products can be purchased locally in countries with EU-approved central purchasing bodies.

Products not used during the missions are given to our partner hospitals to treat patients in need. MdM also provides for additional tests when patients come in for their normal checkups.

Consultation and schedule of operations.

The missions normally begin with a half-day of consultations with those present. A schedule of operations is drawn up based on the cases identified in advance for surgical procedures.

The operations are carried out at regular inter-

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Niger © Catherine Henriette

Recruitment is finalised after consultation with the local team, usually on the first day of their arrival.

vals; all patients operated on are visited at the end of each workday.

Throughout the missions, the Opération Sourire and local teams work jointly. In addition to the exchange of practices and paired training, theoretical training sessions are also provided

by Opération Sourire professionals.

Post-operative care for patients during or after the missions is provided by local doctors. Complex cases receive “remote” support (i.e. off-site) from Opération Sourire surgeons. Subsequent visiting programme teams follow up with patients with pathologies requiring consecutive missions.

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

MISSIONS BANGLADESH From 27th February to 5th March and from 4th - 10th December

BENIN

© MdM

© MdM

Launched in 2008, the surgical missions in Bangladesh have been carried out by a Franco-Japanese team, which visits the hospital in Dhaka twice a year. In 2009, 84 patients have been operated on.

MOUBARAKA’S STORY TOLD

BY DR DE MORTILLET

A six-person Opération Sourire team went to the Saint-Jean de Dieu hospital of Tanguieta where it has been carrying out missions since 1999. This action was carried out in partnership with the Development Assistance Committee of Benin (CAEB in its French acronym), which is in charge of information and recruitment of patients and postoperative monitoring.

The team saw 42 in consultation and operated on 36 patients. The main pathology operated on in this country was cleft lip/palates, which represented 53% of the cases. There were also a significant number of cases of burns (17%) and of keloids.

In this village in Benin, children born with cleft lip/palate are considered child sorcerers; they are thought to be the result of a curse on the family. Legend has it that this family must have made certain mistakes in the past for which it has been punished. Child sorcerers are usually sacrificed and this was what had been decided for Moubaraka. The ceremonies by the river were held one evening and the child was meant to be thrown into the water the next day.

her as part of an Opération Sourire mission.

Her young mother courageously refused the fate intended for her child and she fled, finding refuge with some members of the CAEB organisation. This is how the social workers took in Moubaraka and her mother and asked me to operate on

After three operations carried out between 2002 and 2009, her congenital defect was completely treated. I look forward to seeing Moubaraka a bit later on to see how she's come along, as much physically as psychologically.

© MdM

From 3rd to 10th January

Moubaraka after the operation

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Médecins du Monde has been involved in Cambodia since 1989, chiefly to operate on facial deformities. Over the years the objectives of the mission have evolved, particularly in terms of diversification of pathologies treated and training local staff. In 2009, seven missions were carried out as follows: • MdM Germany: from 14 to 28 March, from 26 June to 11 July and from 21 November to 6 December • MdM Japan: from 31 May to 13 June and from 15 to 25 December • MdM France: from 18 to 21 March; from 18 June to 28 July and from 21 November to 5 December Since 2004, MdM France has been developing a new training course on treatment of meningoencephalocele cases that combines the expertise of a maxillofacial surgeon and a neurosurgeon.

The June mission saw the culmination of a wonderful collaboration of Cambodian and French surgeons: Dr Ngiep defended his doc-

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toral thesis in medicine, completed under the direction of Dr Frank Roux, which was unanimously approved with high honours. “This is the culmination of so much investment, it makes our educational work with Cambodian doctors palpable”, explained Frédéric Lauwers, director for this mission. To the two annual missions coordinated by Dr Lauwers was added that of Dr Micheau. A founding surgeon of the Cambodia mission, he has been very involved in mission planning and follow-up after their departure. Present two weeks before the arrival of the surgical team, he met the partner hospitals or other facilities (faculties of medicine, organisations etc.) interested in reconstructive surgery. Dr Micheau also performs an initial triage of the patients, operates or assists local surgeons with complex cases. As he knows this country so well, he is also responsible for exploration of new sites (Pursat, Païling, Mongolborey etc.).

In total, 425 patients were operated on in Cambodia.

›› Meningoceles, encephalocele and meningo-encephalocele This is a deformity in the vault of the skull, with a hernia of the meninges, of the brain tissue or both. It is common in South East Asia. The causes of the disease are difficult to identify due to a lack of means for conducting

© MdM

© Catherine Henriette

CAMBODIA

Nuon Lok, 2 years old, operated on for meningoencephalocele and her mother

When Nuon Lok was born, everyone urged me to go to the hospital. I didn’t want to. It was a mobile team of doctors who travel from village to village who talked to me about the opportunity of having my daughter operated on by French surgeons. So I came. After the operation, Nuon Lok is doing well. She is tired but I know she is going to get back to having a normal life and most importantly I’m going to send her to school!

large-scale epidemiological studies. In the so-called developed countries, it has virtually disappeared, so few researchers are interested in it.

One cause could be a toxin that develops during the hot and humid months in rice that’s been stored in a poorly ventilated area for a long time.

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

MADAGASCAR ›› Hirschsprung’s disease

© MdM

It occurs during pregnancy and results in an embryological deformity that affects the colon, the sigmoid or the rectum. It affects one birth in 5,000, mostly boys. The disease is treated by surgery that removes the segment of bowel without ganglion cells, then reconnecting the healthy colon over this segment to the anus.

This year four missions were carried out in Madagascar: three to the hospital in Antananarivo (20-26 April, 7-16 August, 2-8 November) and one to Diego (15-24 October); 108 patients were treated.

The two reconstructive surgery missions at Antananarivo and Diego made it possible for 70 patients to be operated on; the primary pathology being a cleft. The Antananarivo mission was carried out by a team from Paris; that for Diego by a team from Clermont-Ferrand. Follow-up of patients operated on during these missions was performed by three Malagasy surgeons. Organisation of the local mis-

sions was managed by a medical coordinator based in Antananarivo.

During the Diego mission, the number of patients almost doubled compared to previous missions, with 85 patients seen in consultation. This increase is mainly due to the expansion of the area of communication even in remote areas. In addition, the provision of travel expenses for indigent patients has encouraged these people to travel for the surgical procedures.

from Reunion Island visits the university hospital of Antananarivo twice a year. The patients are mostly children; 38 were operated on in 2009. The pathology most often operated on being Hirschsprung's disease.

The MdM team is treating increasingly heavy cases of visceral diseases compared to those of the initial missions. Despite the skills of our surgeons, the measures taken during the missions in the hospital are limited due to a lack of essential equipment. Some patients were transferred to Reunion Island to be operated on.

As part of the paediatric gastroenterological surgery project launched in 2005, a team

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MALI

MONGOLIA

From 12 February to 21 March During the February mission, 71 patients were seen in consultation and 25 cases were operated on, 10 of which were hip replacements. Before now, patients needing this surgery had been sent abroad. Operating on them locally represents a significant savings for the Malian government. As a result, health authorities are very supportive of the continued prosthetic surgery and of trauma surgeons teaching the relevant techniques. Three operating units have been equipped since 2004.

© Catherine Henriette

The only orthopaedic mission of Opération Sourire, the Mali programme carried out by a team of two to three people and for a longer term than other missions (approximately six weeks). Learning by “shadowing”, the Malian surgeons are trained in collaborative surgical procedures. Each patient is presented by a Malian surgeon called a “referent”. This referent will have seen the patient in consultation, he operates or participates in the operations with the Opération Sourire surgeon and provides post-operative follow-up. Maintaining high hygienic standards is essential for these surgical procedures. Our team with fellow surgeons, anaesthetists and operating unit staff has established a checklist that must be validated before each operation.

© MdM

From 24 April to 4 May and 9 to 17 October

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For eight years now, the Burn and Reconstruction Surgery Clinic in Ulaanbaatar has been receiving an Opération Sourire team twice a year. The area of specialisation of the Mongolia mission is reconstructive surgery of severe burns. Other trauma and scarring aftereffects, which have gone untreated for months or even years, are operated on here. In total, 68 patients were operated on during two missions conducted in Ulaanbaatar.

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

NIGER From 6 to 16 February and from 6 to 16 November

"In every country in the world, treatment for burns is a bit like the last--and least important--wheel on the cart. When we arrived there was practically nothing at the burn injuries hospital. You can’t ask the medical and paramedical staffs to do in a few years what we’ve done in a century. It’s changing slowly, but that’s good. In a few years they will be independent for most of the operations”.

Didier Guinard Director, Mongolia mission

r

n a f rs , -

The main causes of the burn after-effects operated on are from household accidents, very common in Mongolia: many families live in yurts, where the stove used to heat and cook is on the floor. The cold,

aggravated by numbing alcoholism, is also a significant vector for accidents and frostbite: there are twice as many patients in winter than in summer.

Since 1993, regular missions were organised to the national hospital of Niamey in partnership with the Sentinelle organisation in order to treat the after-effects of noma, but also of clefts and of burns. In 2009, 69 patients were treated.

Surgical procedures for the after-effects noma are part of an academic work initiated and coordinated by Professor Jean-Marie Servant. Several operations are needed for the reconstruction of the face. Each case is listed and monitored. For some patients, samples are brought back to France and analysed at the Saint Louis hospital in order to conduct further testing. ›› A gangrenous infection, noma is a fatal disease for 90% of all cases. The most affected are children under six living in extreme poverty and suffering from malnutrition. If the disease is detected early, its progression can be prevented by antibiotic treatment, a balanced diet, and a few simple rules of oral hygiene. If, as happens in the majority of cases, the disease is not treated, the ulcer spreads rapidly and painfully: the cheeks and lips swell and the progress of the gangrene is established. Deep lesions can quickly develop, destroying part of the face and sometimes involving ankylosis of the jaw and preventing eating.

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CHAD From 21 to 28 February and from 6 to 14 November The missions in Chad began in 1999 at the general referral hospital in N’Djamena, but their frequency depends on the political and security situation of the country. Due to the irregularity of the missions, local staff cannot be provided with regular training.

© MdM

This year two missions were organised. The team operated on clefts in particular, 47% of the surgical procedures, but also on tumours and cysts. A total of 58 patients were operated on.

Abakar, 10 years old. Single bilateral cleft lip

›› The cleft lip and palate or “hare lip” is a deformity of embryonic origin of the upper lip and palate. Between the 35th and the 40th day of pregnancy, two parts, called buds (or arches), unite: the maxillary bud forms the cheek and the lateral part of the upper lip and the nasofrontal bud forms the nose and forehead. These two buds must fuse to create a harmonious face, otherwise, a cleft is formed. This deformity, also known as a harelip, affects about one in 500 newborns. In developing countries the incidence is approximately the

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same as in Europe. The cleft lip and palate can be isolated or associated, totally or partially, from one side or both. If the cleft is not treated, several complications arise such as respiratory problems, difficulty in feeding, difficulty in hearing, frequent ear infections and speech disorders.

The treatment is exclusively surgical.

In Europe, before the age of 6 months, we correct the lip, the velum palatinum (soft palate) and the nose.

A bit later it is possible to operate on the palate. Intrauterine surgery is sometimes possible. Some cases

require subsequent small reoperations. As it is not lifethreatening, this type of deformity is seldom operated on or not at all in developing countries.

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

MISSIONS MAP

Mongolia

Bangladesh Mali

Niger Cambodia

Chad Benin

Madagascar

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SUMMARY OF THE YEAR 2009 In 2009, 873 patients were operated on, of which 515 patients by teams from MDM France, 210 by teams from MDM Germany and 148 by the teams from Japan.

Most people operated on have been young people under 30 years of age (76%) (Graph 1). Among these, 39% are children several months old to 10

Graph 1

Age of patients operated on 39 %

years. There are also patients aged between 30 and 50 years old (16%) and several cases being over 50 years old.

21 % 16 % 9% 0-10 years

5% 7%

Graph 2

Gender of patients operated on

Mongolia 8%

46 %

Bangladesh 9%

Niger 8%

Male

This year, females represented 46% of patients operated on and males 54% (Graph 2).

Madagascar 12%

Cambodia 49%

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1%

Graph 3 Number of patients by country

54 %

Female

2%

11-20 years 21-30 years 31-40 years 41-50 years 51-60 years 61-70 years + de 70 years

Chad 7%

Benin 4% Mali 3%

Regarding the proportion of the number of patients by country, we saw that Cambodia had the highest number with 49% of the total number of people operated on (Graph 3). As the first country with an OpĂŠration Sourire programme, Cambodia today received seven missions annually, carried out by teams from France, Germany and Japan. Similarly, in Madagascar, the significant number of cases is due to the four missions that MdM France organises every year.

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

Table 1

Pathologies by country

Pathologies

Cambodia

Madagascar

Bangladesh

Niger

Mongolia

Chad

Benin

Mali

Total

Total (en%)

Cleft lips and/ or palates

62

48

16

30

0

27

19

0

202

23 %

Burns

28

10

13

13

45

5

6

0

120

14 %

Deformities

53

1

31

0

0

0

2

0

87

10 %

Tumours

61

0

7

2

0

10

1

0

81

9%

Cysts and lipomas

55

0

1

0

0

7

0

0

63

7%

Gastroenterological surgery

0

38

0

0

0

0

0

0

38

5%

Orthopaedic surgery

9

0

0

0

2

0

0

25

36

4%

Trauma injuries

17

0

2

6

7

3

0

0

35

4%

Meningoceles

19

0

0

0

0

0

0

0

19

2%

Noma

1

0

0

16

0

2

0

0

19

2%

Keloids

4

9

0

0

0

1

2

0

16

2%

Other

116

2

14

2

14

3

6

0

157

18 %

Total

425

108

84

69

68

58

36

25

873

100 %

The most common pathology was cleft lips and/or palates with 23% of the total number of operations carried out (Table 1). This pathology was furthermore treated in six of the eight programme countries. Following these were after-effects of burns (14%), deformities (10%) and tumours (9%). Cysts and lipomas operated on particularly by the Ger-

man and Japanese teams represented 7% of the total number of patients operated on and the cases of gastroenterological surgery, operated on exclusively in Madagascar, represented 5%. Less numerous but more complex were programmes against meningoceles and after-effects of noma (2%).

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MDM FRANCE The MdM France teams operated on 515 patients in 15 missions. An exploratory mission was carried out in Armenia from 29 August to 2 September in order to assess the needs for treatment for after-effects of burn injuries.

The results of this mission demonstrated the competence of the local medical staff and its ability to meet the demands placed on it. In fact there is no plan to open a mission here.

As the table below shows, 29% of all cases were cleft lip/palate; the country with the greatest number of these is Madagascar. Then, after-effects of burn injuries, particularly operated on in Mongolia, representing 19% of the total number of surgical procedures. Cases of tumours, gastroenterological and orthopaedic surgery were all treated in equal proportions, that is, in 7% of the surgical procedures.

Complex pathologies requiring several operations, such as the after-effects of noma and meningoceles, were operated on in Niger and Cambodia. Besides these priority pathologies, several cases of keloids, cysts, snakebites, ankylosis etc. were operated on in each mission.

Table 2

Pathologies operated on by country Pathologies

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Benin

Cambodia

Madagascar

Mali

Mongolia

Niger

Chad

Total

Total (en%)

Cleft lips and/or palates

19

23

48

0

0

30

27

147

29 %

Burns

6

20

10

0

45

13

5

99

19 %

Tumours

1

25

0

0

0

2

10

38

7%

Gastroenterological surgery

0

0

38

0

0

0

0

38

7%

Orthopaedic surgery

0

8

0

25

2

0

0

35

7%

Trauma injuries

0

6

0

0

7

6

3

22

4%

Noma

0

0

0

0

0

16

2

18

4%

Deformities

2

13

1

0

0

0

0

16

3%

Meningoceles

0

16

0

0

0

0

0

16

3%

Keloids

2

0

9

0

0

0

1

12

2%

Kystes et Lipomes

0

0

0

0

0

0

7

7

1%

Other

6

40

2

0

14

2

3

67

14 %

Total

36

151

108

25

68

69

58

515

100 %

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

MDM GERMANY This year, MdM Germany organised three missions in Cambodia. These missions made it possible to operate on 210 people presenting cysts and lipomas (20%), cleft lip/palates (14%), tumours (13%) or deformities (10%).

Table 3

Number of patients by pathology Pathologies

Number of patients

Cysts and lipomas Cleft lips and/or palates Tumours Deformities Trauma injuries Burns Keloids Meningoceles Other Total

43 29 28 20 11 7 4 3 65 210

Total % 20 % 14 % 13 % 10 % 5% 3% 2% 1% 32 % 100 %

MDM JAPAN The MdM Japan teams operated on 148 patients in four missions carried out in Cambodia and Bangladesh. The most common pathologies were deformities (35%), followed by cleft lip/palates (18%) and then tumours (10%). After-effects of burns and cysts and lipomas were also treated.

Table 4

Number of patients by pathology Pathologies

Number of patients

Deformities Cleft lips and/or palates Tumours Burns Cysts and lipomas Trauma injuries Other Total

51 26 15 14 13 2 27 148

Total % 35 % 18 % 10 % 9% 9% 1% 18 % 100 %

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PARTICIPANTS Bahe Laurent Barabas Jozsef Barcat Emmanuel Bataille Benoît Bathelemy Isabelle Beaujard Hélène Beauval Agnès Berg-Börner Britt-Isabelle Brusset Marie-Claire Captier Guillaume Cataldo Daniel Château François Collin Jean-François Crenn Rolland De Mortillet Stéphane De Rouvray Thibault Dekoleadenu Peter Djonga Ouangbi Dobremez Eric Dos Santos Séverine Evano Françoise Fauché Paulette Fourcade Laurent Foussadier François Gay André Gouvet Anne-Marie Guinard Didier Hanusch Joerg Harada Masako Harper Luke

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Heindl Walter Honda Takayuki Huber Bertrand Ingallina Fabio Ishihara Megumi Jacob Alain James Sophie Joly Bruno Josbé Alain Jürgens Philipp Klumpp Fabian Kramer Florian Lacombe Pascale Landru Jérôme Lauer Günter Laure Boris Lauwers Fredéric Liguori Anne Luce Johan Mahieu Gérard Martinaud Catherine Martineau Marie Matéo Gérard Maurin Sophie Mayer Marie-Noëlle Micheau Philippe Miyao Yoichi Moellendorf Ines Mole Bernard Mompeyssin Bruno

Monteil Jean-Paul Morioka Daichi Müller Annett Müller Steffen Nguyen Luc Oussmane Issa Elhadji Otsubo Noriko Oura Norihiko Page Jean-Philippe Philandrianos Cécile Pinzer Thomas Pochet François Poussain Catherine Rapidel Jean Raulo Yvon Roux Robert Roux Franck Sam Auteur Sandorfi Yolande Schwenzer-Zimmerer Katja Serein Agnès Servant Jean-Marie Siebold Martha Simonnet Sylvie Sirakanyan Armenak Smail Nadia Soum Ratha Sterckx Bernadette Terashima Sawako Thomas Dominique

Tissedre Jeanine Tougloh Ayayi Touré Abdoul Wvatt Bon Vilain Gabriella Vitkovitch Stéphanie Voulliaume Delphine Watcher Klaus Williger Babett Yamada Nobuyuki Yoza Satoshi Zimmerer Stephan

MÉDECINS DU MONDE OPÉRATION SOURIRE 2009

PLANS FOR OPÉRATION SOURIRE 2010 We are going to continue to pursue the programmes we led in 2009 - i.e., 25 missions in eight countries: Bangladesh, Benin, Cambodia, Madagascar, Mali, Mongolia, Niger, Chad.

However, we will focus equally on two axes: - Exploration of new sites of intervention and the reopening of the mission in Pakistan.

- Consolidation of some projects through developing activities with local partners: for example, in Cambodia, where local practitioners were trained over 20 years ago in treating cleft lips/palates, there is thought about a project that would help them toward greater autonomy.

We also plan to step up recruitment efforts: - by opening recruitment for medical teams via MdM United Kingdom and MdM Netherlands, organisations from the Doctors of the World international network.

- and by pursuing communication and sharing activities (participation in surgery congresses etc.)

COORDINATOR: HÉLÈNE VALLS EDITOR: LAVINIA ILIÉ IMAGE SELECTION: AURORE VOET LAVINIA ILIÉ GRAPHIC DESIGN: ISABELLE MARTIJA-OCHOA THANKS TO: GISÈLE LEMIERRE, DOMINIQUE PESSOTTI, NAO KUROYANAGI, HILKE SCHNEIDER, NIVO RAMAMONJISOA

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Madagascar © MdM

Médecins du Monde/ Doctors of the World 62 rue Marcadet 75 018 Paris www.medecinsdumonde.org

Tel. +33 01 44 92 15 15 Fax. +33 01 44 92 99 99

Opération Sourire Lavinia Ilié Tel. +33 01 44 92 14 09