Since her first trip to Nigeria in 2016, Dr. Melissa Amundson has spent at least one month every year in the country, providing reconstructive surgery to children and adults with noma, a type of gangrene affecting the face. She does so through Médecins Sans Frontières/Doctors Without Borders (MSF), an organization bringing doctors to communities that need medical support around the world.
Dr. Amundson first applied to MSF knowing the organization provides surgery to people affected by war, but was told they had no need for an oral and maxillofacial surgeon at the time, as most of what they do is emergency care. A few months later, however, MSF reached back out, informing her of a new project supporting the Sokoto Noma Hospital in Nigeria.
Long-term Project, Long-term Success
Dr. Amundson has been involved in medical “missions” in the past, but explained the term “intervention” is becoming much more widely used, as it reflects the fact that these trips are both nonreligious and long term. The Sokoto Noma Hospital hosts oral and maxillofacial surgeons four times a year, a full month each time, and capacity building is a main focus of the project.
“It’s becoming very outdated to have it where you go in for a week and do all these surgeries — everyone looks cool and takes pictures — and then that’s it,” Dr. Amundson said. This causes a society entirely dependent on short-term visitors coming in and “doing everything,” without the ability to manage complications.
“That’s a system fraught with failure. There are cost analyses that show the drop-in mission trip concept is incredibly expensive, and for a fraction of that money spent, a local physician or nurse can be trained.”
Instead, the noma hospital operates 24/7. When international doctors are not there, Nigerian doctors, nurses, and surgeons care for patients and are “more than capable” of handling follow-up procedures and aftercare, according to Dr. Amundson. Plus, they provide patients with a shared language and cultural connection. During these in-between times, patients are prepped for surgery with intensive nutrition regiments. Patients also receive psychological care, entertainment, support finding employment, and other resources during their lengthy (usually six-month-long) stays.
Although there are currently no Nigerian oral and maxillofacial surgeons at the hospital, Dr. Amundson is participating in a project, currently in the capacity-building stage, to train local surgeons to perform these surgeries.
A Disease of Poverty
Noma is a complex disease stemming from socioeconomic issues that often result in poor dental hygiene combined with profound malnutrition. The disease itself starts when an abscess forms on a child’s gums. If caught early, it can be treated with antibiotics. If it remains untreated, it develops into a form of gangrene, which “causes destruction of facial structures and can lead to holes in their faces,” Dr. Amundson said.
“This condition only occurs in areas of the world where people are essential starving to death, so it’s known as the ‘disease of poverty.’” The lack of nourishment leads to the body’s inability to fight the disease. The mortality rate is 90%, and those who do survive are often shunned and face social stigma.
“It’s shocking the first time you see it. To eat, they have to push food in their face, hold it in the back of their tongues, and swallow,” Dr. Amundson said. “In some regions, there are preconceived ideas that these kids have a curse. Many kids are isolated and not allowed to leave or enter society.”
Reconstructing Lives
Dr. Amundson in surgery.
To treat the condition, oral and maxillofacial surgeons do a number of surgeries.
“We’ll do flaps and reconstruction to close the holes,” she explained. “If they’re missing a nose, we’ll give them some reconstructive tissue that looks kind of like a nose to reintroduce them back in society.”
A common problem many patients experience is ankylosis. When this happens, if surgeons close a facial hole, patients will be unable to feed themselves. To fix this, “ankylosis release will generally precede the flap closure of the defect,” said Dr. Amundson.
When people affected by noma come to the hospital, they’re able to see others who look like them, as well as get the care they need.
“The impact it has on their mental health is night and day,” Dr. Amundson explained. “They realize they are not alone.”
And because the hospital doesn’t just operate and send the kids away, the risk of post-operative issues is low.
Who Should Volunteer?
Volunteering for a project like this is time-consuming. It requires Dr. Amundson to take vacation time as well as unpaid time off for one month every year. She must coordinate with her American patients before traveling, and often communicates with them on WhatsApp when she’s gone. She’s the only American oral and maxillofacial surgeon involved in the program, as a more flexible work structure is easier for her European counterparts. But this program structure is beneficial to the community, so Dr. Amundson believes it’s worth it.
MSF is incredibly picky when it comes to accepting applications from interested doctors. They want dedicated volunteers committed to regular visits. People involved must be okay working with imperfect equipment and navigating multiple language and cultural barriers. They have to be comfortable with the little inconveniences, too, like living with bugs and without air conditioners. Some doctors believe these trips will be glamorous “medical vacations,” but this is not the case.
Although Dr. Amundson sees issues with certain types of one-week, drop-in trips, she recommends short-term dental missions to surgeons interested in getting started with international interventions.
“That’s something that’s sustainable. You’re not leaving right after you did some monster surgery that might need revision or has a high risk of failure or complications. You’re taking out teeth, so you can leave those patients a couple of days after finishing a project and not worry you are abandoning the community.”
She believes it’s a great way to help people while also getting used to an unfamiliar surgical environment.
“If you find your week of taking out teeth with instruments you don’t like a frustrating challenge, larger international projects are probably not for you. It does not get easier from there.”
Melissa Amundson, DDS, MPH, FACS is currently a full-time, hospital-based maxillofacial trauma surgeon. In 2020, she joined the faculty of Florida State University School of Medicine to start the first oral and maxillofacial trauma program for the “Big Bend” region at Tallahassee Memorial Hospital. She manages complex trauma and pathology for the region including Alabama, Florida, and Georgia.
She received her bachelor’s degree in molecular biology from the University of Wisconsin-Madison and received her DDS from the University of Illinois-Chicago in 2007. She started her career in OMFS with an internship at the University of Pennsylvania followed by her residency at the University of Miami/Jackson Memorial Hospital in 2012. In 2015, she returned to an academic setting and completed her fellowship training in advanced craniomaxillofacial surgery and trauma in Portland, Oregon at the Head and Neck Institute/Legacy Emanuel Medical Center.
After completing her fellowship, she remained with Head and Neck Surgical Associates from 2016 to 2019, managing complex trauma for Southern Washington, Central and Western Oregon, and Northern California. During this time, she was also the program site director for resident education and was the CMF/Trauma fellowship director from 2018 to 2019. She is an editor/reviewer for several publications and has authored/co-authored several articles and chapters on craniomaxillofacial trauma.