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By Andrew and Sarah Hodges

Leaving Uganda after our 1998 cleft project was hard. The project had been an overwhelming success; in the course of 8 months we performed 377 deft repairs and trained 5 local surgeons.

Settling back into life in England was difficult, however, knowing that there was still so much unmet need in Uganda. The entire population of 21 million people is served by just one plastic surgeon. Most patients born with a cleft lip or palate have no prospect of receiving treatment.

So, last year, again with funding from CLAPA, we made another trip - this time taking with us two other surgeons so we could make maximum use of our time there. Our first week was spent back at Kagando Hospital, where we used to live and work. Our idea was to spend a week there visiting old friends, but the local doctors had other plans! Around 50 patients with all sorts of conditions were waiting for us. We made an assessment of those patients we knew we could do something for and worked the theatre staff hard trying to operate on them all in the few days available. Though we performed some deft repairs, most children had severe burns - one child had his eye and ear burnt off and his neck was stuck to his chest.

At the beginning of the second week we met up with fellow plastic surgeon Peter Saxby, and flew off in a shaky little plane to Lira hospital. As we arrived on the grass landing strip, full of anticipation, we were disappointed that there was no-one there to meet us. It turned out that our letters had not arrived and no-one was expecting us. For two days we were there with no patients - not a promising start. The Medical Superintendent at the hospital was not discouraged and immediately put out an announcement on the local radio calling anyone with a deft to come as soon as they could.

We were amazed by the response. Over the next two days 44 cleft patients arrived. The boys were all called Ojok and the girls Ajock - this means "cursed by God'. The Medical Superintendent urged us to stay longer as those living further away would first need to raise money for travel by selling animals in the market. We had our deadline, however, and had to leave - even though more patients were turning up as we were packing our bags. We encouraged them not to despair and promised to try to return next year. During our brief stay we were again amazed by the dedication of the theatre staff.

Despite the early starts and late finishes, some of the staff who had been transferred to other wards requested to come back to the theatre to assist us. Before driving off, the local district governor received us into his office and presented us with gifts in appreciation of the service to his people.

From Lira we drove to a nearby rural hospital and checked into their guest house. Here we diversified and operated on patients with burns, clefts and huge keloids (bad scars). Theguest house was simplicity itself with no running water or electricity and, judging by the evidence, a rather sizeable and hungry rat which lived in the bathroom and devoured the visiting surgeon’s soap!

In our final week we returned to Kampala to work in a very well equipped orthopaedic hospital. Here we were joined by another plastic surgeon from England, Tim Goodacre and, after the chaos of the previous hospitals, we were impressed at how well things were organised. This was important as we were performing a lot of complex reconstructive surgery in addition to deft repairs. As well as many terrible burns contractures, we treated one twoyear old child who had been bitten on the face by the family pig. Most of the cheek had been bitten off and scar tissue had grown in its place, leaving her unable to open her mouth at all.

She had survived on liquids for a whole year. After a complex operation skin was moved from around the face and neck to reconstruct the cheek, lip and eyelid. It was a privilege to beinvolved in such a life transforming procedure.

As on previous visits to Uganda we were struck by the incredible need. We operated on 100 patients in the three weeks - 60 deft repairs and 40 other procedures. Many of the patients had been suffering with their problems for many years before receiving treatment, and many patients arrived after we had left. We feel compelled to attempt to help more patients. All of the hospitals we visited would like us to return. The key to the future will lie in the hands of Ugandan surgeons but there is presently no training program for them to learn plastic surgery.

We would like to link up with some young surgeons on future visits so that, as well as treating patients, we can train local people and pass on skills. We have already identified three committed surgeons who we know well and who wish to be trained in plastic surgery. Hopefully they will join us when we visit in 2001.

At CLAPA’s last AGM we were interested to hear about the changes to cleft care in the UK which will move treatment from "local' hospitals to more specialised centres of excellence. It struck us, however, that, in a very different environment, we are aiming to do precisely the opposite in Uganda. Villagers in remote districts will not travel to Kampala for treatment and our aim is to send teams to the district hospitals in remote areas to treat patients where they live.

CLAPA has enabled the beginnings of cleft care in Uganda and lives are being transformed. There is still such a huge unmet need. We look forward to continuing our links with CLAPA and bringing you news of future trips.