ANTHONY F. MARKUS
Consultant, Maxillofacial Surgeon
Head of Department Maxillofacial Surgeon,
Poole Hospital and Royal Bournemouth Hospital
Director, Dorset Centre for Cleft Lip and Palate
E-mail: anthony.markus@poole.nhs.uk
Honorary Consultant Maxillofacial Surgeon, Worthing Hospital
Honorary Consultant Maxillofacial Surgeon, Royal Naval Hospital, Haslar
Honorary Consultant Maxillofacial Surgeon, Guy’s Hospital, London
Visiting Fellow, Bournemouth University
Member, Clinical Standards Advisory Group, UK Department of Health
Member of Council, British Association of Oral and Maxillofacial Surgeons
Chairman, British Association of Oral and Maxillofacial Surgeons Cleft Group
President, Oral Surgery Club of Great Britain
Fellow, Royal Society of Medicine
Fellow, Royal Society of Public Health
Member, British Association of Oral and Maxillofacial Surgeons
Member, Societé Française de Stomotologie et Chirurgie Maxillo-Faciaux
Member, International Association of Oral and Maxillofacial Surgeons
Member, European Association of Craniomaxillofacial Surgeons
Member, American Cleft Palate - Craniofacial Association
De Puy Surgical Prize, British Association of Oral and Maxillofacial Surgery
Author of several papers on cleft lip and palate
Craniofacial Anomalies - The Burden of Care,
Meeting the Treatment Need in a Global Context
A. F. Markus, Poole, UK
Craniofacial deformities (CFA), a term that encompasses a large number of
conditions of which the most common is cleft lip and palate, affect a significant
proportion of the global community.
Clefts are themselves frequently
associated with other severe abnormalities ranging from learning difficulties of
varying severity, to heart and limb abnormalities. More severe craniofacial
abnormalities occur, for example, Crouzon’s and Apert’s syndrome in which
there is failure of normal cranial and facial growth due to synostosis of the bones
that make up the cranial vault and cranial base. There is considerable
geographic and racial variation, with the rates being highest amongst North
American Indians followed by the Japanese and the lowest amongst Caucasians.
Worldwide 15,000 children are born each hour and this represents a child born
with a cleft every two and a half minutes.
The costs incurred from CFA in terms of morbidity, health care, emotional
disturbance, social exclusion and restricted employment opportunities, are
considerable for affected individuals, their families and society as a whole.
Assessment of the true financial costs of all aspects of management is essential
in an environment of increasingly restricted budgets. Surgery is expensive and
it is important that the best techniques are employed by the best surgeons,
surgeons who have developed their skills on the back of the best educational
training opportunities. It must be the principal aim of the cleft surgeon to restore
the deformed and displaced regional anatomy to as close to normality as possible.
Only in this way can one reasonably expect restoration of function and so enable
optimal growth and development. Primary surgical methods encompassing these
ideals should, theoretically, reduce the frequently observed sequelae of both the
cleft deformity itself and surgery and so, in turn, the need for secondary surgery.
In reality, given even the most favourable circumstances, secondary surgery will
be required. There has been little work as yet on the health economics of CFA.
Health status and the utility of care and associated quality of life may be
estimated using techniques of time trade-off and conjoint analysis. Economic
prioritisation models use decision analysis and simulation to assess the resource
costs and patient benefits of current treatment patterns and therefore the “costs
– effectiveness gap” or in other words potential gain from diverse surgical
procedures for CFA. There is no major widely accepted registry which enables
critical appraisal of different kinds of CFA interventions. REACH (Rural,
Effective and Comprehensive Community Healthcare) is a management system
that has been implemented in Andhra Pradesh, Southern India, on a localised
basis with the aim of addressing some of these issues.
An awareness of the existing problems is essential if research is to be
appropriately directed and funded, if the correct level of human resource is to be
identified and made available, if health care professionals and organisations are
to be brought together with the affected individuals and communities, and if the
necessary information, by for example, modern IT facilities, is to be accessible
and have an impact on education and, therefore, prevention of disease. In this
way, treatment need can be identified and addressed.
Globalisation is primarily an economic phenomenon - the rapid economic
integration between countries by removing obstacles to the global movement of
capital and the production of goods and services. Its ideological parent is neoliberalism and it is oiled by new technology, especially IT. Its supporters have
pointed to the creation of unprecedented wealth globally, the creation of
hundreds of thousands of jobs; mainly in selected Asian countries where
poverty levels have sharply reduced. Its critics point to the ever-widening gap
between the rich and poor countries and between rich and poor people, even in
the north. And indeed the statistics are daunting. The share of the poorest fifth
of the world's population in global income has dropped from 2.3% to 1.4% over
the past 10 years. The proportion taken by the richest fifth, on the other hand,
has risen from 70% to 85%. In Sub-Saharan Africa, 20 countries have lower
incomes per head in real terms than they did two decades ago. Globalisation,
with significant percentage increases in GDP of many developing countries
should make possible achievement of the ideals as defined in “Global strategies
to reduce the health-care burden of craniofacial anomalies: Report of WHO
meetings on International Collaborative Research on craniofacial anomalies”.
Yet, whilst research as the basis for long term improvements in the
management of CFA is absolutely essential, in the immediate future efforts to
reduce healthcare burden and treatment need must continue,