Seattle Children’s Takes Cleft Training Program to Africa

The first thing Dr. Michael Cunningham noticed was the crowding. Hundreds of African mothers and their young children, pressed shoulder to shoulder in a time-worn hospital’s hallway, waiting patiently for hours — if not days — to receive cleft lip and palate care for their child. It was then when he fully understood the importance of his goals in Africa and how much work lay ahead.

Cunningham, who is medical director of Seattle Children’s Craniofacial Center, and the Center’s surgical director Dr. Richard Hopper, had traveled to Africa as part of a specialized cleft training program they co-founded in 2007 now called Partners in African Cleft Training (PACT).

Unlike mission-based medical programs that focus on treating as many cases as possible in short, fixed periods of time before returning home, Cunningham and Hopper sought to create a sustainable environment in which African health professionals became completely self-sufficient in treating cleft cases.

Building a sustainable program

Dr Richard Hopper (left), Dr Peter Donkor, Dr Michael Cunningham and Dr Olasoji Oladapo at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana on 21 May 2014.
Dr. Richard Hopper (left) and Dr. Michael Cunningham (third in from the left) with surgeons in Africa during a PACT Program visit.

The two men and their team have spent eight years developing unique programs that are designed to equip African health professionals in Ghana, Ethiopia and Nigeria with surgical techniques, nurse anesthetist training, speech language therapy and feeding techniques.

Hopper said that while mission-based programs are of great value, working alongside and training African surgeons has proven successful thus far in terms of creating a lasting impact. To treat five children per day for one week is one thing, Hopper says. To treat five children per day for one week — while simultaneously training four African physicians who can use and pass that information on to their colleagues — that’s how real progress can continue long after he and Cunningham return to Seattle.

“The trainees bring an incredible energy, enthusiasm and a desire to learn. They’ll learn a new technique and say to a colleague, ‘Hey, I have to show you what I just learned.’ Now you have another person doing something they couldn’t do before,” Hopper said. “With this approach, it doesn’t take long before the number of patients treated reaches the thousands. Then you start to get on the scale of the burden of clefts in Africa.”

Understanding the environment

Hopper said that a big part of developing a successful program was being able to understand problems on a regional level. You can’t come to a solution, he said, unless you understand the environment and the challenges people have faced already.

A nurse created an improvised pacifier from a sterile glove to soothe a baby awaiting surgery for a cleft lip at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana in May 2014. Medical professionals from across the African continent had come together with a team from Seattle Children's Hospital as part of an ongoing initiative to improve cleft lip and cleft palate treatment capabilities on the continent.
A nurse created an improvised pacifier from a sterile glove to soothe a baby awaiting surgery for a cleft lip at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, during a PACT Program visit.

Part of this was their decision to leave the state-of-the-art tools they have available to them at Seattle Children’s and instead face the same challenges as surgeons in Africa. There needles and sutures are bigger and operations are often lit with nothing more than a 60-watt lightbulb rather than a bright, brand new surgical lamp. Hopper said that through this experience, he learned new surgical skills as well.

“My touch, my sense of feel of tissues, of skin, of a needle passing through…it all became better,” Hopper said. “I was never challenged to learn these skills in Seattle.”

Upon their return to Seattle, Hopper said he re-examined his existing surgical toolkit and realized that, much like his African surgical counterparts, who only had four or five tools at their disposal, he seldom used more than that himself.

“I came back in Seattle and realized I had around 200 instruments on my cleft palate set,” Hopper said. “But, when I really thought about it, I realized that I only use four or five of them. Now our cleft palate and cleft lip sets in Seattle are similar to what you’ll find in Africa.”

Addressing “brain drain”

A patient is examined during a check-up at the Cleft Clinic at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.
A patient is examined during a check-up at the Cleft Clinic at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.

Another large part of building a sustainable program, Cunningham said, was to create a climate in which skilled African physicians are willing to stay in Africa rather than be lured to other parts of the world where different lifestyle opportunities or greater medical resources exist. A phenomenon commonly referred to as “brain drain.”

This is particularly common in Africa, where many surgeons, despite best intentions, are simply overwhelmed by the volume of patients and scarcity of resources at their disposal. It’s not about a situation of brain drain as much as “brain burnout.”

“They’re not just looking for more money or a bigger house. They’re looking for an environment where they can do good work,” Cunningham said. “If you can create an environment that is stimulating, engaging, energetic and fulfilling for physicians in Africa, then they’ll stay in Africa. That’s what we’re creating through PACT.”


  • Seattle Children’s Hospital Craniofacial Center
  • Cleft Lip and Cleft Palate care at Seattle Children’s