World Health Organisation

Baroness Brinton Excerpts

Wednesday 2nd July 2014 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I declare an interest as a past trustee of CBM UK, of which I am a current patron. I thank the noble Lord, Lord Ribeiro, for initiating this debate, which will cover a very great area of experience and expertise. Having listened to the noble Lord, I am even more aware of my extensive ignorance in this area, so I hope that he will allow me to focus on just one thing that he mentioned. I want to talk about a multi-partner club-foot initiative which started in Africa, and in which CBM has been involved over the past decade. It acts as a model for surgeons and aid agencies working together in the future.

CBM is an overseas disability charity, founded more than 100 years ago, which has worked in Malawi for many years. For some reason, Malawi has the highest incidence of club-foot in the world, and CBM has worked for a long time with local hospitals, the Global Clubfoot Initiative and, more recently, the Royal College of Surgeons on supporting young patients born with this disability. This work typifies the hope that my noble friend expresses in the title of this debate.

Steve Mannion, a consultant surgeon in the NHS and senior lecturer on surgery, is the orthopaedic adviser to CBM. All orthopods know that treatment for club-foot should be started early; diagnosis at birth is ideal, rather than later in life, especially for cases that require surgery. He used the Ponseti treatment, which is a physiotherapy technique not well known but which has become the gold standard in the last decade, mainly because of this innovative work. It can be provided effectively and economically. The club-foot medical community also wanted to manage the care of others who had not been treated as young children, and for whom the damage to their feet, legs and ligaments would take longer to treat. The noble Lord, Lord Winston, who cannot be in his place this evening, filmed this project in Malawi in 2008.

The Ponseti method uses corrective manipulation and then keeping the patient in a plaster case. In most cases, this will avoid surgery. The surgeons have also found a cost-effective method of producing the Steenbeck foot abduction brace, which young patients have to wear full time for two to three months, and then at night for two to four years, to ensure that the foot grows into the correct position. The NHS version of this brace is a bit like Ford motor cars—you can get them in one colour only. It is effective, expensive and dull. This surgeon, working with local craftsmen in Malawi, developed a brighter and much cheaper arrangement, which he brought back with him to the UK and which, if my memory serves me right, cost around one-fifth of the UK equivalent. Suddenly, UK parents were asking for it in preference to the NHS version. So here is an assistive technology product from the developing world, saving the NHS money—good news. For £12 million, the cost of one advanced surgical robot in the UK, one-quarter of a million children can be treated and taught to walk.

The work in Malawi progressed well. Diagnoses were made early, but Steve Mannion told me four or five years ago that Malawi Ministers had expressed real concern to him that there were more Malawian doctors in Manchester than there were in Malawi and, helpful as medical aid and support was, there was a serious brain-drain problem. This is where the Royal College of Surgeons comes in. It has developed a local project training surgeons in-country under their own auspices, so there is no need to leave their home to learn the leading techniques. It has worked well. The Royal College of Surgeons developed this further and hosted an international conference on global surgical frontiers in January 2012, bringing together surgeons and aid organisations. The editorial in the Lancet on 21 January 2012 says:

“The greatest burden of surgically treatable diseases falls on people in developing countries, but the poorest third of people receive only 35% of operations and have the lowest numbers of surgeons per head of population. These statistics, combined with the emphasis on reducing global deaths from infectious diseases, make surgery feel like a neglected specialty in the current global health arena. But, as the conference showed, reducing the disparities in surgery between developed and developing countries will take a massive, coordinated, worldwide effort”.

Some 30 months on from that conference, orthopaedic surgeons such as Steve Mannion and the Royal College of Surgeons are training large numbers of local surgeons and physiotherapists in club-foot and other techniques, with the College of Surgeons of East, Central and Southern Africa, and now elsewhere in the world. As the Lancet says:

“The move away from the paternalistic approach of parachuting in Western surgeons on brief missions and towards teaching skills to local surgeons needs to continue, although the need for skilled surgeons to take part in sustainable programmes is still great. Coordination needs to exist between surgical institutions in developing and developed countries so that skills taught are appropriate to requirements. In addition, coordination between and within countries needs to increase to ensure that qualifications have no borders … It is also essential that efforts continue to plug the brain-drain from developing countries”.

The treatment of club-foot is life-changing for patients. Disabled children are often at the back of the queue for medical support and education, and as they grow up they are the last to get employment opportunities in their communities. This simple surgical and non-surgical intervention and treatment is not only benefiting thousands of children across Africa, in Laos, in Papua New Guinea and in other countries; it is providing local craftsmen with work—and local surgeons are being trained in world-leading surgical and physiotherapy techniques. Perhaps most importantly, it is changing the centuries-old view of the West parachuting experts in to solve problems. The surgeons from the UK say that they are learning as much from their colleagues in-country as they are teaching them.

To conclude, I have one simple question to ask my noble friend the Minister. What can the Government, both in DfID and in the Department of Health, do to ensure the dissemination of successful projects like this, and to encourage more in the future?