DEPARTMENT OF PLASTIC SURGERY
International Outreach

Bhutan, India, February 2005
Linda L. D'Antonio, PhD
Professor and Director of International Outreach
Department of Plastic and Reconstructive Surgery
Loma Linda University

Bhutan is a small Buddhist kingdom high in the Himalayan mountains bordered by Tibet to the North, Nepal to the West, and India to the South and East. The King restricts visitors in order to preserve the natural environment and the lifestyle of the people without upsetting their socioeconomic balance. His administration is protective and concerned about issues of development, education and health care, and environmental and cultural preservation. The population is estimated to be less than one million with the majority being farmers. Health care in Bhutan is free to all citizens. There is a National Referral Hospital in the capital of Thimphu, two regional referral hospitals and smaller hospitals in each district. Rural health care is provided through a network of Basic Health Units (BHU) staffed by a health assistant, nurse-midwife, and a basic health worker. Seventy-eight percent of the population has access to a BHU within a two-hour walk.

Repair of a cleft lip normalizes a child's appearance and decreases the social stigma associated with clefting. A major goal of cleft palate repair is to normalize speech quality. Most children with cleft lip and palate or isolated cleft palate will demonstrate some abnormalities in speech. For most children, if the palate is repaired near the onset of meaningful speech (usually 12-18 months of age), normal or near normal speech is possible. However, if palate repair is delayed (or for some children regardless of the timing of palate repair) severe problems with speech and language can occur often resulting in significant social stigma.

In developed countries, the discipline of speech-language pathology addresses these speech disorders associated with cleft palate. However, in most developing countries, speech-language pathology services are not available or are available only on a limited basis. Therefore, children with severe, disabling speech disorders associated with cleft palate remain isolated because of their inability to communicate.

In Bhutan surgical repair of cleft lip and palate is becoming increasingly available. In other underserved countries in the world as surgical services increase in availability, families, patients, and surgeons begin to request assistance in normalizing speech. This same sequence of events is beginning to occur in Bhutan.

The WEcare Bhutan Reconstructive Surgery Project began a formal three-year contract with the Ministry of Health in Bhutan in 2001 to achieve two objectives:

1. to train a Bhutanese surgical team to perform repair of cleft lip and palate at the National Referral Hospital in the country's capital and
2. to decrease the backlog of untreated or inadequately treated individuals with cleft lip/palate and other physical disabilities amenable to plastic surgery at regularly scheduled surgery camps.

As the availability of cleft care increased in Bhutan the need for speech pathology services became more apparent. In November 2004 we visited Bhutan along with the WEcare team to assess the need for speech services for children with cleft palate, assess the current level of speech services, and outline suggestions for making speech-language services available.

Together Roopa and I have partnered since 2000 to develop and implement programs for increasing speech services for children with cleft palate in India. We have emphasized the use of a multi-tiered approach to communication services including institutionally based rehabilitation, outreach programs, training allied professionals, and utilizing community-based rehabilitation (CBR) programs as models for delivery of speech services. Our assessment for Bhutan and our proposed solutions were based on our extensive experience with similar work in India and the surrounding region.

Photo: Dr. Linda D'Antonio is a speech-language pathologist from Loma Linda University with extensive experience establishing speech and language services for children with cleft lip and palate in developing countries. She has performed needs assessments and developed both training programs and speech service delivery models in China, Thailand, and India. Ms. Roopa Nagarajan is a speech-language pathologist and audiologist in India who has been the country's leader in promoting communication services for children with cleft palate and sensitizing health-care workers regarding communication impairment associated with clefting.

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