This post has been in the works since before Thanksgiving when I interviewed Jeff Marsh, who has been a friend for at least 30 years, in his CWE home. It was on my way home from that interview that I broke my foot, and while the two events are related only by timing, and while it has taken the intervening four months to get this story together, it has taken even longer to get back into my dancing shoes. I hope you enjoy reading about this CWE couple's medical missions and viewing the gorgeous photographs of Bhutan that Jeff provided. Thanks to Beki and Jeff for their editing help–they've been incredibly patient with this medical novice.
Longtime CWEnders Dr. Jeff Marsh, Director of Pediatric Plastic Surgery at Mercy Children's Hospital–formerly St. John's–(front row, third from left) and his wife Beki, (second row, far left), a retired operating room nurse, have been journeying halfway around the world to Bhutan to perform cleft palate surgery since 2003. The couple travel with a team of equally-generous medical professionals who use vacation time to perform surgery, speech therapy, and dental services over a ten-day period. The "Smile Train" organization provides most of the funding for these medical missions—Jeff served on their Advisory Board for years–and private donors assist in the transportation and lodging of the medical team.
The international team, above, varies depending on who's available. The last mission included two surgeons, N.Y.-based Dr. John Girotto and Dr. Thomas Lambrecht from Switzerland, two anesthesiologists, Canadian Dr. Stuart Neil and Dr. Paul Schueller from Germany, and two speech therapists from India, Suraj Subramanian and Vijay Kumar (not pictured). Also in the photograph are two recovery room nurses, New Yorker Heather Garbarino, and Israeli Edna Gabby, Shannon Skidmore, an OR nurse from Canada, and a volunteer patient coordinator, Sharon Shuteran, from Colorado. Bhutanese surgeon Dr. Karma Tobgyel (holding child)—more on Dr. Karma later—and his wife, Mika (far left) are also pictured above.
In 1991 Dr. Marsh began traveling to Bangkok Children's Hospital to teach cleft lip and palate surgery as a volunteer. How the Marshes wound up in Bhutan actually has its genesis in the CWE, specifically in Jeff's passion for yoga. He began practicing yoga–at Beki's suggestion—20 years ago under the tutelage of Deni Roman, in a workout studio located in the space currently occupied by Pi.
During a layover in the Bhutan airport bar on his way to a take a week-long class with world-renowed yoga master Rodney Yee, Jeff met a USA plastic surgeon who was performing cleft palate surgeries in Bhutan. As Jeff, who studies Buddhism semi-seriously said, "the meeting was 'fated'–a good thing according to Eastern thinking." The surgeon had a mandate from the Bhutanese government to begin a cleft care team and enlisted Jeff to join him. The Bhutanese government chose a local surgeon, Dr. Karma, to head the team. As Jeff said: "With a name like that, how could I refuse?" (Bhutanese refer to each other using their first name although they usually have two names, e.g. Karma Tobgyel.)
According to Jeff most cleft medical missions involve "parachute teams," like ones depicted on "M*A*S*H*. They fly in, perform surgery, and leave–no one having been taught to perform the surgery once the medical team has departed. Dr. Marsh has a different approach he summed up with the following quote:
"If a man is hungry, don't give him a fish, teach him to fish."
Dr. Marsh loves to teach and was happy to instruct Dr. Karma on the latest cleft palate surgery techniques. Dr. Marsh and several of his colleagues brought Dr. Karma to the USA and to Switzerland for advanced training. A very important part of cleft care is speech therapy. Dr. Marsh sponsored Kuenzang Dorji, one of only two speech therapists in Bhutan, as the American Cleft Palate-Craniofacial Association's Visiting Scholar in 2010. Kuenzang spent a week each in St. Louis, Cincinnati, and Atlanta studying with cleft speech therapy masters and then attended the Association's annual scientific meeting.
When I asked Beki how long it takes to get to Bhutan, she replied:
"We have never been able to figure it out. There are two plane trips, including an overnight flight to Bangkok, an arduous bus trip to the clinic in Bhutan…you cross time zones, lose days, gain days…we just don't know."
Ninety percent of the Bhutanese population is rural and the country is sparsely populated. A daily tax on tourists of $150 to $200 a day pays for the education and healthcare systems. There are 25 district hospitals, and in addition, each village has basic health care units. According to Jeff: "Medical practice there has a very good grassroots organization, but tertiary care is available in only a few hospitals and is limited in what services can be offered."
There are no actual addresses in rural Bhutan, so information travels by word of mouth, radio, TV and newspaper. For the first few years that Jeff, Beki, and the medical team traveled to Bhutan hundreds of people would walk for 2 to 3 days hoping to receive cleft palate surgery for their children or themselves at Trongsa Hospital, above. The team can perform 60-70 operations in 10 operating days, so potential patients would wait on the hillside beside the hospital hoping to be called for treatment—many were not and would come back the next year.
For the past three years public service announcements have been used to alert the villagers that the operations are to be performed, provide them with a phone number for registration (now feasible due to the prevalence of cellphones) and consequently surgeries are now scheduled in advance. In addition, cellular communication makes it possible to do follow-up communication.
There are two operations going on simultaneously in the small operating room. Power-outages and water shortages are a common occurrence. The prime operating table is the one next to the only window, in case the power goes out. In addition, the operating team is now equipped with LED headlamps, just in case. In the photo above you see Dr. Marsh, left, Beki Marsh in her role as operating room nurse, and anesthesiologist Stuart Neil, middle.
The team carries all the donated medical equipment they will need over the ten-day period in suitcases. Any equipment or medicines that aren't used are left behind for Dr. Karma.
The optimum age for cleft palate surgery is before speech develops, or about 12 months of age. Inability to communicate orally negatively affects education and employment, and is the prime reason parents want surgery for their children, or adults want the operation for themselves. Cleft lip surgery can be done at any time but is preferably done in infancy to minimize psychosocial consequences due to facial difference.
Dr. Marsh also said: "Because the Bhutan Cleft Care Project Team has been operating in Bhutan for eight years, and Dr. Karma has been able to repair clefts himself when the Team is not present, the average age of the cleft palate patient has dropped. However, older unrepaired patients still present for treatment."
This family is all smiles after surgery, above.
Bhutanese children gather around the team's bus hoping for a balloon, which one of the doctors brings with him. Jeff said a typical day at the hospital starts at 8 a.m. and operations continue until about 6 p.m. The team then heads to the guest house for a happy hour and dinner. Beki chuckled when I related Jeff's account. She said it's more like 8 or 9 p.m. by the time they wrap things up, and there wasn't much of a happy hour—or much of a dinner. Everyone is just too exhausted.
On a 2010 trip to Bhutan the Marshes ran into a patient post-surgery with his/her father at the local market. When I asked Jeff whether the baby in the photo was a boy or girl, he said that the Bhutanese have two names that are assigned by a monk on an auspicious day after a child's birth and the names have no correlation to family or gender. So many patients have the same name. This can make record keeping very confusing for Westerners.
Whenever the Marshes travel they explore the markets where they find the best examples of local culture, native foods, and spices. As an aside, Beki, a fabulous cook, was the leader of the Slow Foodmovement in St. Louis for many years. She will drive for hours every November just to purchase a heritage turkey from a Missouri breeder for the family's Thanksgiving table.
On their way to the hospital each morning the medical team sees children climbing up the mountains heading to school wearing the traditional male costume–"goh"–which adults must also wear during the work day. The girls and women wear traditional dresses called "kirtin."
Some Bhutanese boys between the ages of 6 to 8 are sent to school to study Buddhism on the path to becoming monks. At the age of 16 they are asked to decide whether to continue their education in the monastery or to return home to a secular life. The photo above shows a prayer wheel in the center of Trongsa.
Prayer wheels and flags, above.
You might be surprised to learn that the monks in the photo above are watching an archery contest, the big national sport in Bhutan.
What is even more admirable about the Marshes' contribution to aiding a population in a remote corner of the world is that it is done very quietly. To make a donation to the Bhutanese Cleft Care Project, send a check to Dr. Jeffrey Marsh, Mercy Hospital, 621 S. New Ballas Rd. #260A, St. Louis, MO 63141. Donations are tax-deductible.
Someday soon I hope to share the couple's gorgeous photos from a recent trip to Israel, where Dr. Marsh performed surgery on several patients with Beckwith-Widemann Syndrome and other complex craniofacial deformities.
P.S. When our children were young, Jeff's artistic surgical skills were visible on the most fabulous show-stopping pumpkins he carved for Halloween.