Smile Train:  Around, 1994 I merged a surgical charity I’d started in New York City called Operation Smile, with another charity in Virginia also called Operation Smile. 

It seemed like a good match because my charity, Operation Smile in New York City was helping provide surgeries for underprivileged American while the Operation Smile Virginia was providing surgeries for underprivileged kids in developing countries. There was no overlap. I joined the board of Operation Smile Virginia and helped them increase fundraising by millions of dollars. But my favorite part was going on medical missions to places like China, Vietnam and Gaza City. It was an incredible experience to witness first-hand the power of these surgeries.

 

 

 

 

 

 

 

 

 

 

 

 

 

I’ll never forget the first surgery I watched. It was performed on a little 9-year old girl named Colorful Cloud in a very remote, poor village in Southern China. In just 45 minutes, I watched our surgeon transform her from a severely deformed, depressed child into a smiling, normal little girl. I felt I witnessed a modern-day medical miracle. I carried Colorful Cloud out of the O.R. and into recovery where I waited with her dad  for her to wake up.  After 15 minutes she woke up and a nurse ran to get a mirror.  I’m never forget watching her hands tremble as she slowly raised that mirror and stared into it.

I was expecting Colorful Cloud to holler and cry for joy but she remained totally silent – just staring into that mirror. Just as I started to think something was wrong, I saw a teardrop slip out of her right eye and down her cheek. And then another. And another. Soon nine years of tears were pouring down her cheeks as she stared at her new face and her new life.  That surgery didn’t just change her life, it changed my life too.

 

What made these miracle surgeries even more impressive was that we were providing them for the poorest children on earth. Most of these children and families traveled many days and many miles to reach our partner hospitals when word got out that a medical mission was offering free surgery. They would show up with no money, no food, shoes, nothing but the  tattered clothes on their backs. 95% of our patients and their families were illiterate and living on less than $1 a day. Most of them had never seen a doctor in their life. To pay for their travel to get to our mission sites, they would sell their rickshaws, livestock, homes, land. Many would be forced to borrow money from family or friends or their village. They would do anything to get to this hospital and give their child a chance for surgery because they knew it might be their last chance.  You could see the desperation in their eyes.

On a typical 2-week mission, Operation Smile would send 40 to 50 volunteer surgeons, doctors and nurses to a small village or town in a very poor, developing country. They would ship 10,000 pounds of medical equipment to build operating rooms that were as close as possible to the standards for operating rooms in the US. The team would spend the first week screening hundreds of children to identify what surgery they needed and determine who was healthy enough to undergo surgery.

In many countries we visited, 50+% of the children were suffering from malnutrition and stunted growth. Few if any of these kids had ever seen a doctor before. Many had other medical problems ranging from a cold or fever to more serious things like a heart condition or a syndrome. On average, 300-400 children would show up at a mission accompanied by their mom or dad or neighbor. They’d register, be examined by doctor and then they’d wait and see if they were chosen to receive surgery. We usually only had the resources and time to operate on 100 or so children. The surgeries would take place the second week. Then we’d pack up all our equipment and supplies and fly home. These missions were a dream come true for the 100 lucky children who received surgery.

But they were a nightmare for the 200- 300 kids who were turned away. The hardest job on every mission was telling 200 to 300 mothers that their child would not be receiving surgery. What followed was hard to watch. The mothers would cry and plead and throw themselves on the ground, begging for their children to be helped.  With tears streaming down their faces, they would plead, please, please, please add one more child to the list. Please save my child – I beg of you. 

I was horrified when I first witnessed this common practice of turning away hundreds of children. Op Smile on average was turning away 2 to 3 kids for every kid they operated on. I thought this was insane. What hospital turns away three patients for every patient they help? I complained again and again about this practice to the husband and wife who co-founded Operation Smile Virginia. They would always just shrug and tell me there was nothing they could do. They told me said the solution was to raise more money so we could send more missions.

At first, I thought they were right. I devoted a lot of time to helping them raise millions of dollars of incremental donations. In a couple of years, we tripled Op Smile’s annual revenue. But instinctively I knew raising more money was never going to be the answer.  Doubling our missions would only mean doubling the number of kids we turn away. We didn’t need more money, we needed a new business model. The 2-week mission model that Operation Smile was built around was great for a small Mom and Pop charity that wanted to help a couple of thousand kids a year. 

But my dream was not to help provide a couple thousand surgeries a year, but a hundred thousand surgeries a year. I wanted to solve the problem of clefts. It was estimated that there were between 1 – 2 million children with unrepaired clefts in the world that needed surgery. I wanted to be part of a team that made sure they got it. To do this, we would need to find a way to scale up the number of surgeries we were doing while also significantly reducing the cost per surgery.

After joining the board, going on missions and spending a couple years learning all about Operation Smile, it was very clear to me that the 2-week mission business-model could never scale up to 100,000 surgeries a year for many reasons. First and foremost, the mission model is very expensive. It costs a fortune to ship 10,000 pounds of medical equipment and 40 volunteers halfway around the world for one week of surgery. Operation Smile’s cost-per-surgery was $1,000+.  Multiply that by 100,000 surgeries a year and the cost is $100 million a year. At the time, Op Smile was barely raising $3 million a year so this wasn’t even remotely feasible.

Another problem was that the mission model isn’t scalable. An average 2-week mission provides only 100 surgeries. That means to provide 100,000 surgeries, you need to send 1,000 missions a year which would require 40,000 volunteer doctors and nurses. At the time, Op Smile had 300 volunteers and was sending 23 missions a year. This too wasn’t even remotely feasible.

Finally, and perhaps most importantly, the mission model is not sustainable. Missions breed dependency – not independence. Op Smile’s busiest mission site today, 25+ years after it started, is the very first place it ever sent a mission: The Philippines way back in 1985. Over the past 36 years, as Op Smile has sent more and more medical mission, The Philippines has grown more and more dependent on Op Smile missions. Philippino surgeons don’t do cleft surgery because they know Op Smile comes every year and offers free surgery. And parents prefer American surgeons.

To solve the problem of clefts, we needed a new business model that could:

1. Dramatically reduce Op Smile $1,000+ cost-per-surgery.
2. Scale up to at least 100,000 surgeries a year.
3. Help very poor but very proud communities become self-reliant.

I found the answer to our search for a new business-model on an Op Smile mission to Bac Thai, Vietnam, 3 hours north of Hanoi, near the border with China. I asked an Op Smile American surgeon why the local Vietnamese surgeons didn’t provide any cleft surgeries. He laughed and said, “They provide cleft surgeries every day – except when we show up.” I had been led to believe that only American surgeons could do these surgeries. “Are the local surgeons any good?”  I asked incredulously because I had also been led to believe that the local surgeons were not very good. “Actually, most of the local surgeons are much better cleft surgeons than the ones we bring on missions.” he told me. “It’s because they do many more cleft surgeries every year than we do. Most of the surgeons who go on missions don’t do any cleft surgery back in the States.”

He explained why, “A Vietnamese surgeon might do 500 cleft surgeries a year whereas an American cleft surgeon might do just 10-15 cleft surgeries a year. To make matters worse, most surgeons who go on missions are NOT cleft surgeons and haven’t done a cleft surgery since med school.” I couldn’t believe what I was hearing. We were spending tens of millions of dollars flying American surgeons with little to no cleft experience half way around the world to operate in hospitals that had local surgeons and nurses that were perfectly capable of providing safe, high-quality cleft surgery. Now that didn’t make any sense. “How much do Vietnamese surgeons make a month?” I asked. “Between $300 and $600 a month,” he said. “Nurses make $25 a month.” My head almost exploded. We were spending $1,000+ per cleft surgery on missions to places where local surgeons – who were better cleft surgeons – cost just $22 a day. My mind was racing. Imagine if we took the $120,000 that this 2-week medical mission cost and that will provide about 100 surgeries, and instead, used it to fund local surgeons, nurses and this hospital?

Instead of 100 surgeries, that $120,000 could fund 500 surgeries.

So that’s how I stumbled across the radical, unprecedented, unorthodox idea of empowering local surgeons instead of sending American surgeons and nurses on 2-week medical missions. This new business model would turn the cleft surgery business upside down as it would dramatically reduce the cost per cleft surgery while the number of surgeries would soar. This new business model was affordable, scalable and sustainable. And it could slowly but surely help very poor but very proud communities become self-sufficient one surgery at a time.

I stopped talking when I saw the look of horror on the American surgeon’s face. He asked, “You really want Vietnamese surgeons to do the surgeries?” “Yes!” I replied, “Vietnamese, Chinese, Indian, Kenyan, whatever! Local surgeons are better cleft surgeons, they’re so much less expensive and they could operate every day of the year not just one week! This might mean we never turn away any child ever again!“

It was all so clear to me. This was the new business model we had been searching looking for! I couldn’t understand why this American surgeon wasn’t as excited and happy as I was. After a long pause, he asked me, “If we start letting the local surgeons do all the surgeries…then what will I do?” Good question. I had no idea. But I did know that this new idea of empowering local surgeons was a very, very big idea and I couldn’t wait to learn more about it and find out if it was as big an ideaas I thought.

I stopped talking. But I couldn’t stop thinking this new idea of empowering local surgeons. It seems no one had ever tried that before. When I returned to New York, a small group of us started to quietly work on this new idea of empowering local surgeons. The person who helped the most was Delois Greenwood. She was one of Op Smile’s most senior, experienced and talented managers. She started out as a scrub nurse who went on Op Smile’s first mission to the Philippines in 1982. Since then she’d gone on a gazillion missions to 50-70 countries as she helped provide surgeries for thousands and thousands of children. Delois knew more about delivering surgeries in developing countries anyone. Her ideas, input and feedback were critical to the development of the Smile Train.

Around this same time, I met with a man who owned a own steam locomotive. He wanted to use it to help fundraise Op Smile. I didn’t think that would work. But it got me thinking about trains which are the backbone of most developing countries – especially China and India.

 

What if we created a special train in China to test this new idea of empowering local surgeons? (We picked China because my client, Charles Wang, was Chinese. I was going to ask him for a big donation to launch this new idea.)

 

 

 

 

 

 

 

 

 

 

The idea was to design a train with operating rooms and classrooms that would travel all around China. The train would stop in villages and towns for two-week periods – just like a mission. But unlike a mission, the main goal was not to provide a ton of surgeries but rather, to leave behind well-trained surgeons and medical equipment so they could keep operating long after the train was gone. We were switching the focus from operating to training.

American volunteer doctors, anesthesiologists and nurses would fly to wherever the train was and live on the train for 2-weeks at a time – just like a mission. But the goal of these missions would change from Op Smile’s goal of doing as many surgeries as possible to training as many surgeons, anesthesiologists and nurses as possible. This would reduce the number of surgeries done on each “mission” –  but the number of surgeries that would happen after the train left would be enormous. This way we could leverage hundreds of Op Smile volunteer surgeons, nurses, etc. with this exciting new idea of empowering local surgeons. It was the best of both worlds.

We envisioned a truly one-of-a-kind train with huge pictures of smiling children on the outside so when it arrived in a small village or town, it would make be like the circus coming to town. It would raise awareness about the problem of clefts and the impact of life-changing surgery. Coming up with a name was easy. Just look at these graphics and you can clearly see that this is a Smile Train.  My ad agency partner and award-winning art director Mike Schell created the fantastic, smiling, Smile Train logo and all of these visuals of what our Smile Train might look like.It would have state-of-the-art operating rooms outfitted with cameras and teaching aids. Classrooms with video feeds from the O.R.s and smart boards.And cargo cars filled with medical and computer equipment that would be left behind to help the local surgeons and nurses keep operating.

All we needed now was to raise some money to fund a pilot program and find out if this new idea worked as well as we hoped. Smile Train started out as a pilot program of Op Smile to see if it did work. To fund it, we decided to hold a fundraiser and invite Op Smile donors as well as new supporters. We held a black tie event at The Winter Garden in New York City in January, of 1998. More than 800 people showed up including many celebrities, Wall Street heavy hitters and lots of media. NBC Today Show host Ann Curry emceed our event and she was awesome. We started our program before dinner and tried to show everyone what The Smile Train project was all about.

 

 

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We showed a video featuring a 9-year-old girl in China named Wang Li who had a very severe cleft. She is outside a school, crying, watching all the other kids playing on the playground. Wang Li wasn’t allowed to go to school because of her cleft. 

Everyone clapped when Ms. Curry announced that thanks to The Smile Train Project, Wang Li was going to receive the cleft surgery she had been waiting for 9 years.  Then, as a surprise, we went live to China, via satellite, for an interview with Wang Li. She told the audience how painful and difficult her life had been, living with an unrepaired cleft in one of the poorest villages in China. Her dad worked at a brick factory and could never afford to pay for surgery. She said that her dream had always been to go to school and soon, after her surgery, her dream would come true. She thanked the audience for helping her.

This satellite interview gave everyone a lot to talk about during dinner. Afterward, there were the usual speeches and then in her final remarks, Ann Curry said, “We’d like to send each of you home tonight with a smile on your face so we have a surprise for you. While you were eating dinner, a team of Chinese surgeons halfway around the world, were performing cleft surgery on Wang Li!” The entire room gasped.

Ann Curry  continued,  “Let’s go back live right now, to China, via satellite and see how Wang Li’s cleft surgery turned out!” The big screen opened up to Wang Li  sitting upright on her operating table, beaming, crying, surrounded by a team of surgeons,  and nurses. Wang Li was smiling and crying, shaking her head, and her cleft was GONE! Through her interpreter, Wang Li kept saying, “I am so happy! Thank you everyone!” Ann Curry asked her a great question, “ Now that you can finally go to school, what are you going to study Wang Li? What do you want to be when you grow up?” Wang Li paused, smiled and said, “ I want to be a doctor…”  and that of course brought the house down as 800 people stood up and cheered. That Smile Train event was the best charity dinner I have ever attended.

A month before this fundraiser, the President of China, Jiang Zemin, came to the U.S. for an historic visit. It was great news for us since we wanted to launch the Smile Train in China and believed it could be a great example of a US-Chinese partnership that would bring many surgeries to children and also help foster goodwill between our countries. President Clinton hosted a state dinner for President Zemin. Everyone wanted to be there especially the CEOs of Fortune 500 companies who were doing business in China. When The New York Times printed the guest list, I wrote to every CEO asking for help with Smile Train. Only one CEO responded, Maurice “Hank” Greenberg of AIG.

Mr. Greenberg was one of America’s most successful and admired CEOs and no one knew China like he did. I met with his foundation, The C.V. Starr Foundation, and they became one of Smile Train’s biggest supporters giving us almost $20 million over the next decade.  I got to thank Mr. Greenberg personally for his generous support and I am still in touch with him more than 20 years later.

Former President George H.W. Bush met with President Jiang Zemin during his visit and told him all about Smile Train. President Zemin approved it on the spot and told one of his top people to “make this happen”  The next step was to meet with the Minister of Railways in China. Since his boss –  the President of China  – had already approved our idea, I thought the meeting with the Minister of Railways was just a formality. It was a very cold, windy January day in Beijing when we met in an old government building with dim lighting and virtually no heat.

Zhubin Han, the Minister of Railways walked in with a large entourage of government bureaucrats. After the usual perfunctory greetings in both Chinese and English,  I gave a short presentation on all the wonderful things Smile Train was going to do in China.  During my presentation, the minister looked angry and bored.   When it was his turn to respond, the Minister wasted no time in telling us that we knew nothing about the Chinese railway system. He told us it is the second largest railway network in the world which transports 2+ billion people a year over 75,000 miles of track. The trains run on precise timetables and the thought that we could park our Smile Train in a village for two weeks while we did surgeries was naïve and IMPOSSIBLE.  Most towns have just one track so we’d be blocking all traffic in and out. Just one of dozens of reasons why our idea could never work. He saved the best for last when he told us “you people are pain in my ass!” Then he sat down.

We all sat stunned and in silence for a minute as we tried to regroup. I thought it would be better to go down swinging than walk out with our tails between their legs. So I stood up and told the minister a famous story that every child in America learns is told at least once: the story of The Little Engine That Could. As I told this story, I summoned as much emotion as I could — especially with the “I think I can, I think I can, I think I can” part. The minister seemed absolutely riveted. For a minute, I thought I had opened his heart to The Smile Train. But right before the ending, the Minister slapped the table and said,  “Aha! I know that story –  that train is Charlie Choo-Choo!” Everyone laughed and I sat down and wrote on my notepad, NO TRAIN.

It was a long flight back to the United States. Everyone was depressed. But when after we discussed the situation, we realized our big idea was not the train – our big idea was to empower local surgeons instead of sending missions. If anything, losing the train would save us all the trouble and expense of creating a train and outfitting it with all the special cars that we needed for operating rooms in classrooms. So we immediately got back to what really mattered:  Empowering local surgeons and nurses who work at local hospitals and developing countries.

It wasn’t long until we faced a much bigger problem than getting a real train. The co-founders of Operation Smile did not like our Smile Train at all. They had been going on missions for decades. He was a dentist that loved to do surgery and she was a social worker. I thought they’d be excited about our idea of empowering local surgeons and nurses because it would mean Operation Smile could stop turning away thousands of children every year. Not to mention the fact that we had already received a $10 million pledge from Wang’s company which was ten times bigger than any donation Operation Smile had ever received. The co-founders asked the Op Smile board to reject the $10 million pledge. They had a long list of objections including their opinion that Smile Train was too “China-centric” and it was too “risky” to let local surgeons and nurses perform cleft surgery.

Another reason was that they considered Smile Train as competition for an idea they were struggling to get off the ground called the Pope Project. For years, they had been struggling to raise money for a Pope Project which would bring a thousand children with clefts, from very poor developing countries to Rome to be blessed by the Pope. Then all these children and their chaperones would fly back to their developing countries where they would undergo surgery. Then Op Smile would fly all of these children back to Rome to see the Pope a second time and to celebrate their new smiles and new lives. For a tiny mission charity that was turning away thousands of children every year due to a lack of funds, the Pope Project seemed like a PR event and a massive waste of money. While the Smile Train project was focused on bringing down the cost per surgery from $1,000 to $250, the Pope Project was going to drive the cost per surgery up exponentially. 

At the Op Smile board meeting where I announced Wang’s $10 million pledge from his company for the Smile Train Project, the co-founders tried to kill it. The discussion got quite heated. One of the co-founders actually told the board of directors that he was the only doctor on the board and that he knew “children would die” if the Smile Train Project was ever approved. This of course was not true. To date, Smile Train has provided 1.5+ million cleft surgeries, and each and everyone was delivered through the hearts and hands of local surgeons. Safety and quality reviews of these surgeries show conclusively that local cleft surgeons are much more proficient than American volunteer surgeons because the local surgeons perform so many more cleft surgeries. Fortunately, cooler heads prevailed and the Operation Smile board voted overwhelmingly to approve the project – over the co-founders objections. So we moved ahead with The Smile Train being managed as a special project of Operation Smile.

For 1-2 years, a small team of us worked very hard to try and make it work. But the two co-founders never accepted the program and did everything they could to obstruct and undermine it. After two young children died needlessly on an Op Smile mission to Beijing, my cofounder Wang called me and demanded that we both resign from the Op Smile board. We decided we had no choice but to spin Smile Train off as a completely independent charity with no ties to Operation Smile. After we figured out how much money we’d raised for the Smile Train project (around $4.5 million) we took that money, signed the papers and left Operation Smile.

Neither one of us had ever started a charity before. We didn’t really know where to begin. We hired a very expensive headhunter who found us Smile Train’s first Executive Director. He was a Duke grad who’d just spent 10 years working for the Peace Corps in Africa. He was a nice guy but he didn’t have an ounce of entrepreneurship in his body nor any sense of urgency. When he told me it would be many years before we provided any surgeries my head almost exploded. After wasting a year trying to light a fire under this guy we fired him. Our next President was another “nice guy” who came from another non-profit. He hoped he’d have much more “get up and go” than his predecessor. But he did not. Worst of all, we were still providing very few surgeries. So we fired him too.

This was a real low point. The last thing my co-founder and I wanted to do was hire our third very expensive headhunter to search for our third Executive Director in as many years. Reluctantly, I agreed to serve as interim President of Smile Train for one year to get it “on track.” I had been an entrepreneur in NYC for almost 20 years and had just sold my own business so I had the time. I had the passion. And I had the motivation. After spending two years complaining about our slow progress, the pressure was on – the last thing I wanted to do was end up firing myself.

After I took over, I found that Smile Train was in even worse shape than we thought. There was no business plan, no strategy, no programs, etc.

But the one thing Smile Train did have, which I was very grateful for, was a small team of really talented, dedicated, remarkable people including: Delois Greenwood, Karen Lazarus, Hana Fuchs, Melody Farrin, Satish Kalra and Michele Sinesky. Working together, shoulder to shoulder, we spent the next decade working together and built Smile Train into the world’s largest cleft charity with partners and programs in 92 of the world’s poorest countries.