The year 2009 was a landmark one for Smile Train. After the worldwide financial meltdown the previous year, we had been certain that donations would go down with the stock market. But in fact, while many nonprofits were cutting budgets or closing their doors, we had our best year ever. After our Oscar win in February, we were now raising more than $100 million a year, and acquiring hundreds of thousands of new donors. Smile Train had become one of America’s most well-known, respected, and beloved charities.
There was only one problem: we were beginning to have too much money. I know it might sound strange—and we were probably the only charity in America facing this particular issue—but we were accumulating a huge amount of unused donations.
Our immediate reaction was to increase our program spending to expand current programs and fund new ideas that we never felt we could afford before. We built operating rooms and increased funding for speech therapy. We launched dentistry programs for our patients who often struggled with severely misaligned teeth even after their surgeries. We bought vans and cars to help our partner hospitals find and help patients in very rural, hard-to-reach areas. We significantly increased our training and education programs. But as hard as we tried, our program spending just couldn’t keep pace with our fundraising growth. It wasn’t even close.
The surplus of unused donations grew larger and larger, until it exceeded $100 million. At this point, I became very uneasy. Things were out of whack. I didn’t want to raise money we couldn’t spend. I didn’t want money that could be changing lives wasting away in a bank. Most importantly, I didn’t want to mislead our donors.
The way I saw it, we either had to increase our program spending or reduce our fundraising. It was that simple.
Or maybe there was a third path. Maybe this additional money wasn’t a problem at all— maybe it was an opportunity.
Over the years, I had visited so many hospitals in some of the poorest countries in the world. I would always meet with cleft surgeons and cleft patients because clefts were the one and only focus of Smile Train. But on almost every visit, the local doctors would show me other areas where they desperately needed help. They would bring me to the burn ward so I could meet children who had been severely burned. The orthopedic ward filled with children who had been born with clubfoot who were unable to walk or stand. Blind kids, deaf kids, I witnessed some of the saddest and most heartbreaking suffering as the local doctors quietly pleaded with me to help these children as well as patients with clefts. And I would politely listen and take these tours, but I always ended with a stock answer: “I’m sorry, but we’re a cleft charity, and all of our money has to go to cleft programs—we cannot help you.”
After so many of these heartbreaking tours, I would always promise myself that in the future, when we had clefts under control, I would come back and help with these other problems.
When our surplus of unused donations zoomed past $100 million, it occurred to me that it might be time to start fulfilling that promise.
In late 2009, I met with my senior management team in New York and we discussed expanding the Smile Train mission beyond clefts. All of us felt very unhappy about accumulating a large surplus of unused donations. We were on the front lines, we saw the suffering every day. We wanted to spend as much as possible helping as many children as possible every year.
The first question was which problem would we want to tackle next? Some people wanted to fight hunger; malnutrition is a huge problem in the developing world. Some folks wanted to tackle much higher-profile global health problems like AIDS, tuberculosis, and malaria. Some wanted to switch our emphasis on developing countries and start doing more work in at home in America. But after a lot of discussion and healthy debate we all came to consensus that we should stick with what we knew best: providing simple, inexpensive, high-impact surgeries for children in the developing world.
As we narrowed the focus, we found there were major medical problems that, just like clefts, can be solved through simple, inexpensive surgeries. A five-minute surgery—along with six weeks of treatment—can cure the common birth defect of clubfoot and enable a child to walk and run for the first time in his or her life. A $300 reconstructive surgery can rebuild the face of a severely burned child. Perhaps most compelling of all, we learned there’s a miracle surgery that can give a blind child or adult their eyesight back in as little as five minutes and for as little as $35. We were shocked to learn that half of all the blind people in the world, around 20 million, remain blind solely because they are poor.
Everyone on the team was blown away by these new opportunities. Each one was larger than the problem of clefts and many of the surgeries cost much less than cleft surgery.
Suddenly this idea of expanding the mission of Smile Train began to take on a life of its own.
I spoke with our lawyers to make sure there were no legal issues. We reached out to more than 1,000 partner hospitals around the world asking for their feedback. The overwhelming majority of them loved the idea of Smile Train applying its model to other problems. I even reread our Smile Train bylaws to make sure there was nothing in there that restricted our work to cleft surgeries—and there wasn’t. The more research I did, the more viable the whole idea seemed.
Around the same time we were beginning to think about expanding the mission, something unprecedented happened. For the past year or so, in an effort to spend more money, we had been working hard to triple our network of hospitals in China from 150 to 450. We fully expected our surgeries in China to triple as a result. But they didn’t increase at all.
What was happening? This was the first time we had added partner hospitals but hadn’t see any increase in surgeries.
Perplexed, we turned to Steven Levitt, renowned professor and economist from the University of Chicago and coauthor of the bestselling Freakonomics books. Steve was a valued consultant as well as a longtime donor to Smile Train. He had written an article about our organization in the New York Times where he described us as “one of the most productive charities, dollar for deed, in the world.”
We sent Steve and his team at the University of Chicago about 600,000 patient charts from our digital database and asked them to help us figure out why our numbers in China were decreasing. It didn’t take long for them to come back and tell us they’d found the answer.
“Brian, are you sitting down?” Steve asked.
I braced myself for bad news. Instead I got the opposite.
“The reason your cleft surgeries in China have stopped going up isn’t because you haven’t been working hard enough,” Steve told me. “It’s because Smile Train has been doing a great job.”
Steve explained. Over the past ten years, Smile Train had helped clean up the backlog of children waiting for surgeries in both China and India. Today, in both of these countries more than 70 percent of cleft surgeries were being performed on newborn babies and infants less than two years old. No wonder numbers were going down. The backlog was clearing and there simply weren’t as many patients to operate on anymore.
I was stunned. After I regained my composure, I asked Steve how he’d figured this out.
“It was simple,” he told me. “We looked at the median age of your patients. In America, there are five thousand babies with clefts born every year, and they all receive surgery in the first few months of life. So the median age of all cleft patients in America is around nine months. It’s the same in Europe.
“When Smile Train started helping children in China, the median age of your patients there was around four years—and many patients were much older, such as ten and fifteen years old, some even in their twenties and thirties. But now, after almost a decade of Smile Train doing surgeries in China, the median age has been cut in half! It’s dropped from four years to less than two years as the backlog has been reduced. It won’t be long before the median age in China is the same as it is in the US.”
Steve went on to explain that the same phenomenon was happening elsewhere. “When Smile Train started work in India, the median age of cleft-repair patients was about six years. But now, after hundreds of thousands surgeries, the median age there has also been cut in half to three years. Just like China, the backlog of children with unrepaired clefts is being significantly reduced.”
This was nothing short of astonishing. India and China account for more than 80 percent of all the clefts in the world! If we could clean up the backlog in those two giant countries, it meant we could reach our goal of eradicating unrepaired clefts worldwide.
After I thanked Steve for giving me some of the best news of my life, I hung up and took a breath. For years we had lived in fear that our fundraising wouldn’t be able to keep up with the demand for cleft surgery. For years, our surgeries per year would jump by 5,000, 10,000, even 15,000. We expected it to continue to rise and rise, and felt very lucky to be able to raise enough money to help all the kids who needed it year after year. But now our surgeries per year growth had slowed way down, and, thanks to Steve Levitt, we now knew why.
“The tide has crested,” I told our team later that day. “This is why our surgery numbers in China haven’t gone up even after we tripled the number of partner hospitals. There simply aren’t as many older children who need cleft surgeries anymore. Our numbers have leveled off not because we’re not working hard enough—but because we’ve been successful.”
We were closing in on our goal of eradicating unrepaired clefts worldwide.
Of course, babies were always going to be born with clefts, and in the developing world, there would still be many poor families that could not afford cleft surgery. Smile Train would need to continue its mission of helping families gain access to cleft surgery no matter where they lived and regardless of their ability to pay. So there was still plenty of work left to do. But we had figured out the delivery model. We had more than $100 million in the bank. And our fundraising machine was as strong as ever. We had climbed the mountain. We had solved the 200,000-year-old problem of clefts.
This great news from Steve Levitt gave me new urgency to work on expanding the mission of Smile Train.
In January 2010, together with DeLois—who by then had become my right hand woman—I took a trip to East Africa that galvanized my resolve to expand the Smile Train mission. We were visiting partner hospitals in Ethiopia and Kenya, all of them doing astonishing work helping children with clefts under extremely challenging circumstances. It also happened that this trip confirmed our recent research—everywhere we went, we encountered children who needed simple procedures other than clefts, but who didn’t have the money for surgery.
Our first stop on the trip was Ethiopia—one of the poorest countries in the world, with a population of 80 million. After landing in Addis Ababa, we were driven in a van to a small hospital two hours outside the capital. Here our partners were holding a cleft camp to register patients from all over the country. They had set up ramshackle tents to help corral the huge crowds of patients, many of them traveling from hundreds of miles away to get to the camp. Inside the tents it was dark and ferociously hot—at least 100 degrees. The patients sat on the dusty ground, waiting to be examined. Some had brought blankets to sit and sleep on, because if they were lucky, they would be chosen for surgery and would be here for several days.
As I was walking around, taking photos and talking with patients, I saw a little boy who had a friend or older brother holding him by the arm, leading him around. Looking more closely, I saw that his eyes were half closed and glazed over. He was blind.
I went over to talk to the boy and learned that his name was Asrat. He was five years old. A few days ago Asrat had received his cleft surgery and he had been recovering since. Tomorrow he would go back home. His little friend informed me that Asrat had been born blind. I’d spent the past year reading about blindness, but until that moment, I’d never met a child who was blind.
INSERT PHOTO: Asrat
On the long ride back to our hotel, the image of that little boy haunted me. We had fixed Asrat’s cleft, but what about his blindness? At the end of the day, Asrat would go home and he would still be blind.
DeLois and I agreed. This chance meeting at the camp in Ethiopia only added to the urgency of expanding the mission.
The next day, we boarded a small Cessna plane bound for the border area between Kenya and Somalia. An hour later, we landed with series of bone-jolting bumps on the dusty airstrip. Beyond the window stretched a desert landscape that was as bleak and barren as any I’d ever seen. No buildings and not even a control tower for the airstrip—just a couple of rusty jeeps with UN stickers and an army truck filled with Kenyan soldiers awaited us.
We were here to visit Dadaab, the world’s largest refugee camp and home to over 400,000 people, in order to meet with our partner surgeon at the camp, Dr. Dan Poenaru, to find out how we could better support him in his work. Dr. Dan is a Romanian-born pediatric surgeon based in Nairobi who travels to the border region every two months to operate on patients there. As we clambered out of the plane, we saw Dr. Dan, striding toward us, a baseball cap on his head and his hand extended.
“Welcome to Dadaab,” he said.
We loaded into the back of a waiting car. As we drove, Dan gave us some background on the place we were about to visit.
“Dadaab is probably the biggest casualty of Black Hawk Down,” he explained. In 1993, two Black Hawk helicopters were shot down in Mogadishu during a botched US military raid to kill a Somali warlord. This ended with eighteen Americans dead, seventy-three wounded, and one soldier captured and dragged through the streets. President Clinton ordered the withdrawal all US forces from Somalia, and the country went into a tailspin.
“Two decades of civil war, violence, and chaos have left millions of Somalis dead and displaced,” Dan went on. “Many ended up here in Dadaab. The camp was built as a temporary refuge for 90,000 Somalis. Today, more than 300,000 people live here, and another 5,000 show up every week begging for food and shelter.”
As we drove, huge clouds of dust billowed from the scorched earth. Outside, the landscape was parched, with no signs of water or vegetation. Animal skeletons and still-decaying carcasses littered the side of the dirt road.
After a short drive, we arrived at the camp. Stretching in every direction, as far as the eye could see, were rows and rows and rows of huts. Huts made of sticks tied together with pieces of string. Huts made from corrugated metal and tarpaulin. Huts made of mud and cinderblock. It was 2010 and I had a smartphone in my pocket, yet here was an entire city’s worth of dwellings made from sticks and string.
We pulled up to the small medical clinic where Dan worked, one of only three serving the entire population of 300,000 people in the camp. Inside the clinic, dozens of children and their parents were already waiting for Dan. Everyone wanted the doctor’s attention. We didn’t need a translator to understand what the parents were saying; begging for help sounds the same in any language.
“You have to understand, before coming to Dadaab, most of these people had never seen a doctor in their life,” Dan told us.
By now, we were engulfed in the crush of bodies, everyone waving medical notes from their last visit, promising medicine or surgery.
“See, this is my handwriting: ‘Needs surgery ASAP,’” Dan read aloud. “I am embarrassed to say that this is dated over a year ago.” He shook his head in frustration. Clearly he was overwhelmed.
Dan told us that he was in dire need of another operating room, another surgeon, and more supplies. And he also needed help for patients who had really serious, life-or-death issues, who needed to be taken outside the camp to be seen at a larger hospital. Dan had funding to choose only six people per month to be transported elsewhere; the rest had to wait and hope to survive. Most of them did not.
We kept walking through the crowd. We met a young boy who was blind and missing part of his arm.
“His family was killed in an explosion in Mogadishu,” Dan explained. “He survived, but now he is all alone. I am trying to order him a prosthetic arm. He needs a prosthetic eye as well, but that’s almost impossible to get.”
Next we met a twelve-year-old girl with clubfeet, her legs hanging lifelessly from her hips, her feet turned inward at 90-degree angles. She stared up at me, her eyes imploring. Her mother, next to her, had the same desperate look. Dan explained that this girl’s feet could be completely fixed—if he only had the funding.
A ten-year-old boy came over to us. Dan told us he had been horribly burned after falling into an open fire. Without any access to medical help, the boy had spent days in bed curled in a fetal position. Somehow, he managed to survive, but as his wounds began to heal, the scar tissue had fused his chin to his chest. This poor child couldn’t smile, he couldn’t speak; he couldn’t even move his head from side to side.
We saw children lying on blankets in the dirt with oversized heads, suffering from water on the brain, a condition that can be easily treated by inserting a shunt from the brain to the abdominal cavity, draining the excess spinal fluid that causes the swelling. “That is, of course, if we can find the money for the shunt,” Dan said, “which costs around $35. Otherwise, these children will die. And they do, every month.”
Everywhere we went that day there were children with easily treatable conditions who were likely to suffer their entire lives because they had been born desperately poor, in the wrong country, and at the wrong time.
In the small room Dan used as an office, he showed us a chart listing the medical problems he was seeing at the camp—more than half of them could be corrected through surgery.
LIST OF SURGERIES
Clefts didn’t even make the list. If we had ever been in doubt that there was a massive need for additional funding for other types of surgeries, we had just received confirmation, with our very own eyes.
Good Reads: Before and After by Brian F. Mullaney, Co-Founder of Smile Train and WonderWork.
