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C. Lawrence and T. Lawrence
noma sufferers in Nigeria four times a year, were
contacted, which sparked the founding and registration as a charity of Facing Africa (FA) in the
UK in 1998 by CL and his wife, Terry Lawrence
(TL). This in turn resulted in a productive collaboration of CL and the teams of health professionals led by Dr. Marck from the DNF, together
with a German charitable organization called
AWD Kinderhilfe. The effort clearly needed
assistance with fundraising to stabilize and
broaden its activities. CL, with his extensive
business and fundraising experience in the travel
and fashion industries, along with his knowledge
necessary to deal with potential difculties or
dangers in different countries and cultures, was
an ideal administrative leader of this team of
expert physicians and nurses. To overcome the
many obstacles and challenges presented to each
team on each mission, CL used some of his talent
as a “hustler.” Through his popularity as a
recruiter for Marathon des Sables (MdS), an
annual 245 km foot race across the Sahara in
Morocco, CL was able to raise £ 250,000 each
year, which were used to help fund the noma missions to Nigeria. As CL sold his travel company
in 2005, he dedicated with his wife their organizational skills to develop an outstanding and
innovative surgical care system for victims of
noma.
Country andSite Selection
When the situation in Nigeria deteriorated
because of wars and corruption, FA looked elsewhere in Africa for a country that was able to provide (a) direct ight connections to major
European cities; (b) where corruption by bribing
was not always required to innovate; (c) where
government was relatively stable; and (d) where
English was spoken. Another requirement was to
(e) have access to a government hospital that was
welcoming, well equipped for complex surgeries
and affordable to FA. After exploring several
West Africa countries, it was decided that
Ethiopia was a suitable place to bring regular
teams of surgeons, anaesthetists and wound care
nurses to carry out reconstructive surgery on the
victims of noma. Initially, a government hospital
appeared suitable. The team was assured by the
hospital director that specic drugs, consumables, disposables. and almost everything were
available in abundance but that it would be wise
to bring certain items that were unavailable in
Ethiopia. In order to avoid excess customs duties
and taxes on the suggested items, it was decided
to address them to the hospital. This led to any
unused medical items, such as very expensive
sutures, to be used by the hospital rather than
being kept for future use by the team. They had to
be bought again for each mission. This lesson
was followed by another, in that equipment and
disposables of which FA was assured were on
site were really unavailable and had to be sought
elsewhere. With such experience, the staff was
instructed to take all precautions against misunderstandings or devious interpretations of rules
and regulations. They were also asked not to
agree to or make any kind of promises regarding
medical or surgical items. The FA continued to
work at this hospital despite its difculties with
the hospital’s management, facilities, stafng
problems and insoluble negotiation issues.
This then led FA in 2009 to change site for
future missions. CL along with a hired Ethiopian
“xer,” experienced in public relations and communication (necessary hire to deal with local
organizations and the public), focused now on a
variety of privately owned and managed hospitals
in and around Addis Ababa. After visiting a variety of private hospitals with attention to (a) location, (b) facilities, (c) cleanliness and (d) the cost
to FA, six hospitals were screened by phone and
e-mail in order to establish the level of fees, what
would be provided by the hospital and what was
expected of FA to bring. Five were eliminated:
two for extravagant fees, two for inadequate
facilities and equipment and one that insisted on
their own surgeons participating actively in the
operations beyond their skill sets. Finally, an
American Christian foundation was selected to
serve as the base for FA activities. Although satisfactory for one mission, on renewal of the contract, the hospital uninchingly doubled the fees
that had been charged for the previous trip. This
resulted in another change of site in 2010 to
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another private hospital in Addis Ababa, South
Korean MCM (Myung Sung Christian Medical)
Hospital. It had four ORs, was well equipped and
staffed and welcomed the team. As time progressed, however, the hospital continued to
increase their charges for uncertain reasons, and
FA had to nd another site, primarily for nancial
reasons.
After 14 missions, the relationships between
MCM and FA deteriorated on the basis of many
nancial and administrative reasons. Most importantly, the hospital neglected to obtain legal
licenses for the staff and for FA during 14 missions as required by law, and for which, FA was
charged. When it had become obvious that it was
time to nd an alternative hospital, FA moved
briey (two missions) to another new and wellequipped private Ethiopian hospital, before landing at a small, spotlessly clean and extremely
well-maintained hospital (Nordic Medical
Centre) built by a Norwegian friend of CL.This
Scandinavian establishment was used for three
surgical missions, and then came the pandemic.
The missions had to stop not only because of
COVID but also because of an ongoing civil war
(tribal), which broke out in 2020.
As can be seen from this abbreviated story, an
NGO focused on a rare surgical condition must
choose its major site of operation carefully, and
negotiate even more carefully, with the motto of
“Trust and Verify” (President Reagan), on every
occasion. Mission leaders must remain exible in
their activities and demand fair and just treatment
from their hosts.
Facing Africa House
andRehabilitation Facility
Even cheap hotels would not accommodate people
with open wounds on their faces for fear of alienating other guests who would automatically assume
that these diseases were contagious. The original
35 patients who had agreed to have reconstructive
surgery who were brought to Addis Ababa were
accommodated in a most appalling, lthy hostel,
which was totally unsuitable for people who were
about to undergo complex surgery. This became an
important factor in that 70% of the patients developed wound infections. The error that was never
repeated was to check the site where patients
would stay prior to scheduling their arrivals. A
solution was required to accommodate these
patients arriving from remote rural villages, many
of whom had never owned a pair of shoes, been in
a car, seen a building higher than one storey, or is
some cases had never seen a white person.
Accommodating these gentle but uneducated people in a suitable alternative site had to be found for
pre-operative workup and for post- operative follow-up and rehabilitation.
The search for a site ended when CL and his
wife found a delightful rehabilitation centre for
children with polio located in a countryside
setting about 20 miles outside Addis Ababa.
The facility had several dormitories with showers, kitchen and dining room, a basic physiotherapy room, playroom and acres of lawn and
gardens. The management of the facility was
willing to accommodate up to 50 FA patients
twice a year for up to 8weeks on each mission.
The new patients could stay there for 2weeks
prior to the arrival of the surgical team. During
that time, a Western doctor and two wound care
nurses along with six Ethiopian trainee nurses
would be based at the facility throughout the
8weeks. The trainees would be taught how to
use many of the different dressings used in
Western hospitals, pain management and general nursing and more intimate contact with the
patients. This gathering of 30–40 people with
severe facial deformities quickly realized on
meeting each other that they were not the only
people with such disgurements and previously considered freaks in their villages. After
meeting others, they gained immediate condence and were seen to make new friendships.
From being outcasts in their own village societies, they made friends. Children under the
age of 14 were encouraged to come with a parent or guardian.
This beautiful facility was where FA patients
would be fed, accommodated and clothed for
2 weeks prior to their operations, for 2 weeks
while being hospitalized, and a further 2–4weeks
for recovery time and intense rehabilitation.
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C. Lawrence and T. Lawrence
In 2011, the trustees of FA accepted the offer
by the management of the facility to loan a part of
their land for FA to build their own facility. The
buildings designed by an architect would include
four dormitories with ten beds in each for male
and female patients, showers with hot water, toilets, dining room, recreation room, laundry room,
doctor’s ofce, storage room and a play area surrounding the buildings, for football and volleyball. The new facility, called “Facing Africa
House”, was ofcially opened by the British
Ambassador to Ethiopia in 2012 after a cost overrun from £ 50,000 to £ 350,000. It became, and
remains, a critical site for future patient intake
through their rehabilitation.
Public Relations
FA was becoming noted for the amazing reconstructions, and soon, FA was being contacted by
surgeons, anaesthetists and medical organizations wanting to offer their time, skills and help.
Volunteers from different countries wanted to
join FA teams; one trip included nine different
nationalities among the team members. Few local
surgeons, anaesthetists and nurses participated as
assistants to learn new techniques and apply them
to their own work.
Word of mouth and local newspaper articles
helped generate interest and some contributions
to the FA charity.
Once the BBC decided to make a documentary about the work being done by FA teams,
which was rst screened in the UK in 2010, more
than US$ 500,000 was donated within a few
weeks. Despite international interest, public
interest in Ethiopia and WHO interest globally
for these poor children with noma did not improve
their preventive healthcare and antibiotic distribution as needed.
Meeting Legal Requirements
andLicensing
An ofcial charity licence issued by the Charity
Commission in Addis Ababa was both desirable
and necessary for FA’s optimal function. Very
little progress was made despite many meetings
at the commission’s ofces. The Charity
Commission put up obstacles until one was
issued with conditions that were not only
extremely cumbersome but would also entail
maintenance an expensive army of local accountants, auditors, bookkeepers and lawyers. The
promised tax-free concessions to FA were so convoluted that they were unattainable. Another
obstacle that nally resulted in returning the
license to the commission was the demand that
the foreign charity/NGO must have an Ethiopian
partner with the right to sign checks to open a
bank account. In these unfortunate circumstances, FA appealed to the Federal Ministry of
Health and was granted a special licence to carry
out clinical work under their auspices. Similar
obstacles are frequently encountered in many
LMICs and need to be legally circumvented to
continue the health work benecial to the local
population.
Direct appeal to the Ministers of Health will
facilitate function as long as their priorities are
included in the NGO’s agenda. In the case of
noma, the greater interest of the federal authorities as expressed by one famous Minister of
Health (subsequent head of WHO) was in missions dedicated to the treatment of heart and kidney problems, diabetes, orthopaedics, cancer,
strokes, bone fractures, etc. rather than to a disease like noma, which was almost unknown in
Ethiopia in spite of the fact that there are probably thousands of children who die quietly in rural
areas, disgured and tortured by their
inrmities.
The other issue is timely applications for individual permits to practice surgery in the host
country. This process may be done through the
hospital where one will practice. The problem
with that may be that after all the fees are collected by the hospital for submission of applications and the fees for the applications themselves,
nothing gets done until it is too late. It is important to check, verify and obtain the personal permits before embarking on the mission. Alternative
processes may be to do this directly with the
Ministry of Health or occasionally through the
local consulate or embassy of the host country
(more difcult).
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Although laborious and sometimes costly,
personal license must be secured, if required, to
avoid practicing illegally, which could have
disastrous consequences and must be avoided at
all costs. Maintaining or obtaining malpractice
insurance is also strongly advised.
Negotiations
The negotiations with the hospital and the
Ministry of Health aimed to establish the rules
and regulations governing foreign healthcare
staff coming to Ethiopia as clinicians were the
rst order of business. In parallel, one must investigate and negotiate with the hospital about the
availability of drugs, antibiotics, surgical instruments, consumables and disposables. Before proceeding further, it was advisable to nd a local
“xer” bureaucrat who can help process the various licences and permits, as well as to identify
and refer noma patients from rural areas and to
negotiate with hotels for the team to base themselves and with the Ethiopian Airlines for any
group concessions. All activities require some
form of negotiations. These require patience,
diplomacy, mutual understanding of limits and
conditions and, most importantly, trust.
Unfortunately, the latter can sometimes be questioned. All agreements must be checked and veried as well, especially regarding dedicated
personnel and their compensation, as well as
availability of equipment, drugs and space for
recovery room, for hospitalization and for
storage.
A walk through the designated hospital may
be very helpful – preferably with a local
witness.
Recruiting theTeam
ofProfessionals
FA initially reached out for volunteer surgeons or
anaesthetists in the UK.CL sought qualied and
experienced volunteers who might be interested
in joining an FA surgical mission to Ethiopia for
a few weeks. With little understanding of the different types of surgical specialities and no knowl-
edge or understanding of anything other than
noma being a esh-eating disease, it was very
challenging to nd qualied individuals to work
in LMICs in relatively basic hospital facilities
with meagre resources. Once an experienced
consultant plastic surgeon was identied in UK
and was willing to join the FA team going to
Addis Ababa, other healthcare workers began to
volunteer. This included a prominent maxillofacial surgeon and a university professor who was
also curious and interested in participating in the
new FA undertaking. The original Dutch mentor
agreed to lead the team to Ethiopia as the rotations to Nigeria ended. This small group was then
able to recruit a very experienced anaesthetist,
who in turn brought his friends, an anaesthetic
ODP and his wife, a very experienced ward
nurse. The FA program was ready to begin its
work in Ethiopia in October 2007.
Recruiting thePatients withNoma
Once a team was prepared to work, it needed to
identify appropriate patients, prepare them for
difcult and lengthy operations, optimize them
nutritionally and otherwise and obtain consents
(with translators and with guardians as necessary). An Ethiopian native (“a xer”) was hired,
who worked previously for TV news channels,
and although he had no health contacts, he was
familiar with ofcials in the ministries of
immigration, media/PR and communications. He
spent the coming months sourcing children and
adults who had unsightly facial disgurements
caused by noma or injuries. Finding noma victims in the poorest areas of Ethiopia was expected,
but identifying them was very difcult. Parents of
noma children considered the disease as a curse;
out of shame, therefore, they hid them at home
and denied knowing anyone, child or adult, with
severely damaged faces.
Despite these obstacles, there were 35 patients
treated by FA in 2007, among which were 18 with
noma and 17 with various trauma, animal bites,
tumours and nose reconstructions. They understood from FA surgeons explanations that their
original good looks may be only partially restored
following surgery. Other people with noma
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C. Lawrence and T. Lawrence
declined the offer, believing in some cases that
they would never wake up after an anaesthetic,
while others preferred to take treatment from a
traditional healer using herbs, prayers and lies.
Motivation andMaintenance
oftheTeam
The members of the team are all volunteers who
are motivated primarily by wanting to contribute
to the treatment of the most unfortunate, disabled, disgured, poor young individuals imaginable. The team members are all very talented,
distinguished members of various medical and
nursing specialists. They include plastic, maxillofacial and oral surgeons, anaesthesiologists,
wound nurse specialists and ward and recovery
room nurses and other specialists as needed. It is
not unusual for some of these individuals to
recruit others to participate in these 2-week missions where they all operate as a unit every day
and care for the patients after their operations.
FA pays for all its volunteers’ ights, hotels and
meals on each trip and encourages social cohesion
among the volunteers. During the 2-week mission,
FA sponsors nightly joint dinners for the staff at
one of the many excellent restaurants in Addis
Ababa, which encourages relaxation and potentiates close interactions among members of the
team. As a result, strong friendships have emerged
from the trips, and there is always a strong feeling
of bond and mutual assistance and appreciation for
everyone’s part in the mission. Teamwork is the
fundamental quality needed for the mission’s success. Fortunately, FA is well funded enough, to
make this group, however large or small, work as a
team by providing all the essentials and comforts
that people did not expect. Providing and caring
for each individual while in a strange country with
very different cultures maintained the team spirit
and a sense of gratitude for the organization. CL
and his wife, based on a 35-year business experience in travel and fashion industry, focus on transferring the nest hospitality and appreciation to
their hardworking team. FA missions have become
the envy of most NGOs. They provide not only
personal comforts but also the use of an excellent
hospital with Western standards of nursing, equipment and facilities that people do not expect.
Lessons fromInitial Missions
Besides the lessons described above on how to
deal with the site that the mission will use where
there has to be mutual trust and collaboration,
there were many other lessons that had to be
learned from FA’s initial experience with the rst
35 patients and subsequent missions.
1. Hospital and rehabilitation/recovery site. This
needed to be addressed for pre- and postoperative care not only for patient comfort but
also to test patients pre-operatively for
endemic diseases, train in hygiene and wound
care and train student nurses to eventually
avoid the unacceptable high rate of postoperative wound infections and problems.
2. After each operation, the patients were sent to a
surgical recovery ward staffed by young nurses
who had limited training and were very restricted
with basic essentials, including pain management drugs and bandages. Their form of wound
care required total re-education, which was provided by the visiting nurses (see Chap. 40, under
wound care) both at Facing Africa House for
nursing students and following operations both
at the hospital and at FA House.
3. Negotiations with the hospital authorities
must be clearly dened on both sides. One
must check everything regarding any verbal
commitments by the facilities. With experience such as that of FA, all precautions for
misunderstandings or devious interpretations
of rules and regulations must be observed and
all team members instructed not to agree privately to or make any kind of personal promises regarding medical or surgical items.
Inspection of the facilities, “a walk-through”,
may be very valuable to avoid any
misunderstandings.
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4. Appropriate licenses to practice in LMICs
must be obtained prior to the visit, relying primarily on the organizer of the mission or preferably on personal initiative if possible.
5. To continue and maintain high standards of
each mission, there is an obvious need for a
highly motivated, experienced and gifted
administrator with a dedicated associate. They
raise funds, recruit volunteer professionals
and arrange and support ights, living quarters and living expenses. To maintain the
team’s cohesiveness, close clinical collaboration and patient selection and care, FA provides all the essentials and comforts. It helps
maintain a high level of collaboration and
individual satisfaction so that team members
are eager to return and to train new cadre of
individuals to continue this critical service not
only to save lives but also to help their patients
gain dignity and function within their
communities.
Summary andPlans
There are a number of issues that needed to be
addressed for future FA trips, many of which
have been or are being addressed:
1. FA needs to take more of its own consum-
ables, disposables and drugs because of the
inadequacies and unreliability shown by the
host on FA’s rst trip. All medical supplies
should be taken as personal baggage on the
ight so as to avoid having to argue with hospital management about ownership of any
products at the end of the mission.
2. FA would need to nd more suitable accom-
modation close to the hospital for patients
coming from rural parts of Ethiopia. A small
but clean and habitable hotel to provide all
the rooms may be the best solution. FA
solved this by building its own facility within
a pre-existing rehabilitation centre.
3. It is essential to accommodate the patients for
at least a week prior to their complex surgeries to carry out all essential pre-op medical
tests for malaria, HIV, etc. as well as teaching
them the basics of hygiene with showers and
dental care. This was done following construction and opening of FA House.
4. All team members in the future had to agree
never to make any offers of donations of
equipment, consumables and disposables.
Even using the word “maybe” is inappropriate since “maybe” could be considered a rm
promise.
5. FA decided that future trips should include at
least four, if not ve consultant surgeons as
well as having two consultant anaesthetists
who specialized in difcult airways not to
overtax a smaller group while instructing
local health providers.
6. It would be agreed in writing on all future
missions what was being provided by FA by
way of medical and surgical equipment,
drugs, consumables and disposables and
what would be provided free of charge by the
hospital. This includes overtime pay to some
needed ancillary staff to have their allegiance
(such as oor sweepers).
7. FA would, in the future, bring two experienced British ward nurses to cover the many
nursing inadequacies and to train local staff
in maintaining clean facilities (day and
night), dressing changes and pain
management. The training will begin at FA
House prior to surgery (as is already being
done). This is necessary to prevent infections
and pain.
8. Once it is known that that very complex
reconstructive surgery is being done, space is
needed in the OR for medical students and
local medical personnel to assist, observe
and learn new surgical and anaesthesia
techniques.
9. Evaluation following each mission visit will
lead to improvement. It is never too late to
make necessary changes. FA changed hospitals from one that was ill-equipped and insufcient to an alternative better managed with
more ORs and more services and nally to
another hospital more amenable to reasonable contracts, to develop and be able to use
the world-class skills of volunteer surgeons,
anaesthetists and nurses to capacity.
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10. Once established, FA needed to decide how
many missions it should carry out per year,
how to staff them and how to fund them.
Having gained experience of working in
Ethiopia for three annual missions, it was
decided that from 2010 onwards, Facing
Africa would be condent enough and would
be able to source two teams every year to
take to Ethiopia instead of one.
This summary enumerates many details, both
favourable and unfavourable, of the many FA
missions as an example for other similar volunteer surgical missions. The presentation is
extracted from the history of the many FA missions. It focuses on pertinent facts to illustrate the
many problems that the missions have faced over
the years and to present the many solutions that
FA provided in full or in part to make the surgical
visits very effective and successful. The public
relations campaign has remained limited to raising the necessary funds to continue the mission in
only one country so far. No plans have been made
yet to expand the effort to other countries.
How toApproach NOMA andFacial
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Infections, Trauma andTumours
Through Charity Missions: Facing
Africa Non-operating Mission
HiroshiNishikawa
35
Introduction
Much is known about the ideal proportions of the
Western face. The horizontal thirds and the vertical fths that make the proportions of the Western
face (e.g. the correct proportions between the
width of the eyes and the width of the nose or the
distance the eyes are apart) were well known in
the Renaissance. Leonardo drew cephalometric
diagrams to help him paint and to understand the
basis of human proportion (Fig.35.1).
I nd it fascinating that Leonardo’s painting of
the Duke of Milan’s Mistress, the Lady with an
Ermine drawn 500 years ago, still resonates to
European minds as a girl of beauty (Fig.35.2).
We are conditioned, taught, educated or maybe
genetically wired to appreciate her.
Yet when African art (face) inuenced Picasso
(see Desmoiselles d’Avignon, Figs. 35.3 and
35.4), then the frame of reference was thrown.
This was partly because of the huge conceptual
differences between the depiction of the African
face and Western art and maybe because the
known benchmarks of the Western face were
invalid for the African one. Picasso (hence
H. Nishikawa (*)
Craniofacial/Plastic Multidisciplinary Department,
Welbourne Center and Birmingham Children
Hospital, Birmingham, UK
Western aesthetic appreciation) tried to explore
this during his African phase of paintings, and he
eventually produced quite outrageous art based
upon African images and, at the time, its primitive and alien nature.
Western cephalometric proportions guide
reconstructive and cosmetic surgery of the face,
if one has been trained in Europe. The relative
gross facial reconstructions we carried out in
Addis Ababa for severe abnormalities will never
achieve these ideals. The yardstick that we judge
aesthetic results is based upon will never achieve
these ideals. The yardstick that we judge aesthetic results is based upon our pre-conceptions,
education, genes and exposure to a world that is
distinctly not African. So when I look at the
African face, I realize that I am not trained to
fully analyse it. I am therefore curious to understand whether my concept of a normal or a beautiful African face will be the same as that of an
indigenous person. This has inspired me to try
and construct a study on the differences between
my European-based perceptions of facial aesthetics and that of the African ones.
This study would take the form of a eld trip
involving two surgeons, an anaesthetist, the CEO
of FA, and a translator, who ideally should be an
anthropologist. The anthropologist should have a
deep understanding of the indigenous people of
Ethiopia and their languages, customs and social
structures. The areas to be visited will be inuenced by known previous referral patterns.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_35
449
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Fig. 35.1 Cephalometrics of the human face
H. Nishikawa
Fig. 35.3 Self Portrait.
Piccasso
Fig. 35.2 The Lady with an Ermine. Leonardo Da Vinci
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The reasons for this are complex. Western surgeons usually cannot communicate effectively
with these patients (there are over 90 languages
in Ethiopia). Translation is often unreliable. It is
also difcult for Westerners to understand behavioural and cultural cues (a nod may mean a no, a
smile may indicate anger or disdain, yes may
mean “go away”). There are also intrinsic difculties of validated outcome measures for all
facial surgeries.
Outcome measures have traditionally centred on functional changes (e.g. improved
breathing and mouth opening) and noting measurable changes of appearance such as simple
linear alterations (changes in the length of the
Fig. 35.4 Les Desmoiselles d’Avignon
Aims
There are several aims to the non-operating
mission:
1. Improve our understanding of surgical outcome of patients treated for noma.
2. Pilot future potential studies for benchmarking the perception of normal and facially
deformed patients in remote areas of Ethiopia.
3. Improve pre-assessment methods for noma
patients.
4. Enhance the understanding of cultural and
sociological differences that have a bearing on
improving FA healthcare delivery.
5. Disseminate these ndings in scientic publication and meetings.
Discussion
The primary purpose of this mission is for clinicians and the CEO to have a much clearer idea of
the patient’s true perception of the outcome of
surgery carried out for complex facial deformity
in Addis Ababa. This may in turn help improve
FA healthcare delivery.
It is often unclear as to the real feelings of
indigenous people from remote areas of Ethiopia,
concerning the outcome of their facial surgery.
nose or eyelids). For increasingly complex
parameters involving volume, symmetry and
shape changes, analysis is much harder. The
mathematical comparison of these changes
compared to the norm is the basis of complicated research involving digital mapping of
thousands of coordinates topographically [1].
This is clearly still experimental, but simpler
validated research based on the response of
trained, unbiased observers to photographic
appearances of pre- and post-operative patients
have been used to assess cosmetic outcome [2–
4]. This kind analysis is based on the assump-
tion that the observer has a rm grasp of what a
normal appearance is. However, probably the
most important parameter is the patient’s own
perception of outcome. Patient-reported outcome measures (PROMS) have been used quite
widely in the UK and the USA for the analysis
of patient perceptions of surgical result. In
Ethiopia and other developing countries, there
are probably signicant problems in a PROMS
approach to outcome analysis because we have
no idea what the benchmark of “normal” or
“acceptable” is. There will almost certainly be
problems for indigenous people to understand
the concept of the questionnaire or looking at
photographs comparatively for the purposes of
assessment. However, unless we start to make
some approaches along these lines, then the
benchmark will never be understood, and FA
will never grasp the true nature and ramications of the complex surgery it carries.
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