Interview with Bharti Katbamna, Ph.D., CCC-A

Topic: Volunteer Experience with Smile Train

Bharti Katbamna, Ph.D., CCC-A

CAROLYN SMAKA: Today I am talking with Dr. Bharti Katbamna about an organization called Smile Train and her recent volunteer experience with them. Dr. Katbamna, thank you for joining us today. Could you start by telling us about your background?

BHARTI KATBAMNA: Yes. I am a professor at Western Michigan University. I have been at Western since 1995 and teach primarily in the area of diagnostic audiology. My clinical work also involves neurodiagnostics - I see predominantly pediatric patients from the normal nursery or the neonatal intensive care unit or from the hematology/ oncology clinics from hospitals in the greater Kalamazoo area.

Most of the research I do looks at the effects of teratogens on the peripheral and central auditory systems in humans, as well as in the frog model. It is great to be able to evaluate the effects of teratogens on a molecular level and try to tease out the mechanisms of damage in an animal model, since ultimately the mechanisms help us better understand the manifestations of the pathology and perhaps provide insight into possible preventive measures. I will give you an example;we are working with children with fetal alcohol syndrome (FAS) - a couple of students are evaluating if FAS influences auditory evoked potentials at the level of brainstem and cortex in humans and a couple of other students are looking at how developmental alcohol exposure may disrupt 'pattern formation' in the frog. Pattern formation is time- and location-specific order in which genes are turned on and off during development. When key regulatory genes do not turn on and off in a predictable manner, organization and positioning of specific cell types is disrupted, thus, leading to malformations of the craniofacial structures and other problems with normal growth. Alcohol exposure during critical periods can in fact produce severe craniofacial anomalies - like the human cases of FAS, the tadpoles show cleft palate along with other malformations of the head and face. We have shown that one of the connexin genes, connexin 43, actually gets displaced from its normal locations in the hindbrain during development and may influence both the auditory and facial nerves.

In any case, this tells you then, about my interest in craniofacial anomalies and cleft palate - so when an opportunity to do volunteer work with a cleft palate team through Smile Train came about, it was easy to just go for it.

SMAKA: Could you give us an overview of Smile Train?



KATBAMNA: Smile Train is a charitable organization that funds cleft lip and palate surgeries for children in developing countries. They work with different partnering companies and coordinate payment to the hospital or surgeon for conducting the surgery. They have optimized this process so that the surgical costs have come down to as little as $250 per child.

They also provide these different partners opportunities to meet with professionals to provide training in topics related to cleft palate, including the surgery itself. For example, speech-language pathologists and audiologists can join the program to provide training for cleft therapy to partnering organizations.

Smile Train is unique in that it is open-ended. When you contact them, they provide you with a book that lists all the partners in developing countries throughout the world: Pakistan, Afghanistan, India, The Middle East, etc. The book provides a brief overview of the partnering facilities and name/contact information of the local contact person, usually the plastic surgeon. If you are interested in serving at a specific location, you make contact with the person via email or phone call and proceed accordingly. Now, this information is available online at their website (www.smiletrain.org);you can select a country and a state and obtain all the information online.

In my case, it was my colleague, Donna Oas, a retired speech-language pathologist, with expertise is cleft palate and lip, who made all the initial inquiries. She came to me with this book and said that she would like to go to India to do some charity work with the cleft team - since India is an English speaking country, she thought it would be the place of choice. India is a very large country and I was not familiar with almost any of the hospitals listed in the book, so we narrowed it down by selecting programs in big cities. She sent emails to several programs - most programs responded, but the most enthusiastic response came from Dr. Partha Sadhu, the plastic surgeon from the J. Watumull Global Hospital and Research Center in Mount Abu, located in the northwestern state of Rajasthan in India. As a Smile Train partner, Dr. Sadhu had hosted many visitors including ENTs and several speech-language pathologists from the U.K. and Sweden, so he was familiar with the process and that made everything very easy. Mt. Abu is a small hilltop community, but the hospital provides extensive services to the greater Rajasthan areas covering a 250-400 mile radius, serving people even from other states who must commute long distances to receive services in Mt. Abu.

So that is how the process began and I am not sure when in the process I seamlessly became Donna's partner, but I did and it was fun to be a speech pathologist/audiologist team. It worked out beautifully and I am glad I went. It was a great opportunity to serve and learn;we saw 55 cases in a short span of seven days. They were very interesting cases - from cases that received repeat repairs due to poor repair work elsewhere, but handled skillfully by Dr. Sadhu, to new cases that received care from Dr. Sadhu from the beginning.



(from left to right) Bharti Katbamna (audiologist), Donna Oas (speech-language pathologist), Dr. Partha Sadhu (plastic surgeon), Dr. Anuradha Sadhu (anesthesiologist), Sana Ahmed (Dr. Ahmed's wife) and Dr. Faiyaz Ahmed (maxillofacial surgeon).

We were the first speech-language pathologist/audiologist team to visit the program, and with the plastic surgeon and the maxillofacial surgeon by our side and parents by the child's side everything melded together so well, it was easy to see the whole picture and make recommendations - a student as part of the team would have gained an incredible experience in a short time with the cleft population. We began each case by overviewing the extensive audio, photo and video, pre- and/or post-op records of each child's history, speech sample and any other relevant medical reports that Dr. Sadhu maintained. We then proceeded with speech and if needed hearing evaluation, followed by nasoendoscopy and video fluoroscopy, as needed. All new cases that came to Dr. Sadhu as babies showed remarkable speech and essentially no middle ear problems. Dr. Sadhu's contention was that if the surgery is performed using certain techniques that he developed, it should produce minimal speech impediment and auditory problems post-operatively. We saw vivid evidence of his viewpoint in the results he obtained on the babies that were under his care from the initial evaluation. Other cases showed severe middle ear problems, some with chronic perforated eardrums that needed immediate attention and/or tympanoplasty. Thus, my role in the team was multifaceted, since not all cases needed an audiological evaluation or recommendation - I was Donna's assistant and facilitated her speech-language evaluations via interpretations and translations. I spoke 3 languages, in addition to English, so it was easy to serve in the role of a translator - the idea was to be of service in every way ....

SMAKA: Dr. Sadhu was the plastic surgeon who repaired the cleft lip and palate - was there an otolaryngologist there as well?

KATBAMNA: Yes, however, since Dr. Sadhu had some ENT training, he was able to screen for ear, nose, and throat problems and if need be insert PE tubes. An evaluation with the otolaryngologist was scheduled if the patient needed more comprehensive evaluations and surgeries like tympanoplasty.

SMAKA: Of the 55 cases that you saw, what was the age range?

KATBAMNA: They were mostly pediatric cases. The youngest was probably 15 months old and the oldest was probably18 or 19 years old. However, in India, it is not uncommon to see adults with cleft palate and lip;in the USA, children are eligible for comprehensive cleft services, so it is rare to find adult cleft cases. The cleft patients were typically recruited via screening camps held around the state every month, however, many patients who heard about the clinic through word of mouth showed up at the doorstep of the clinic at any time for a free surgery - these were in addition to cleft cases - cases with malformations of the head, face and neck. Such patients were also operated when we were working at the facility - we were in awe of the transformations we saw - real life before and after pictures - it takes a skillful hand, such as Dr. Sadhu's, to do such fine work.

SMAKA: What is the current state of audiology in India?

KATBAMNA: In India, when you get your bachelor's degree, you are trained to be both a speech-language pathologist and audiologist. You can get a master's degree if you want to specialize, but most people practice straight out of the bachelor's program. I received my bachelor's degree in India and with 500-clock hours of hands-on experience felt comfortable practicing both professions. The cleft team in Mt. Abu had a speech- language pathologist who also served in the role of an audiologist when needed. However, he moved 2-3 months before our visit to Mt. Abu;retention is hard in small community hospitals - everybody is lured to better jobs and better opportunities in bigger cities.

It is remarkable that Dr. Sadhu who is so talented is still in this small little town. He has developed and established a program successfully and feels compelled to be in a community with such an underserved population. In villages of a country like India people are skeptical that they can go to a doctor and their cleft can be repaired and that they can really look and sound so much better. So the screening camps that I mentioned earlier are used to disseminate information, dispel fear and welcome evaluations on-site and schedule surgeries.

Have you seen the movie Smile Pinki? It won the 2008 Academy Award for Best Documentary Short.



Smile Pinki won the 2008 Academy Award for best documentary short. It follows a child's experience with a cleft lip repair at a Smile Train center in a rural village in India.

SMAKA: No, is it about cleft lip and palate?

KATBAMNA: Yes, it provides a good idea of how children with cleft palate/lip are identified and eventually operated by surgeons partnering with programs such as Smile Train. The documentary follows a girl named Pinki with cleft palate/lip from a small village in India who travels to a facility for cleft surgery and the ordeals the child and family must go through to access the services. It is a rather touching documentary - everyone in speech-language pathology and audiology should see this documentary - it not only gives you a sense of how this program works, but also provides you with ideas of how as a speech pathologist or audiologist you can make contributions beyond your job....

SMAKA: I can't even imagine the impact of the repair on the child and the family after the surgery;it changes your whole life immediately because of the cosmetic issue alone, not to mention the functional issues.

KATBAMNA: Yes, the cosmetic issue is a huge issue - so repairing the cleft in itself is a big deal - in the documentary they show little Pinki evaluating her face in the mirror before and after the surgery and you can read the emotions on her face....

SMAKA: Could you tell us about one of the children that particularly touched you?

KATBAMNA: There were so many of them, the whole experience was actually quite overwhelming. We practically lived in the outpatient clinic - patients were scheduled back-to-back, in fact, they were double scheduled, since there were concerns that the distance and time may preclude some patients' participation - but, almost all patients came, even those that were not cleft cases, all seeking speech-language and hearing assessments and recommendations - we saw a cerebral palsy case, an autism case, a stammering case, etc.



(from left to right) Donna Oas (speech-languagepathologist) Dr. Partha Sadhu (plastic surgeon), a child with a cleft being evaluated, the child's father and Bharti Katbamna (audiologist).

Stories that come to mind have to do with individuals who were really cognizant of their speech and hearing problems post-surgically and who could not go to school or find jobs. One particular girl from New Delhi came specifically to see us. Her cleft palate was repaired, but she said she could not find a job because people did not understand her speech. She worked as a teacher for a short time, but was fired and had no luck with any other interviews for a job. She truly brought home the message that cleft cases need to be helped as early in life as possible. After her we saw a little one, the youngest baby we saw at age 15 months with a repaired palate - he stole your heart away - his speech sounds and his words were so age-appropriate and normal, you could not tell he had any problems and that is how the life of every cleft case should start.

Unfortunately, not everyone is so lucky. There are those who never go back to school and the surgery simply repairs their cleft palates but not their lives. Such cases show gaps in the programs that still need attention. The repair is just part one of the equation - there need to be more follow-up services that can also be covered by funding agencies.

SMAKA: I hear that a lot with mission trips. It is heartwarming to help these people, but it is frustrating to see how much more is needed.

KATBAMNA: Yes, but the first step in the care of cleft palate is initiated and it is up to us, any one of us to take it to the next level - initiate the intervention process - we have opportunities to give back to the community, not just in the form of giving people a hearing test and a hearing aid, but helping people be freestanding and independent.

SMAKA: How would audiologists get involved - visit the website?

KATBAMNA: Yes, it may be best to first visit the website (www.smiletrain.org) and then call the headquarters in New York if you have any questions. The people working at the headquarters are extremely knowledgeable and helpful and can guide you as appropriate.

SMAKA: It is a very productive charity, dollar for dollar, according to The New York Times. Only $250 to perform a surgery;what an amazing return on your donation.

KATBAMNA: Yes indeed. It is a meager amount of money to give a child a head start in life.

SMAKA: Do you think you'll go back?

KATBAMNA: Donna and I would love to return in December 2012, three years from the first visit. It would be great to see how some of the same children we saw on our last trip are faring with their speech and hearing problems. I am so glad I had the opportunity to be part of this experience - if Donna had not brought the book to me, I would not have ventured into this expedition. One can volunteer in so many programs and it can be a lot of fun, particularly if you go as a team with another professional or a group of professionals.

SMAKA: It has been just so wonderful to hear about this. Dr. Katbamna, thank you for sharing your experiences with us. I encourage anyone who is interested to learn more about Smile Train to go to www.smiletrain.org for more information.